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Adopting technology enabled care
services for delivery of care for people
with LTCs
Dr Ruth Chambers OBE, Clinical lead for WMAHSN
LTC Network; GP; Chair, Stoke-on-Trent CCG
Care Providers
–all settings
Public
Academia/ education
Industry
Shared care
records
LTC Network: new ways of
delivery of care
Commissioner
s: applying
intelligenc
e
The Local Digital Roadmap (LDR)
ChallengeDelivering Sustainability & Transformation Plan (STP)
priorities
– Demonstrating dependency on data, information and
technology
– Return on Investment - mapping investment in
technology to measurable benefits: health, finance
Establishing real partnerships
– Between NHS organisations
– Between health sectors
– Between NHS & other public sector bodies
– With patients, carers and the 3rd sector
– Industry (including large corporates and SMEs)
Emerging LDR ThemesInfrastructure
– Connectivity & bandwidth
– Kit
• Desktops (Windows XP!)
• Mobile devices
Rolling out national systems
– SCR
– ePS
– e-Referrals
Information sharing
– Interoperability & interfaces
– Information Governance
User focus
– Not just professionals!
• Patients & carers
Making sense of data
– Analysis & visualisation
LTC pathway
Patient –self care
Evidence base
Clinical team
Data and measurement
Technology
Innovation
Minimise duplication –
shared care plan
Workforce training/upskilling
Collaboration around a defined LTC priority – new ways of delivery of care
5. Person selects and purchases own technology to support or improve their own health
and/or social care and/or lifestyle habits: they may include goal setting, reminders, records of
feelings/bodily measurements etc, action plans, information about best practice. They may or may
not share their personal information/record keeping generated by the technology (eg health app)
with a health/social care professional.
4. Shared delivery by individual professional with patient/carer: TECS initiated & delivered
by health /social care professional who updates other health/social care professional(s) or teams
involved in the patient’s care (ie giving information rather than interactive decision making
between professionals). It might be that a patient requested the inclusion of their personal
technology such as an app in their health or social care, that the initiating health/social care
professional has adopted; with shared care plan agreed by patient, that optimises patient
responsibility for their own care.
3. Shared multidisciplinary protocol with one TECS operator: ≥2 clinicians/ social workers, of
different disciplines, in same organisation or setting; sharing (delegated) responsibility for providing
TECS directly (≥1 mode of technology) for continuing care of same patient/≥ 1 conditions via
agreed care plan. (This might be by the most senior/expert defining patient pathway and endorsing
TECS protocol(s) for others to provide with real time support eg advice in person/by email; with
shared care plan agreed by patient, that optimises patient responsibility for their own care.)
2. Shared sequential responsibility: ≥2 clinicians/ social workers, in different
organisations/settings interface; so one hands over responsibility to the other for providing TECS
directly (same mode of technology or different) for continuing care of same patient/same condition
via agreed care plan.(This might be by the most senior/expert defining the patient pathway and
endorsing the TECS protocol for others to provide with real time support eg advice in person/by
email; with shared care plan agreed by patient, that optimises patient responsibility for their own
care.)
1.Shared real time responsibility by ≥2 clinicians/ social workers, in different
organisations/settings share TECS directly (same mode of technology or connected if
different) for delivery of an agreed shared care plan of same patient/ same condition at
same treatment phase (clinicians/ social workers have agreed responsibility via shared
care plan agreed by patient, that optimises patient responsibility for their own care)
Responsibility for delivery of integrated & connected care via technology enabled care services (TECS)
Stoke-on-Trent CCG Similar CCGs 10+1* (range) NHS England average TECS exemplar you can try
1 Hypertension prevalence1
0.61 0.57-0.63 0.56 Simple Telehealth Flo
2 Stroke & BP not <150/90mmHg1
10.7% 8.5%-10.7% 9.7% Simple Telehealth Flo
3 Asthma prevalence (all ages) 36.3% 6.0%-6.8% 5.9% Simple Telehealth Flo
4 Emergency children asthma admissions3
(per 100,000 resident population)
320.8 150.9-399.9 219.1Simple Telehealth Flo, App, Social Media e.g.
Facebook group
5 Emergency adult asthma admissions3
(per 1,000 practice population)1.62 1.02-1.75 1.09 Skype, Simple Telehealth Flo, App
6 Inpatient spend
(respiratory over 75+)2
(per 1,000 population) £221,581 £127,873-£233,569 £167,739 Simple Telehealth Flo, Skype, App
7 Inpatient spend
(respiratory under 5s)2
(per 1,000 population) £85,910 £53,065-£85,910 £49,680 Simple Telehealth Flo , Skype
8 COPD QOF prevalence (all ages)3
2.4% 2.1%-3.2% 1.8% Simple Telehealth Flo
9 Emergency COPD admissions3
(per 1,000 practice population)3.56 2.27-4.72 2.15 Simple Telehealth Flo, Skype, App
10 Excess weight (overweight or obese) in adults1
66.5% 60.2%-69.6% 63.8%Social media e.g. Facebook group, Simple
Telehealth Flo
11 Diabetes control (<HbA1c 59)4
61.8% 57.6%-64.5% 59.6% App, Simple Telehealth Flo
Sample CCG intelligence pack
Example LTC Pathway
10
Evolving a particular mode of technology –example Manage Your Health app
• Person Driven Design
• ‘Patient [Person] focussed apps’ start with people asking the questions
• Validated by clinicians and presented in a simple style and language
Our aims were to
• Persuade not patronise
• Motivate not monitor
• Content localised to your region
• Local support groups
• Content that is regularly updated
• Match changing guidance
• Improve existing information
• No personal data monitored or recorded
Manage Your Health• Available now on:
• Uses text/images/videos and avatars to explain how to Manage Your Health
• Downloadable and updatable information packs are available for
• Asthma• COPD• Diabetes• Lower Back Pain
In Development • ADHD • Hypertension & CKD• Atrial Fibrillation & Stroke• Cardiac rehabilitation
Improves access for patients
Focuses appointments
Reduces DNAs in hard to reach groups
Encourages self care
Can reduce admissions
Skype & remote care – V-Doc
How Simple Telehealth monitoring worksStage 1: User texts vital signs or self-assessment to Florence
Stage 2: Florence compares data to set parameters and texts feedback/advice to user
Practitioner can view data, alter parameters and message user
•Improved clinical outcomes•Quality/savings targets attained•Wealth creation eg patients stay in work•Upskilled patients & workforce•Patients stay independent
Technology enabled care underpinning the STP- the future
Patient populationsOutcomes
Current Practice
NHS/social care
ClusterNHS/social care Cluster
NHS /social care
Cluster
Re-DesignTechnology enabled care
under-pinning service re-design
Technology Enabled Care Services (TECS) – Local Digital Roadmap
Delivering a connected vision raises critical issues:•How to deliver ‘real’ technical inter-operability across STP area?•Can we trust data provided by devices, wearable sensors and apps?•Can we balance privacy & confidentiality with sharing & openness? •How do we evaluate and assure the clinical validity and efficacy of TECS?•Can TECS truly deliver value for money –support QIPP/service redesign?•Are patients who need TECS able to use and access technologies? •What impact will utilising these technologies have on health and social care staff?•What are patients’ & citizens’ needs & preferences for TECS?
It’s about the basics – keep remembering!!Improving delivery of best practice care for long term
conditions should focus on patient empowerment,
integration & innovation
19
Best clinical practice &
shared management
Tech
Improved QUALITY of clinical
care
Map focus of evaluation to
technology enabled service aimsand stakeholder priorities
Clinician
s
I’m stressed...will this
ease my workload?
Commissione
rs
Is this more for less?
PATIENTS
Is this going to be easy to
use? Will it help?
Feedback from Flo telehealth patientQ – How have you been finding Flo? Is it
helpful?
A- I find Flo very helpful and I have found it to
be very reassuring.
Q – Do you find Flo easy to use?
A- Very easy, it is very simple and to the
point.
Q – Do you feel any benefits from using Flo?
A- I feel more confident, I feel stronger and I
feel really good knowing that I can contact
somebody at any time. It makes me feel
calmer and more able to deal with my
condition.
Q- Who would you contact if you were feeling
unwell, if you did not have Flo to text each
day?
A – I really not sure, it feels so reassuring to
have a point of contact like Flo. I guess I
wouldn’t contact anybody until the problem
was so bad I’d more than likely be
readmitted.
Q – How likely would it be that you
recommended Flo to another Heart Failure
patient?
Supporting people at
home
Enhanced support at
home
Manage Crisis Effectively
Specialist acute
input
Enhanced support at
home
Supporting People at
Home
Manage step down from
acute effectively
Crisis Acute Trf of care
Home HomeSupport* Support
Long term
hypertension
Smoking
Cessation
Long term vital
signs monitoring
Care Homes
Pain Mment
Medicines
Management
“Worried Well”
INR
Weight loss
motivational
messages
Health self
assessment
Sexual health
Unstable
Hypertension
Newly diagnosed
hypertension
Medication
Reminders for: -
Hypertension /
Ashma inhaler /
pain management
Paediatric ashma
COPD
Diabetes (type1& 2)
Heart Failure
Palliative care carer
support/wellbeing
Falls prevention
Virtual Wards
Intermediate
care
Step down
facilities
Unstable vital
signs monitoring
Medication
management
As *Pregnancy induced
hypertension
Gestational diabetes
COPD
CHD
Diabetes
physiotherapy
Monitoring of pre op
patients to reduce
cancelled operations
Out patient acute
specialist follow up
DNA management
Support early discharge
EMAS unstable vital
signs monitoring
Oncology
Neurology
Speech therapy
Alcohol support
Learning disabilities
Mental health behaviour
Mental Health appt &
medication reminders/
supportive messages
Daily living/ medication
reminders for people
with Aspergers/autism
Long term
hypertension
Smoking
Cessation
Long term vital
signs monitoring
Care Homes
Pain Mment
Medicines
Management
“Worried Well”
INR
Weight loss
motivational
messages
Health self
assessment
Sexual health
How telehealth can
support peopleLevel 3: High Complexity
Case Management
Level 2: High risk
Disease/Care Management
Level 1:
70-80% of LTC population
Self care support/management
Low cost, large-scale: ‘Simple Telehealth’
Wider dissemination
Case studies Academic literature
Conference posters, presentations or workshops
Education events or activities