Symposium 22 - Telehealth in Community

Telehealth encompasses the delivery and facilitation of health and health-related services, including medical care, education, health information services, and self-care, via telecommunication and digital communication technology.
Telemedicine emerged as a feasible and acceptable means for the Community Geriatric Assessment Team (CGAT) to deliver multidisciplinary care to residents in Residential Care Homes for the Elderly (RCHEs) in the early 2000s. However, its use was limited by costly hardware, unreliable connections, camera resolution, and data security concern etc. The COVID-19 pandemic revolutionized the development and application of telehealth in the care of older adults. More than 67,000 teleconsultations by CGAT were delivered to nursing home residents during the pandemic for medical care. Post-pandemic, teleconsultation by CGAT continues to support nursing home residents in scheduled follow ups and during outbreaks and long public holidays, aiming to reduce avoidable emergency department visits and hospital admissions. The development of institutional account for nursing homes can further enhance workflow and efficiency of teleconsultation. Tele-rehabilitation services have also been used in selected Geriatric Day Hospitals with promising outcomes. Moreover, residents and their families can access health data, health information, and manage appointment bookings with various mobile applications in HA Go. 
Telemedicine can potentially improve accessibility, efficiency and quality of healthcare services. Nevertheless, teleconsultation is limited by the inability to conduct physical examinations and procedures as well as cognitive and sensory deficits in older adults. Other challenges in the use of telehealth include availability of user-friendly devices, digital literacy and additional resources in nursing homes. Continued development and careful evaluation of patients and clinical outcome are essential before a wider adoption of telemedicine in care homes.

To expedite recovery, caring in a familiar environment could help. Moreover, home environment can reduce the stress and anxiety that relatives often experience when their loved ones are in the hospital.  Hospital@Home is an innovative healthcare delivery model that provides medical care to patients in their own homes rather than in traditional hospital settings. This approach has been adopted in different countries, e.g. United States, Australia, the United Kingdom, and Singapore. Its objectives are multifaceted, aiming to improves patient outcomes, increase patient satisfaction, improve access to care by reducing hospital overcrowding, broaden public health goals, and drive innovation in healthcare delivery.


In response to the challenges posed by the COVID-19 pandemic in 2019, the Hospital Authority introduced elements of Hospital@Home, such as care provision at Residential Care Home for the Elderly (RCHE) and tele-consultations, to address the overwhelming demand for medical services. Since 2021, a similar initiative known as the "Virtual Ward" has been implemented by the Hospital Authority, demonstrating a measurable reduction in hospital re-admission. Two community care programs have also proven their effectiveness as evidenced by decrease of AED attendance.


To further optimize the existing Hospital@Home program, an enhanced service model is proposed with symptom monitoring using telehealth devices and electronic Patient-Reported Outcome Measures (ePROMs) reported by patients. Patients and / or families can monitor patients' own progress and identify trends or patterns on their symptoms using self-reporting e-platform, leading to better self-management and facilitate virtual ward rounds. With PROMs, patients at higher risk for complications or adverse outcomes can be identified, allowing for timely intervention and management.


Although there are several Hospital@Home programs within the Hospital Authority, a clearly defined and optimal service model has yet to be established. Incorporating telehealth with Hospital@Home programs offers a range of significant benefits that enhance the quality of care, patient experience and overall efficiency of the healthcare system.

Introduction
Chronic Obstructive Pulmonary Disease (COPD) is a debilitating respiratory condition marked by chronic symptoms and frequent exacerbations. 


Smart devices enable continuous monitoring heart rate and oxygen saturation. It provides real-time data so that health care providers can conduct timely interventions to reduce admission. Also, it arouses patients' awareness to enhance their self-management on COPD. 


Besides, breathing exercises for COPD patients can improve respiratory muscle performance and reduce dyspnea result in improving their life quality.


Thus, NTEC COST conducted a pilot of using continuous SaO2 monitoring device on COPD patient to detect early sign of exacerbation and educated patient breathing and coughing training since November 2021.


Objectives
1. To review patients SpO2 pattern to facilitate nursing intervention
2. To reduce hospital admission rate due to COPD exacerbation
3. To educate patient to perform breathing and coughing training


Methodology
COPD patients with Abbreviated Mental Test(AMT) ≥6, were invited. CAT score were assessed as baseline and evaluated at last monitoring day. Patients wore O2 ring (ring-like continuous SpO2 monitoring device) at least 3 days. Nurses analysed the correlation between patient activities and SpO2 pattern from smart phone. Medical and nursing interventions provided according to the result. 


Besides, patient start breathing and coughing training with Pearl 8 if required. Nurse can check the record when home visit.


Result
From Nov 21 till Mar 25, 94 patients were recruited in the project. 59 among 94 patients conducted breathing and coughing training with "Pearl 8" device. They includes 83 males and 11 females. Mean age was 78.6. 29 patients had no admission due to COPD exacerbation within 1 year before recruited. Whereas 16 patients were admitted more than 2 times due to COPD exacerbation within 1 year before recruited.


Intervention included puff regime adjustment, breathing and coughing training and ad hoc medical consultation had been taken as indicated. Average pre and post CAT score were 17.1 (range:2-34) and 12. 9 (range: 1-32) respectively. It reduced 24.6%. 13 patients (13.8%) were admitted due to COPD exacerbation. 3 of them had history of frequency admission≥3 in a year.


Conclusion
Smart device provided continuous SpO2 monitoring and training logs for COPD patients during their daily activities, which provided useful information for nurses in identifying patient issues and facilitating prompt interventions. It is recommended the use of wearable sensors for ongoing measurements to assess clinical relevance in community care settings.

Frail elderly individuals often face complex medical issues requiring intensive care. The Integrated Discharge Support Program (IDSP) currently offers limited community nursing (CNS) and allied health services, lacking on-site medical support. This gap leads to increased attendance at Accident and Emergency Departments (AEDs) and frequent hospitalizations.


To address these needs, the Community Care Division (CCD) of the New Territories West Cluster (NTWC) launched the Integrated Care at Home (ICAH) Clinic for Frail Elderly with Chronic Diseases in 2018. The ICAH program involves home visits by geriatricians and nurses, in collaboration with the Allied Health Team, to provide medical consultations. This initiative helps alleviate the caregiving stress of family members and caregivers in the community.


During the COVID-19 pandemic, on-site visits became challenging, prompting the adoption of teleconsultations via Zoom. In 2020, the E-smart Vital program was piloted within the NTWC CCD. This program provided patients with sphygmomanometers, thermometers, and oximeters. Community nurses trained patients and caregivers to measure vital signs and upload the data to the Clinical Management System (CMS) for remote monitoring. Despite weak signals in some areas, the feedback was positive.


From February 2018 to February 2025, the ICAH clinic recruited 102 frail elderly individuals. Diabetes mellitus (DM) is a common chronic disease among this population, and 39 patients (38%) with DM participated. These patients frequently sought medical advice due to fluctuating blood glucose levels. Community nurses used structured triage questions to assess the severity of health issues and determine whether to recommend further medical consultations or continue monitoring. The results showed a significant decrease in mean AED attendance from 0.97 to 0.44 and a reduction in mean hospitalization days from 9.51 to 1.64, largely due to better DM management.


In conclusion, the ICAH program effectively addresses service gaps and enhances community care for frail elderly individuals. Future advancements in telehealth, such as electronic patient-reported outcome measures (ePROMs) via HA GO or other applications available 24/7/365, could further improve patient care by enabling timely interventions and facilitating closed-loop communication.

The aging population is expected to create a significant burden on society and healthcare systems, particularly concerning chronic diseases. Knee osteoarthritis (OA) leads to pain and dysfunction and is a contributing factor to falls. The medical costs associated with prolonged medication use, joint replacement, and post-operative rehabilitation are substantial. Maintaining healthy knees is essential for quality aging and effective medical care.
Screening for knee OA aims to shift the focus from reactive treatment to proactive prevention, fostering a healthier population. The goal is to identify individuals at risk before symptoms appear, enabling preventive strategies. The targeted population is large, necessitating a simple, fast, and easy-to-use tool that is both valid and reliable. Digital screening, empowered by AI, can stratify older adults in the community who are at higher risk of knee pain or OA, facilitating cost-effective care.
Current digital screening tools include online risk calculators, wearable devices, and smartphone apps. Our team has developed a mobile app that is easy and convenient to operate in community settings, capable of identifying older adults at risk based on influencing factors. A mobile phone is used to capture walking performance along an 8-meter line and the ability to perform sit-to-stand movements in 30 seconds. Pose estimation is employed to identify joint positions, allowing for the computation of walking speed and the number of sit-to-stand movements in 30 seconds. The outcomes are compared with age- and gender-reference scores. The screening can be conducted by anyone, anywhere, at any age, in 10-15 minutes. The mobile app can screen older adults with and without knee pain and provide risk stratification for further management.
Preventing disease progression through precision management is another role that digital screening can fulfill. The use of digital screening in managing knee OA subtypes will be further discussed.