The project team implemented an innovative, secure, low cost, and high impact program using readily available digital technology, to transform the current tuberculosis service to a patient-centred delivery model.
Aim
Identify and trial a patient-centred, cost-effective remote service delivery model for tuberculosis patients. Implementation was planned for early 2017 but dependant on case notification.
Benefits
- Promotes privacy and confidentiality for the patient
- Protects patient from many of the social impacts of the disease, such as fear of losing job and cultural stigma
- Lessens associated travel time and costs to the patient and provider
- Reduced risk of disease transmission during the infectious period of the case
- Clients can negotiate appointment times for wherever they are in the world and at a time that suits them and their case manager
Background
Previously, nurses administered directly observed treatment supervision (DOTS) but it was complex, time consuming and resource intensive. Time constraints meant that attending a weekly clinical review was often difficult for clients and staff.
The telehealth service in rural and remote NSW was identified as an opportunity to provide tuberculosis (TB) service clients, who are often marginalised groups, including refugees, transient groups and Aboriginal people, with remote access to the services that they need. Anecdotal evidence showed that most TB patients already use a version of telehealth in everyday life and had the equipment and skills needed to participate in video directly observed treatment supervision (V-DOTS) service delivery.
Implementation
A virtual clinic was created where patients can negotiate appointment times for staff to watch them take their tablets and check for treatment side effects each day. If the patient or nurse requires support, a clinical nurse consultant or the treating physician can enter the virtual clinic in real-time to assist. Maintaining visual and audio contact helps to sustain relationships, enhances patient treatment compliance, and promotes rapid recognition of treatment side-effects.
The V-DOTS system also has capacity to invite others to the consultation. Should staff encounter difficulties such as the patient experiencing medication side-effects, they can invite other clinicians to the call and issues can be resolved in real-time. This rapid response can result in reduced serious treatment side effects. Community nurses who wish to participate in the program receive training and are registered with the program before delivering the service.
When a patient receives a TB diagnosis they are invited to participate in V-DOTS and their technology literacy is assessed. Consents are completed, education provided, and equipment is set-up. Appointments can be arranged for a time that is convenient for the patient. All staff involved in the patient’s care can use V-DOTS to deliver their service.
Murrumbidgee and Southern NSW Local Health Districts (LHDs) Tuberculosis Service is the first in NSW to design and implement V-DOTS . This is currently the only NSW telehealth daily virtual clinic, which has been successfully been implemented for more than six months.
Status
Sustained – The project has now been implemented and is sustained business. It is routine practise in Murrumbidgee and Southern NSW Local Health Districts, other NSW LHDs have also implemented this service delivery model, and the NSW Health TB Program are moving towards incorporating DOTS using telehealth as a formalised service delivery pathway.
Dates
The V-DOTS project started in July 2014. Planning continued for two years until a suitable telehealth platform became available and the implementation trial commenced in April 2017. V-DOTS is now accepted as a service delivery alternative and has been ongoing since January 2018.
Implementation sites
- Murrumbidgee Local Health District
- Southern Local Health District
Partnerships
HealthDIRECT and Southern NSW LHD (Note public health is a hosted service covering both Murrumbidgee and Southern NSW LHDs ).
Results
The simplicity of the program and its use of readily available, LHD-supported digital technologies and frameworks help to support its sustainability. Working in a virtual clinic provides greater transparency and higher levels of accountability for staff (best practice) and patients (compliance).
V-DOTS is easy to replicate and already, a further eleven LHDs are planning to implement the services in their clinics. All required information technology devices (laptops/tablets) and programs (Google Chrome) are readily available within LHDs across NSW. Following the implementation of the electronic medical record across NSW, LHD staff have developed good information technology literacy skills and working in the virtual clinic space has become common practice.
All participating patients are asked to complete a Telehealth Satisfaction Survey. Overall elevation to date indicates that the client found the service convenient and saved time, travel and money; clients strongly agreed it was as good as face-to-face and privacy was maintained. Staff were reported as helpful, set up was easy and they would be happy to use this service delivery methodology again.
Case study
On routine DOTS , Client A would have to leave his workplace and travel to a community health centre to take medication, or have a community nurse attend his workplace to watch medication. With V-DOTS , Client A can go to his car, prop the phone on the car dash, enter the virtual clinic and take his medication. Within ten minutes Client A can return to work with colleagues unaware that he left the office. This client’s attitude has completely changed, compliance is simple; he has even taken a holiday whilst still undertaking V-DOTS . He has his life and privacy back.
Awards
V-DOTS was a finalist in the Patients as Partners category of the 2017 NSW Health Awards.
Lessons learnt
- Issues about privacy, confidentiality and firewall access were initially major stumbling blocks to this project.
- Other sites have trialled self-recorded DOTS but report that it doesn’t save time because you still have to return later to review the recording.
- Engaging local Information Service Telehealth team and clinical staff early on is critical to trialling and embedding change into the health service.
- Never doubt a client’s capacity to adapt to service delivery pathways and don’t be surprised when health professionals are your greatest barrier.
Further reading
- World Health Organization. Tuberculosis (TB): Pursue high-quality DOTS expansion and enhancement
- NSW Ministry of Health. Tuberculosis control guideline
- ACI. Telehealth resources
- Commonwealth of Australia, Department of the Prime Minister and Cabinet. Closing the Gap: Prime Minister's Report 2018
- NSW Ministry of Health. Refugee Health Plan 2011-2016
Contact
Catherine McKenna
Tuberculosis CNC3/District Coordinator
TB Services Public Health Unit
Phone: 02 48241858
MLHD-TBProgram@health.nsw.gov.au
