Managing Chronic Care & Tele-Monitoring Model for enhancing integrated care – The MOMA Suggestion

摘要

Background : In the 21st century healthcare systems are striving to create cost-effective solutions for integrated chronic care. The use of communications and information technologies for providing remote medical treatment - Telemedicine - may be the answer to this challenge. MOMA is a multi-disciplinary healthcare center founded at 2012 by Maccabi HealthCare Services. The Center provides tele-medical services to complex chronic patients suffering from various conditions: CHF, COPD, diabetes, fragile, homecare and oncological patients under treatment. It is staffed by multi-disciplinary health practitioners including nurses, consulting physicians, clinical pharmacists, physical therapists, social workers and nutritionists. The Center currently serves 6,000 patients, and has to date rendered services to a total of about 20,000 members. It operates in full collaboration with primary physicians and other healthcare practitioners, including various treatment facilities. Intervention : MOMA performs treatment according to the chronic care model via telemedicine. The patient’s personal nurse proactively conducts medical monitoring of the patient’s condition to prevent complications through early diagnosis and real-time interventions. Nurses consult with and update primary physicians on their patients’ condition, and coordinate treatment. Thus, MOMA facilitates care continuity and serves as an integrator along the treatment continuum. Treatment is performed in a multi-disciplinary teamwork where the personal nurse consults as necessary with specialists, social workers, nutritionists, and clinical pharmacists within the center and in the community. Health goals are defined for each treatment field derived from standards of care accepted worldwide, and these goals are used to assess the clinical results. The Center’s work is supported by advanced technologies. The technological systems in use include a patient monitoring management system and electronic patient medical files, which also contain evidence-based digitized treatment protocols. Currently in use are several tele medical sensors: tablets, Transmitting glucometers, and Electronic pill organizers. Method : After three years of operation Moma's population was examined compared to similar population treated within regular community healthcare. MOMA’s Impact was assessed on clinical outcomes and service usage. Cohorts included patients from 4 treatment fields: Fragile, CHF, COPD and diabetes. For each patient (MOMA/standard care) service uses were examined one year before and after entry date to assessment status. Results : A significant decrease in HbA1c levels was found among diabetes patients due to entry to MOMA compared to standard care (p < 0.001). Propensity matched regression models were performed where dependent variable was average monthly hospitalization days in all 4 cohorts. MOMA was found to reduce hospitalization days significantly in the fragile cohort (β= -0.043, p<0.05) and the diabetes cohort (β= -0.073, p<0.05). Moreover, in a similar analytic process MOMA reduced hospitalization cost significantly in the fragile cohort (β= -0.052, p<0.01), the diabetes cohort (β= -0.073, p<0.05) and COPD cohort (β= -0.085, p<0.01). Conclusions : Our proven MOMA experience suggests that providing both efficient and quality care services to growing chronic populations is feasible. The combination of a flexible care model and telemedicine supports integrated care.