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