Abstract
A telehealth system that can transmit vital signs data, and also empowers patients to maintain their autonomy and learn how to manage their disease better, can improve patients' quality of life. Such a system can form part of a high-quality and efficient health-care service. The Bosch telehealth system, which focuses on self-management, has been used by thousands of patients with long-term conditions in the USA and Europe. The efficiency of the programmes, as well as their positive effects on quality of life and compliance, have been proven for a number of chronic conditions, as well as for patients with multiple co-morbidities.
Introduction
Chronic diseases are one of the main challenges facing health-care systems in industrialised countries. 1,2 Chronically ill people have health-care needs which are different to those with acute conditions. 3,4 The disease progression is individually different. Symptoms may be diffuse, and therapies and treatments are complex. Chronic diseases may have a major effect on daily life. 4,5,6 In long-term conditions, the Chronic Care Model 7,8 and the World Health Organization (WHO) 3,9 emphasise that the efficient and effective care of chronically ill patients goes beyond the conventional biometric care model. Patients should receive effective self-management support, i.e. they should have a central role in managing their health: ‘Patients and their caregivers need to be informed about self-management strategies and be motivated to implement them on a daily basis over the course of time. Self-management training (for example, to improve adherence to medications, consistent exercise, proper nutrition, regular sleep, and tobacco cessation) can reduce the frequency of follow-up visits and will prove cost-effective with time. Health-care workers are crucial in educating patients and families about self-management. They are instrumental in helping patients initiate new behaviours.’ 3
Self-management support via telehealth
Telehealth plays an increasingly important role in the treatment of patients with chronic conditions. Telehealth applications generally involve the regular transmission of the patient's vital signs to their health-care provider, allowing the latter to identify any deterioration of their condition and intervene at an early stage. 10 This reduces the number of hospital admissions and calls to emergency services.
Recently, telehealth applications have been supplemented by additional functions, such as reminders or the provision of information via interactive education modules for the patient. This raises the question as to what content to choose in order to support patients and their health-care providers in effectively managing chronic diseases.
Patient self-management
The Bosch Model of Care underpins the Bosch telehealth system. It aims to improve the quality of life of chronically ill people, or those at risk of developing chronic conditions. It focuses on the patient, consistently encouraging self-management, and it supports professional caregivers, as recommended by the WHO, in strengthening patients' self-management competencies.
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The Bosch Model of Care comprises five dimensions of self-management:
Managing the therapeutic process
Understanding the disease Identifying and reporting symptoms and vital signs Taking medication Following treatment recommendations Other disease-related activities Managing healthy and preventive behaviour
Nutrition Physical exercise Cognitive exercise Social activities Stress reduction Routine health care Managing the role of a chronically ill patient
Understanding health status and disease process Awareness of the health-care system Relationship to health-care professionals Establish an action plan Managing daily life
Maintaining independence Deal with disease-related implications Support from family, friends and carers Managing emergencies
Have an emergency plan Recognize critical symptoms Call for help
The first dimension encompasses evidence-based knowledge about the disease, actions and behaviours patients should learn directly related to their condition. The contents may relate to a chronic condition or to co-morbidities. The second dimension covers topics that generally have a healthy and preventive effect, ranging from knowledge about vaccinations, through to motivating patients to take an active part in local social life. The third dimension deals with aspects that help the patient to feel more secure about living with a chronic condition, both in understanding the disease process and in communicating with authorities and carers. The fourth dimension focuses on daily life. The patient is encouraged to manage their daily life as independently as possible and as far as they can to compensate disease-related restrictions with the support of family, friends and carers. Finally, the patient learns how to prepare for emergencies related to their particular chronic condition in order to avoid hospitalisations, stress situations and complications.
The design of the programmes' content is evidence-based and adheres to medical guidelines, care standards and clinical expertise. Special topics, such as education about fall prevention, refer to the most relevant scientific literature.
The programmes are designed for a specific chronic condition, with or without co-morbidity, and typically cover a period of 360 days. Each day the patient receives an educational session focusing on different topics. In order to enhance their competencies and motivation, patients receive feedback about their answers. Vital signs measurement and information about the patient's symptoms are usually monitored daily.
The data recorded in the patient's home are transmitted via telephone line to the the telehealth centre, where the patient data are classified by vital sign, symptoms, behaviour and knowledge. Critical values occurring in these four categories are highlighted for further analysis by health-care professionals, allowing changes in a patient's condition to be quickly identified and corresponding treatment administered. As well as the monitoring of vital signs, the telehealth application can help to assess and support patients' understanding and behaviour over time.
Supporting patients and health-care providers
The Bosch Model of Care makes it possible to develop comprehensive health management programmes to meet the needs of chronically ill patients. Patients learn step-by-step over an extended period of time to manage their condition in their daily lives. The goal is to build up their self-management competencies, while giving consideration to all aspects that affect or are affected by their conditions.
With the help of the application, caregivers can support patients in understanding the importance of vital signs for their own condition, measuring them regularly and transmitting them via the base station. Health-care professionals can quickly identify in a group of monitored patients those who are high-risk and require more intensive intervention. A wide range of supplementary data can be displayed, as well as all individual information provided by patients relating to their subjective state of health. Health-care professionals receive detailed information about how well the patient has understood the education modules. This shows where the patient still has a need for more information. Support can be personalised to take account of patients' individual needs, whether for more detailed nutritional information or advice on how to establish and maintain social contacts while living with the disease.
Conclusion
A telehealth application that is based on transmitting vital signs, and also empowers patients to maintain their autonomy and learn how to manage their disease better, makes an important contribution to improving patients' quality of life as well as to a high-quality and efficient health-care service. It can be used as an independent educational model or be integrated into other existing activities, for example within the scope of Expert Patient Programmes or similar initiatives. 11
The Bosch telehealth system is used by thousands of patients with long-term conditions in the USA and Europe. The efficiency of the programmes, 12 as well as their positive effects on quality of life 13 and compliance, 14 have been proven for a number of chronic conditions, as well as for patients with multiple co-morbidities. 15
In the future, health-care systems will not be able to provide for and finance the health-care needs of a rapidly growing number of chronically ill people. This calls for a systematic review of health-care provision, newly designed care processes with targeted decision support and the application of clinical information systems. 16 Intelligent telehealth solutions, i.e. solutions that do more than just monitor vital signs and that meet the overall care needs of the chronically ill, can make a significant contribution to this.