Transcript Dr David Geddes – Practice experience of Telehealth

Practice
experience of
Telehealth
Dr David Geddes
GP &
Medical Director NHS North
Yorkshire and York
North Yorkshire and York
3,200 sq miles
760,000 people
4.9 million tourists
Introduction to LTC and Telehealth
National strategy - shift in the management of long term
conditions
• Shift from a reactive to a more proactive, organised, preventative and
multidisciplinary model of care
• Partnership working between the patient and the healthcare
professional associated with regular review, adherence and
compliance to treatment, good communication and exchange of
information
• A more structured and systematic approach to admission
• Promotion of self-management and self-care though education and
training, peer support, tools and devices (such as telehealth),
information and healthy living
• An improved design and targeting of clinical interventions
• Redesign of incentives schemes and system management
Introduction to LTC and Telehealth
North York and Yorkshire (NYY) – Changing health needs
• Our aging demographics means the prevalence of LTC is continually
increasing
• People with LTC are intensive users of healthcare services.
• Non-elective admissions are increasing by 5-10% a year.
• Rurality of North Yorkshire leads to issues regarding access to
services
• To proactively address this growing demand and to respond to the
shift in the management of LTCs nationally, LTCs were set as priority
project within NYY’s Strategic Plan
• The PCT’s strategy for LTCs highlights the benefits of self
management and the introduction of telehealth to facilitate patients
remaining at home and reducing the need to access NHS services
Long term conditions
•
The development of care pathways for Long Term Conditions and the
associated implementation of the Telehealth programme is a key priority
within the PCT’s Strategic Plan
•
The project is planned to make a significant contribution to Q&P savings
and the new pathways will underpin commissioning arrangements for
2011/12 with partner acute Trusts.
•
As an enabler to this work, the PCT has purchased 2,120 telehealth units
from Tunstall, which will be rolled out across all Localities in NYY.
– Making NYY the largest telehealth site in the UK
•
A Q&P target of £1,400,000 has been set across a range of ambulatory
conditions, with a minimum target of £600,000 for CHF, COPD and
diabetes. The Telehealth business case suggests that greater savings over
and above this minimum can be achieved.
Care pathway principles
• The overall focus to redesign the care pathways is to optimise the care of patients with LTCs
• Technology is an enabler for the optimisation but not the whole solution
• The pathways have been developed in conjunction with published NICE guidelines and National
strategies for the management of LTCs, where available
• The pathways were further informed by Map of Medicine and have gone through systematic reviews
with clinicians across North Yorkshire, where front-line primary, community and secondary care
practitioners were consulted in order to draw on their local expertise
• Key principles were followed throughout the process of development of the new pathways:
o Patient centred
o Conforms to NICE Guidelines (published this summer for CHF and COPD)
o Uses innovation and technology (particularly telehealth) appropriately to support the patient
o Care is provided as close to home as appropriate
o Focus on self management
o Focus on education and prevention
o Outcomes focused
o Integration of Care across the Health Economy
o Uses resources efficiently
o Delivers national COPD strategy and diabetes national service framework
Map of Medicine
Localisation
Telehealth
refer to telehealth where patient would benefit from being supported by a telehealth device
Patients considered must be able to operate basic electrical equipment (e.g. a TV) and in addition must fulfil
ONE OR MORE of the following criteria:
•Patients that have had two or more unplanned admissions or emergency department attendances in the
last 12 months
•Patients that are deemed to be at risk of having an unplanned admission
•Patients with additional co-morbidities
•Patients that have high anxiety levels that usually defers to unplanned or emergency services and could
benefit from this level of support
•Patients who access GP services, out of hours services or the emergency services frequently i.e. frequent
flyers and frequent callers
•Patients who the referring clinician deems would benefit from telehealth
•Patients where telehealth would support the optimisation of medication
Please see Telehealth related links below:
Guidance:
http://www.nyypct.nhs.uk/adviceinformation/referraltoolkit/_mom_docs/Tele-3-Guidance.pdf
Referral Process:
http://www.nyypct.nhs.uk/adviceinformation/referraltoolkit/_mom_docs/Tele-3a-SystemProcessMap.pdf
Referral Criteria:
http://www.nyypct.nhs.uk/adviceinformation/referraltoolkit/_mom_docs/Tele-3b-PatientSelectionCriteria.pdf
Referral Form:
http://www.nyypct.nhs.uk/adviceinformation/referraltoolkit/_mom_docs/Tele-3c-ReferralForm.pdf
Amendments:
http://www.nyypct.nhs.uk/adviceinformation/referraltoolkit/_mom_docs/Tele-3d-Amendments.pdf
Clifton Medical Practice
• York city centre
practice
• 5200 patients
• Deprived
• High ‘GP footprint’
• High prevalence of
respiratory /
cardiovascular and
mental health illness
Clifton Medical Practice
Clifton Medical Practice
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•
Mrs JT
60 years old
Lives with her son
Diagnosis
– COPD
– Hypertension
– Depression and
anxiety
– Arthritis
COPD – a year of care
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9 appointments in primary care
2 hospital admissions (7 + 4 days)
3 OOH contacts
3 A&E attendances
6 courses of antibiotics +/- steroids
worsening breathlessness (20-30 metres)
reduced smoking from 20/day to 2 daily
unemployed
Increase stress- going through an acrimonious divorce
Investigations
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FEV-1 = 0.84
38% predicted
FVC = 1.75
CXR – no significant
abnormality
• Pulse Oximetry 90%
(on air)
Medical management…
• Have we maximised medical management?
• Has she a clear management plan?
• Can we minimised infective exacerbations damaging her
lungs?
• Are we over or under treat her when she presents with
discoloured sputum / increased breathlessness?
• Have we managed her associated anxiety / depression?
• Is she aware of her hypoxia ?
• Does she need LTOT?
Introducing telehealth in practice
• Getting clinical ‘buy in’
– GP lead
– nursing lead
– receptionist
• Training
• Mapping the practice
pathway.
• Identify ‘willing
volunteers’ – and give it a
go!
Process for managing ‘alerts’ in Practice (Calder & Partners Practice)
Vital sign readings are validated and only alerts that are outside
of the parameters will be passed to the Practice.
Service desk
Triage
10am to 11am
11am
Patients take vital sign
readings (telehealth)
5 days or 7 days – 6am to
10am
A list of patients which haven't been
able to perform a retest will be passed
to the practice by email or call at 14:00
or rolled over to the following day
Practice
reception fax
Service desk to fax
practice reception at
11am with today's
validated patient
alerts.
Patient alerts passed
to nursing team
after morning clinic
11:30am
Telephone
Advice
Patient
vital signs;
1) Blood pressure
2) Pulse
3) Oxygen saturation
4)Temperature
5) Weight
6) ECG
7) BG
8) INR
Discussion with
Triage Doctor
on call
Same / next day
clinic
appointment
Afternoon GP
Visit
Nursing team makes a
clinical judgement as to
what intervention is
needed
Does it work in practice?
• Individualised care
• Variation in PO2
• Monitor trends over
time
• Audit the care you
provide
• Evidence your
outcomes
PO2%
severity
Audit / evaluation in practice
Auditing a year of care
Review COPD patients before and after telehealth
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Risk stratification – our most high risk patients
6 patients currently being monitored
Freq of admissions / high cost
Patient satisfaction
Number of PO2% patient alerts
Number of treatments with antibiotics / steroid dose
Number of unscheduled interventions (OOHs / A&E/
admissions)
Infection
treated
Patient feedback
“ It is my new best friend!….I love it….I know
what my breathing is doing, so I can get
help for my chest before I get into
trouble…. I know when I need to start
antibiotics and I can see myself getting
better with the treatment I get.”