care anywhere
Ann Wagner
Director of Strategy & Business Development
2
SCENARIO FOR A FRAIL ELDERLY PATIENT TODAY
EDNA IS 79 YEARS OLD, HAS
CHRONIC CHEST DISEASE
AND LIVES ALONE AT HOME
1
2
E...
3
SCENARIO FOR A FRAIL ELDERLY PATIENT TOMORROW
EDNA IS 79 YEARS OLD, HAS
CHRONIC CHEST DISEASE
AND LIVES ALONE AT HOME
1
...
introducing Airedale
our focus
right care
telehealth, e health,
digital health…..
 Telecare
 Telecoaching
 Telemonitoring
Teleconsultation
teleconsultation journey
 Prison health care
8 year programme
Live in 15 prisons
Up to 50% change in patient flow
>1600 c...
Telehealth Hub
 24/7 seven day working
 Experienced acute nurses
 2nd tier - physician
 Shared electronic record
 Res...
0
100
200
300
400
500
600
700
Acute Admissions 1
Year Prior to
Deployment of
Telemedicine
Acute Admissions 1
Year Post
Dep...
care homes (continued)
0
200
400
600
800
1000
A&E Attendances 1
Year Prior to
Deployment of
Telemedicine
A&E Attendances 1...
call outcomes
results: 24 hr teleconsults to 26 patients with
COPD (at home) – 1 year pre/post
 Video system displays via home TV
 Pat...
nurse led triage is the norm
results: primary care
applications
case studies
 Trapped wind
 Sleep walker
 Falls
 CPR
 Allergic reaction
 Medication
 Good death
feedback
Patients/Carers
“The Telehealth Hub came into its own last
winter when snow and ice brought traffic to
a halt. My...
what are the challenges?
 technical (care homes)
 tariff
 scheduling
 collaborative working
(community teams, GPs)
 c...
our future vision
our next steps
 Scale up our teleconsultation work
 Transform workforce
 Adopt new models of care
 Close gap between p...
so what are we waiting for?
“Just been to Airedale
hosp & seen some of
best tech anywhere in
NHS including digital
patient...
any questions?
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Ann wagner Airdale NHS Foundation trust

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Directors of communications from 15 Swedish county councils visited London to learn more about the health and care system in England.This presentation is from this visit.

NHS Improving Quality planned and hosted the study tour as a result of close links with Jönköping, one of the councils represented in the delegation. Our guests learned about the important role of communications specialists in transforming healthcare in England, and the leading role NHS Improving Quality has taken in engaging and mobilising staff at scale and pace.

During the study tour it became obvious that many of the challenges and opportunities we face in our health and care system mirror those in Sweden, in particular issues such as emergency care, obesity and smoking, patient safety and working with the media. This was a fantastic opportunity for NHS Improving Quality to strengthen alliances at an international level and share ideas and approaches, and we hope to build on this in the future

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  • Take people through traditional patient journey

    Frail, elderly person – Edna – unwell and doesn’t know what to do so she calls services.
    An ambulance is dispatched and they take her to local ED.
    ED don’t have access to Edna’s record – they stabilise and admit her
    Edna stays in hospital longer than needed due to break down in system – at risk of falls and infection, disoriented and losing confidence
    Eventually discharged but no proper hand off – left alone and confused
    Huge risk

    Not the care anyone of us would like for our parents

  • So how could that story have been different?

    Edna is identified as someone who could benefit from a new model of care
    Edna is enrolled into the new care system with a multi professional team in support, integrated around her individual needs
    With their support Edna agrees she needs support in self management including pulmonary physiotherapy
    Edna is encouraged to monitor her own health – self care with support – using technology installed at home – not only does this give her control it also helps build confidence and supports independent living
    Part of the enabling technology includes telemedicine so Edna can access her health professionals, 24/7 and have routine consultations from the comfort of her own arm chair – the health and social care professionals can access Edna’s records so they have the latest information about her care and treatment and any changes in her condition
    Through this way of working home visits from primary care professionals are reduced and hospital attendances avoided
    Not only is it better for the patient, our modelling shows us this is a much better use of resources, with the potential to save health economies hundreds of thousands of pounds if deployed at scale





  • Mid 20’s of care homes locally, 1700-2000 residents. (More reliable data). Trust audit based on HES.
    Previous audit 17 homes and 1000 residents.

    Not all same residents, but all the same homes compared in year pre TM and year post TM.
  • We advise and do consultation and onward refer if necessary, asking for a GP visit if needed. Previously, many GP’s agree their figure would have been much higher than 27%, as homes understandably often needed a clinical opinion.

    CLAIRE – HOW FACILITATE GP OR NURSE REVIEW AT THE HOME?

    It doesn’t stop all admissions, and it shouldn’t as those that need to come in do, but the admission or attendance is then more planned/supported by the Hub who can contact appropriate people here to help prepare for the admission/attendance.

  • In addition to these figures, 60% drop in A&E attendances


  • So for our first 25 COPD patients with at home installations, you can see number of admissions compared to the previous year has reduced by 30%, plus a corresponding reduction in bed days


  • There are many applications for Teleconsultation to support people with a range of long term conditions such as COPD, diabetes, CHD, Parkinsons Disease. These include
    - nursing and residential care homes; Patients own homes; in the community; hospices to support people approaching end of life and to support their carers; In GP practices; occupational health; Prisons; Young Offender institutes; Connecting community hospitals; supporting clinical networks and clinical rotas. HEE, Paramedic transfer, use within the hospital

    And why stop here – what about retail, schools. Whilst we have focused predominantly on frail elderly, could also see a market for children and young adults using mobile technology such as smart phones – we are only limited by our imaginations as the technology already exists

  • Feedback from patients and their carers and healthcare teams is excellent.

    Our patients and their families rate the service highly, as do colleagues in nursing and care homes, primary care, hospices and other providers.

    As you would expect clinicians need a bit more convincing – but nevertheless overall clinicians also very satisfied

    Having pilotted in a number of patients own homes and a small number of nursing and residential care homes, our local CCG has now commissioned the service to be provided to all 30 of their nursing and residential care homes. By delivering at this scale we are confident this will have a significant impact once we go live in a few weeks
  • Vision overview as per Bridget voice over
    How will this be achieved:
    The GP practice will enrol patients with chronic conditions using a supported self-care tool (Vitrucare) to agree:
    Life (and Health) goals
    Patient led interventions
    Clinically led interventions
    Patient led monitoring of biomedical and personal condition and lifestyle markers (BP, weight, diet, exercise level, etc.)
    Using predictive analytics based on the power of the detail in TPP’s Research 1 database and the pan-district availability of SystmOne single patient record we will:
    Identify the top few % ‘frequent fliers’ and test new interventions to support their care in the community.
    Identify patients with patterns of clinical conditions and care delivery that predict adverse outcome for a wide range of common situations
    Address these individuals using a range of measures, including but not limited to:-
    Manage by exception, using the integration of the care record to identify those patients whose behavioural and biomedical outcome markers are deteriorating rapidly (i.e. monitor rate of change, not just absolute values)
    Rollout Airedale’s existing, proven telehealth solutions on a wider scale.
    Install teleconsultation support in the patient’s home (inside their internet delivered self care service) to support proactive management to prevent non-elective admissions
    Have case manager led coaching for those failing to deliver on the health plan which they have agreed with the GP
    Provide follow up calls 24-48 hrs post in-patient or A&E discharge to reduce readmissions
    Enable pharmacist led medicine reconciliation for multi-morbid patients which looks at the patient as a whole, optimising their medications and reducing potential for adverse events
    Develop integrated pathways, working across organisations, which are optimized by blending the patient’s health and social needs and using the power of the integrated SystmOne and VitruCare record to identify patients’ needs in a timely and granular way
    Iterate the approach, guided by near real-time reporting and rapid cycle tests of change (IHI methodology) which when combined with the rapid update of the software (3 weekly release cycle for SystmOne and apps based release cycle for VitruCare – both extremely rapid) means that the lab can perform many “experiments” over a short time frame.
    3) The key people involved in making this happen are:
    Patient at the centre of the model, self-managing and self-directing - by virtue of the fact they are supplying the whole system with real time information
    GP or specialist nurse adopting the lead coordinator role, enrolling the right patients and being the consistent clinical face
    Motivational Coach/Nurse the central case manager focused on patient coaching and monitoring
    Lay navigators non-clinical staff supporting the nurses
    Specialist consultants providing required support and helping shape interventions
    Social care staff getting involved early to support social requirements and enabling patients to stay at home
    Pharmacist working in the patient’s home to review medication
    ---------------------------------------------------
    Carers sitting alongside the patient and supported by the system to provide effective care
    Care Trust providing mental health, community health and support services
    Voluntary Sector & Other Agencies


  • “Jeremy Hunt @Jeremy_Hunt 3h Just been 2 Airedale hosp & seen some of best tech anywhere in NHS including digital patient records shared with GPs - and gr8 patient care”
  • Ann wagner Airdale NHS Foundation trust

    1. 1. care anywhere Ann Wagner Director of Strategy & Business Development
    2. 2. 2 SCENARIO FOR A FRAIL ELDERLY PATIENT TODAY EDNA IS 79 YEARS OLD, HAS CHRONIC CHEST DISEASE AND LIVES ALONE AT HOME 1 2 EDNA IS ALONE AND DOES NOT KNOW WHO TO CONTACT, SHE CALLS 111 AN AMBULANCE IS DESPATCHED AND TAKES EDNA TO THE EMERGENCY DEPARTMENT THE EMERGENCY DEPARTMENT DOES NOT HAVE ACCESS TO EDNA’S PRIMARY CARE RECORD. EDNA IS STABILISED AND TRANSFERRED FOR INPATIENT CARE DURING EDNA’S INPATIENT STAY HER SOCIAL CARE PACKAGE IS PLACED ON HOLD. THIS SUBSEQUENTLY RESULTS IN HER DELAYED DISCHARGE 3 5 4 6 EDNA’S CONDITION DETERIORATES EDNA AIREDALE PARTNERS FOLLOWING HER DISCHARGE EDNA IS CONFUSED ABOUT HER MEDICATION AND HER FOLLOW UP CARE PLAN ANNUAL PATIENT JOURNEY COST: £40,500ANNUAL PATIENT JOURNEY COST: £40,500
    3. 3. 3 SCENARIO FOR A FRAIL ELDERLY PATIENT TOMORROW EDNA IS 79 YEARS OLD, HAS CHRONIC CHEST DISEASE AND LIVES ALONE AT HOME 1 2 EDNA IS ENROLLED ONTO THE NEW MODEL BY HER GP EDNA IS SUPPORTED BY AN INTEGRATED, MULTI- PROFESSIONAL TEAM EDNA RECEIVES SUPPORT IN SELF MANAGEMENT, INCLUDING PULMONARY PHYSIOTHERAPY EDNA MONITORS HER OWN CONDITION USING GUIDANCE BUILT INTO HER ELECTRONIC WORK SPACE WHICH SHE ACCESSES FROM HOME EDNA USES HER WORK SPACE TO COMMUNICATE WITH OTHERS IN A SIMILAR POSITION AS WELL AS HEALTH AND CARE PROFESSIONALS IN THE EVENT OF A DISEASE FLARE, EDNA USES TELECONSULTATION TO SEE AND SPEAK WITH HEALTHCARE PROFESSIONALS AND SAFELY DEAL WITH THE ISSUE IN THE COMFORT OF HER OWN HOME 3 5 4 6 7 RULES DRIVEN ANALYTICS IDENTIFY EDNA AS SOMEONE WHO SHOULD BE SERVED BY THE NEW MODEL EDNA SUPPORTED SELF CARE PATIENTS IN CONTROL REDUCTION IN UNPLANNED HOSPITAL ADMISSIONS PRIMARY CARE CONTACTS MINIMISED BETTER REOURCE UTILISATION & VALUE FOR MONEY AIREDALE PARTNERS ANNUAL PATIENT JOURNEY COST: £26,100
    4. 4. introducing Airedale
    5. 5. our focus right care
    6. 6. telehealth, e health, digital health…..  Telecare  Telecoaching  Telemonitoring Teleconsultation
    7. 7. teleconsultation journey  Prison health care 8 year programme Live in 15 prisons Up to 50% change in patient flow >1600 consultations past 2 yrs  Stroke patients  Care at home  Nursing and Residential care homes  Supporting end of life patients  24/7 Telehealth Hub
    8. 8. Telehealth Hub  24/7 seven day working  Experienced acute nurses  2nd tier - physician  Shared electronic record  Resilient infrastructure  Technical partnership  Opened September 2011 – now supports >3238 people (April 2014)  EU 3 star status
    9. 9. 0 100 200 300 400 500 600 700 Acute Admissions 1 Year Prior to Deployment of Telemedicine Acute Admissions 1 Year Post Deployment of Telemedicine care homes results -35%
    10. 10. care homes (continued) 0 200 400 600 800 1000 A&E Attendances 1 Year Prior to Deployment of Telemedicine A&E Attendances 1 Year Post Deployment of Telemedicine 0 2000 4000 6000 8000 10000 Acute Beds Days 1 Year Prior to Deployment of Telemedicine Acute Beds Days 1 Year Post to Deployment of Telemedicine -53% -59%
    11. 11. call outcomes
    12. 12. results: 24 hr teleconsults to 26 patients with COPD (at home) – 1 year pre/post  Video system displays via home TV  Patients measure their Oxygen / Peak Flow  Typically have “rescue” meds at home -45%
    13. 13. nurse led triage is the norm
    14. 14. results: primary care
    15. 15. applications
    16. 16. case studies  Trapped wind  Sleep walker  Falls  CPR  Allergic reaction  Medication  Good death
    17. 17. feedback Patients/Carers “The Telehealth Hub came into its own last winter when snow and ice brought traffic to a halt. My Husband’s condition deteriorated suddenly, and having visual, instant contact with the team was very reassuring. A wonderful service.” “I only have one word to describe [the] Telehealth [Hub] – excellent.” “Telemedicine became our lifeline – what a wonderful piece of equipment! At the press of a button we could have face-to-face contact with a medical team, which is so important for both a patient and carer, and that helped to keep Geoff’s spirits high…” Care homes “A very good service. It made me feel confident within my job so I could do the best I can for our residents. This service takes the pressure off us as we have access quickly to a health professional…” “The Doctor was fantastic when one of our dementia patients fell and hurt herself. I would have called an ambulance and she would have endured an A&E visit which would have terrified her. Your consultant saved her from this and reassured me that the cut was superficial and she was fine...” “Definitely has reduced admission rates. Telemedicine is an asset to the home with benefits Out Of Hours and weekends”
    18. 18. what are the challenges?  technical (care homes)  tariff  scheduling  collaborative working (community teams, GPs)  culture change…STILL (evidence?)  the importance of scale  noise – right noise
    19. 19. our future vision
    20. 20. our next steps  Scale up our teleconsultation work  Transform workforce  Adopt new models of care  Close gap between primary & secondary care  Greater cross org working  Integrated, supported self care becomes the norm  Maximise benefits from technology  Understand resulting financial flows
    21. 21. so what are we waiting for? “Just been to Airedale hosp & seen some of best tech anywhere in NHS including digital patient records shared with GPs – and gr8 patient care”
    22. 22. any questions?

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