Digital solutions to enhance the Why continuity of care for - - PDF document

10/8/2018 1

Digital solutions to enhance the continuity of care for refugees and migrants: Telehealth

Dr Thomas Schulz Infectious Diseases and General Physician, Royal Melbourne Hospital Victorian Infectious Diseases Service

Background

• Immigrants settle in all parts of their new country
• 12% of refugees in regional areas in Aust
• Overall healthy
• Some complex health needs
• May need specialists
• Needs to access interpreters

Canadian Resettlement providers

Why

• Work
• Low skilled
• Areas of need
• Lower cost of living
• Communities develop
• Often are from rural areas

DSC6699-31.jpg

Problems to address

• Access to Specialists
• 50% of refugees in first year
• However
• Major cities 122 Specialists /

100000

• Regional Centres 38 -56 /100000
• Remote 16 / 100000
• Access to Interpreters
• Majority of refugees don’t speak

the host country language

• Most interpreters based in large

cities

• Large use of ph interpreters

Telehealth (telemedicine) Clinic

• 1000 consultations
• Over Internet (VOIP)
• Free or low cost softwares
• A Webcam and speaker
• Patient is either with local

doctor or at home.

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How it works

• Medication – Send prescription for medication (or send medication)
• Pathology and Radiology – send request form
• Interpreters on the phone at the Regional site
• Sometimes need to see onsite

Patient and consultation variables Median Age 39 (IQR* 32 – 49) Number of males 75 Number of females 44 Consultations with GP with patient 91 GP’s who conducted at least one consultation 29 Consultations with practice nurse with patient 28 Median return distance from GP practice to tertiary hospital 494km (IQR* 188 – 648km)

Medical conditions managed during telehealth consultations. Method of provision of Interpreter service for clinical consultations

Benefits

• Reduced patient travel/time
• in first year;

– Over 54000km travel avoided – Median distance saved 494km/consultation – 15200kg CO2 not emitted (if all by car)

• Better communication with GP’s
• Patients very happy

Green Vehicle Guide, Aust Greenhouse office

Technical issues experienced during consultations

IT issues

• Less with time
• Practice
• It is getting easier
• Passwords are a problem
• Onsite is simplest to

schedule

• Simplicity is crucial

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Figure 1: Rated quality of a multipoint videoconference at varying bandwidths (score of 3 or more represents an adequate consultation) Figure 2: Rated quality

• f a multipoint

videoconference at varying latencies

Is Telehealth effective

• We know:

– It’s cheaper – Patients like it – Clinicians like it – It’s good for the environment – But do patient’s get good clinical care?

Number of Patients Sustained Virological Response (%) Failed treatment (%) Lost to follow up/ceased/did not start (%) All 58 51 (88%) 1 (2%) 4 (7%)/1 (2%)/1 (2%) Male 44 39 (89%) 4 (9%)/1(2%)/0 Female 14 12 (86%) 1 (7%) 0/0/1(7%) Genotype 1 36 35 (97%) 1(3%)/0/0 Genotype 2 1 1 (100%) Genotype 3 20 15 (75%) 1 (5%) 3(15%)/0/1 (5%) Genotype 6 1 0 (0%) 0/1(100%)/0 HIV Co-infection 2 2 (100%) Cirrhosis 11 11 (100%) Previous failed Treatment 13 11 (85%) 2 (15%)/0/0 Started treatment at onsite visit 34 30 (88%) 1 (3%) 2 (6%)/1 (3%) /0 Started treatment via telehealth 24 21 (88%) 2 (8%)/0/1 (4%)

Hep C treated via telehealth In combination with onsite visits

Schulz J Telemed 2018

• Randomised trial
• Chinese immigrants with

depression

• Used Bilingual Specialists
• Model of collaborative care

Yeung et al J Clin Psych 2016

Opportunities

• Mental Health

– Large issue for refugee arrivals – Needs ongoing care

• Need to increase use
• Ontario

– Immigrants 11% use – Local population 22% use – Lack of local language interpreters a barrier

(Batista 2013 poster)

Improving access to interpreters

• 28% of Australians were not born in Australia

– Many do not speak English

• 200000 immigrants to Australia each year

– Most from Non- English speaking countries

• 15000 refugees annually

– Most do not speak English

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Need for professional interpreters?

• Quality of care

– Reduced length of stay – Reduced readmissions – Reduced clinical errors – Improve clinical outcomes – Increase patient comprehension – Increased patient satisfaction

• Legal considerations

– American Civil Rights act – Multiple guidelines – Legal payout’s

It’s harder but its worth the effort!! Improving Interpreter Access

1 2 3 (New) 4 (New) Specialist Interpreter Patient Phone link Video-conference link

• Survey’s of patients and doctors

– patient survey conducted by interpreter’s after consult

• 50 patients

– 43 video consults – 7 multipoint video consults

• Median patient age 31
• 51% female

Interpreter via video survey

• Median 11 months in Australia
• Only 60% of interpreters in first language

Ethnicity

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Patient comparisons

19% concerned the doctor may have missed something

Doctor’s comparisons

Conclusion

• Including an interpreter via video is well accepted and preferred

to phone interpreting

• Having the interpreter onsite remains the ideal for both patients

and doctors

• Great potential for improving access, especially rural areas
• Slightly more complicated to organise

The future

• Interpreter’s who are mobile

joining by videoconference

– Tablet? – Confidentiality? – International? – Phone apps to translate?

• A real opportunity to

improve health care for immigrants

Tuckson NEJM 2017

Thankyou