Klara is a 86 year old woman living alone in her three-room apartment. She has a slight disability and suffers from a depressive psychosis. Klara is able to do most of the daily activities on her own and is relatively independent. She is however a bit forgetful. A social carer visits her just once a day in the morning hours. She likes to cook on her own, but twice a week she gets meals on wheels. Klara is often alone for a long time without making contact with other people.
Klara's daughter, Kathrin lives about 30 km away from her mother's flat. Because of her job, she is not able to visit her mother more than once or twice a week in the evening hours. She gets in contact with the practitioners and manages all the administrative things for her mother.
Because of a recent fall incidence Klara has decided to become a user of a social alarm device. The social alarm button is carried by the user day and night. In case of an emergency situation Klara can now press the button to raise an alarm at the social alarm service centre inkontakt. Inkontakt receives the alarm and gets in contact with the carrier via the social alarm unit installed in the flat. Is the carrier fine and answers the phone call and is not badly injured, the nursing service or the general practitioner and the relatives can be informed, to go to the patient's home and take a look. Is the carrier not answering the phone call or is badly injured the emergency is called immediately.
The social alarm is installed at Klara's home and she is asked to sign a consent form to agree to the data transfer between inkontakt, the hospital and other service providers.
Some weeks later Klara suffers from a strong pain in her breast. She is very anxious about this situation and presses the social alarm button in order to receive immediate help. Maria, a call centre operator at the social alarm call centre inkontakt, receives the call and calls the rescue coordination centre which sends out an emergency unit to Klara. In parallel, patient data available at inkontakt are transferred to the rescue coordination centre. Dr. Schmitt who is on duty in the emergency unit examines Klara and decides that she has to go to hospital for further check-ups. While Klara is on the way to the hospital, inkontakt is informed that Klara is brought to the City Hospital. Inkontakt itself informs the social care provider who is responsible for Klara about the hospital admission. The social care provider then provides relevant information about Klara to the hospital she is brought to. Beside the basic information (name, address, telephone number, relatives and general practitioner) the hospital can receive information about the disease pattern, disease-specific diagnosis and current medication.
Some days later Klara's health has significantly improved and can be discharged from hospital. Now, the hospital informs the social care provider about Klara's discharge and the social care provider can (re)arrange all the necessary services for Klara at home (e.g. meals on wheels). The social care provider also informs inkontakt about the discharge.
One year later Klara is advised by her doctor Dr. Heimlich that she should get an operation of her varices in the left leg. Klara agrees that this is a necessary surgery and makes an appointment at the hospital. A few days in advance of the surgery she informs her social carer Sandra about the upcoming hospital stay. The social care provider provides relevant information about Klara to the hospital. Beside the basic information (name, address, telephone number, relatives and general practitioner) the hospital can receive information about the disease pattern, disease-specific diagnosis and current medication. The social care provider informs inkontakt about the hospital admission. One week later Klara is about being discharged from hospital. Now, the hospital informs the social care provider about Klara's discharge and the social care provider can (re)arrange all the necessary services for Klara at home (e.g. meals on wheels). Inkontakt is also informed by the social care provider.
Damien is 72 years old and lives alone in his apartment. Damien suffers from high blood pressure and has respiratory problems recently. David is Damien's father and regularly takes care of him. The last time his father suffered an emergency situation and went to the hospital, it took him some time to find out in which hospital he was being treated as the information was not easily available.
Damien is registered with Junta de Andalusia by using the +65 card. His last visit to the general practitioner revealed that his health condition is worsening. David applies to register his father with the tele assistance service offered by FASS which includes a push-button alarm system that allows him to get in contact with the FASS telecare service immediately in case of any social need or emergency situation by just pushing a button. Additionally, the FASS personnel will keep track of his situation by regular follow up calls. The service also provides that in case of emergency situations, FASS telecare service will get in touch with the necessary emergency service in order to get a quick and effective mobilisation of resources.
FASS organises the installation of the social alarm system in Damien's home. FASS personnel explain the use of the device and gather all the relevant information from Damien, including address, contacts details, medication, illness, allergies, medication, assigned GP, habits and hobbies among others.
Some weeks later, Damien suffers an episode of arrhythmia and pushes the alarm button to get medical attention. Luckily, some beneficial changes have been made in the emergency handling procedure and the communication system between FASS and EPES now allows for a quicker response to emergency situations and for an exchange of information between all the involved parties automatically. Tina, one of the call centre operators at FASS, receives the call from Damien and immediately transfers the call to EPES. The EPES call centre operator Helen receives an electronic message with all the relevant information from Damien's file in FASS and Tina is able to put Helen in touch with Damien without having to cut the communication at any point and obtaining the relevant information about Damien automatically in her computer. Damien is assessed and doesn't get confused during the process as he didn't have to hang up the phone at any time. Both personnel from FASS and EPES provide him the attention he needs and after being evaluated by Dr Byrnes at EPES, Tina keeps in touch with Damien over the line until the emergency mobile unit with Dr Miles and Mrs. Holmes arrives to Damien's place.
Dr. Miles decides to take Damien to Trinity Hospital in the north of the city as the roads that lead to the Mater hospital are experiencing traffic delays due to road constructions nearby. The new system alerts Tina automatically about Damien's status and she advises his father David accordingly. The whole process is very smooth and quick, and the time taken to evaluate the situation, gather the information and send the necessary resources is shortened by 5 minutes. Furthermore, David has been informed about his father's situation and location and goes straight to the hospital where his father is being treated.
Rita is 69 years old and lives alone in her apartment and has no children. Rita is in rather good health, although she has chronic osteoarthritis and suffers from social isolation.
Rita finds herself very isolated and spends most of the time alone at home and misses social contact and friends, and somehow, someone to talk with.
Laura is a former neighbour of Rita and visits Rita from time to time. Recently, Laura gets more and more worried about Rita since she has been very lonely and has no attention from anybody. Rita often uses the emergency health service to get some medical attention related to her chronic osteoarthritis, although she has already been advised by her doctor to follow a programme to relieve the pain so there is no real emergency in these calls. This situation is implying the use of emergency health resources that would be better used in real emergency cases and the health professionals are starting to think that what Rita really needs is further social attention.
Some weeks later, Rita feels again lonely, without activities to do, the chronic pain is annoying her and she decides to call the emergency number once again. Dr. Byrnes from EPES recognises the user and although Rita has previously been found to not have a real emergency situation, he doesn't want to take unnecessary risks and finally sends the mobile unit to check on her. When the emergency mobile unit arrives with Dr. Miles, he finds Rita is alright and after talking a little bit with her, she recognises that she is alright but feels very lonely and that's why she keeps on calling so she can get social attention. Dr. Miles is very kind and gives her some support but does not know where to report this case as his company EPES does not deal with social isolation.
After few months, FASS and EPES have come to an agreement that will enable EPES personnel to report to FASS the cases in which social isolation is the cause for emergency health calls to EPES. Both systems are integrated, and EPES has the option to report on those cases of social isolation electronically so that every month, they forward a list of people who they feel require further social attention and are not FASS users of any social care provider service.
Dr. Miles reports to the call centre in EPES the case of Rita, which is recorded into a specific file to be forwarded to FASS by the end of the month. FASS personnel get in touch with Rita and offer her the option to sign up for the tele assistance service offered by FASS. She agrees that this is a good option and accepts to give it a try. After a few days, she realises she can get social attention, and friendly conversation with the personnel working in tele assistance and loves the fact that she can get all that just by pushing a button. At the same time, the emergency health service is not receiving anymore calls from Rita and as a result, more resources are available for emergency cases.
Henry is 78 years old and 10 days ago he was admitted to the hospital 'Maxima Medische Centrum' with a Myocardial Infarction (MI), with a moderate heart failure as a result. Henry has two sons, John and Eric, who both live in the western part of the country. They visit their father as often as possible but are not able to manage his daily care, since they both have demanding responsibilities at work and at home.
Henry is currently recovering from his heart attack which he had 10 days ago. The cardiologist Ronald visited his bed this morning during the round and told him that he is ready to be discharged from the hospital.
The discharge nurse Linda calls Mary, the case manager for heart failure patients at the call-centre of SHOKO to explain that Henry will be discharged and they discuss the facilities needed for Henry. Linda confirms that all medical data of the patient is sent electronically to the GP office, which is directly linked to the Pozob/Shoko database. Mary, the case manager follows the standard protocol to inform everyone and arrange the required services for Henry (social alarm, telehealth equipment, social services).
Henry leaves the hospital the same day. After a week Jane, Henry's GP makes a home visit. She sees that the treatment of Henry's heart failure is appropriate and explains that his heart failure condition will be monitored by the HF nurse, with whom an appointment has been made. The next week the telehealth equipment consisting of a scale and a blood pressure meter is being installed by the telecare service officer.
During the first appointment with Henry, the HF nurse, Ben, explains that he will make check-up appointments about three times a year. Ben sets the reference range for the measuring equipment and explains and trains Henry in using the system. Henry finds it very comforting that he will be contacted if his data is out of range. Moreover, Ben gives Henry the central number of the call-centre to which Henry can call 24 hours for medical emergency and every working day between office hours for social care questions.
After the second consultation 4 months later, Henry is diagnosed as a stable CHF patient. However, in a conversation with Henry, the HF nurse understands that Henry's eating habits are unsuitable for a person with his condition. The HF nurse calls the case manager and makes sure that an appointment with the dietician will be arranged. When the HF nurse has left Henry, he realises that he forgot to inquire about the chair lift that has still not been delivered. He calls the call-centre number to ask when it will be arriving. After some inquiries Mary has found out that it will be delivered within the coming two weeks and notifies Henry about it. Henry explains to Mary how happy he is that everything has been arranged for him and that he now feels comfortable to be at home when he knows he is constantly being monitored and has one central point that he can call.
Sophia is a 72 year old woman living alone. Sophia suffers from chronic heart failure after two serious heart attacks.
Sophia contacts the call-centre of Pozob/Shoko on Saturday morning at 11 am. She explains to the case manager (Mary) that she is experiencing breathing difficulties. The case manager Mary has ready access to the database of Pozob/Shoko, where she finds that Sophia suffers from chronic heart failure after two heart attacks. She looks at the medication and finds out that Sophia is already taking diuretics once a day. Moreover, she finds out that Sophia is connected to her centre reporting daily data concerning her weight. She can see that her weight has gone up gradually the last 10 days, which is still within the reference range. Moreover, she can see that Sophia has recently received a check-up of her blood parameters which were fine. She decides to call the GP (Jane) who is on duty.
Jane listens to the history of Sophia as summarized by Mary and decides that Sophia is at risk for an exacerbation of her chronic heart failure. She advices to double the dose of diuretics and instructs Mary to ask Sophia to call back at five pm. Mary follows the advice of Jane and Sophia calls back in the afternoon to mention that her condition has improved, but explains that she does not have enough medicine for the coming weeks. Mary passes the information to Jane who advices to continue the double dose for the weekend. Jane writes a new digital prescription and asks Mary to contact the pharmacy to have medicine delivered directly to Sophia. Mary contacts Harold, the on-call local pharmacy, who will deliver the medicine to Sophia. When Mary calls Sophia back on Monday morning, she is very grateful to Mary that she reacted so promptly and confesses to her that it gives her great reassurance knowing that she can call at any time if she needs to. Sophia explains to Mary that she is feeling much better, but that she still has no strength preparing her own food. Mary arranges that the meal facility 'Tafeltje dek je' will bring food for Sophia the next few weeks.
Albert is 78 years and lives at home with his wife. On Sunday morning, the case manager Mary receives a red alarm at the call-centre that Albert's values are out of range. Mary looks up Albert's medical record, and finds out that Albert had a serious heart attack 4 months ago. There is a special note from the cardiologist that an ECG showed a poor ejection fraction which means that Albert is at high risk for the development of serious chronic heart failure. Albert has a telemedicine connection with the call-centre. His weight is registered every day and the data is sent to the call centre. She notices an increase of 2 kg over the past four days and his blood pressure is 170/135. Apart from cardiotrophic drugs and a statin, Albert is not on diuretics. She decides to contact the GP (Jane) who is on call.
Jane decides that a home visit is needed. There is a possibility that Albert is on the way to a serious heart failure attack (asthma cariale). Mary calls Albert to let him know that the GP will make a home visit. The wife of Albert, Ann answers the phone and she confirms that Albert's condition is getting worse. She tells that he complains of shortness of breath which actually started at night. He also had difficulties to lie down in his bed and used three pillows to sleep for a while in an upright position in bed.
The GP (Jane) visits Albert and gives him an intravenous bolus of a diuretic. Albert recovers within ten minutes and Jane decides that no ambulance is needed to bring him to the hospital and advices Albert to take more diuretics orally. His wife should contact the call-center nurse in the afternoon to inform about the progress of Albert's problem. She also makes a note that the next morning another visit should be done to see whether Albert is recovering further. Albert's wife calls the call-centre number in the afternoon to inform Mary that Albert is doing much better and Mary makes a note for the visit the next day.
When the GP makes the home visit the next day they discuss the Albert's condition, which is improving. The wife of Albert tells the GP that Albert sometimes is having problems sticking to his medication regime and that he is often feeling down and worried lately. Jane, Albert and his wife discuss this thoroughly and Albert agrees that he feels isolated and would like to do more social activities. It also becomes clear that Albert's hearing is deteriorating and that this also limits him in his social activities. Together they call the case manager Mary in the call-centre. She immediately takes action and makes an appointment for Albert with the hearing-aid centre. She also contacts the social services that will pick up Henry once a week so that he can play snooker with a group of people.
After a few months the HF nurse, Ben, pays a regular home visit to Albert. In the data record of Albert he can read about the exacerbation the few months before and the actions taken to resocialise Albert. He finds Albert very well, his heart condition is stable and Albert and his wife confirm that Albert is in much higher spirits lately.
Mildred is 72 years old and lives alone in a sheltered housing bungalow. Mildred has severe arthritis and has recently had a number of falls. She is currently using a walking frame to move around her bungalow, outside the bungalow Mildred now uses a wheelchair as she can no longer manage to walk distances.
Twice a day Mildred is supported by the Council In-house homecare service that carries out personal care needs and also assists Mildred with her housework and shopping. Mildred's primary condition is COPD and she was recently admitted to hospital in an emergency due to an exacerbation of her symptoms.
Her daughter Susan is in regular contact with Mildred; she lives locally but works full-time and has a young family. Susan rings Mildred every evening and aims to visit her once a week.
After a particularly unstable period Mildred was admitted to hospital. When Mildred was stabilised and ready to go home, James the specialist respiratory nurse discussed Telehealth monitoring with Mildred and she agreed to have a monitor installed. The Telehealth monitoring will capture Mildred's vital signs including her SPO2 and her heart rate.
Whilst coordinating the support Mildred will require for her return home from hospital, James refers Mildred for a Telehealth monitor by sending a referral through to the Telecare Team. James informs the Community Matron Team of Mildred's planned discharge and that she has agreed to have a Telehealth monitor and it is Community Matron Hilda who is assigned to Mildred. When the monitor is installed Hilda sets the upper and lower alert limits for Mildred. Mildred is asked to carry out her readings seven days a week.
In addition to installing the telehealth monitor, Mildred current social alarm unit is updated to a Connect + unit as it is able to receive wireless signals from telecare sensors should they be required. Mildred already has a PNC record and once her details are entered on to the Telehealth CSO System Database the Telecare Officer can link this to her PNC record via a new box in the CSO interface. Once this link has been created the CSO user has a composite real-time view of the data from both systems.
Some weeks later Mildred is planning to go away for a week with her daughter. On the Friday evening she presses her alarm button and informs Tony the Control Centre Operator that she is going away. Tony, the Control Centre Operator at the Community Alarm Service, updates the Control Centre PNC Database. The system updates prevent what would have been lots of telephone calls to Mildred's home and to her daughter re concern over missing Telehealth readings and consequent escalation to Hilda the Community Matron.
A couple of weeks after her holiday one weekday afternoon Mildred does not feel very well and decides to carry out a telehealth reading. Since the parameters for Mildred are out of range, Tony receives the alert on his computer screen. Tony calls Hilda on her mobile. Hilda decides to speak to Mildred prior to possibly carrying out a home visit. Mildred tells Hilda that she had had a fall whilst in the garden this morning, with a bit of a struggle she was able to get herself up and although she was a little shaken she was unhurt, the struggle to get up had caused her breathlessness. Hilda advised Mildred that if she were to feel unwell again to press her pendant alarm and ask the Control Centre staff to call her or the on duty District Nurse and they would visit her. Mildred feels reassured by this as she has been feeling quite vulnerable since returning home from hospital.
Harold is 68 years old and lives with his wife Mabel in a private bungalow. Harold has COPD and has spent several weeks in hospital due to an exacerbation of his condition. On leaving hospital Harold has agreed to try to give up smoking with the support of a smoking cessation programme. He has also agreed to have a Telehealth monitor installed which will provide trend information about his condition when he attends the fortnightly outpatients clinic. The Telehealth monitoring will capture Harold's vital signs including his SPO2 and heart rate.
Whilst coordinating the support Harold will require for his return home from hospital, James, the specialist respiratory nurse, refers Harold for a Telehealth monitor by sending a referral through to the Telecare Team. James informs the Community Matron Team of Harold's planned discharge and that he has agreed to have a telehealth monitor installed. Community Matron Hilda is assigned to Harold. When the monitor is installed Hilda sets the upper and lower alert limits for Harold. Harold is asked to carry out his readings seven days a week. At weekends and out of hours the red alerts are passed from the Control Centre staff to the on duty District Nurse or the twilight nursing team who have access to CSO.
In addition to installing the telehealth monitor, Harold current social alarm unit is updated to a Connect + unit as it is able to receive wireless signals from telecare sensors should they be required. Harold already has a PNC record and once her details are entered on to the Telehealth CSO System Database the Telecare Officer can link this to her PNC record via a new box in the CSO interface. Once this link has been created the CSO user has a composite real-time view of the data from both systems. Harold had previously been advised to carry out his Telehealth readings at the same time every day. He knows that if he alerts outside of his limits that the staff at the Community Alarm Centre will pass on the detail of the alert to Hilda or a member of the Community Matron Team and they will decide if he needs a visit from them or his GP or whether he should rest for a while and take another reading. Since Harold has a busy routine in the morning he would prefer to take his readings in the afternoon. He is happy to have the monitor installed as he understands the benefits it has in supporting him and now has the freedom to choose a time that is convenient to him.
Several weeks later, Harold carries out a Telehealth reading on late on Sunday morning. Since the parameters for Mildred are out of range, Tony, the Control Centre Operator at the Community Alarm Service, receives the alert on his computer screen. Tony calls the district nurse Pam on her mobile phone and informs her of the alert; he is also able to provide her with information relating to Harold's readings over the past week. Pam then calls Harold who tells her that he has been busy in the garden and has probably overexerted himself. Pam is aware from the information passed from Tony that Harold has been quite stable for the last two weeks and feels that this is most likely to be the case. She advises Harold to rest and also to contact the Control Centre if he continues to feel unwell.