A Mixed Methods Evaluation of the Community Remote Care Management Program: An Integrated and Person-Centred Hybrid Model of Chronic Disease Management

Abstract

Introduction: The Burlington Ontario Health Team is a collaboration of health and social service providers who plan and work together, as one coordinated team, to provide integrated services and supports to meet the health needs of Burlington and surrounding communities (Ontario, Canada). Together, interested groups from primary care, community paramedicine, home and community services, acute care, and patient partners designed and launched the Community Remote Care Management (RCM) program in November 2020. Patient partners played key roles in contributing toward program vision, program design, and survey/materials development. The RCM program connects individuals managing chronic disease or isolating at home with mild COVID-19 symptoms with an interdisciplinary team using remote monitoring technology. Patients and caregivers may bring their own devices or borrow a tablet/biometric devices to measure their vitals and communicate with the clinical team regarding managing their chronic conditions and connecting them to available resources. Objectives: We will employ a mixed methods approach to evaluate the degree to which the RCM program has changed patient and caregiver experiences, selfmanagement and system navigation outcomes, and provider experience. We will use program data to examine program enrollment, assessment, care planning, escalation workflows, and community connections. We will summarise results from patient and provider experience surveys and conduct interviews with program participants. Additionally, operational documents such as minutes and notes will be reviewed and summarised to evaluate the internal processes of the program. Results: An earlier review of assessment data revealed that patients with chronic disease were screened to have significant needs in depressed mood/loneliness, recent high acute care use, and additional comorbidities. Patients were most often connected with a pharmacist, respiratory therapist, or system navigator. We anticipate that patients and caregivers will gain insight about their health condition and signs and symptoms, report more timely access to advice and support, and ultimately, be more confident in their ability to self-manage beyond the program. We also anticipate that the ability to share information on the same platform will improve providers' ability to work with patients, caregivers, and other providers. Conclusion: We anticipate that the RCM program will demonstrate positive changes to the quintuple aim and achieved through a strong community focus, integrating health and social services, and simplifying communication between patients, caregivers, and providers. Implications: The RCM program is a key initiative of the Burlington Ontario Health Team to bring together holistic needs assessment, care planning, and system navigation for patients, caregivers, and care providers. If shown to be successful, the goal is to expand this model to other populations such as those with social or physical frailty. [ABSTRACT FROM AUTHOR]