HTF 402 National First Nations Telehealth Research Project

Case Study: Fort Chipewyan, Alberta

Community description

Fort Chipewyan, located on the western shore of Lake Athabasca in northern Alberta, is a community of about 2000 people belonging to the Athabasca and Misikew Cree First Nations. Health services are delivered by the Nunee Health Authority (NHA).

Fort Chipewyan's telehealth project

The needs assessment, completed in winter 1999, followed on prior identification by the NHA of rehabilitation services as a priority for the community, on existing mobilization of the nursing station in support of using telehealth in this area, and on a prior technologically unsuccessful telehealth initiative. The telehealth project adopted by Fort Chipewyan enabled the provision in the community of physiotherapy, occupational therapy and speech and language therapy by trained rehabilitation assistants under the supervision of rehabilitation specialists located at the Northern Lights Health Centre in Fort McMurray. One of the two rehabilitation assistants is also the telehealth coordinator. After undergoing an assessment in Fort McMurray, patients receive rehabilitation services in Fort Chip on an ongoing basis according to an established treatment plan. Every fifth session is observed through the telehealth system by the remote practitioners. The rehabilitation assistants assure that patients are able to attend the appointments, usually by driving them to and from their sessions. The community also selected televisitation as an application, through which family and friends in can visit with hospitalized patients in Fort Chip. The final application selected was continuing professional education.

In the Fort Chip project, staff were trained and the system was deployed in early spring 2000, with the first encounter forms received in March 2000. Speech and language therapy was implemented first, with physical therapy beginning in June 2000 and occupational therapy following in July 2000.

Case study results

Utilization levels

Number and length of telehealth sessions

In Fort Chipewyan, telehealth has enabled the delivery of rehabilitation services in the community which, although they use the telehealth equipment only one-fifth of the time, would not have been possible without the presence of the telehealth link. In the data provided below, all rehabilitation sessions, whether or not observed through the telehealth link, are counted as telehealth sessions.

During the evaluation period, from March 2000 to the end of February 2001, a total of 755 telehealth sessions were held: 696 rehabilitation and 57 televisitation and 2 telelearning. Among the rehabilitation sessions, 367 were speech therapy, 237 were physical therapy and 92 were occupational therapy. Ninety of these 604 sessions involved use of the telehealth link. A total of 59 unique patients were seen, of which 46 (78%) had repeat visits.

The average number of visits per month was 61.7 (28.9 in speech therapy, 19.5 in physical therapy, 6.5 in occupational therapy and 5.0 in televisitation), with a high of 121 in November 2000. Sessions lasted, on average, 42 minutes (54 minutes for physical therapy, and 30 and 32 minutes for speech and occupational therapy, respectively.) Over all types of rehabilitation sessions, 89% started on time, and 8% had scheduling problems. For 142 scheduled sessions, patients did not keep their appointments.

Types of care enabled by telehealth

The table below shows the types of rehabilitation interventions conducted, according to the community encounter data for each type of therapy.

The table below shows the types of follow-up indicated after each telehealth-supervised rehabilitation session, according to the remote encounter forms data. Note that all three recommended transfers were in the area of physical therapy.

Data were also provided on the remote encounter forms about what would have happened for each session had telehealth not been available. These data are shown in the table below. Of the 15 patients for whom transfer had been avoided through the use of telehealth, none were among the 31 in speech therapy. Transfer was avoided for six of seven patients in physical therapy and all patients in occupational therapy.

Televisitation sessions

The average number of family members and friends using televisitation per month, including those in the remote and community locations, was 17.5.

Technical performance

The number and proportions of rehabilitation sessions with each type of technical problem, according to the remote site data, are shown in the table below.

According to key informants, any technical problems have generally been quickly resolved with help from the vendor's technical assistance desk. For both sites, progress would have been impossible without this support, as in-house technical staff would not have been able to provide it. The visual quality problems seem to be related to lighting control in the telehealth rooms, where windows have to be covered to lessen glare. The sound problems are sometimes related to inability to connect at the highest speed, which affects the capacity to achieve the quality of sound required for speech therapy.

Acceptability of telehealth to patients and communities

The key informant interviews found that telehealth in Fort Chipewyan is widely accepted in the community. It has been highly publicized, and according to key informants, community members are both generally aware of it and proud of its success in improving access to health services. The Board members, band management and elders interviewed are highly supportive of the initiative, and are very satisfied with its level of success in Fort Chip. Nursing station staff are committed to making it part of the regular services offered in the community, as well as to expansion to other areas. The project has also been recognized as a success story among telehealth initiatives, and the team has been asked to make presentations or attend meetings with several different groups interested in similar issues across the country.

Telerehabilitation

Fifteen patients who had received either occupational therapy or physical therapy completed patient satisfaction questionnaires, for which the data are summarized below in terms of numbers of dissatisfied patients. (Satisfaction questionnaires were not given to speech therapy clients because of time constraints: most of these clients are children who are taken out of school for their sessions.)

The rehabilitation staff in both the community and remote settings reported that telehealth is very well received by patients. Because the initial assessment occurs in Fort McMurray with the follow-up treatment in Fort Chip, patients are comfortable with the rehabilitation supervision when it occurs. Physical therapy staff reported that some patients are a little shy at the first session, especially about disrobing in front of the camera, but this shyness is overcome. According to key informants, three patients who had initially refused telerehabilitation later came to use the services. One patient's family refused, citing concerns about confidentiality issues.

The patients interviewed were very enthusiastic about the rehabilitation services they had received. It was clear that for them, the access to these services which telehealth had allowed was more salient to them than the technology itself: they were strongly appreciative of the quality of care they were receiving and of the supportive relationship with the rehabilitation assistants.

Televisitation

Forty-seven televisitation users completed satisfaction questionnaires. The number of dissatisfied users for each of the dimensions assessed is shown in the table below.

Televisitation users are also very happy with the service, according to both the remote and community televisitation coordinators. Initially, users have a tendency to think they are on live television and to speak as though being interviewed, but this is overcome with familiarity. In several cases, televisitation had allowed relatives to meet for one last time before a patient passed away. The patients interviewed who had used telehealth had found comfort and relief in seeing their hospitalized relative. Demand for televisitation sessions is lower in the winter, when road access to Fort McMurray is possible. According to community representatives, televisitation is an important service because it supports the community value of keeping family ties strong.

Quality of care delivered through telehealth

According to the remote rehabilitation staff, the quality of the telehealth-enabled rehabilitation care is excellent. Staff at both ends are comfortable in their roles, and are confident that the treatment plans are appropriate and well-delivered. In the case of uncertainty about a particular aspect of a patient's treatment, the rehabilitation assistants ask for guidance from the remote staff, which they are usually able to give within a relatively short response time. There is mutual trust and respect on both sides: rehabilitation assistants appreciate knowing that their interventions are supported, and the remote staff are confident that therapy is proceeding according to appropriate standards. Remote staff mentioned this as a critical success factor in the telehealth program, as they are responsible for patients under their care through telehealth.

According to the remote rehabilitation staff, the telehealth project has also resulted in more targeted and judicious use of their resources. Because of the involvement of the rehabilitation assistants in the decisions to transfer patients back to the remote centre, more informed decisions are made and patients are more likely to come back when they really need to and not just on a arbitrary date. Although the process is now more complicated to manage, this ensures that the best possible use of made of the patients' and providers' time.

Impacts on patient outcomes

According to the key informant interviews, telehealth in Fort Chipewyan has brought significant health benefits to patients. First, for speech therapy clients, telehealth has meant that they can receive regular therapy sessions twice per week, instead of once every several months. Their progress has advanced accordingly, with significant gains for many in their language. This progress is evident to all that the patients come in contact with. As many of these patients are young children, the preventive impact on their school performance and social integration may be enormous. The therapy may also have impacts on self-perception and self-esteem, risk factors for a host of social, psychological and behavioural problems: for example, the rehabilitation assistants reported a case of a 13 year- old girl who reported that because of the therapy, she was no longer being laughed at in school; her self-esteem and school performance had improved as a result.

In terms of physical and occupational therapy, impacts may be found on two levels. First, transfers out of the community tend to be hard on these patients. The discomforts of the travel sometimes worsen their condition and erase the benefits of the health visits. To the extent that receiving rehabilitation inside the community avoids those transfers, their heath outcomes are improved. This is especially marked for short sessions such as the fitting of orthotics. Second, the rehabilitation itself has positive effects on outcomes (or outcomes as positive as they would be if the patients were receiving care directly: for many of the chronic cases, benefits of rehabilitation are slow to accrue and difficult to assess, according to the rehabilitation specialists). According to the patients interviewed, the rehabilitation services received have benefited their health. One of the patients interviewed, a woman in her 70's, had recovered enough mobility through the rehabilitation program to be able to leave her house; she was looking forward to being able to walk to see her 92 year-old mother in the spring. This woman stated that without the program, she would have had to be going out to the McMurray hospital all the time, which she did not like to do. Another patient interviewed had seen significant relief from her condition, and said that before the rehabilitation program came, she had been doing no exercise at all.

Impacts on access to health within the community

According to all key informants interviewed, telehealth has unequivocally improved access to health within the community. The provision of rehabilitation services through the telehealth link has enabled patients who were receiving some services before to receive them more often, more regularly and with more professional support. It has also enabled some patients who were not receiving rehabilitation services before to access them: there have been no occupational therapy services in the community for 14 years.

Telehealth has also had important indirect benefits in terms of health access in the community. The very active role of the rehabilitation assistants in promoting not just telehealth but patient health has mobilized the community around the telehealth project. Moreover, support from band and nursing station management has mobilized community support. Effects related to this mobilization were noted at several levels, by several different key informants both within and outside the community. Most directly, the rehabilitation assistants have extended their roles within the community, offering for example a weekly exercise program for elders at the elders' lodge, and more generally becoming advocates and supports for patients who can be helped through their actions (for example, in securing donation of a computer for a handicapped man). At the level of the nursing station and community management, the success of the project has led to a strong sense of accomplishment and ownership of the project, which had helped develop capacity for undertaking health initiatives.

Organizational, administrative and human resource issues

A key factor in the success of this project has been the commitment and dedication of the staff involved, as well as their stability within the community. All those interviewed gave high praise to the individuals involved, stating that the project would not have achieved so much if not for their work.

During the negotiation phases of the project, some frustrations were experienced due to the perceived lack of timely responsiveness of the project officer appointed by Health Canada. This led, according to key informants interviewed, to delays and complications in the signing of the Memorandum of Understanding and the project start-up. Withdrawal of this officer was seen as a satisfactory result by all parties. As for the MOU itself, there were mixed views on its ultimate usefulness: the community management had not found it particularly useful, whereas the remote centre had referred to it a number of times to verify orientations and set policy direction.

During the initial phases of the project, the vendor was very actively involved in developing and documenting procedures to facilitate workflow and information transfer and storage. According to the remote and community interviewees, their role was invaluable in designing the procedural part of the telehealth system. With this assistance, it was felt that many operational problems were foreseen and avoided; it was also acknowledged that remote centre staff would not have had the time to fully develop these procedures without the vendor's support. According to the remote centre management, this support was especially important concerning the definition of professional roles and tasks within the system and the specification of procedures for dealing with patient information. A wish was expressed that resources be available to keep updating the service design manual produced by the vendor, in order to ensure that ongoing decisions and new policies, for example around appointment cancellations, were recorded. The model developed for the telehealth project may serve in other initiatives as well.

Since the project has been fully implemented, the main organizational issue that has arisen in the project is a direct result of the improved access to health it has generated: so much demand for services had been created that, given the capacity of the remote centre to perform assessments and initiate the therapy programs, waiting lists of up to several months are now a reality. This is particularly acute in physiotherapy, where the remote centre has experienced a staff shortage. Patients on the waiting list in the community are dissatisfied with this situation, as are both the community and remote staff. The waiting lists are a concern for quality of care, because of the overall benefit of intervening as early as possible in rehabilitation situations.

To ensure that services are being directed most appropriately, the remote and community rehabilitation and nursing staff have worked together to prioritize patients in the waiting list, so that when an opening occurs, it can be given to patients who can benefit most. However, this creates even longer waits for other patients. Some of these, according to the remote staff, have sought services in private clinics instead.

The remote providers of rehabilitation services in this initiative, although generally satisfied with their participation, noted that it has created a strong pressure to provide services to patients in Fort Chip, in part to contribute to a successful demonstration of the potential for telehealth and in part to develop their relationship with this First Nation community. Faced with staff turnover and shortages in their own institution, the Fort Chip project has significantly affected their workload. Moreover, because of general resource shortages, they feel that this pressure has negatively affected their ability to respond to the clienteles outside of Fort Chip who are also part of their mandate. In this context, missed or cancelled appointments have caused frustrations for the remote providers, as they are usually unable to replace the Fort Chip patients with patients from their waiting list because the notice provided has been too short. This reduces their overall productivity at a time when demands for increased productivity are high. In addition, the cost-sharing arrangement for the provision of services has not, in the view of the remote hospital administrators, been able to offset the considerable indirect costs associated with the telehealth services, including training and administration. It was estimated that the true costs are approximately double the current allocation. However, the community administrators estimate that from their end, the project has come very close to its budget.

Scheduling the sessions has created additional secretarial workload in the remote centre, related not only to the patients and providers but also the scheduling of the different rooms in which the equipment may be used.

Both the remote and community providers feel that more resources would benefit response to community need for rehabilitation services. According to community staff and management, more resources for speech therapy would free up time to develop occupational and physical therapy. In addition, the physical arrangements of the current rooms are not completely adequate, as some forms of therapy require large pieces of equipment in the room. As well, the original budget did not foresee the cost of renewing supplies associated with therapy, nor for the costs of meetings and presentations which have turned out to be quite numerous. The amount allocated to the rehabilitation assistants for patient transport is also felt by them to be inadequate. In the remote centre, more resources are needed to overcome the backlog of cases requiring assessments.

Linkages within provincial health systems

Links to the regional health organization

As a results of this project, stronger links, based on the development of rapport and trust, have grown between the regional nursing station and the Fort Chip community. Both parties feel that this new relationship is mutually beneficial. However, the current bottleneck and waiting list situation is difficult for both parties to deal with.

Links to the provincial telehealth program

In Alberta, a major provincial telehealth initiative called Alberta Wellnet supports the development of telehealth throughout the province, including making funds available to each regional health authority to initiate telehealth services. Although each health authority is autonomous in its choice of telehealth applications, interoperability is ensured by the provision of guidelines from the provincial coordinating body. The vendor selected for the Fort Chip project is among those most strongly recommended by Wellnet, and the Fort Chip site is fully included as a member of the provincial telehealth network.

Although prior to the Fort Chip project, the Northern Lights Health Authority had not yet become involved in the provincial initiative, it is currently on the brink of doing so - a possible result, according to provincial officials interviewed, of the stimulation provided by the Fort Chip project.

Alberta Wellnet also coordinates access to a program of continuing professional education, in which rehabilitation and other nursing station staff have recently begun to participate. This program is seen as offering many potential benefits in terms of professional and personal development and, according to nursing station managers, may facilitate retention of workers in the community. The remote center staff also expressed interest in participating in these programs.

Cost effectiveness

The issue of cost-effectiveness is difficult to address in the Fort Chip telehealth project, because its main impact has been to generate significant levels of care and demand for care, which in turn of course increase costs to the overall system despite the reduction in costs of patient transfers. From the community's perspective, the benefits of telerehabilitation resemble those of in primary prevention: they will be seen in long-term outcomes such as improved school achievement, leading to improved productive capacity and fewer health and social problems for children in speech therapy, as well as longer-term autonomy maintenance and improved quality of life for the elderly. Because the greatest benefits of telehealth in the community seem to be occurring among these populations, immediate impact on standard economic benefits such as days lost from work due to disability are less relevant. However, this situation may change as the number of patients in physical and occupational therapy increases, relative to the number in speech therapy. In general, health system managers interviewed about the Fort Chip initiative felt that a long-term time horizon, from a health rather than a financial perspective, would be needed to adequately capture cost-effectiveness.

Sustainability

The telehealth initiative in Fort Chip is very likely to be sustained: it has significant support from within the community, from the nursing station management, from the band administration, as well as from the relevant provincial and federal agency representatives. Many new uses for the equipment have become apparent, and there is great interest in developing further applications to respond to the community's health needs. Those mentioned included telecounselling and telepsychiatry, especially for children, remedial education, vision screening in diabetes, genetic counselling, teledermatology, teleradiology, and teleconsultations in general care. According to those interviewed, plans are being developed to seek funding for continued rehabilitation services, as well expansion into the provincial diabetes program and perhaps other areas. Sustainability within the community's health services will also be ensured by developing staff capacities for telehealth, so that all are able to use the systems and there are backup resources available.