Implementing Telehealth in
Gloucestershire
David Cockayne
What does a mainstream telehealth service look
like & what will Providers be expected to do?
Clinical Intervention:
Phone consultation, self care advice, home visits,
practice appointment, review patient parameters etc
Perceived activity scheduled into PN calendar,
usually 1 to 2 - 10 min tel triage appointments
Patient identified &
referred
for Telehealth service
(20 units per practice)
(2.6 units per GP)
Service desk:
patient enrolled onto
TH
Service desk:
installation visit
scheduled
Patient/carer trained and
equipment installed & tested
by on-site visit
Additional support provided
Practices have implemented layered
to help provider units:
COPD, HF, & Diabetes care pathways clinical triage to support TH :
First
review = Practice Nurse
Suggesting appropriate TH referral
points
If
further
support needed review with
Risk stratification
GP
or
Spec/Com
Nurse
List of SUS Data activity
Clinical advocates
Practice/clinical activity
Clinical escalation rate
ranges 2 to 4%.
Batch update at Practice
relevant time i.e. 11am to
Technical triage2pm.
=
non clinical
validation
of alert
(based
on 4% = <1
ALL incoming
per daydata
per to
practice)
prevent inappropriate
alerts being escalated.
Contact patient/carer, arrange installation Generally only validated
red alerts are escalated to
Co-ordinate equipment inventory
clinicians
Co-ordinate home assessment
Co-ordinate letter to GP, Consultant etc
Single point of contact
Referral management
Installation
Ongoing Service Support
Review & De-registration
Information Reporting
Service desk activity
Clinical assessment
of validated data
Escalate validated
high alerts
to Practice
Technical triage
validation of all data
Patient data accessed via
web-based triage software
hosted on N3
Telehealth is not an emergency response system
Collect
written
Usually once to
twice a day readingsIdentifiable
, often just Mon
to Fri
Anonymised
data
data
Daily
dataconsent
collection:
Ensure end to end transmission
(patients
may
do
7
days
a
week)
transmitted via
hosted in N3vital signs & health
Health & Safety procedure ensured
Recent NYY 200 patient satisfaction survey
secure
telephony
environment
question
responses
Answer any patient queries (non clinical)
96% satisfaction
Mainstream telehealth overview – NHS Glos
• NHS Glos procured a fully managed telehealth service for 2000
concurrent patients based on a lease deal. Includes provision of an
full time implementation team to support the implementation,
clinical engagement and deployment of the 2000 patient systems
• Telehealth forms an integral part of the PCT’s QIPP programme to
deliver financial savings in current financial year.
• Originally telehealth service was implemented within primary care,
primarily within COPD and CHF pathways, with Diabetes and CHD
pathways as co-morbidities.
• Now focussing on a wider scope due to improved reporting system
and support for clinical innovation
• Strategy was to initially engage health care providers through care
pathway optimization and then implement across all 6 localities in a
phased approach of 3 stages, 2 localities at a time.
Mainstream telehealth overview 2
• Primary care engagement commenced Aug 2011 (Nov 2011
deployment) and focussed on each locality for 6 weeks. Localities
selected on weighted criteria (see next slides)
• Although primarily focussed on managing patients through primary
care, whole health economy approach for engagement including
OOH, acute, community, mental health and social care (telecare)
services
• NHS Glos has an established small scale service for telehealth
based within spec nursing service (COPD & HF – 200 patient
systems - initially Tunstall supported). Managed separately from
mainstream programme but step up & step down process between
specialist services and primary care
• Community Services (DN service) CQUIN target for
recommendations for referrals into PC
Prioritising the localities – overall scoring
After applying the criteria, the localities have been scored and prioritised as follows:
Locality
Disease
prevalence
(criteria 1)
Finance/ activity
(criteria 2)
History of joint
working
(criteria 3)
Clinical
buy-in
(criteria 4)
Gloucester City
5.0
5.0
6.0
6.0
22.0
1
Forest of Dean
3.0
2.5
6.0
6.0
17.5
2
Cheltenham
5.0
5.0
3.0
4.5
17.5
3
Stroud
3.4
3.8
4.5
4.5
16.2
4
Tewkesbury
1.6
1.0
4.5
4.5
11.6
5
Cotswolds
2.4
2.8
3.0
3.0
11.2
6
Total
score
Priority
Notes:
1.
Criteria 3 and 4 are weighted at 1.5 to reflect the need for clinical engagement to roll out the telehealth equipment
2.
Fof D given priority as number 2 as it has higher clinical engagement score than Cheltenham. It also enables an urban and rural
implementation to commence at the same time.
5
Engagement Schedule
July
06
August
13
20
27
04
11
September
18
25
01
08
15
October
22
29
05
12
November
19
26
03
10
17
Phase 3
Pathways
►
Stakeholder Engagement
►
Workshops
►
New pathway
confirmation
Engagement
Confirmation
Implementation
►
Phase 1
►
Phase 2
►
Phase 3
Phase 1
Phase 2
Phase 3
Workshop – 2 a week
Pre-meet with locality PBC leads before start of phased implementation
Note: After October a targeted implementation will be carried out depending on the results of the fist 5 months.
6
24
How the managed service is implemented
in Primary Care within NHS Glos
Progress so far
•
Care pathways reviewed/optimised and telehealth embedded within care
pathways. Optimised pathways placed on MoM
•
All 6 localities are now engaged (see next slide). Practices engaged are now
beginning to refer and manage patients.
•
Primary care incentive agreed for QP QOF (9,10,11) and additional short term
(12 months) LES payment for initial workload of having staff trained and activity
associated with consenting patients (per patient LES payment). 81 out of the 85
GP practices have now signed up for the QOF payment through TH. 550 TH
service users – 350 – GP
•
Approved incentives for care services (CQUIN) for referrals to primary care and
number of staff trained. Supported care services in tools to support patient
referrals – assessment template
•
Developing clinical advocates for peer to peer support – sharing best practice
•
Working closely with early adopters to ensure managed service is working
seamlessly and efficiently for each practice
Next steps
•
Continue with primary care engagement and support practices on the
practicalities of implementing TH. Key focus is:
– Increase number of practices referring and managing patients
(realising the 81 signed up practices (65 ish referring)
– Supporting patient selection and capitalising on the number of
patients each practice refers (e.g. patient centred objectives for
management - see slide)
– Establishing practice processes and managing and reviewing alert
escalations
– Developing clinical advocates for peer to peer support
•
Continue to support whole health economy engagement ensuring TH
processes are embedded within relevant services
Example implementation summary
Tewksbur
Cheltenha
y
Cotswolds
m
Stroud
Glouceste
r
FoD
COUNTY
Held
Scheduled
Introductory meeting
TBC
76
Training meeting
6
36
21
Introductory meeting
28
10
Training meeting
0
7
2
Introductory meeting
1
2
18
Training meeting
8
0 1
3
Introductory meeting
8
19
Training meeting
1 0
10
6
Introductory meeting
4
14
Training meeting
3
7
6
Introductory meeting
0
4
11
Training meeting 0
2
4
4
0
1
Training meeting
4
0
1
80%
90%
10%
0
9
Introductory meeting
0%
3
20%
30%
40%
50%
60%
70%
100%
Example patient objectives for managing on
Telehealth
Highlighting examples of where telehealth has been found to be helpful, backed up
by peer to peer endorsement and patient examples has proved effective, e.g.
•
Stable but significant illness – use as a tool to reinforce self management
and observation
– Trend monitoring for example weight in heart failure patient
– Symptom monitoring for example change in sputum colour and volume
•
Extra vigilance during a period of medication titration
– Bblocker titration in heart failure checking heart rate
– Monitoring of hypotension in Ace inhibitor up-titration
•
Alerts to identify episodes of decompensation early
– Oxygen sats dropping in patient with COPD
– Significant unusual weight gain in heart failure patient
Key considerations when implementing
telehealth
Communications are key – especially in early stages of engagement
Experience has shown that it is important to communicate clear messages on:
• Why TH has been purchased
• What the desired outcomes from implementing telehealth are
• Time frame for deployment & how it will be resourced/supported
In Glos this has been based on:
•
•
•
•
A need to reduce local health care costs especially around NE activity and to do so quickly.
Growing prevalence's of LTC and an aging population
Need to manage things differently with the same size or a reduced workforce
Evidence for effectiveness of TH to empower patients to self care and support remote
management of patients in their own home while reducing NE activity
– Other key issues:
•
•
•
•
Engage key/influencing clinicians in procurement
How Telehealth will benefit each clinical group (GP, Specialist, Community Nurse etc)
Any incentives to adopt TH into their normal clinical practices? E.g. QP QOF, LES, CQUIN etc
What processes/services are in place to support the implementation of TH and minimise the
impact on their already busy workloads.
12
• How the service will be evaluated
• TH is here to stay – not just another short term initiative!
Key considerations – Practical
Once we get patients onto Telehealth, keep gathering
momentum:
• Intensively work with early adopters to ensure TH
service is running as smooth as possible and all clinical
escalations are appropriate – referral initiatives
• Build hearts and minds
– Look to develop local clinical advocates
– Capture any early good news stories and patient champions etc
• Provide timely updates on service progress (see next
slide)