Residents in central Alberta are enrolling in a remote monitoring project that uses technology to support health care management. The pandemic has increased the need for alternative care delivery models, as patients with chronic health conditions are at an increased risk of serious complications from exposure to illness. The initiative, called the Alberta Central Zone PCN Home Health Monitoring (HHM) Project, uses teams of Primary Care Network (PCN) nurses and physicians to remotely monitor care for patients with chronic health conditions, minimizing risk of exposure to COVID-19 while easing stress on the health system. The project is a collaboration between the Government of Alberta, Alberta Health Services (AHS), Alberta Central Zone Primary Care Networks (PCNs), Boehringer Ingelheim (Canada) Ltd., TELUS Health, Alberta Innovates, and Health Cities.
The expansive geography of Central Alberta presents many barriers to optimal care, including limited resources and access issues. In response to the COVID-19 pandemic, primary care networks (PCNs) within Central Alberta partnered with a technology provider to rapidly implement home health monitoring (HHM) for patients with chronic diseases. In the 37 patients evaluated in phase 1 (90 days), diabetes was most common (73%), followed by hypertension (38%), chronic obstructive pulmonary disease (27%), and heart failure (11%). Overall, patients were comfortable using the HHM technology, and >60% reported improved quality of life after follow-up. Patients also made fewer visits to their family physician/emergency department compared with the pre-enrolment period. In January 2021, the HHM initiative was expanded to a larger patient cohort (phase 2; n = 500). Interim results for 90 patients from eight PCNs up to the end of May 2021 show similar findings to phase 1.
Health Cities interviewed a series of patients enrolled in the program to provide insight into their experiences. The interviews below are part of this series.
When Clarence Wayne was diagnosed with COPD in 2018, he was able to manage the condition successfully with only minimal intervention from medical professionals. With a combination of medication and therapy, Clarence went on with his day-to-day activities. However, as time went on, there were a few incidents that required emergency services and hospitalization.
“I had to call an ambulance one or two times,” Clarence recalled. “I recovered quickly, but there were a few times my doctor had to escalate my care.”
Clarence learned about the Alberta Central Zone PCN Committee Home Health Monitoring project from his family doctor, who recommended that he participate. As his doctor is a member of the Wolf Creek Primary Care Network (PCN), he was able to participate in this new opportunity.
The goal of the Alberta Central Zone PCN Committee Home Health Monitoring Project is to ensure that patients living with chronic conditions are supported to manage their care remotely. Using medical devices such as blood pressure cuffs, weigh scales, glucometers, pulse oximeters and thermometers, patients monitor their health at home. The data from these home measurements is added and stored in a secure online system that is monitored by their primary healthcare team.
“To be honest, I thought the daily measurements would be overkill because I would normally only survey my condition about three times per week,” Clarence reflected. “But it provided really good feedback in terms of a data trail in how I was doing. Because of the daily check-ins, I would notice that my condition was changing, so I could be more proactive than reactive. That was one of the goals of the program, and it was successful.”
Kenny Wilkes* was on a mission to get in shape. By all accounts, all of his work was paying off and he was seeing the results desired. However, in January of 2021, an appointment with his doctor came with unexpected news: Kenny was diagnosed with type II diabetes. The condition requires regular medication, maintenance, and monitoring.
Kenny explains, “In my home country, many men living with diabetes lose a leg. I have three kids, and my family was depending on me financially. I started thinking, ‘am I going to die and leave them?’”
Kenny had already started changing his eating habits in an attempt to reverse the effects of his diagnosis. Working with his primary care physician through the Red Deer Primary Care Network (PCN), Kenny began participating in the Alberta Central Zone PCN Committee Home Health Monitoring Project to monitor his condition and progress each day.
“It was good because of the daily check-ins with the care team. I would monitor throughout the day and see the trends in my readings,” says Kenny. “The project is particularly helpful for people who are living alone. If you miss one check-in, the care team will call and see if something is going on, and provide intervention if you need it.”
Through lifestyle change, regular maintenance, and monitoring, Kenny was able to come off most of his medications. Even without the medication, Kenny continues the monitoring.
“The monitoring and lifestyle changes made a big impact on my condition.”
*Name has been changed at the patient’s request
Although Debra Duquette has been living with diabetes for some time, the diagnosis originally took a toll on her outlook, as her life changed drastically overnight.
“I was quite upset about becoming diabetic. I thought my life would change as I know it, and it did. Being diabetic, you have to make sure you have your snack and you do your testing, watch what you order when you go out to dinner. It’s a total learning curve that you go through to pay attention to what you’re eating, and a lot of the stuff I used to eat I can no longer eat,” Debra explained.
While she eventually grew used to some of the changes, Debra sought support for some of the aspects of diabetes she found to be a struggle; in particular, the daily monitoring required of patients with diabetes. At the suggestion of her Big Country Primary Care Network care team, Debra enrolled in the Alberta Central Zone PCN Committee Home Health Monitoring Project, which uses remote monitoring to support patients living with chronic conditions. Debra was excited to try the program because it would include regular contact with her care team to ensure her readings stayed on track.
“My care team were able to see my numbers each day and then reach out if something was off. It makes such a difference. If something was out of whack, the care team could tell the doctor and he could offer guidance on what to do.”
When asked about future participation in the project, Debra was enthusiastic.
“I really appreciated the project because it held me accountable to someone aside from myself. Knowing my team would see my data every day was very comforting. I hope that the project continues.”
Pearl O’Gorman is no stranger to the challenge of living with Diabetes, a condition she was diagnosed with in 2012.
“Diabetes is in my family. My mother and my father had diabetes, so my doctor was watching for it already. While my parents had it, they never really talked about it, so I was still a little confused and overwhelmed by the diagnosis,” recalls Pearl.
Despite some familiarity with the disease, Pearl was still surprised by the extent of lifestyle adjustments she required. Her medications had a number of side effects, and she had to overhaul her diet.
“I had a lot going on at the time. It was hard to keep up with life, and while I tried to eat healthy, the progression of my diagnosis made me realize I needed to look after myself more,” Pearl adds.
Pearl’s primary care physician at the Red Deer Primary Care Network recommended her for the Alberta Central Zone PCN Committee Home Health Monitoring Project to help manage her condition and monitor her treatment. Pearl was excited to get started and see what the project was all about, and thought it might be useful to have extra support.
“I said I was definitely interested in participating. It was encouraging and exciting to be able to see the measurements each day. I recently saw my doctor after completing the project, and my blood sugar was down and my weight was down. My lifestyle has changed. The extra support made a difference. I feel like a new me!”
Find out more about the project here.
The Central Alberta Zone PCN Committee HHM project has been met with excitement and enthusiasm from the patients, clinicians, and partners involved. Listen to four project leads discuss outcomes and what the project means for health innovation in Alberta:
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