The NHS is under pressure to deliver more effective services without adding burden on the healthcare budget. As care needs change and the number of people living with long-term conditions rises, commissioners and providers are seeking a solution that can mould and modernise the NHS. The aim being a more efficient and effective model of care that ultimately supports patients, by enabling them to manage their own conditions successfully.
Recent results from the Department of Health's Whole System Demonstrator (WSD) programme have proven that telehealth works at scale, delivering a 45% reduction in mortality rates in addition to a 20% reduction in emergency admissions. The question is how do you successfully integrate telehealth technology into existing care pathways?
The notion that patients should be providers of their own care ensures that patients can actively contribute to the management of their own conditions. All too often there is a gap between the vision and application of holistic services. Time and time again we've found that, when considering the effectiveness of patient care, the whole system fails when patients do not engage or are not willing to change, despite help from service providers.
What we did
The aim of our project was to bring together providers from health and social care, and mental health services to discuss patients jointly in order to improve care provision. The project involved the Sutton Commissioning Group, which provides services for over 24,000 patients and involves seven GP practices. Two years ago, the Sutton Commissioning Group was one of the few groups to successfully bid for Integrated Care Organisation (ICO) status and this project reflects this ICO vision along with comprehensive international evidence.
The project consisted of two pilots, which were run alongside each other. One pilot looked at the integration and collaborative working with providers centring on the multidisciplinary team, an extension of the ICO. The second was a joint project between social services and the Sutton Commissioning Group exploring the implementation of ‘telepods' to a group of patients. The telepods, which were used as an extension of the community matron's responsibility, look like automated blood pressure machines and can record blood pressure, oxygen saturations, temperature and weight at regular intervals. Of the 40–50 patients on a caseload, 10–20 patients were to be given a telehealth system from Tunstall.
The focus was on patients who had lung-related conditions such as COPD or heart failure, with the intention of reducing unnecessary hospitalisation for frequently re-admitted patients with long-term conditions. The underlying concept was about providing real-time support to patients after recurring visits to hospital, specifically those who were frequently admitted and discharged.
Patients were selected via an analysis of primary and secondary care data and then jointly discussed in the multidisciplinary team (MDT) meeting. The MDT met weekly to discuss patients, not only for their suitability for community matron support, but also to see if telepods would be a suitable addition to their care package. The GPs in the group meet weekly to discuss referrals, and so the room nextdoor was used to hold the MDT.
Patients were discussed on a practice by practice level, and the GP linked to that practice was asked to come into the MDT to discuss his/her patients, before going back to the GP referral meeting. It was decided to hold meetings weekly as the team felt they needed to be responsive to patient need as close to their intervention in hospital as possible.
Once a patient was selected, a provider instigated an action plan instigated which was logged and evaluated the following week. The concept is that the best provision of care is given to the patient at that current time, whether this means GP follow up or something more joined-up.
In order to improve the quality of patient care within the community, the MDT issued questionnaires to those patients who were given telepods, to evaluate if the devices helped with the management of their condition. The team also took regular logs of each patient and care providers, to establish the influence of care on each patient.
What we found
What we have learned from the project is that when used in the right way and on the right patient, telepods delivered significant results for patients and clinicians alike.
Patients or carers with telepods were given questionnaires six months after they had a telepod installed to qualitatively evaluate if their care had improved during the pilot. Six out of 10 returned questionnaires and the results are back up providers' experience: if the telepod is working well, the feedback is positive and if the telepod isn't working well it's negative.
For those anxious patients who had difficulty managing their condition in the community, the patient-centric nature of the telehealth equipment put them at ease and enabled them to live more independent lives.
For patients who had multiple visits with individual care providers, co-ordinating care for the patient was much more effective and efficient and ensured fewer visits from providers and more positive experiences.
The relationship between GPs and the community team also grew as a result of the collaboration, and it is hoped that the communication between the two will increase further as they continue to have weekly meetings to discuss mutual patients.
Over a 12-month period, the project saved 24 unnecessary hospital admissions for patients with long-term conditions, compared to the previous year, equating to around £55,000. Although telehealth is a small part of the bigger picture of integrated care, it is an important component of the way we support those patients out of hospital and in their own homes.
The future
Telehealth is an important step in the systematic shift towards early intervention, prevention and service modernisation and embodies the concept of patient-centred care. Communication between service providers is key for successful telehealth deployments, and service providers have experienced better outcomes with input from a multidisciplinary team. Providing a suitable platform for discussion ensures patients remain the top priority, while motivating them to be providers of their own care.
Having a clinical lead helps to facilitate the process and encourage engagement. Devolve as much of the technical side of the telepods to a service which can install, maintain and support the telepods, such as Tunstall. Likewise, take away as much of the technical side of the telepod from the community matron and district nursing team. Their job should be to see patients and teach them how to use the telepods - not to install them or manage phone lines etc.
Patient satisfaction is particularly important as they need to feel comfortable using the technology. Our patients have been extremely positive about telehealth as a whole because they require fewer home visits and feel more in control of their own conditions. Providers can continue to provide joined-up care without this fragmenting when patients are hospitalised.
Choose your patients carefully. For the right kind of patients it is a good tool and yields considerable cost savings while improving on patient care. However on average a scattergun approaches to telepod implementation in my opinion isn't recommended. Patients who perceived their condition was worse than it was, anxious patients, housebound patients and those with multiple co-morbidities seemed to respond best to the initiative.
Finally, it is not just GPs who need to take responsibility for telehealth. Nursing staff have equal value and responsibility for the success of any telehealth programme, as the frontline support for patients with long-term conditions. By making best use of nursing staff, providers can free up GP appointments and take advantage of the expertise of nurses who are best suited to the management of long-term conditions.
Raza Toosy is a GP in Wallington, part of the Southern Consortium.
