GP-support by means of AGnES-practice assistants and the use of telecare devices in a sparsely populated region in Northern Germany – proof of concept

All participating AGnES-practice assistants were qualified by the project staff and external experts. The qualification included e. g. documentation, communication, knowledge of age-related diseases, pharmaceutics, practical application of falls prevention, practical application of telecare, geriatric assessment [17‐19].

The project included three field phases of respectively two, three and five months duration between November 2005 and March 2007. During the first and second field phase, one AGnES-practice assistant (primary qualification: registered nurse) was implemented in a general practice. In the third field phase, two AGnES-practice assistants were implemented in two GP-practices. The study region was the Baltic Sea island of Rügen, belonging to the Federal State of Mecklenburg-Western Pomerania in the very Northeast of Germany (table 2).

The GP selected eligible patients to participate in the project, informed them about the concept, obtained informed consent and determined the specific tasks to be performed by the AGnES-practice assistant. Although the GP was free to select the patients, it was achieved to include patients with limited mobility, dependent on home visits.

When a patient was included in the project, the AGnES-practice assistant transferred the patient's personal data as well as his diagnoses, therapy and prescribed medication into the project documentation. Additionally, the patients were asked for information about their household, education and mobility in a base interview. After the different field phases, the patients were asked for acceptance of the concept by completing a final questionnaire.

Use of personal data was restricted to the AGnES-practice assistants and the GP, all scientific monitoring and evaluation was based on pseudonymized data.

The AGnES-practice assistants documented all delegated tasks, modules conducted and questionnaire responses into an ergonomically optimized integrated documentation software installed on a portable tablet-pc equipped with touch-screen functionality and character recognition.

Every day, the collected data was encrypted and transferred over a safe connection via the internet (virtual private network, VPN) to the project-server for verification and analysis. Data transfer to the GP was tailored to each physician's individual preferences and included genuine .pdf files and manual entries in the patient files.

As a measure for acceptance, the patients were asked for their judgement about the concept, the competence of the AGnES-practice assistants in health issues, and if they built confidence in the AGnES-practice assistants.

Upon completion of the second and third field phase (table 2) patients who used telecare devices were asked whether they would be willing to continue using these devices for a longer period of time. In systems with more than one device (e.g. the system digital scale/sphygmomanometer), every device was treated separately. These questions were used as a measure for the acceptance of telecare within the concept.

After every field phase, both AGnES-practice assistants and GPs were asked for a judgement about the usefulness of home telecare in GP-practices.

All questions were assessed by a standardized questionnaire.

After the second and third field phase (table 2), all participating GPs and AGnES-practice assistants were asked for their judgement about the benefit of the concept and the quality of health care provided to each project patient. The assessment was based on standardized questionnaires.

20 patients participated in the first, 29 in the second, and 56 in the third field phase. Unless otherwise indicated all results refer to the pooled sample of all field studies. 29 patients were male (27.6%), 76 female. The mean age was 73.7, the age range was 37–92 years.

Most patients were multimorbid with chronic diseases including hypertension (75% of the patients), coronary heart disease (55%), diabetes mellitus (52%), cancer (23%), heart failure (7%), and dementia (7%).

In the third field phase, the mobility of each patient was documented in three categories (N = 56): 37.5% of the participating patients were immobile and confined to their beds. 51.8% of the patients were restricted in their mobility and incapable to visit the GP-practice without assistance, 10.7% of the patients were mobile and in principle capable to visit the practice by themselves. In these cases, the GP had arranged the home-visits for other reasons (e.g. temporary immobility, assessment of the home situation and patient's social environment, monitoring of home care).

98.1% of the participating patients (N = 103) completed the base interview, 82.9% (N = 87) completed the final questionnaire. Failure to complete the base interview (N = 2) or the final questionnaire (N = 18) occurred in patients who were physically or cognitively incapable to answer the questions (N = 8), were hospitalized (N = 5), not willing to answer the questions or not at home during the respective period of time when the final questionnaires were applied (N = 7). Hence data analysis is based on 550 home visits with 85 patients, for whom complete data sets were available.

In the three field studies of the project, a total of 550 home visits were conducted. 98.1% of the participating patients (N = 103) completed the base interview, 82.9% (N = 87) completed the final questionnaire. Failure to complete the base interview (N = 2) or the final questionnaire (N = 18) occurred in patients who were physically or cognitively incapable to answer the questions (N = 8), were hospitalized (N = 5), not willing to answer the questions or not at home during the respective period of time when the final questionnaires were applied (N = 7). Hence data analysis is based on 550 home visits with 85 patients, for whom complete data sets were available.

Table 3 shows the specific activities that were delegated to the AGnES-practice assistants. In the first and second field phase, the GP was hesitant to delegate qualified tasks to the AGnES-practice assistant. Beside the standardized assessment of the patients' health condition, drug history and falls prevention, predominantly monitoring tasks e.g. measuring blood pressure and blood glucose were delegated. During the third field phase the spectrum of delegated tasks was significantly extended mainly with respect to interventional tasks such as conducting complex diagnostic measures and medical counselling.

During 550 home visits, the AGnES-practice assistants initiated 15 unscheduled GP contacts directly from the patients' homes. In 12 cases these were motivated by an unexpected poor state of health of the patient, the remaining 3 contacts referred to problems with or questions about the medication. In all other cases, all information transfer between practice assistant and GP occurred during scheduled contacts.

The mean duration of the home visits was 23 minutes, which is as long as home visits of GPs.

Most patients (96.5%) felt that the practice assistant was competent for health issues. 93.1% developed a degree of confidence to the AGnES-practice assistant that was comparable to their confidence in their GP. 87.4% of the patients supported the statement that a practice assistant should carry out routine home-visits, prevention and telemedicine, and that GP's home-visits can be restricted to situations requiring special medical attention.

During all three field phases, four different telecare-systems were implemented in the homes of a total of 48 (45.7%) eligible project-patients (table 4). The telecare-systems were used over varying time periods ranging from three weeks to four months.

The patients were trained by the AGnES-practice assistants in using the various telecare-devices. After the training, most patients had the ability to use the device. In two cases, the wife of the patient provided support, in four cases home care nurses carried out the measurements.

The second and third field phase covered 40 patients with telecare equipment, 17 patients used systems with more than one device, so yielding a total of 57 devices. 75.4% (N = 43) of the patients were willing to continue using telecare devices for a longer period of time. Acceptance depended strongly upon the device. All patients that had used a one-lead-ECG device (N = 4), 78.3% (N = 18) of the patients with a digital scale and 76.9% (N = 20) of the patients with a sphygmomanometer would use this device for a longer time period.

On the other hand, only 2 of 10 patients were willing to use the twelve-lead-ECG equipment for longer times.

All participating GPs and practice assistants judged the implementation of home telecare useful for eligible patients.

The participating GPs (one in the second, two in the third field phase) evaluated for 75.3% of the participating patients a particular benefit (high and fair approval combined) from the health care of the AGnES-practice assistant. The participating practice assistants judged 77.6% of the patients to have had a particular benefit (table 5).

The second question addressed the quality of health care provided during the project for each participating patient. The GPs judged the quality of health care during the project, supplied by the practice assistants and the GPs appropriate for 74.1% of the participating patients (high and fair approval combined). The AGnES-practice assistants confirmed this for 84.7% of the patients (table 5).

All participating GPs agreed to the statement, that delegating tasks to a practice assistant relieves them in their daily work.

The physicians' acceptance improved with increasing duration of the project. In the first field phase, the AGnES-practice assistant conducted just the standardized questionnaires relating to the patients' health condition, conducted falls prevention, documented drug history and applied training modules for telecare. During the second and third field phase, many tasks were delegated including conducting ECGs, taking blood samples and providing advice about various themes, including diet and fluid balance.

In the AGnES project, home telecare was accepted very well: 75.4% of the patients could imagine continuing the use of home telecare devices for a longer period of time. Also the AGnES-practice assistants and GPs were positive about implementing telecare equipment in the homes of eligible patients. For the first time in Germany, practice assistants were responsible for training the patients, installation of the devices and controlling the data obtained. The GP received a message only when measurements deviated from the predefined ranges.

Notable are the differences in patients' acceptance between the different telecare devices. The implementation of a twelve-lead-ECG device was not successful: out of 10 trained patients only 2 could handle the particular device effectively. Schwaab et al. [10] reported positive results with the same device. However, the patients in the sample of Schwaab et al. had been preselected from a large group of cardiologic patients and conducted the ECG under controlled circumstances in a hospital. A lower average age (64 years in the sample of Schwaab et al. vs. 73.7 years in our sample) further limits the comparability of Schwaab et al.'s study with ours.

After the second and third field phase, the participating physicians judged the quality of health care through a team of GP and practice assistants as appropriate for about three-quarters of the project patients. This corresponds to the results in a systematic literature review of Laurent [20], who concluded that appropriately trained nurses can deliver health care in a comparable quality to primary care physicians.

Rosemann et al. [5] showed that in customary primary care, practice employees are rarely involved in medical tasks in the GP practice. The AGnES project indicated that, with sufficient qualification, practice assistants have the potential to be integrated in genuine medical tasks such as home visits.

All participating GPs reported that delegating specific tasks to practice assistants supported them in their daily work. Notable is that all participating GPs planned to continue the cooperation with an AGnES-practice assistant in some form, for example by engaging the AGnES-practice assistant further after the project or by increasing the number of working hours of qualified practice staff for conducting home visits.

Both participating GPs judged the implementation of telecare-devices to support patient-monitoring useful. An important requirement here is that there is no additional workload for the GP. In the project, the AGnES-practice assistants were responsible for handling the telecare part. The GPs were only involved selecting the patients and assessing alarm values. This way of handling with telecare in a GP-practice was successful.

Our study has some limitations. Due to its design as a proof of concept, the number of participating GPs and AGnES-practice assistants is too small to allow for meaningful evaluation of subgroups. Also, the duration of the field studies was short (2–5 months), limiting the possibility to measure longterm clinical results in the patients who participated.

Based upon the experiences in this project, new projects in different settings with more GPs and AGnES-practice assistants have been initiated in four federal states in Germany. In the Federal State of Brandenburg, a project started in July 2006 with three practice assistants (all registered nurses), supporting six GPs in a regional medical centre. In the Free State of Saxony, six AGnES-practice assistants (three registered nurses and three physician's assistants) support six GPs in underserved areas since July 2007. In the Federal State of Mecklenburg-West Pomerania a new project started in July 2007. Here, three AGnES-practice assistants (two registered nurses and one physician's assistant) support 14 GPs in three regions. In December 2007, a project with 8 AGnES-practice assistants in 4 GP-practices was launched in Saxony-Anhalt. A corresponding project investigates legal aspects of qualification and training as well as limits to the delegation of physicians' tasks to practice assistants.

The projects received considerable media coverage and triggered a broad discussion about structural challenges for GPs in rural regions and new concepts to delegate medical tasks and competences to the different professions in health care.

The AGnES projects demonstrate considerable potential to initiate changes in the health care system in Germany. Every participating federal state initiated a steering committee representing major institutions in health care in order to facilitate and accelerate the transfer of the project experiences and results into the health care system. Additionally, delegates of the ministries of health of all eastern German federal states initiated an "AGnES-working group".

In three of the subsequent projects (in Saxony, Saxony-Anhalt and Mecklenburg-Western Pomerania), two important partners, the Association of Statutory Health Insurance Physicians and the statuatory insurances themselves, are cooperating both conceptually and actively contribute to the funding of AGnES projects.

As a result of the activities of the "AGnES-working group", in March 2008, a change in legislation made delegation of home visits to AGnES-practice assistants possible. At the moment, representatives of the federal Kassenärztliche Vereinigung and the statuatory insurances are negotiating the terms of reimbursement of these delegated home visits.