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Transforming telehealth through enhanced General Practices partnerships

Introduction: In 2014, a health needs assessment conducted between a Local Health District (LHD), a local government council and a Primary Health Network showed a Chronic Obstruction Pulmonary Disease (COPD) hospitalisation rate of 105, higher than NSW benchmark (100), along with sub-optimal access to health services. Practice Change: In 2015, a new model of care via telehealth developed in partnership with General Practitioners (GP) allowing regular clinical readings at home to transmit to a telehealth coordinator, has offered benefits in terms of quicker access to patient information and less time spent performing home visits, while still maintaining that crucial ‘face-to-face’ contact. Aim / Theory: Promote wider collaboration between hospital, GP and private provider to improve a seamless and rapid access to care and coordination for the community, using telehealth technology. This proactive approach to chronic disease management will improve patient self-management capabilities, understanding of their condition and reduce presentations to Emergency Department (ED), through early recognition and intervention utilising telemonitoring in consultation with treating GP. Population: The telemonitoring project was developed for a regional area community with high rates of chronic disease hospitalisations and sub-optimal access to healthcare. Timeline: After identifying the priorities for the region through the 2014 health needs assessment, the telemonitoring initiatives commenced in 2015 and have been sustained. Highlights: Outcomes included: 1- Wider collaboration with 90% of the GP practices participating in the project with 5 Telehealth Clinics established to connect patients to specialists. Streamlined access to care and coordination for the community using telehealth technology through processes for triage and escalation based on integration of care and provision of services between patients, GP, telemonitoring nurse coordinator, and telemonitoring provider. Patient compliance (performing readings as per GP care plan) was very high. At risk readings comprised 55%, showing that health issues were appropriately detected, escalated and timely managed, preventing unnecessary hospital presentations. 2- Qualitative patient experience “Client who had up to 15 admissions has not presented since clinical intervention and care coordination via telemonitoring”, comment by treating GP. Sustainability: This initiative has transitioned as part of the LHD Chronic Disease Management Program and is now sustained within an ongoing service delivery model. Transferability: This initiative and its model of care has been scaled and rolled-out to other Local Government Areas.  The target patients group has also expanded to include chronic heart failure and diabetes. Conclusions: This project provides an integrated healthcare opportunity by co-designing the solution with the GPs and telemonitoring provider, it also enhances patients and carers experience as partners.  In addition, the solution is seamless connected care by providing rapid feedback and ready access to clinical support in a sub-optimal serviced locality utilising technology which transforms healthcare. Discussions: This study has served to increase understanding of practical ongoing implementation of telemonitoring in a real world integrated health neighbourhood including a large local health district, a commercial telemonitoring provider and a number of General Practices. Lessons: The missed readings / lost contacts and its interaction with usefulness and reliability of telemonitoring needs to be explored.