Health Service Focus

Towards self-management

An EU-wide project to asses the impact of telehealth has facilitated self-management of patients across Milton Keynes. CommonWell project lead Sarah Hibble and advanced nurse practitioner for respiratory medicine at Milton Keynes Hospital NHS Foundation Trust, Mark Baverstock, spoke to NHE.

Telehealth has long been cited as a costeffective option to improve the lives of millions of people with chronic conditions, but recent reports from the Whole System Demonstrator seem to indicate that whilst equipment can significantly reduce hospital admissions, the cost savings were not so clear.

NHE examined the impact of the successful CommonWell project and what this could mean for the future of telehealth.

Project lead Sarah Hibble and advanced nurse practitioner Mark Baverstock explained how telehealth had improved their patients’ lives, with 79% of the users and 88% of the carers involved reported to have found major benefits from it.

“They really liked it,” Hibble said, and Baverstock agreed: “All our patients think it’s fantastic!”

The CommonWell project took place across four cities in the EU, with the UK site designated as Milton Keynes. Set up by the community health service, the council and the trust, 100 patients with chronic obstructive pulmonary disease (COPD) were identified for support with telehealth.

Once installed, the equipment allowed patients to take daily readings of blood pressure, oxygen saturation and so on, which were measured between parameters of risk set by the community matron team.

Red alert

Any readings outside of these parameters would trigger a ‘red alert’, bringing the case to a clinician’s attention. They would then contact the patient to ascertain the circumstances of the reading and resolve any issues. Faulty or missed readings could be down to something as trivial as low batteries, but could indicate something more serious, such as a patient experiencing a fall.

The technology can indicate early signs of an infection or exacerbation of the patient’s condition, allowing patients to start treatment earlier and avoid admission to hospital.

Although Hibble d e s c r i b e d the initial implementation as “quite overwhelming”, the project is now securely embedded in the community health service, with matrons able to manage unplanned demand effectively.

The triage of alerts each morning means patients will not be phoning in “ad hoc” and the focus of care can shift from reactive treatment to prevention and preparation.

Baverstock said: “It helps the community matrons prioritise their workload; it helps them to use their time as effectively as possible. It can be done day-to-day as well so they can change their day’s schedule according to the alerts that have come through.”

Alleviating anxiety

Hibble admitted that the introduction of new technology and procedures would always be met with certain misgivings but that once patients got used to the equipment, they wanted to keep it.

“They were concerned in the beginning, because I think they thought they would just have this machine and no links with our matrons and nurses – but they soon came to realise that wasn’t going to be the case. If there was anything out of the ordinary, a clinician would respond.

“People found it useful and beneficial; actually a lot of people who got the equipment in place didn’t want to give it back.”

A key part of the project was for the machine to pose a verbal question of whether the patient would like to be contacted by their clinician. This helped to reassure patients for whom anxiety is often a significant aspect of their disease.

Baverstock said: “We know with COPD anxiety is a huge component because of the breathlessness, so sometimes just the reassurance of having that button there is enough and certainly for the patient’s relatives as well who are holding down full-time jobs and have their own families, they’ve got that reassurance knowing there’s another rung of support.”

Early discharge

Referrals for the project came from GPs, practice nurses, the community matron service and the hospital, where monitoring on the ward could be continued at home to free up beds more quickly whilst promoting patient safety.

Hibble described how they set up an early discharge system to “get [patients] home earlier by putting the telehealth support in and knowing that they were safely going to be monitored.”

Evidence showed that the project prevented readmission, with 168 hospital admissions and 85 GP visits avoided based on the use of telehealth.

“There have certainly been instances now where patients have started to develop a chest infection and the early intervention and prescription of antibiotics and steroids and the follow up after that to make sure they are recovering has definitely prevented hospital admissions,” Baverstock said.

Another benefit of the project is that patients build up “a really clear record of their readings”, making it easier for consultants to see what has been happening with the patient on a day-byday basis.

Self-management

In the past, telehealth projects have been criticised for creating dependency; once a regular link to clinicians is established, this can sometimes be difficult to break.

But Hibble said that the CommonWell project had been “a useful tool to support people with their self management.”

Being able to see the readings meant that patients could relate this to how they were feeling, making them more aware of their vital signs and what steps they could take to prevent an exacerbation of symptoms. This also meant that many people were not then readmitted to hospital, as treatment could be started earlier.

Some patients were at a stage in their disease at which they could self-mange without the use of telehealth. Additionally for certain patients it could inadvertently damage their wellbeing, Hibble explained.

“If they’re very anxious, and the readings are coming up constantly that their oxygen levels are a bit low, then that can actually make them more anxious and the benefit is outweighed by the anxiety.”

A step up

The hospital has continued to refer patients for telehealth, past the conclusion of the CommonWell project. This is often implemented as a temporary measure to smooth the transition between hospital care and being left to manage their symptoms independently.

“It’s a good ‘step up’ and none of our patients have wanted to get rid of the machine; most want to cling onto it,” Baverstock said.

Although the CommonWell project focused solely on patients with COPD, he stated: “I can see it being useful for lots of other long-term conditions.”

“We’ve realised that this is a useful tool and developed it with other long term conditions,” Hibble added, “for example heart failure and diabetes patients. We’re up to approximately 160 patients at the moment and looking to increase that. There’s evidence that a lot more people can benefit from it so we’re looking at how we go about resourcing support.

“I think different councils will be looking at different areas; it’s about talking to our colleagues in different areas about the different incidences of the disease and how much we can do to support that.”

Concerning the future of telehealth, Baverstock considered that if used carefully, it could be of great benefit both clinically and financially.

He said: “I certainly think for COPD, just preventing one admission would probably pay for the unit and its upkeep for a while so just the economics of it are attractive. You’ve obviously got to pick your patients carefully but we can do that – it’s a long term condition that doesn’t just suddenly come out of nowhere. It’s all about preventing the exacerbations and reducing their number. It would pay for itself.”

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