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Managing health with mobiles

Managing health with mobiles
22 April 2016

Using telehealth as a way to manage long-term conditions has helped patients and also cut costs in Stoke-on-Trent

Using telehealth as a way to manage long-term conditions has helped patients and also cut costs in Stoke-on-Trent

So many people die prematurely from largely preventable illnesses such as circulatory and respiratory conditions, and cancer. The ageing population has an increasing prevalence of long-term conditions, some of which are undetected (eg, diabetes) and some inadequately managed (eg, hypertension, chronic obstructive pulmonary disease (COPD)).
In Stoke-on-Trent, Staffordshire, teleheath and other modes of technology-enabled care such as social media and skype have been trialled across practices in the city for the last three years to improve delivery of health care.
The focus includes:

  • Identification of long-term conditions. For example, confirmation of hypertension.
  • Prevention of deterioration. For example, monitoring of patients with heart failure for a month post-discharge to prevent re-admissions.
  • Enhancing shared care with individual patients. For example, trigger of rescue-medication, when a patient is directed by telehealth messaging underpinning the agreed shared care plan.

The vision for technology-enabled care services (TECS) for all NHS organisations and local authorities working together across Staffordshire is to optimise the “potential of technology to transform traditional models of care and support and to enable greater self-management of care and support people and their carers to be as independent as possible. This will help people of all ages to take greater responsibility for their own health and well-being and that of their families, as well as reducing admissions and readmissions to hospital and enhancing long term care among older people”.1

About Stoke-on-Trent
Nearly 300,000 people are registered with the 52 general practices in the city of Stoke-on-Trent. There is a gap in life expectancy of nearly 10 years between local people living in the most affluent and most disadvantaged localities of the city. A quarter (25.1%) of all deaths are due to circulatory disease and a sixth (16.0%) to respiratory disease; with the population having a lower than average life expectancy and high mortality rates. There is a higher than the national average prevalence of long-term conditions; due in part to the related consequences of high deprivation (many areas in the city are among the top 5% of the most deprived in England).

What we did
The CCG worked with the inventor of a telehealth, mobile phone texting programme with shared IP arrangements. The programme’s inventor promoted it across the UK and created a community of users to share their protocols and experience.
The initial program in Stoke-on-Trent focused on the clinical management of hypertension in 10 practices. The pilot was funded by the Health Foundation as one of the Shine innovation awards in 2011-12. We evolved a shared care approach so that the mobile phone texting programme was designed as a tool to accentuate and reinforce key points of a mutually agreed-upon shared-care management plan between a patient, and GP or practice nurse. We showed that this improved patient engagement and adherence with prescribed care (medication or intervention such as change of lifestyle habits). So for the hypertension (high blood pressure) focus this included:

  • Clarification of the diagnosis of hypertension – recording home blood pressure (BP) readings over one week.
  • Supporting clinical management of inadequately controlled hypertension as the GP increased medication, or the patient was reminded to adhere to the treatment agreed.

The texting programme’s options include information giving, daily messages promoting medication adherence and sensible lifestyle advice. They also provide interaction whereby the patient receives automated prompts to send responses relating to bodily measures such as their BP or weight and then receives automated advice (that reinforces their pre-agreed shared-care management plan).
The pilot allowed us to gather evidence of the success from the texting programme and the publication of that evidence2,3 encouraged more practices locally to get involved and we continued to widen the scope of applications.

How we worked with GPs to implement telehealth
Everyone is so busy, so any new way of working has to be easy to put into practice, hopefully save clinicians’ time or at least take no more time, and enhance clinical management in visible ways. So we appointed a clinical telehealth facilitator to work alongside practice nurses teaching them how to use the mobile phone texting programme on the frontline, as practice nurses tend to do most of the follow-up care for patients with long-term conditions. We helped GPs and practice nurses to see that they needed to book out two minutes per patient signed up to text programme per week to review its website and an individual patient’s texted in responses. The nurse can leave the programme running, or unusually, interact with a text message or phone call to the patient if different clinical advice or action is needed.
We presented the programme’s protocols based on The National Institute for Health and Care Excellence (NICE) guidance, but our facilitator could adapt them for practices who wanted to deliver care differently or teach them how to do so themselves.
We described other practice teams’ experiences – as case studies often have more impact than learned research reports.
We interacted with the area team to get local agreement as to how the text programme’s telehealth usage could fulfil requirements for follow-up care within national incentive schemes (currently the unplanned admissions directed enhanced services (DES)).
We have extended the options for the texting telehealth programme to include respiratory conditions, mental health foci, lifestyle habits – any long-term condition that a practice wants to focus on. The CCG then expanded support for technology-enabled care to include recommended apps, social media (such as closed Facebook groups) and skype/video consultations.

How have patients found it?
On the whole, patients love using the mobile phone texting program – so long as the protocol is for their purpose and the telehealth program suits their preferences and lifestyle. Relatively few drop out – though they can do as they know they just need to text ‘stop’ to do so. Many describe the feeling of confidence that it gives them to understand more about their condition(s) and feel more in control via the shared care management.3,4 Videos are good ways to relay people’s perspectives to other patients.5

Financial input/savings
The usual arrangement is for a CCG to buy the annual licence of the texting program and included patient texts (£10,500 per annum). Thus there are no costs for a practice team and patients. Table 1 relays the maximum costings of different protocols.

If the use of the texting programme prevented one patient with chronic kidney disease (CKD) stage four from deteriorating or another patient from having a stroke, by helping to control their hypertension or adhering to their medication then the investment in the program on a widescale is much less than the costs of dialysis or rehabilitation/medical care.6

Professor Ruth Chambers, GP and clinical telehealth lead for Stoke-on-Trent CCG.

1 Turner AP, Sloan AP, Kivlahan DR, Haselkorn JK. Rehabil Psychol. May;59(2):136-46. doi: 10.1037/a0036322. Epub 2014 Apr 7; 2014.
2 Cottrell E, Chambers R, O’Connell P. Using simple telehealth in primary care to reduce blood pressure: a service evaluation. BMJ Open, November 2012. (access 13 April 2016).
3 Cottrell E, McMillan K, Chambers R. A cross-sectional survey and service evaluation of simple telehealth in primary care: what do patients think? BMJ Open, November 2012. (accessed 13 April 2016).
4 Cottrell E, Cox T, Chambers R, O’Connell P. Patient and professional user experiences of simple telehealth for hypertension, medication reminders and smoking cessation: a service evaluation. BMJ Open. March 2015. (accessed 13 April 2016).
5 The Health Foundation. The Power of People. (accessed 13 April 2016).
6 Cottrell E, Cox T, O’Connell P, Chambers R. Implementation of simple telehealth to manage hypertension in general practice: a service evaluation. BMC Family Practice 2015; 16: 83. DOI 10.1186/s12875-015-0301-2 (accessed 13 April 2016).

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