HTF 402 National First Nations Telehealth Research Project

Case Study: Berens River, Manitoba

Community description

Berens River is an Ojibway community of about 1800 members on the northeastern shore of Lake Winnipeg, at the mouth of the Berens River. It assumed governance of its health system in April 1999.

Berens River telehealth project

The needs assessment in Berens River was conducted in winter 1999 by the project officer; it was also informed by an existing survey of health conditions in the community and services utilization data. Following the needs assessment, the Berens River community selected real-time video-conferencing applications to address diabetes care and patient education, specialist consults with infectious disease and psychiatric physicians, as well as continuing professional education. Prior to the project, the community's telecommunications access was limited to regular telephone service. For the project, a satellite communication link was established with the Winnipeg Health Sciences Center. Staff were trained and the system was deployed in spring 2000, with the first encounter forms received in July 2000. During the implementation period, the community was in the process of opening a new Health Center, resulting in the movement of the satellite uplink and telehealth station in the fall of 2000.

Case study results

Utilization levels

Number and length of telehealth sessions

During the evaluation period, from July 2000 to mid-March 2001, a total of 40 telehealth sessions were held: 8 for patient care (infectious disease specialist and psychiatry consults), 10 for diabetic care and education, 5 for diabetic education only and 17 for continuing professional education. A total of 17 unique patients were seen: 6 in patient care, 7 in diabetes care and education and 4 in diabetes education. Thirty-five percent of patients (6) had repeat visits using telehealth.

The average number of visits per month was 4.5 with a high of 12 in November 2000. Visits lasted on average, about one hour (one hour and three minutes according to the community encounter forms, and one hour and eight minutes according to the remote encounter forms). According to the remote site, 61% of sessions started on time, and 11% of sessions had scheduling problems. This latter proportion was 5% according to the community forms.

Types of care and education provided through telehealth

The proportion of patient care visits for which each type of personnel was present in the community and remote locations are shown in the tables below.

For patient education, five individual sessions and 4 group sessions were held, with participants ranging from 2 to 9 (total 32).

For continuing education, two individual and 12 group sessions were held, with participants ranging from two to eight (total 51). The types of participants present in the continuing education sessions are shown in the tables below.

For patient education, five individual sessions and 4 group sessions were held, with participants ranging from 2 to 9 (total 32).

For continuing education, two individual and 12 group sessions were held, with participants ranging from two to eight (total 51). The types of participants present in the continuing education sessions are shown in the tables below.

The types of care provided in the patient and diabetic care and education sessions are shown in the tables below, for the community and remote locations.

According to the community encounter forms, in 11 of 18 patient care visits, follow-up was required, 7 with telehealth and 4 without. According to the remote forms, eleven of 15 visits required follow up with telehealth, 1 without telehealth, and 1 with a patient transfer.

According to the community forms for patient care visits, without telehealth, 2 patients would have received no services at all, and three patients would have been transferred. For diabetic care and education visits, seven patients would have received no services at all, three would have waited until services came to Berens River, and four patients would have been transferred. Of the total 18 patient care visits for which this information was complete, 44% of visits resulted in avoiding a transfer.

For the diabetes education sessions, the table below shows the topics covered.

Finally, for the continuing education sessions, the table below indicates the topics covered.

Technical performance

The proportion of visits with each type of technical problem, for the community and remote sites, is shown in the tables below.

Acceptability of telehealth to patients and communities

According to the key informant interviews among community respondents, telehealth is generally well-accepted in the community. No patient refused to use telehealth, although some did not keep their appointments. According to one of the specialists interviewed, patients seem to find telehealth a little strange at first but then quickly get used to it. The positive reaction is echoed in the 15 completed patient satisfaction questionnaires, for which the data are summarized below in terms of numbers of dissatisfied patients.

All patients stated they would use telehealth again, and all stated they would recommend it to others.

Within the community, it was suggested that many community members are not yet aware of the telehealth service, and that more publicity could be carried out.

Quality of care delivered through telehealth

According to nursing station staff, telehealth has improved quality of care because of quicker access to specialists, especially in terms of diagnostics. A comment was made that for psychiatry consults, the lack of physical proximity hindered empathetic responses. No other positive or negative impacts on quality of care were noted.

According to the data provided on the encounter forms for diabetes education (a proxy measure of quality of care), the issues most often addressed were diet, exercise and glucose monitoring. The topics most infrequently addressed were counselling/social support, hypertension, and alcohol consumption.

Impacts on patient outcomes

The diabetes education program has, in the eyes of both community and local diabetes workers, improved patient knowledge of nutrition issues (dietary fibre, sugar substitutes). Similarly, one key informant felt that the psychiatric services have improved patient outcomes because of decreased waiting time. However, the nursing staff stated that the main factor in determining patient outcomes was the competency of the staff involved, rather than the equipment. Moreover, remote providers felt that turnover in staff had greater (negative) impact on patient outcomes than the telehealth technology. Other key informants noted that the lack of continuity in staff has created general problems for quality of basic care (such as lack of dispensation of prenatal vitamins, although stocked) that telehealth cannot address.

Through the continuing professional education program, workers in the community are able to access information on a variety of topics. There were however mixed views about the value of this for community personnel: some felt that it was a valuable source of information for local staff which could indirectly improve patient outcomes, while others felt it was not well-adapted to their needs.

Impacts on access to health within the community

The telehealth program in Berens River has, according to the key informants interviewed, improved access to health services within the community, in particular to specialist care and to information about diabetes management. It does not seem to have produced changes in the overall approach to self-determination of health within the community: telehealth is seen as an adjunct or complement to existing services, which patients have the choice to use. One specialist interviewed echoed this view stating that face-to-face services are preferable, and that telehealth should be viewed as a complement to existing services rather than a substitute.

Organizational, administrative and human resource issues

The main organizational issue for the Berens River telehealth project has been the turnover in key nursing, medical and mental health staff. These changes coincided with the transfer of health governance to the community, and were followed by a period of little or no nursing service or by short-term personnel. Although a community health representative was designated as the telehealth coordinator early in the implementation period, the lack of stable personnel disrupted existing relationships with secondary/tertiary providers and affected uptake of telehealth.

In general, once established or re-established, for patient care and education, the linkages with remote sites have evolved positively throughout the course of the evaluation period. Although secondary and tertiary providers of all forms of service acknowledged that there have been some frustrations and difficulties, the linkages have generally gone smoothly.

Scheduling difficulties have been minimal, although tertiary providers attribute this to the pilot nature of the program and the low usage levels. Appointment cancellations are a problem for some of the tertiary providers and practitioners, although it is recognized that failure to keep appointments is also a problem in FTF services.

The key informant interviews showed that another difficult issue lies in the availability of other forms of specialist expertise for which telehealth services could be offered. Staff expressed frustration that some of their more pressing needs for access to specialists through telehealth (for example, in radiology) were not being met because of lack of participating specialists in the remote site.

The telehealth system seems to have little impact on the nursing station in terms of information flow and storage. In terms of other administrative issues, staff turnover has required additional training but no other issues or impacts were noted.

Linkages within provincial health systems

According to the key informants interviewed, there are no other significant telehealth initiatives in Manitoba, so this is a new model. It is felt, however, that the future model should work toward integrating telehealth services within the regional health authorities, as is the case for the diabetes education program, rather than work through the Health Sciences Centre. This will provide greater integration within the provincial system.

In terms of integration into the provincial health care system in general, respondents felt that some new linkages had been created, notably with the regional diabetes education program and between psychiatric services and the solvent abuse worker.

Cost effectiveness

The level of usage in Berens River is as yet too low to make any valid statements about cost-effectiveness of telehealth. Practitioners in the remote sites expect that while some travel costs may be reduced, the increased access to care may increase overall costs.

Sustainability

Nursing centre and remote staff stated that the key to sustainability and eventual health impacts in the community lies in the stabilization of the local health care system and the provision of good clinical and preventive care with or without telehealth. One key informant maintained that the same problems would be faced in achieving health impacts even if specialists were available to fly in to the community regularly; another felt that the social issues facing the community would not be solved through provision of more ineffective preventive measures. Other informants mentioned that the success of education intervention in particular depends on the ability to effect broader changes in the community as a whole; for example, in the availability of the health foods that the diabetes education program encourages patients to eat, exercise opportunities, etc.