Authors (including presenting author) :
Carrie Tang (1), Cheung TY (1), Lam CM (1)
Affiliation :
(1) Occupational Therapy Department, Tuen Mun Hospital
Keyword 1: :
Occupational Therapy
Keyword 3: :
Self management
Keyword 4: :
Telemonitoring
Keyword 5: :
Respiratory Conditions
Keyword 6: :
Home oxygen therapy
Introduction :
Patients diagnosed with various chronic respiratory diseases, including Chronic Obstructive Pulmonary Disease (COPD), often experience debilitating exacerbations and increased healthcare burden. The increasing trend of managing these conditions at home aims to reduce healthcare costs while enhancing patient comfort (Bolton et al., 2011). Telehealth offers a viable solution for home management through continuous assessment and timely interventions, empowering patients in their disease management. The Integrated Care Model - Case Management (ICM-CM) program at Tuen Mun Hospital provides essential transitional and integrated support services for high-risk patients aged 60 and above upon discharge.
Objectives :
The primary objective of this pilot program is to evaluate the effectiveness of home telemonitoring combined with multidisciplinary support in empowering patients with chronic respiratory diseases, improving their self-management skills, facilitating their reintegration into daily routines, and reducing unplanned hospital admissions.
Methodology :
Patients with respiratory conditions, whether using home oxygen therapy (HOT) or not, were included in the program, provided that they could use a telemonitoring device independently or with caregiver assistance. The intervention involved home telemonitoring paired with in-home visits from a multidisciplinary team focused on rehabilitation. An occupational therapist guided the participants through a self-management program, which included education on dyspnea management, a self-monitoring approach, and goal-setting for daily activities. Telemonitoring utilized a Bluetooth device to track SpO2, heart rate, and respiratory rate, with data uploaded to a cloud platform over four days. Alerts were triggered for abnormal values, enabling timely communication between the occupational therapist and patients. This telemonitoring approach allowed extended observation periods as patients weaned down supplemental oxygen and captured comprehensive data from their daily routines. The data was monitored daily, and the occupational therapist initiated phone calls to assist patients in developing their self-monitoring skills.
Result & Outcome :
From December 2023 to June 2025, 11 patients participated, with an average monitoring duration of 2.72 days. Among these, 10 patients used HOT, with 30% weaning or reducing their dosage. Notably, 50% initially demonstrated poor compliance with HOT, among which 80% improved following telemonitoring. Statistically significant improvements were noted in patients' functional abilities. The average Modified Barthel Index score increased from 79.8 to 94.9 (p=0.005), and the average Lawton IADL score rose from 6.5 to 11.1 (p=0.007), indicating enhanced daily functioning. More importantly, there was a statistically significant reduction in rehospitalization of patients within six months after the program (p=0.01). Additionally, 100% of patients expressed satisfaction with the telemonitoring program. The pilot program demonstrated a promising partnership between patients and occupational therapists for improving health outcomes in respiratory conditions via telehealth. While on-site visits and support remain essential in the early stages following patients' discharge, telehealth contributed to provide extended and timely assistance in the self-management process. Furthermore, improved compliance with home oxygen therapy resulted in a notable reduction in rehospitalization. This approach is designed not to replace professional healthcare but to enhance the quality of care and support available to patients.
