Is Chronic Disease Management Possible in Rural Places?

Every year, the number of Canadians with chronic diseases grows. The need for services that support chronic disease management has never been greater.

Fortunately, there’s reason for optimism. We’re witnessing the rise of the empowered patient. If you work in home care, you’re already aware that this is good news for those with chronic diseases.

Empowerment means more control over personal health outcomes. For many, it means managing health conditions from the comfort of home.

But not everyone benefits equally. For patients who are disconnected from supportive health care providers, living with a chronic disease can be overwhelmingly difficult.

In rural regions, support is often inadequate – if not completely unavailable.

Given this disadvantage, can rural patients really manage their care on an ongoing basis? And is there anything that home care agencies can do to improve the situation?

Tackling A Public Health Scourge

Each year, chronic diseases like diabetes and COPD (chronic obstructive pulmonary disease) cost our economy $190 billion. This figure – from the Public Health Agency of Canada – sheds light on the massive risk these conditions pose.

The same organization found that the number of Canadians with at least one chronic disease grows by 14% annually. As costs continue to mount, federal and provincial governments are working to find solutions.

Investing in home and community care is one step policymakers are taking. And it just makes sense. At-home care can be very cost efficient. And in most cases, caring for independent patients who don’t face immediate danger in facilities doesn’t make sense.

But it’s easy to forget that even independent patients may need strong support. This is especially true of those who have suffered from major health events associated with chronic conditions.

According to the Canadian Institute for Health Information, one in twelve Canadian patients is readmitted to the hospital within 30 days of being discharged.

After a heart attack or similar event, a patient may need encouragement to adhere to a care plan. Nurses, PSWs, and specialists who communicate with patients at home are in a unique position to provide this support.

But why is chronic disease management so difficult for patients?

Of course, there are many reasons patients fail to adhere to instructions. Poor health literacy is one. Forgetfulness is another. However it comes about, failure to understand the consequences of non compliance can be dangerous.

Communication is a critical, and often weak, piece of the chronic disease management puzzle. This weakness can extend to care providers. Unfortunately, poor communication may have a larger negative impact on patients in some past of the country.

Rural Communities: It’s Time to Take Action

In Ontario, northern and rural communities have the highest rates of complications from diabetes. These are the same areas where access to specialists – such as endocrinologists – is most limited.

These findings, courtesy of the Institute for Clinical Evaluative Services, will come as no surprise to those in health care.

Rural and remote regions of Canada are diverse. But one trait most communities in these areas share is limited access to health care services. First Nations communities are hit particularly hard.

Reports show that on many reserves, staff members in nursing stations aren’t adequately trained. Specialists are rarely, if ever, available.

These problems are less serious in some remote and rural communities than in others. But as a rule, the care available in these regions lags behind what’s available in cities.

What does this mean for rural patients who need help with chronic disease management?

Consider what happens after a patient experiences a health event associated with a chronic disease. Let’s say a woman with heart disease leaves an urban hospital after a stroke.

If the she lives in the city, this patient is more likely to make the lifestyle changes that could lead to a full recovery.

She’ll never be far from highly-qualified caregivers and physicians. Getting referrals and travelling to appointments will be relatively easy. Crucially, if she need at-home care, finding a provider that meets her needs will almost certainly be possible.

Now let’s say the same patient returns to a rural town after discharge. Being in a community that doesn’t have proper supports in place will likely make healthy living difficult.

Communication between hospital staff and local providers will probably be (at least somewhat) disjointed. The patient’s professional caregiver may not receive all of the information critical to her case. That’s assuming a local caregiver is available, which may not be the case.

Following up with specialists probably won’t be easy either. It may mean flying to the city – alone. At a certain point, the patient may not bother.

It can be challenging to follow medical and personal care instructions in the best of circumstances. Without oversight, positive changes may not last long.

In some rural settings, there are far too many opportunities for mistakes to occur. These mistakes place an unnecessary burden on our health care system. Sadly, the human cost can be even higher.

Promising Solutions for Chronic Disease Management

Luckily, among health care providers and government policymakers, there’s a growing awareness of the problems surrounding rural health care. With this awareness, a new crop of technologies have emerged to provide solutions.

Let’s return for a moment to the woman being discharged after a stroke.

During discharge planning, needs will be assessed. Referrals will be made. Follow-up appointments will be set. Instructive discussions will be carried out with the patient and her attendant family members.

Let’s say that, after discharge, you become the patient’s rural home care provider. She is now your client.

For you and your agency, coordinating with hospital staff and specialists probably won’t be seamless. Getting all relevant health information could require a lot of back and forth, and it may take time.

Then there’s self care and the patient’s ongoing disease management efforts. You – or the caregivers who work at your agency – can’t always be there for her. How well can she can get along on her own?

Can she keep track of changes to her routine, such as dietary restrictions and prescribed exercise?

When her caregiver isn’t there, will the she be able to follow her medication instructions down to the letter?

Will she recognize the symptoms she’s been told to watch for if they appear?

Will she make it to her follow-up appointments, some of which will likely occur in the city?

Technology can help home care providers – and anyone else directly involved in a patient’s care – address these questions. How? By improving communication.

In this context, communication means the transfer of information related to a patient’s health or wellbeing.

Test results indicating the patient’s health status. Notes from a specialist’s examination. A care provider’s reminders to a patient. A description of symptom distress, passed from patient to caregiver. All of this information needs to find it’s way to its intended recipients – and fast.

When a patient lives rurally, the communication gap between those within her circle of care can be especially wide. To improve health and quality of life, we need to close the gap.

Telemedicine connects health care professionals to patients outside of their immediate vicinities. It can also connect home care providers to physicians, specialists, and – of course – people who require care.

With the right communication technology, the patient described above could make it to all of her follow-up appointments. She could check in easily with home and community care providers.

Just as importantly, every professional involved with her care could share relevant health information.

Here’s one example: if she suffers from poor circulation, the patient could develop a complex leg ulcer. In a rural setting, she may not have access to a wound care specialist.

With the right videoconferencing technology, a specialist could assess her wound remotely. Her caregiver can provide expert care, all from the patient’s rural home.

When it comes to chronic disease management, communication is key. Care providers need to do everything they can to strengthen communication with patients. They also need to ensure that they send and receive the right information from other providers.

Moving Forward

For those who have been diagnosed with one or more chronic diseases, positive lifestyle changes should last a lifetime. Unfortunately, rural patients don’t always have the right tools or support to manage their conditions long term.

To solve these issues, health care organizations and policymakers need to work together. Right now, technology has the potential to help by improving communication and the transfer of information. These cost-efficient solutions are empowering patients with chronic diseases – wherever they happen to live.

Feature Image Courtesy of James Jordan

Image Courtesy of Nico Paix

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COPD Education – Onboarding

Objective

To complete a thorough needs assessment / initial evaluation for a COPD patient of an outpatient clinic

Actors
Patient, Educator (Nurse, RT, the Physician could also be the educator)

Timelines
One 60-90 min session with the Educator

Description
  • This protocol should be established for all COPD patients from a given clinic, independently of whether they are new patients or they are known to the clinic. This protocol is the basis to engage the patient into other protocols such as education, exacerbation follow-up, etc.
  • We need to identify patient goals/concerns to guide the interventions
  • A thorough evaluation is carried on, with the objective of understanding where the patient is on their disease journey and follow-up treatable traits: dyspnea, exacerbation or dyspnea and exacerbation.
  • It includes the use of objective questionnaires such as the mMRC, CAT, HADS, Frailty Scale, etc.
  • Identify if the patient needs to be referred to other resources (e.g. Physiotherapist, social worker, occupational therapist)
  • Once Onboarding is completed, the patient continues to the COPD Education workflow
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COPD Education – Continuous Maintenance

Objective 

To cover in depth all the necessary elements of self-management education as per the LWWCOPD, with priorities based on patient goals and identified treatable traits

Actors
Patient, Educator (Nurse, RT or Physician)

Timelines
A number of “Core” educational modules have been identified which cover the basic COPD education from the LWWCOPD program. Additionally, optional modules can be used to respond to patient needs. The timeline (frequency, number of modules to be covered at a given education session) is fully customizable, although we recommend to have education sessions every 2-weeks during the “active” phase of education. Once this is completed, the patient continues to the Maintenance Mode (see below).

Description
  • Launched at the onboarding protocol
  • Provide basic overview of COPD self-management based on LWWCOPD (medication adherence, inhaler techniques, PLB technique & energy conservation) up to the development of an Action plan for early exacerbation recognition and management.
  • Prioritize self-learning by the patient (e.g. watching videos, reading educational materials, completing homework) in addition to live sessions with the Educator. Educational materials are sent to the patient directly via the platform, and become the patient’s own library. The Educator can customize which “homework” the patient receives.
  • Educators have access to “User guides” to standardise their educational intervention. These user guides include: objectives, interventions, suggested questions, evaluation of self-efficacy, and learning contracts for each module.
  • Once the core education is completed, the patient can continue to the Respiratory Status Follow-up Workflow (run in parallel)

The Maintenance Mode
  • As soon as the maintenance mode is engaged, the frequency of visits Educator/Patient is reduced to once every 6 months.
  • During the Maintenance Mode sessions, the educator has access to all the education modules and can choose any piece of content that needs to covered with the patient. 
  • A streamlined evaluation (similar to the initial eval.) is done during each “maintenance” visit to identify any substantial changes on the patient’s needs that will require some adjustment. The patient could come back to an “active” education mode (more frequent education sessions, e.g. every 2 weeks).
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COPD Respiratory Status Follow-up

Objective

Monitoring of stable patients from a clinic in order to identify early any aggravation of symptoms (exacerbation) and implement an action plan

Actors
Patient, Educator (Nurse, RT or Physician)

Timelines
Scheduled regular automated follow-up to the patient symptoms. Intensity/Frequency can be adjusted by the Educator depending on patient needs (e.g. daily, every week, etc.). Ongoing through the year.

Description
  • Launch: Patients who have completed the Core Educational including setting-up an action plan.
  • Regular automated questions allow to identify any change in patient’s symptoms and severity.
  • If an exacerbation is detected the patient gets a reminder to engage their self-management strategies while waiting for the Educator to call back.
  • An alarm is generated for the Educator, so they immediately call back the patient. At this call they will evaluate any further intervention required and schedule additional follow-up.
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