Transcript How is Carmarthenshire promoting independence

How is Carmarthenshire
promoting independence,
interdependence and self
care for its citizens living
with chronic conditions?
Leo Lewis
Project Manager
Presentation outline
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Telehealth and telecare
COPD electronic pathway
Lifestyle advisor
Community Oxygen Service
Other initiatives
Telehealth and Telecare
Better Breathing Project
• Funded through the EU eTen programme
• Hywel Dda Health Board
• Carmarthenshire Council Telecare team
HOSPITAL
resp nurses
Consultant
registrar
COMMUNITY
resp nurses
resp physio
clinical manager
• Welsh Health Informatics Service
TELECARE
team manager
telecare assessors
Aims of the projects
Better Breathing
To assess the safety and
feasibility of telehealth home
care in COPD in a UK
healthcare system
Telehealth and Telecare
Does home telemonitoring
reduce healthcare use in
recurrent hospital attenders
with COPD?
Secondary objectives
(usefulness):
• Does telehealth reduce
healthcare contacts?
• Does telehealth reduce
hospital admissions?
• Does telehealth improve
quality of life?
Secondary objectives:
• Does telehealth reduce primary and
community healthcare contacts?
• Does telehealth reduce secondary care
contacts and duration?
• Does telehealth improve quality of life?
• To record telehealth usage /
concordance during the 12 month
monitoring period
• To determine cost-effectiveness of
telehealth using changes in EQ5D, CAT
scores and healthcare contact
information
Study design
Better Breathing – 6
months, RCT
40 patients who had:
• established (usually severe)
COPD
• completed pulmonary
rehabilitation
• were known to Chronic
Disease Management
(community) COPD Team
• Monitoring undertaken by
nurses
• Telehealth device - Docobo
HealthHUB
Telehealth and Telecare –
12 months & crossover
RCT
240 patients with COPD
• of any severity of airflow
obstruction
• who have been admitted to
hospital once in the last 2
years
• Monitoring undertaken by
Telecare assessment team
• Only alerts responded to by
nurses
Telehealth devices –
Docobo HealthHUB
Tunstall RTX3370
Learning from Better Breathing
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Feasible model for delivering care
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Patients found technology easy to use
Reduced number of GP contacts
Trend towards reduced hospital admissions
Unsuitability of wired devices for some patients
Quality of Life was not improved
Patients may fail or forget to take daily readings
Telehealth may increase patient anxiety
Learning to date from large
study
Study design:
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Accuracy of number of patients with multiple admissions
Recruitment:
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Nurses are more effective in recruiting patients compared to the researcher
Training patients:
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Approach needs to be individually tailored to meet the patient’s ability to learn and understand
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Patients sometimes need reminding to monitor daily
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More emphasis on level of service, eg not 24 hours
Technical issues:
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Potential problems with different telephone landline providers
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Positioning of electrical and telephone sockets
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‘Immobile patients’
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Tunstall device generates alert for single exceeded parameter responses
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Increasing number of patients without landline
Operational issues:
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County Council staff are not routinely insured to deliver services in other counties
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Clinical alerts are required by text messaging as well as Email
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Timing of back-end system training for staff
COPD electronic care pathway
Structured template to collect, record and manage patients with COPD in
primary care:
• Optimises a patient’s ability to self manage
• Enables delivery of high-quality, evidence-based care
• Reduces unnecessary variation in practice
• Structured documentation to support better information sharing
• Colour coded sections for different care practitioners
• Facilitates communication between practitioners & audit
• Data collection, eg exacerbations, medication, chest related GP
practice contacts and hospital admissions:
– 6 months prior to pathway commencement
– 6 months implementation stage
– 6 months post pathway
What information does the pathway
include?
Based on NICE COPD guidelines:
The key areas are:
• QOF requirements
• Demographics
• Smoking
• Body measurements
• Lifestyle advice
• Tests and investigations
• Symptom severity
• Examination findings and test
results
• Referral templates
• Self management plan
• Medication and review
• Signposting to services
All data entry on pathway is Read coded and automatically
updates the patient’s clinical record – no duplicate data entry
Evaluation and learning
• 86% of patients had fewer exacerbations
• 57% fewer exacerbations post pathway
• 43% patients received a change in their management plan
as a direct result of starting on the pathway
• Clear pathway definition
• Realistic approach from the outset
• Innovate ways to gain appropriate participation from nurses
and GPs working in primary care
• Determine pilot site early on as its practitioners are key
stakeholders
• Plan for success and identify appropriate local service
improvement programme to facilitate roll out
Lifestyle advisor
Provides primary prevention and health promotion for those who are at risk of
developing chronic conditions, offering targeted interventions and lifestyle
support:
• Self referral and care professional signposting
• Up to 6 face-to-face sessions
– Healthy Eating/Diet
– Alcohol
– Smoking
– Physical Activity
– Emotional Health
• Sessions held in GP practices and community settings
• Evaluation includes:
– Patient satisfaction
– GP surgery staff views
– Patient outcome data
– Specific tools relating to lifestyle aspects e.g. Hospital Anxiety and
Depression Score (HADS), Lifepsychol
– Lifestyle Advisor journals evidence base review
Learning to date from Lifestyle
Advisor
• Early and ongoing engagement with GP practices is
essential
• A tailored communications and marketing plan is required
• Little interest in small affluent rural practice population
• Enhanced role of NHS Direct Wales Information Specialists
has been welcomed
• Less intensive training required for Information Specialists
• Positive experience for patients:
“I’ve been waiting for something like this” and “This service
has enabled me to change my life”.
Community oxygen service
Established in Nov 2008 initially targeting highest
cost users of the 550 on Air Products contract
database
• GPs were contacted for additional clinical
information about patients to inform reviews
• Database reviewed and updated
• Patients seen in clinics or visited at home
• Oxygen prescriptions are adjusted to lowest cost
within patients’ needs where appropriate
• Over past year a period of stability has been
reached
Learning from oxygen service
• Carmarthenshire Oxygen spend 08/09 £386,408
• Duplicate, dead patients and incorrect details in Air
Products contract database
• Thorough understanding of Air Products charging
mechanism, eg selecting <2hours/day = up to and
including 2 hours/per day
• Locally held database now managed by Hywel Dda
co-ordinator
• Number of patients now on database is 424 –
reduction of 126
• Estimated saving of approximately £114,534 in 09/10
• Oxygen service model roll-out across Hywel Dda
Learning from additional
initiatives
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GP systems access to Health, well-being and support directory
– Communication through practice managers not entirely effective
– Lack of robust evaluation methodology
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IT System access for CRT co-location
– Simple solution but complicated to implement
– Simultaneous involvement of 4 IT support teams
– Little knowledge or understanding of IT by clinicians
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Information sharing
– Information Sharing Protocols using WASPI are required for the CRTs
– Co-location has enabled clients to move along pathways more quickly
– Trust and confidence has been quickly established in most cases
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Developing, aligning and sharing the vision
– Senior Management
– Leadership Groups
– Staff – particularly those in primary and community