Telehealth can be used to improve standards of care for individuals with long-term conditions, and to boost efficiency of service provision
Telehealth can be used to improve standards of care for individuals with long-term conditions, and to boost efficiency of service provision
The first wave of results from 2011’s whole system demonstrator (WSD) programme strongly supported the effectiveness of telehealth in improving services and outcomes for patients with long-term conditions (LTCs). As the world’s largest randomised control trial of telehealth care, WSD showed that telehealth has the potential to deliver a 20% reduction in emergency admissions, a 15% reduction in A&E visits and a 45% reduction in mortality.
So why do many clinical commissioning groups (CCGs) and providers still struggle to make evidence-based decisions on investing in telehealth? Why is there apprehension in embracing the technology as a means of improving care delivery? To an extent, the answer lies in the breadth of supporting evidence. While the WSD programme was able to conclude that telehealth, if delivered properly, can reduce mortality rates and hospital admissions for people with LTCs, it lacked clarity in implications for financial expenditure and workload. Similarly, patient-reported outcomes are yet to surface from the findings.
As a CCG member, I can empathise with the frustration over certain ‘grey areas’ in the argument for the adoption of telehealth. However, I think it is important for CCGs to recognise that just because programmes such as the WSD are unable to answer all questions relating to telehealth, it doesn’t mean that the technology should be dismissed as a viable approach to care management. Experiences drawn from my work in NHS Calderdale CCG show that, despite the lack of evidence for potential cost savings and operational efficiencies, telehealth indeed does deliver in these areas. Moreover, in addition to cutting mortality rates and hospital admissions, the technology can play a key role in improving the overall quality of life and standards of care for individuals with LTCs, particularly chronic obstructive pulmonary disease (COPD).
Care management and delivery
NHS Calderdale Clinical Commissioning Group serves a population of 213,000 people, almost 17,000 of whom are currently living with a long-term condition such as chronic obstructive pulmonary disease (COPD). Those people with LTCs who are frequently admitted to hospital also account for 36.5% of overall bed day usage. As with many regions of the UK, Calderdale has an ageing population. The Calderdale joint strategic needs assessment (JSNA) states that the number of older people in the region is set to increase over the next decade, and by 2018 it is estimated that 18% of the population will be aged 65 or above. This is likely to have a considerable impact on health and social care services, as the number of older people presenting with health-related problems increases.
With these increased demands on resources, NHS Calderdale CCG developed a commissioning plan for 2013/14 with a clear objective to establish a more sustainable model of care for older and vulnerable individuals in Calderdale; a truly patient-centric approach which would best meet the needs of people with LTCs, while helping to alleviate the financial and operational strain on NHS resources.
In particular, we want to address COPD management. For Calderdale, respiratory-related issues have proved to be one of our largest areas of demand. We know that many patients are being admitted to hospital unnecessarily and there is sufficient scope for improving the way individuals can be supported in the community. Calderdale CCG also want to cut re-admission rates for patients and focus on empowering individuals to give them the support they need to manage their own conditions effectively.
Following careful evaluation of possible solutions, NHS Calderdale CCG felt that telehealth offered the most appropriate and viable pathway to achieving our objectives of improving patient care and safety while also addressing some of the challenges faced by clinicians in primary care. Telehealth presents us with the opportunity to encourage self-management and better care and support. This offers the potential to help reduce costs for the NHS caused in part by unnecessary hospital and GP visits.
Implementing telehealth
Calderdale’s telehealth initiative was introduced in June 2013, with the aim of supporting up to 1,000 people with long-term health and care needs. Working in partnership with Calderdale & Huddersfield NHS Foundation Trust (CHFT), NHS Calderdale CCG is initially offering telehealth to support patients with COPD, living in their own homes, with 24 individuals in receipt of the technology at any one time. Suitable candidates are selected on the basis of having had a hospital admission following exacerbation of COPD, and being identified as at risk of being re-admitted within 30 days of discharge. The cohort also includes those patients who find it hard to access primary and community care due to mobility problems. Each patient is provided with a mymedic telehealth system which enables clinicians to remotely monitor vital signs, including blood pressure, pulse rate and blood oxygen levels on a daily basis. In commissioning the technology, our objectives are to support early discharge and prevent hospital admissions; improve self-management; prevent future complications for COPD patients who haven’t yet started to access extensive healthcare and support the COPD specialist nurses’ workload.
Patient-centred care
Although the initiative remains in the early stages of delivery, its key benefit lies in the provision of a service directly into people’s homes, under the supervision and with the dedicated assistance of Calderdale and Huddersfield NHS Foundation Trust specialist COPD nurses. Already, we have seen how telehealth can provide great reassurance to patients with LTCs. Having the ability to review their own vital signs means that patients are increasingly able to distinguish between there being genuine cause for concern and when they are simply worrying, thus breaking the cycle of anxiety that can lead to exacerbation.
As a result, clinicians in Calderdale are now alerted at an earlier stage if there are warning signs of a patient’s condition worsening. This allows for quicker intervention, preventing any further deterioration and avoiding hospital admission. Overall, telehealth enables us, as care providers, to be more proactive, helping us to anticipate and act on possible problems.
Extending the telehealth initiative
Following the success so far of telehealth in COPD management, our ultimate aim is to extend the service to individuals living with other LTCs such as asthma and chronic heart failure (CHF). Telehealth may prove particularly beneficial for the management of diabetes, mainly as it can help patients gain control and provide a better understanding of the condition. As an ‘educational tool’, telehealth can encourage patients with diabetes to be more conscious of factors such as weight and lifestyle, thus playing a significant role in their care.
We have also invested in telehealth technology as part of our ‘quest for quality in care homes’ across the region. Calderdale has a higher rate of older people in care homes compared to other regions across England. In 2012, the number of people in the area aged 65 or over living in residential care was estimated to be 982. This figure is set to rise to 1,205 by 2020. Research has shown that once within a care home setting, residents are more likely to lose contact with NHS services such as access to specialised care, and have little contact with geriatricians and old age psychiatrists. Residents receive ‘reactive’ care from GPs and, as reported by the Calderdale JSNA, 50-90% are currently receiving inappropriate prescribing.
By early 2014, we plan to be using telehealth systems to support 500 care home residents with LTCs in Calderdale. The aim is to avoid unnecessary hospitalisation and improve health outcomes by enabling early intervention. The technology forms part of a new model of care, developed by Calderdale CCG in partnership with Calderdale Metropolitan Borough Council (CMBC) and Tunstall Healthcare. The model also includes the introduction of a multidisciplinary team, available to support and advise staff in care homes on the prevention and proactive management of the needs of older people including fall prevention and medication management.
So far, telehealth is helping to keep patients at the centre of their care, giving them control and helping them to stay at home.
And that is really what the whole initiative is about; Calderdale CCG has set out to improve care delivery, and although it is hoped that savings can be made, the key factor here is to improve quality of care in the first instance.
