NHS Stoke on Trent

• 270,000 registered patients, 54 GP practices

• 2 new GP practices and GP led Health Centre planned for 2009

• Some of the most deprived wards in England,

• 5 PBC clusters closely aligned with the Local Authority neighbourhood areas

Technology enabled care is a must-

now!Dr Ruth Chambers OBE

GP Stoke-on-Trent;

Clinical lead for WMAHSN LTC priority;

Clinical telehealth lead for Stoke-on-Trent

CCG

Clinical lead WMAHSN TECS exemplars

The challenges

Number of Conditions1 % self reporting

1 30%

2 13%

3+ 10%

The 15 million people in England with long term conditions have the greatest healthcare needs of the population (50% of

all GP appointments and 70% of all bed days) and their treatment and care absorbs 70% of NHS and social care

budgets in England

1. The percentage of people aged 18 and over self-reporting experiencing long-term conditions in the GP Patient Survey

GP practices + other independent contractor practices

(including dentistry, pharmacy, optometry)

Patient

CCGCommissioning

Support Unit

Local Area Team/NHS

England

Public Health

Social Care Loca

l au

tho

rity

End of life care

Emergency services

Ambulance service Community

services

Partnership Trust

Community District Nurse

team

Mental HealthOut of Hours

services (SDUC/ NHS111)

Secondary care Elective referral

Direct

Discharge

Emergency portal

Home GP

Social care

Community services

Other initiative

Public Health England

People with multimorbidity do not feel enabled by

healthcare encounters

In a study of over 3,000 GP consultations, patients withmultimorbidity (compared to those without) had :• More problems to discuss, which were more often

complex (a mix of physical, psychological, and social);Yet• Consultations were not longer for people with multi-

morbidity; and• Patient enablement was lower;• These findings were worse in deprived areas, and

GPs in deprived areas reported more stress in and after the consultations

General practice focus on LTCs: practice nurses, HCAs, GPs

Level 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’

Personal responsibility & self care

Right treatment for LTC, right delivery, right time, right team, right intensity

Technology enabled care services - meaning and scope

Focusing technology enabled care –along pathways

End of lifeSeveredisease

Early onset of disease

Unhealthy lifestyles

Poor life chances

Unemployment

Poor housing

Education

Smoking

Obesity

Diabetes

Hypertension

CHD

COPD

Heart Failure

Prolonging life and quality of carePreventing ill health

Frailty

9

Community Care

Primary Care

University/ Specialist Facilities

Social Care

GeneralHospital

ICare

The Future: co-ordinating TECS

TECS

LTC reviews

Home visits

Reminders

for

interventions

Skill mixAcute care

Patient groups

Incentive schemes

PV-områden (6)

Social care

teams

Patient

empower-

ment/ Better

clinical

outcomes

People

with

LTCs

apotek

How NHS and

social care

professionals can

provide LTC care

Patient focused: TECS

Integrative and innovative

PharmaciesCommunity Trusts

Practices

Trusts –

acute/mental health

Clinical

pathways/

protocols

Other service

providers

Supporting people at

home

Enhanced support at

home

Manage Crisis Effectively

Specialist acute input

How Flo Simple Telehealth can support the whole patient pathway

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

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)

Extent of responsibility for delivery of integrated & connected care via TECS

Implementing TECS in primary care

• skype

• encrypted video

consultation

• apps

• telehealth

13

The importance of self care

Enriching self care as agreed dual management

Helping people to help

themselves – as agreed with their

clinicians

It’s about the basicsimproving delivery of best practice care for long term conditionsvia patient empowerment, integration & innovation

16

Best clinical practice &

shared management

Tech

Improved QUALITY of clinical

care

Your blood pressure is under control when the top (systolic)

measurement is less than 135mmHg and the bottom (diastolic)

measurement is less than 85mmHg.

We hope your blood pressure readings will be below

135/85mmHg when you take them at home.

Follow a healthy lifestyle.

Take plenty of exercise – half an hour walking each day, if you can.

Eat sensibly – 5 portions of fruit and vegetables every day, and cut down

on fat, sugar and salt.

Keep your weight down, and aim for a body mass index of less than 25.

If you smoke, stop now.

Sometimes your blood pressure may be raised, and your reading

may be as high as 175/105mmHg. Although this is a high reading,

it might settle without any further change to your medication if this

is an unusual reading.

Keep taking the tablets every day as your doctor has prescribed.

Think if there is anything which has made your blood pressure worse, and

if you can identify it, take action to alter what has taken place.

Were you angry or stressed?

If your blood pressure remains as high as 175/105mmHg, make an

appointment with your GP or practice nurse in the next few days. If it is

only just above 135/85mmHg, wait and see if it settles and go for your

next usual blood pressure review.

If your BP reading rises further:

above 175/105mmHg (that is above either 175mmHg and / or

105mmHg)

Very high blood pressure could trigger a stroke, so it’s important

for a doctor to adjust your tablets

as soon as possible to lower your blood pressure.

...........................................................................................................

Please note that if you send in a reading that is lower than an

acceptable range, (eg. you text 70/50 or lower), Flo will ask you to

take your BP again.

Stay calm, and continue with your present tablets; try some relaxation

techniques. Just sitting still and thinking about your breathing can help to

calm you down. Or think about a relaxing holiday you’ve had in the past.

If you repeat your blood pressure reading an hour later, and it’s still as high,

make an appointment to see your doctor or practice nurse within the next

couple of days if it is just above 175/105mmHg.

If your blood pressure reaches 200/105mmHg,or even higher, this is very

high, and you should contact a doctor urgently today.

Phone the surgery or, if it’s at night or the weekend, phone the Out of Hours

/ 111 service who can agree with you when you should be reviewed.

..........................................................................................................................

.If it is still as low as this an hour later you should call a doctor urgently

today and they can talk through any other symptoms you have and agree if

you should be seen urgently.

Personalised

Care of the

Highest Quality

Innovative services supportin

g independ

ence

Improve experien

ce & outcome

s

Work with

service users & carers

Empowered &

supported

workforce

Improve efficienc

y & producti

vity

Effective

Positiveexperien

ce

Safe

I will know

when my needs

change

My care & treatment will be co-ordinated to suit me

I will feel in control of managing my health

& Care

I will get the best possible treatment & support to

recoverI will always be treated

with compassion,

dignity & respect

I will feel safe but if things

go wrong I will be told The

feedback I provide will be

acted upon

Organisation’s vision

What we mean by quality

Organisation;s strategic goals

What care will look like for service

users

Remote consultations

Tele-diagnostics

Telehealth (home

monitoring)

Telecare(Supporting

independence)

Online digital support &

Mobile Apps

Alignment with national strategic direction

Unanswered Questions

• How do we identify the needs of our service users with regard to technology?

• How do we determine what type of technology meets the needs of our service users?

• How do we evaluate what works well?

• How do we know what represents good value for money?

• How do we know we are making a difference?

• How do we ensure workforce have skills & competencies to embed technology?

• What interdependencies are there with health economy infrastructure plans?

• How do we prioritise where to start?

• How do we ensure engagement & Buy-in to work in new ways?

Level 35%

High level of professi

onal support

Level 215%

medium level of professional support.

Need to identify those that can use technology

to support self management

Level 180%

self management supportsupport for whole population to

remain independent and informed with aim of identifying when needs

increase

On

line

self

man

agem

ent

& M

ob

ile A

pp

s

Tele

car

e &

pro

mo

tin

g in

dep

end

ence

Tele

hea

lth

& H

om

e M

on

ito

rin

g

Tele

vid

eo c

on

sult

atio

ns

& r

emo

te d

iagn

ost

ics

E-consultatio

ns

&

messaging

Video consultation

s & video therapy

Tele-diagnostics

Palliative care

Self –monitoring

, using advice

Home monitoring

with professional

support

Self care websites &

online solutions

Medicines management

Text based support

Mobile AppsTele-

coaching

Wound management

Support for families &

carers

Wound management

Risk stratification must be used to determine what fits where

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

Driver for TECS via CCG intelligence pack

Quality improvement in provision/delivery of care via TECS