THE DREAMING PROJECTFINAL CONFERENCE

Trieste, 14th June 2012Trieste, 14th June 2012

The experiences in the pilot site of

TRIESTE

Paolo Da Col and Sara Koterleon behalf of the Dreaming Project Group

A.S.S. n.1 “Triestina” and

Barbara Dodion behalf on TesanTelevita srl

The Dreaming staff in TriesteACKNOLEDGMENTS

A.S.S N. 1 TRIESTINA - LOCAL PUBLIC HEALTH AUTHORITY District 1: A.Benedetti, D.Daneu, S.Giussi, R. Fonda, T.Sverko, G.Adamo,

M.Castelli, District 2: M.G.Cogliati L. Di Biasio, F.Coceani, B. Lenardoni District 3: A. Pianca, R.Candido, E. Tommasi, District 4: E. Fragiacomo, A. Tulliani, S. Cuk, R. D’Errico Technical staff: G.Blasetti, L.Grion, D.Crosato, L.Irmi, R.Caramanoli, B.di

Bari General Direction: from start to March 2010: F. Rotelli, M.Reali, F.Franza;

after: F.Samani, A.Maggiore, C. Contento

TESAN-TELEVITA SRL - PRIVATE COMPANY Contact Centre: F. Colucci, M. Nurchis, A. Marchionni, E. Marassi,

E. Ferletti, V. Caramori Technical &ICT staff: S. Furlani, R. Benvenuti, A. Marsich Coordinator: B. Dodi Administration: L. Cernecca CEO : M. Flaborea

The context

Province of Trieste 6 municipalities 212 km2

tot. pop. 236.500 density 1.116 /km2

average income: 20.000 € /p.c./yr

Municipality of Trieste 84 km2

tot. pop. 205.500 (- 2.000/yr) density 2.432 /km2

2,1 subjects / each family

over 65: n=65.647 (27.75)%) over 75: n=33.256 (14%) ½ living alone

elderly index = 243

WELFARE COST: 2.300 €/p.c./yr

65.ooo65.oooover 65over 65

25.ooo25.ooolive alonelive alone

Town Council of TriesteTown Council of Trieste214.000 inhabitants214.000 inhabitants

• 10.000 disabled people

• 6.100 for daily living

• 5.000 mobility-interned

• 2.700 nervous syst. diseased

• 3.500 disability pension (400 €/month/p.c.)

• 3.000-5.000 relative poverty

(814 - 488 €/month/p.c.)

• 800-2.500 absolute poverty

(559 - 373 €/month/p.c.)

18.ooo18.oooover 80over 80

1 : 31 : 3over 65over 65

1 : 61 : 6over 75over 75

146146over 100over 100

Home care in the health care districts for

PHCand community oriented care

Distretto 1

Distretto 2

Distretto 3

Distretto 4

In each district (60.000 inhab.):

• 100 employees

• 50 GPs

• 30 nurses & therapists

for 24/7 home care;

Teleassistance

• 10 cars

• 20 elderly residences

• annual budget 10 ml/€

PROFILE OF SUBJECTS AT START AND AT THE END Pathological profile of TM group at the start and at the end of the

project - FIRST PREFERENCE

11

6 7

42 1

6

4

9

6

33

0

2

4

6

8

10

12

14

16

18

20

start end start end start end

DM CHF COPD

sb

j

M

F

Pathological profile of CTRL group at the start and at the end of the project- FIRST PREFERENCE

74

8

4 3 2

9

7

10

6

20

0

2

4

6

8

10

12

14

16

18

20

start end start end start end

DM CHF COPD

sb

j

M

F

Intervention

N=30

Intervention

N=30

Controls

N= 30

Controls

N= 30

At the end of the trial on March 2012, 26 people dropped-out from

the trial

12 in intervention group

4 died

1 permanently transferred to an elderly home

1 reported “to be afraid” of radiation

1 moved to another city

1 left for personal reasons, 1 for depression

2 refused to use the equipment (inability)

14 in control group

10 died

4 left for personal reasons

TRIESTE DREAMING USERMmmh !

My Dreamin

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Mmmh ! My

Dreaming

TRIESTE DREAMING USERMmmh !

My Dreamin

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Mmmh ! My

Dreaming

14

The Dreaming Contact Centre is based on the existing Tele-care Contact Centres provided by Tesan-Televita on behalf of Public Bodies.They have been working with success since 1994 in the whole Regione Friuli Venezia Giulia and, since 1997, in particular in Trieste.

The public Home Tele-care service is managed on behalf of: Municipality of Trieste since 1989 ( 80 users) Region Friuli Venezia Giulia since 1994 ( 3.700 users) Local Health Authority since 1997 ( 670 users) Municipality of Palmanova (UD) since 1999 ( 10 users)

Contac Centres• are provided with hardware and software dedicated to the service• are runned by trained and qualified operators• offer a 24 hours Tele-care service also integrated with Emergency System (112, local “118”) and Tele-control for social inclusion of elderly• provide a “key service” for handling the alerts (24h/7)• are points of reference for social and healthcare needs• create an optimal match between private and public social-health services

Certified UNI EN ISO 9001:2008 for Telecare, Telemedicine, Telecontrol + Code of Ethics compliant to the Italian Law 231/2001

TRIESTE CONTACT CENTRE 24h/7

TRIESTE CONTACT CENTRE 24h/7

manages Alarms (Type 1 and 2) and web clinical folders

activates network

maintains additional contacts

with users also by video monitors regular use of devices

provides first level Help Desk support users and case

managers promotes social inclusion

TRIESTE CONTACT CENTRE STAFF

Vital Monitors

Environmental Monitors

Type 1 Alarm (not emergency) n=6.525

Type 1 Alarm (not emergency) n=6.525

Type 2 Alarm (immediate reaction) n=416

Type 2 Alarm (immediate reaction) n=416

1 hosp1 hosp

3 hosp3 hosp

During

3 yrs

During

3 yrs

CLINICAL EVENTS IN TRIESTE

from July 09 to March 2012 CONTROLSINTERVENTIO

N DIFFERENCE

Number of hospitalization 99 66 - 33

Total length of stay in hospital 1095 823 - 272

Average length of stay in hospital 11,1 12,5 1,4

Number of accesses to emergency rooms. 18 16 - 2

Number of ambulance transports 65 51 - 14

Number of GP consultations 262 293 31

Number of specialist consultations 337 415 78

Number of home visits by nurses 1048 1219 171

Number of home visits by social operators 22 13 - 9

Permanent transfers to elderly home 0 1 1

Number of falls 6 41 35

Number of bone fractures 0 3 3

Deaths 10 4 - 6

Drop outs 14 12 - 2

HEALTH & SOCIAL COSTS

  INTERVENTION CONTROLS

Hospitalization costs 330.000

€ 495.000 €

Cost of emergencies assistance 1.120

€ 1.260 €

Cost of GP consultations 4.688

€ 4.192 €

Cost of specialist consultations 16.600

€ 13.480 €

Cost of home visits by nurses 30.475

€ 26.200 €

Cost of home visits by social operators 325 € 550 €

Permanent transfer to elderly home 93 € - €

TOTAL 383.301

€ 540.682 €

LESSONS LEARNED

In the intervention group:

lower number of deaths lower number of hospitalization lower total length of stay in hospital lower use of services (but higher number of GP and specialists consultations) lower total costs of care

higher quality of life and self perception of safety higher sharing of relevant clinical information higher degree of personalized care more prevention and proactivity in long term care higher contacts with the person (not lower !)

WEB PORTAL: ELECTRONIC FILE SHARING

LESSONS LEARNED & REMARKS

The higher number of falls: this could be explained by the continuous more accurate monitoring of events (a fall without consequences can be forgotten); fractures in 3/41 (7%)

The longer average length of stay in hospital: in intervention group admissions probably might have been more appropriate and, because of comorbidity and severe disease, thus needed a longer average stays

The permanent transfer to elderly home: during the whole trial it occurred only in one 89 y old woman of the intervention group, after a fall which caused a femur fracture

The higher number of nurse home visits: more than expected, subjects in intervention group required an intensive follow up for instruction/education on the devices, as confirmed by the “user satisfaction questionnaire”

PROS and CONS

STRENGHTNESS new attitude for telemedicine

and positive working atmosphere

info on the web portal ! and ++ professional integration (ASS1 + TTL: meetings, collaboration, etc) to solve problems

user satisfaction (despite some problems with the use of devices)

the majority of older participants feel more safer at their home thanks to the Dreaming equipments

positive change of mind in health professionals about the DREAMING Project: a good experience for the future, a professional increase

WEAKNESS imperfect selection of frail

participants

the thresholds of type 1 alarms are too low and not with a real clinical impact and relevance for a clinical decision

DLS lines connections (some criticisms, mainly solved; costs)

difficulties for many to be trained in handling/using the devices (both for operators and subjects)

difficulties for the set-up video conference - Our older users remain doubtful about the use of Videoconference

RECOMMENDATIONSFrom us to others in case of…

Identify your main purposes for telemedicine at home 1. gathering vital parameters to adjust in due time therapies or to adapt

clinical decisions on the basis of a set of data ? => contact center

2. discovering emergency-life threatening situations (home !) with prompt intervention of the services ? => contact center + emergency/112 ! thus with accurate distinction of type of alarms

Select the expected results If they are linked to the reduction of hospitalization, admittance to

nursing homes, recurrences of disease, number of home interventions by professionals, burden of disease; or to the increase of appropriatness of accesses at home by professionals (unavoidable), increase of self care/management by more active patients and their caregivers (empowerment)

RECOMMENDATIONSFrom us to others in case of…

Select carefully the users/patients

Look for innovation in self care, in empowerment of patients and care givers/informal carers

Identify your goals: Quality of Life ? Appropriate use of services ? Reduction of costs ? …… INCLUDE : Social inclusion ! => Bridging health and social inclusion

Take into account that training to use devices, both for users and professionals, is very demanding; it needs continuous refreshing and supervision on devices efficiency; it requires more resources than expected

Check system devices accuracy/precision

Set protocols and flow chart with personalized threshold of alarms

Make possible that frail people really understand the use of devices to make them more active and the operators more pro-active

Look for a spontaneous participation of the professionals: tech is an opportunity to enhance capabilities not a threat to loose the job

Maintain a rigorous constant feed back with all the final users

Compare this return of investments (RoI) with that obtained FOR THESE FRAIL ELDERLY SUBJECTS if admitted in residential or hospital care; remember: the cost for 30 complete sets of devices is equal to that of one hospital ultrasound equipment

RECOMMENDATIONSFrom us to others - In case of…

FUTURE - PROSPECTIVES

The majority of subjects in the intervention group are glad to continue this new integrated care

In turn, the professionals are now proud protagonists with new skills in “human touch enriched by high-tech”

We can use available - free equipments in other

subjects, maximizing previous investments

At the end of “this DREAMING”, now we are ready (happy) to start a DREAMING 2 PROJECT

NOW !DREAMING for us means…

networking (within & between us)

collecting additional data interpreted by specialized professionals for more personalized decisions and programs of care (need not for less but for more human intervention !)

opportunity to improve new integrated home care

breakthrough for knowledge translation to action and information for an evidence based policy

pride in USEFUL innovation

emphasis in new home care that can outweight the obsolete supremacy of hospital and residential care (and avoidable related expenses)

reappraisal of real life evaluation of cost/benefit