Dr Richard Berkley explains how he has reduced hospital admissions and freed up GP time by managing heart failure patients in their homes
A patient with a long-term condition is often anxious, frustrated and disempowered. GP practices do not have boundless resources, so for the vast majority of the time the patient is left to manage their condition on their own, filling in the gaps between contact with professionals.
Often, the way patients deal with this experience is an important determinant of how their disease will progress. But if health professionals can monitor patients remotely it can offer day-to-day support to improve well-being and quality of life, and reduce healthcare costs.
Telehealth is an area the Government is looking at for precisely these reasons. For the past four years, we have been running a small telehealth pilot for patients with heart failure in my practice, measuring blood pressure or pulse rate remotely on a daily basis.
We have had dramatic results, observing measurable reductions in hospital admissions, A&E attendances and visits to the GP surgery.
Why telehealth?
Like many GPs, I was initially sceptical about telehealth. I couldn't understand how it was going to make much difference.
But if we find something that has the potential to improve patients' well-being and save money to the overall health economy, we must explore it.
When we started this project, significant evidence existed that intensive support for patients with chronic heart failure could bring about positive outcomes, such as improving quality of life, preventing hospital admissions and prolonging life [1].
We decided to focus our project on assessing the benefits of providing more preventive support to patients with heart failure in a community setting.
The equipment was funded through a technology grant from South Gloucester Council Community Care and Housing Department. Tadeka UK supported us by funding running costs for the first three years. The project was set up with district nurses and GPs located in our practice.
What we did
We set up a partnership with Tunstall Healthcare to use its telehealth equipment, initially with 18 patients at our practice in Bristol. These patients were selected by GPs as having moderate or severe left ventricular systolic dysfunction and with a class three or four New York Heart Association breathlessness score.
Patients were trained by the district nurses to use a monitoring unit, enabling them to monitor their 'vital signs' at home. These vital signs included pulse rate, blood pressure, oxygen saturation and weight.
Patients were automatically reminded to measure these on a daily basis and within a scheduled time – which can be individually set by the technology. This information was collected by a home hub and securely transmitted via telephone (landline or GSM/GPRS mobile networks) to a central monitoring station. Measurements on the patient's condition were received and reviewed by the GP, community matron or project nurse.
The system gave an alert to the clinical team if the patient's vital signs were not present, or were outside certain parameters – for example, if they had gained more than 2kg of weight over a short period of time. Initially the patient would be supported remotely – checking how they were and what had happened – but where necessary, cases were escalated to their GP or community matron, who then assessed whether a home visit or other intervention was required.
Learning from experience
As the project was the first of its kind in our area, we had a steep learning curve to understand the equipment, establish robust processes for deploying it and capturing the information received.
The main difficulties were integrating the project into our daily routines, and managing the 'noise' that came from spurious results and faults. Once this was under control – using robust clinical governance procedures – the telehealth system became a very useful clinical tool.
A certain tolerance and urgency was set according to each variable measured. For example, if the systolic blood pressure was 5mmHg above target, there was no point in flagging this as an emergency. But if the blood pressure was constantly above target, the clinician would be informed and would respond within, say, a week. However, if oxygen saturation was at 88%, and was usually at 95%, an urgent same-day response was generated.
We introduced flowcharts to provide a structure for the project and to ensure the nursing team was clear about the most appropriate response to alarms – for example, when to alert the on-call doctor.
Results of the pilot
We found patients readily adapted to the telehealth monitoring equipment, and actively enjoyed being more involved in their care. They found the equipment easy to use, and became increasingly aware of their readings and how this related to how they were feeling. Patients began to have a sense of control and understanding that really helped them to manage their condition. After 12 months, we also had a measurable cost-saving to the NHS. Compared with the previous 12 months, the 18 patients had a 46% reduction in hospital admissions, a 67% reduction in A&E attendances and the number of visits to the GP surgery was reduced by 16%.
There was an issue of managing anxious patients and helping them understand what the readings meant, but this was resolved by giving them confidence to self- monitor and not panic over fluctuations in symptoms that might correct themselves.
As a GP, I found the system very useful for reducing home visits and conducting more contact with patients by telephone. The data helped in titrating complex medication regimens to achieve target doses, and in reassuring patients about potential side-effects such as bradycardia or hypotension.
We were also able to monitor trends to see what the usual fluctuation in a patient's condition was. This helped patients understand what to look out for and report early warning signs, and I was able to use this data to reinforce behaviour and improve compliance with medication.
The future
Many practices might find themselves using telehealth in the future, as there is a massive drive from the Government to adopt these techniques. This pilot was for patients with heart failure, but there is evidence that telehealth can be beneficial for other diseases such as COPD and diabetes.
Our experience shows it is possible to engage patients in better understanding of their own health, and reduce costs at the same time. But telehealth is not a standalone solution – it must be integrated into wider plans to help care for patients with long-term conditions, otherwise its potential will never be realised.
We will continue to run the pilot and are working to expand this to other practices. Increasingly, I am hearing that many primary care organisations and consortia are investing in telehealth equipment. Only when these projects are done on a larger scale will we see a significant reduction in demand on hospitals and a corresponding reduction in costs.
Dr Richard Berkley is a GP in Bristol
