Remote in-home monitoring service in Western NSW Local Health District

December 2022 edition

The WNSWLHD RiHM service uses remote monitoring technology to provide virtual support to patients with acute, chronic and sub-acute conditions including heart disease, diabetes, COVID-19 and long COVID-19.

The service aligns with Integrated Care and Collaborative Commissioning initiatives like Planned Care for Better Health, ED to Community and Care Partnership-Diabetes to identify people with chronic and complex health and social conditions who are most at risk of hospitalisation.

The service is available seven days a week from 8:30am-5:00pm.

Care is tailored and flexible to the patients’ needs and capacity. Patients are supported to correctly measure and report their health measurements (including blood pressure, pulse oximetry, weight, blood glucose or temperature) and symptoms at home. They are also given equipment and support to understand what these measurements mean and how to manage them.

Measurements and symptoms are completed daily by the patient and results are triaged and assessed by RiHM nurses using a central patient dashboard. Patients can also contact the RiHM nurse directly when they have questions or are feeling unwell.

RiHM nurses collaborate with the patient, carers and their local health professionals, including their General Practitioner (GP). Early deterioration is escalated via locally agreed pathways. Case reviews and reports are provided weekly to the multi-disciplinary teams.

Evaluations have demonstrated that RiHM helps patients to learn important skills in self-management and improves their communication with their GP.

“By doing this I could go home [from hospital] a bit quicker. It was better setting me up whilst I was still on the ward, it was really good to know I was capable of using the equipment – I felt safer and more comfortable. Only three days was enough to give me confidence. I’m very independent but when you are in hospital, you become so reliant on medical and nursing staff, you worry whether you are going to cope alone when you go home.”

Remote monitoring patient

Between July 2020 and June 2022 almost 4,000 people were enrolled in the WNSWLHD RiHM service. This included 3,850 people with COVID-19 and 150 people with a chronic disease. The RiHM service collaborated with the COVID Care in the Community (CCiC) Service to monitor high to very high-risk patients. The RiHM Nurses utilised a Philips mobile phone app to enter self-completed vital signs and symptom surveys which helped to increase CCiC workforce efficiencies and improve patient experience. Nurse to patient ratio was increased threefold and patients had less phone call interruptions at home.

The average length of stay in the RiHM service was seven days for COVID-19 patients. The average length of stay for people with chronic disease/s was 12 weeks.

According to the Social Economic Index for Areas (SEIFA), 95% of people who were enrolled in RiHM were from disadvantaged communities, and 30% (a third of people enrolled) were from significantly disadvantaged communities.

Improving experiences of receiving and providing care

Of those enrolled in the service:

• 74% reported a reduced burden and stress.
• 94% reported that their RiHM nurse was extremely or very useful.
• 96% reported that the technology was easy to use and 100% would use it again.
• 85% reported improved communication with their General Practitioner (GP).

“When mum was discharged into my care it was very daunting, all the responsibility fell on me. Just to have the virtual nurse there when we came home, you’ve always got questions after you get home…and it was as simple as a text or ring and she followed up immediately and just having that person where I didn’t have to take mum to the hospital or ring hospital and try to find someone or try to get in mum’s GP – to have that one person that I could just ring or text when it suited me on any day, to get an answer or advice… I thought it was really great. If I was unsure about something, to have her there to double check, to video-conference to check something, to ask, to reassure… it was just great”

Carer

The RiHM service complements local face-to-face care. It supports patients to stay well and out of hospital, supports carers and reduces the burden of care. It also supports continuity of care and provides flexible, responsive health support to people who may have difficulty accessing primary care. RiHM provides additional, timely information to assist healthcare professionals assess and plan care with the patient and multi-disciplinary team.

More information

For more information about the WNSWLHD RiHM service, contact Fiona Martin, RiHM Nurse Unit Manager, WNSWLHD: fiona.martin2@health.nsw.gov.au