For many years, GPs at our practice, and around the country have strived to help patients understand their long term conditions and encouraged them to look after themselves, with information leaflets and self-management plans. However, reviews were six or 12 monthly and not always when needed. Therefore, at the Lennard Surgery in Bristol, we decided to use technology to support these patients more effectively.
What we did
We worked on an eight-month project from January 2015 to implement supported self-care across a group of patients with long term conditions. In total 93 patients were enrolled in three different cohorts, depending on their disease severity and needs.
The 22 frailest patients with mainly severe COPD and heart failure used a personal channel on their own television (through a set top box connected to the Internet) or an app on a tablet to input daily data like pulse, temperature, blood pressure, oxygen saturations and weight. We gave them equipment like thermometers, an automatic BP machine, pulse oximeters and weighting scales. They also responded to educational quizzes and health and mood surveys. This data was monitored by a community matron at a remote clinical hub, which could be based anywhere. The matron would call patients if there were concerning changes in data, assessing them over the phone or visiting if there was a more serious concern. Patients could also call the matron directly if they had any concerns. The matron had direct access to patient’s medical records through EMISWEB, and daily access to the patients’ GP if needed.
25 patients with less severe diseases such as diabetes, hypertension, mild heart failure or mild/moderate COPD were normally managing their own conditions but needed help and motivation to avoid deterioration and improve compliance with good health advice. They received a personalised automated text message once or twice a day, requesting the input of simple data, for example, blood sugar levels. This system was called Florence, or ‘Flo’. After submitting data, patients received an appropriate return text message which gave praise if their readings showed health improvements.
The remaining group of 17 patients were generally well but wished to improve their health through lifestyle interventions and changes e.g. stopping smoking, weight loss and increasing exercise. This was delivered through a smartphone app called uMotif. The app was used to record data about exercise, smoking, drinking, sleep, mood, diet and also sought to help the patients to understand how these were interconnected.
Since the Motiva service for the frailest patients was the most intensive, it was the most challenging to set up. Devices need to be delivered and installed in the patient’s house, requiring some training – about an hour with each patient. Most patients managed well and only a few found it too difficult. The Hub had to be monitored each morning, requiring an experienced Community Matron for an hour. She would not only monitor the information supplied, but would also telephone or visit patients if needed, and liaise with the patient’s GP, and receive calls from patients who had concerns.
The project equipment and community matron were funded by the West of England AHSN at a total cost of £46,000. There was also support provided by Philips and Bristol Community Health and Philips provided some of the technology as well.
The Florence and uMotif systems simply required the patient to set up and log on with voucher codes. Their data was readily available to the practice, and was mainly used at routine reviews and contacts with the patient as needed.
The average length of time for patients using the Motiva system was six months and for the Flo and uMotif 15-16 weeks. The numbers are small and length of time used is relatively short, making extrapolations difficult, however, we were surprised to see positive outcomes for the more complex Motiva-enrolled patients. There was a 50% reduction in hospital admissions, with a 20% reduction in GP appointments and 16% reduction in GP home visits. Similar figures emerged for the Flo patients, with an encouraging reduction of HbA1c of 9.3 mmol/mol and 9.5 mmHg reduction in systolic BP.
There was very positive feedback on the patient experience with anecdotal quotes on improved confidence in managing their own health and positive changes in lifestyle. 71% of uMotif users had become more engaged with their health and care. Nursing staff were surprised at the positive changes in interest and active modification in patients’ lifestyle that the Flo and Motiva systems produced, leading to better disease control for many.
These models have moved on from ‘older’ telehealth models by involving and personalising the interaction with the patient by allowing them to choose which technology to use (television or tablet), having a two-way interaction between the patient and a service and using the telephone as a method of contact. There was no problem with most of our older population adapting and using this technology. The engagement from staff and patients and the positive result makes us excited to try to take these ideas further and continue to use technology to motivate patients to improve their own health.
By Dr Gareth Ronson is a GP at the Lennard Surgery in Bristol
This was a project between the Lennard GP Surgery, Philips and Bristol Community Health. Philips provided the equipment for the project. They have had no involvement in the production of this article.