Look Homeward.

Linda Pearce, RN, C, BSN, MEd, CDE, Consultant, Blacksburg, VA, notes the vital importance of ongoing education, delivered conventionally or via telehealth, whatever it takes to get people living with diabetes on the road to self management….

Technology plays an enormous role in diabetes self-management related to patient education, problem solving, and monitoring. Considering only the facet of technology related to monitoring, much guesswork has been removed from daily care activities. Advanced glucose meters have made diabetes control simpler and easier to manage with less pain, greater convenient, and improved accuracy and speed.
Why is there a special need to find technologies to simplify daily routines and management tasks for patients living with diabetes? A person newly diagnosed with diabetes must learn ~150 different tasks in order to reach disease self management. That competency cannot be achieved during a brief hospital stay, most particularly during a brief educational session just prior to discharge while family or friends are waiting to take the patient home.

Problem solving skills are important for people with diabetes to learn. What makes their blood glucose go up? How much does their blood glucose rise following ingestion of one of their favorite foods? Over time, they must learn in effect to be their own detective and how to use the information from blood glucose testing, or it has no real meaning as a set of numbers collected for some health professional who may never look at them. When the numbers are not important enough for the health professional to spend time studying them, the message is clear to the patients. Sometimes what we don't say speaks louder than what we do say to patients.

Self management- that's the goal, of course. However, the ongoing contact with a person who is knowledgeable and interested in encouraging and coaching the individual with diabetes is the most valuable benefit of telehealth. More frequent contacts are possible, and can be made more economically using telehealth. With more frequent communications, people were shown to have better diabetes outcomes in both landmark research studies-the DCCT [Diabetes Control and Complications Trial] and the UKPDS [United Kingdom Prospective Diabetes Study]. All told, frequent contact and encouragement help maintain motivation 24/7.

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Joan Haizlip, RN, CS, MS, a home healthcare nurse and consultant with VNAFirst, Willowbrook, IL, focuses on the value of patient education and following a telehealth pathway to continually plan and measure the effectiveness of tele- and conventional contact with patients living with diabetes:

Tele-assisting in Diabetes: What's Working
The world is facing a devastating epidemic called diabetes. The health and economic consequences of Americans with diabetes is overwhelming and expected to grow as America continues to age. To help curtail costs, individuals are being encouraged to be more active in the management of their ongoing health care needs. But how can an overburdened health care system achieve this? Well, the answer is right under our noses; it is called telehealth.

How Can Telehealth Help?
No disease is better suited to be monitored through telehealth than diabetes. Effective diabetes care is teaching the patient to self-manage his health through blood sugar control, medication compliance and lifestyle modification. We know that by simply reducing blood sugar levels and sustaining them, a patient can significantly reduce his risk of long-term complications and overall mortality. The largest study ever conducted on diabetes, the Diabetes Complications and Control Trial, demonstrated that every percentage point decrease in HbA1C, like a decrease from 9% to 8%, will result in a 35% reduction in the risk of complications. But in order to achieve these results, the patient must be involved in his care.

So, good diabetes care is really about patient empowerment. It is also about detecting changes in blood sugar and making timely adjustments in medication, diet or activity to avoid exacerbations that could send the patient to the hospital. Telehealth technology is the solution and will become the standard of care in the next decade. CMS is clearly focusing in on the potential benefits of telehealth and has even encouraged its use in the Chronic Care Improvement Program trials that will soon be getting underway. But why is telehealth so essential in diabetes care?

Telehealth is a tool that quickly connects clients, health care and service providers by using technology that transmits images, voice and data between two or more sites. Store and forward systems as well as video based systems can enable health care providers to "be there" and monitor blood sugar, insulin injection, diet, activity and medication compliance. Good management of diabetes requires good blood sugar control. For the most high-risk insulin dependent patients, this means that they can draw up their insulin and demonstrate correct injection technique. A video based telehealth system enables the clinician to watch the patient or his caregiver administer a daily insulin dose and then give immediate feedback on the procedure. A video based encounter with a high risk diabetic can take only minutes but mean the difference between a well controlled diabetic and one whose blood sugar soars out of control.

Good patient education is also the cornerstone of effective diabetes care. Yet studies have shown that even if education programs are offered without charge, the majority of patients will not participate in formal diabetes education programs. Therefore, we need to focus interventions on an individual level that can be timely and personalized, reinforcing the salient and problematic points for each patient. Telehealth enables clinicians to provide this 1:1 care affordably with proven long-term outcomes. With telehealth technology, diabetes self-management improves because clinicians can:

The Telehealth Pathway: Roadmap for Successful Telehealth
Telehealth is a tremendous adjunctive tool in the fight against diabetes. But it is still the clinician behind the tool who must make the right decisions and follow a standard of care for each and every patient. Telehealth practice is not immune to risk. And it was just a matter of time before telehealth guidelines were set into place to ensure that clinical practice remained at the highest standards during telehealth encounters. The good news is that there is now a new product to assist health care providers in meeting clinical and regulatory standards. It is the telehealth pathway.

The Telehealth Home Care Steps^® Protocols are a new product in the telehealth market that are helping to make telehealth programs consistent in their interventions, so that outcomes can be maximized and replicated. Telehealth protocols provide the structure for the telehealth video visit or the telephone call and address the clinical components of diabetes care as well as meeting telehealth guidelines.

For instance, for the typical diabetic patient, the telehealth nurse must make critical decisions based on incoming information from store and forward telehealth monitoring systems or from video visits about "what to do next" in the plan of care. Is an onsite visit needed? Does the physician need to be called? Do the alerts need to be reset? Should another video visit be scheduled sooner than anticipated? The Diabetes Telehealth Home Care Steps^®Protocols incorporate the standard of care and provide a decision tree for that individualized treatment and decision-making.

With the use of telehealth technology and telehealth pathways, the burden of diabetes care on the health system can be reduced and outcomes once thought improbable to achieve, can become a reality.

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Mark Braunstein, MD, CEO and President of Patient Care Technologies, Atlanta, GA, presents his views on the value of telehealth contact and continuous education/assistance with long-term self management for patients living their lifetimes with diabetes:

Telehealth, though 30 years old, is still evolving to meet the changing needs of today's health care system. There is an increasing recognition that improved management of chronic disease in the home may be the single most significant factor in improving outcomes while controlling cost. The new Medicare CCIP initiative is but one example of new ideas being tried to address this long neglected issue.

For telehealth to be a vital part of the solution we, as developers and clinicians, must take a distinctly patient-centric approach to create technology that can assist patients living with diabetes and other chronic diseases in long-term self management routines. In this new paradigm for telehealth, interaction is not just focused on physiological measurements and data collection. Instead, that information has to be used, along with knowledge of the patients' individual orders and lifestyle, to educate patients and support them in complying with their individual care routine. That means educating patients to know what to do, when to do it, and how to do it. It also means using in-home technology to assess their knowledge, skills and compliance and report this to the responsible clinician.

Consider, for instance, a targeted view of working with an elderly, newly diagnosed insulin-dependent diabetic. The ideal telehealth solution for this patient will provide him/her with a diabetes module customized around their orders and will be integrated with the clinical information system used by the patient's caregivers so they can react in a timely and focused way to this patient's current needs. With such technology in place insulin doses, as required, can be tailored to the patient's need of the moment, and the telehealth system used to communicate this new information. The nurse can use virtual technology to walk the patient through the changed dosage measurement and reiterate important information such as proper use of the syringe, rotation of injection sites and the patient's new and unfamiliar dietary restrictions. Done right, this can be part of a technology-assisted day-to-day routine that can help the patient stay on track, feel well and feel connected to their caregiver.

What's significant in this new telehealth paradigm is a very targeted approach to care and to the educational needs of particular populations. In home care, as a rule, the target is the elderly living with multiple co-morbidities, diabetes among them. What do they need? Clearly, as with all of us, usability of the workstations is of paramount importance. If it is too hard to use, it won't get used. If using it is threatening or intimidating, it won't get used. Given the potential visual, hearing and physical limitations in an elderly population, usability almost certainly means technology that presents information in several ways. Obvious options include text, of course, but it must be presented on a large, bright screen to facilitate reading in the largest possible patient group. The same information might also be presented via a clear and audible human voice which, even for patients that can read the text, makes the information more accessible and more likely to be retained. If educational material is to be maximally effective, particularly when conveying instructional material aimed at patient performance of care tasks, illustrations are an important, if not critical, asset.

Convenience is another important aspect of usability. Patients, even elderly ones, move about in their home and may travel to visit friends and relatives. Convenience and usability is enhanced when technology can be easily taken with patients and when it, as needed, can operate without electricity via a battery supply.

Wrapping all this together is a vision of using telehealth as a long-term, customized patient health assistant, one that with stay with and assist patients to achieve the best possible outcome and lifestyle for as long as they live with their chronic diseases.

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