Qualitative literature review
To identify recent technology trend, platform development cases, usability and effect of ICT-based chronic disease management in older adults, a total of 60 articles (23 on hypertension, 18 on diabetes, and 19 on heart failure) were reviewed through Pubmed. The research based on chronic disease management with ICT has rapidly grown after 2009 and this is thought to be due to the development of technology. The technology of the consultation system mainly uses web or mobile-based online platform or single application technology. In most studies, both patients and medical staff participated. For hypertension and diabetes, ICT-based chronic disease management led to significant reduction in blood pressure or blood sugar levels. (Supplementary material) In the case of heart failure, communication was quicker between the patients and medical staff, which improved patients’ satisfaction. However, little research has been conducted on a consultation service model between the medical staff of different institutions. (Supplementary material)
Focus group interview
From June 4, to 28, 2018, focus group interviews were conducted with six medical staff (two acute care hospital physicians, two long-term care hospital physicians, one acute care hospital nurse, and one long-term care hospital nurse), one patient, two guardians, and a hired caregiver. Currently, inter-institutional consultations are not well established; however, due to complex multi-morbidities among the older adults, the necessity of coordinated management between the institutions was high. Moreover, standardized common tools, such as a comprehensive geriatric assessment (CGA), are highly needed for efficient information sharing about the current state of older patients. In addition, an online consultation system was expected to be helpful in the management of duplicate drugs and chronic diseases. To activate the ICT-based, inter-professional consultation system, physicians’ opinions indicated that the invisible resource input provided by personnel should be reimbursed. From the patient or guardian's standpoint, if ICT-based consultation system could be used to regularize outpatient care at a NH or LTCH without having to visit a university hospital or a big center, they were willing to pay for it. They were hoping that the sharing of medical information between the institutions would be more convenient with the ICT-based system.
Structured survey
Through qualitative literature review and focus group interview, we could confiemd the positive aspects of the ICT-based consultation service. To collect and request more specific opinions and component on the ICT-based management and consultation service system, a structured survey was conducted online and offline from August 16 to September 30, 2018. A total of 114 medical staff and 50 patients/guardians/caregivers were surveyed.
Among the 114 medical staff (53% male) who participated in the structured survey, , 80% were physicians and 20% were nurses, and 45% belonged to tertiary hospitals and the others belonged to LTCH and NH. The majority of medical staff (94%) had over one year experience in managing older adults. The most difficult things to manage or care for in the elderly patients were complex multi-morbidity (4.1/5 points), absence of assessment tool and reimbursement system for older patients (4.04/5), duplicate medication management (3.96/5), lack of information about previous medical records (3.93/5) and lack of information about patients pre-morbid function (3.90/5). The most common information transferred at the time of referral to other institutions were the medical certificate, and the medication list and medical records; laboratory results or imaging files were relatively lower in necessity. The respondents indicated using paper (86.8%) as a method of transfer of medical information most frequently but reported being dissatisfied (2.6/5) with the amount, quality, method and management of medical information currently being shared. Among the services expected to be provided by the ICT-based management service, medication and chronic disease management were indicated. Among the chronic diseases, the demand for management services was high in the order of diabetes, hypertension, and heart failure. In addition, as a management method, consultation on acute exacerbation, provision of the latest guidelines, and cumulative inquiry of results were preferred. However, there were also concerns about the lack of an adequate reimbursement system (4.33/5), and the leakage of private or medical information (3.61/5). The type of rehabilitation services that needed to be provided in the ICT-based service were in the order as follows: swallowing, physical, and cognitive rehabilitation.
Among the 50 respondents of the structured survey with the patients/guardians/care givers, 76% were guardians, 18% were hired caregivers and 6% were patients. Patients visited an average of 1.55 hospitals and met 2.66 physicians, with 42% having a history of transfer. The average travel time for outpatient/emergency visits was 1.72 hours, and the average cost was 41.22$ per person. Depending on the patient's place of care, the greatest cost and time was required for the transfer of the elderly living in nursing homes or long term care hospitals (Figure 1). Regarding the sharing of medical records through the ICT-based service, there was a positive response that it would be helpful for treatment (4.16/5), prevention of duplicate prescription or drug abuse (4.26/5), increasing the convenience of delivering medical information (4.14/5) and save money and time (3.92/5). Similar to the medical staff survey results, there were also concerns about the leakage of private or medical information (3.42/5). On willingness to pay for the ICT-based management and consultation system, above average positive answer (3.5/5) was given by patients, guardians, and caregivers.
Development of Health-RESPECT
The ICT-based management and consultation service model for older patients dwelling in nursing homes or long-term care hospitals was developed through literature review, focus group interviews and a structured survey (Figure 1).
Since the health-care workers in LTCH in Korea assess the general function, comorbidity status, and cognitive status, on a monthly basis to claim specified daily fees for care service, we developed CGA based on this data. CGA encompassing the six domains of comorbidity, physical function, swallowing function, cognitive function, activities of living, and medication was developed to be administered on patients when they are initially included in the Health-RESPECT service model. Physical function was evaluated by activities of daily living (ADLs), instrumental ADLs (IADLs) with modified Barthel Index and Lawton and Brody Index.6,7) Cognitive, swallowing and physical function were evaluated by the Korean version of the Mini-Mental State Examination (K-MMSE), the Standardized Swallowing Assessment (SSA), and the Functional Ambulatory Category (FAC), respectively.8-10) We used a validated self-report frailty questionnaire, based on the Korean version of the FRAIL scale (K-FRAIL, an acronym for fatigue, resistance, ambulation, illnesses, and loss of weight).10) Based on Beers criteria and guidelines for chronic diseases, a drug list of inappropriate drugs for older adults was selected in consideration of clinical significance, frequency of clinical use of NH and LTCH.12-15)
Based on the result of the CGA, an individualized problem list and treatment target was provided that included chronic disease management (hypertension, diabetes and heart failure), drug management, and rehabilitation (cognitive, swallowing, physical). The drug management service was developed by screening the medication currently being prescribed and providing the number and specified drugs corresponding to the absolute or potentially inappropriate drug list each month.
The treatment targets for chronic diseases were set differently according to the frailty status of patients (Table 1). A chronic disease management service was developed to provide information about recommended or non-recommended combinations of medications, screening, and what to do when adverse events occur during treatment (orthostatic hypotension, hypoglycemia), drug adjustment according to renal function, co-morbidity screening and management (diabetes-dyslipidemia), guidance for acute decompensated condition, and lifestyle modification based on recent guidelines. 13-15)
Table 1. Treatment target in hypertension and diabetes according to frailty status.
|
Robust
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Pre-frail
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Frail
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Blood pressure (mmHg)
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140/90
|
140/90
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150/90
|
HbA1c (%)
|
<7.5
|
<8.0
|
<8.5
|
Random glucose level (mg/dL)
|
≤190
|
≤210
|
≤230
|
Frailty status was evaluated with K-RAIL. Scores of 3 and more, 1 to 2, and 0 were classified as frail, pre-frail, and robust, respectively.
In the rehabilitation service, video clips of exercise and swallowing rehabilitation of various levels were provided once a week according to patients’ physical and swallowing function evaluated by FAC or SSA. For example, patients who are non-functional ambulatory or ambulatory dependent on physical assistance (FAC 0-1) were provided videos of pressure sore prevention or sitting exercise through correct posture. On the other hand, patients who could ambulate independently were provided videos of more intensive exercise. The cognitive rehabilitation program was developed for increasingly difficult orientation, attention, memory and problem-solving training in which patients with a MMSE score of 10 or more and 21 or less participated three times a week.
In the health-RESPECT service, a written consultation service between institutions was developed for when there were abnormal vital or laboratory findings above the limits or if the medical staff wished to do. In addition, with the development of the video conference tool, patients living in LTCH or NH and participating in the Health-RESPECT service model could be managed regularly with the acute care hospital. (Figure 2)