How can we better serve patients with chronic conditions? Primary care used to require traveling to a family doctor’s office. The Covid pandemic required us to think differently about primary care delivery.

This project rolled out in the summer of 2020, in the throes of the Covid-19 pandemic. At that time, there was enough experience of the pandemic to know that limiting in-person interactions was the key to reducing the spread. The world was working to find ways to deliver services remotely.

 In this project, patients with chronic conditions were provided with free monitoring kits for 90 days. The kits included blood pressure cuffs, pulse oximeters, thermometers, scales, and tablets. 

Patients input their information into tablets loaded with a platform enabling the reporting of results to primary care nurses. Primary care nurses then checked the platform regularly for alerts for clinically significant results. They called the patients directly or consulted with family physicians when appropriate. Many concerns could be addressed by nurses over the phone, while others required the patient to attend either a virtual or in-person visit with their family physician.

Understand

Our evaluation plan involved meeting the needs of several stakeholders, including:

• The Central Zone PCNs operating the program

• Project funders, including Health Cities, Alberta Innovates, and Boehringer-Ingelheim

• System funders, like the provincial government

Our evaluation questions focused on:

1. Project reach (using document review and administrative data)

2. Provider experience (using surveys at different time points)

3. Patient experience (using surveys at discharge)

4. Patient health outcomes (using the EQ-5D-5L at intake and discharge, patient surveys at discharge, and clinical data)

We designed the evaluation plan to minimize the workload on busy providers and take advantage of information already documented for clinical care.

Uncover

All data was collected online to ensure safety and convenience.

We produced interim and final written reports, including a report focused only on seniors for the relevant provincial government ministry.

The evaluation findings have been already been helpful to the project partners. “It helped validate the expansion of the initiative,” according to Health Cities CEO Reg Joseph. “One of our key goals is to scale the initiatives that make sense to scale, in that they drive health adoption of innovation, improve health outcomes and drive economic growth in the health sector. To do this often requires policy change that itself requires evaluation and data.” 

The interim findings were helpful for PCNs and physicians considering joining the second phase of the project. The report was “used as a communication tool,” said Central Zone PCN Committee Operations Lead Jodi Thesenvitz. “It was a source of evidence for those considering participation in the next wave. It legitimized and explained the effort.” 

You can find a journal article we co-authored here.

Utilize