TELEHEALTH SUCCESS STORY 17:
Transforming care for COPD patients in Argyll and Bute
This project, begun in early 2009, was specifically aimed at helping people in remote and rural Scotland manage their long term conditions better, and stay well in their homes longer. The Isles of Bute and Luing were some of the sites chosen for the project. For the health services the principal benefit was to avoid unnecessary admissions which, for islands, can often involve the use of a helicopter out of hours. The main solution chosen by Argyll and Bute CHP was Telehealth Solutions’ HomePod. Part of a whole system change aimed at improving patient care, this device enables remote monitoring of patients’ vital signs and answers to questionnaires, on a daily basis, via a secure link to a server accessible only by clinicians. As a result it enables patients to feel empowered to be part of their own condition management. The initial condition, on which this evaluation has been made, was COPD. Patients and their carers were partners in this work, enabling an increase in self management. Local nurses’ knowledge of long term conditions increased so they are now a resource for all patients.
The Argyll & Bute Telehealth Project had several aims, these were:
• To expand the use of technology to support successful management of long term conditions.
• To develop expertise in local staff to use remote monitoring as part of direct patient care.
• To expand the specialist knowledge available in one locality by developing practitioners with a special interest in long term conditions in the project areas.
• To link the work on monitoring long term conditions to the reduction in crisis admissions to hospital for this patient group.
• To monitor in conjunction with other agencies the effectiveness of this work.
• To showcase Argyll and Bute as an innovative and forward thinking partnership area.
• To assist patients to manage their long term conditions well and take ownership.
The HomePod can be attached to a wide range of peripherals (such as pulse oximeter, scales, sphygmomanometer, glucometer, peak flow meter etc) depending on condition. This device uses a touchscreen with large white-on-dark-blue writing that prompts users to take vital signs readings, poses questions on their condition, and sends responses to a central server. This server raises alerts to the community nursing team if any combination of vital signs and/or responses is outside pre-set parameters, and provides a full set of data including historical trend analyses for triaging and assessing care plans for patients. These touch screen devices are designed to enable patients to measure and record a range of key variables, including their own weight, body mass index (BMI), oxygen saturation, pulse and blood pressure without on site clinical supervision.
Information gathered from the patient home pod is sent securely by wireless or broadband to the Telehealth Solutions secure server, maintained by a third party and behind the NHS firewall. Nominated community nursing teams check this website daily and are alerted to any changes in the patient’s condition, to enable appropriate patient follow up where necessary. Texts and e mail alerts can also be sent to the clinician to make them aware soonest to any alerts waiting.
In contrast to many other telehealth implementations, this project broke new ground by being a genuine whole system change, involving a complete redesign of the management of COPD patients in Bute, integrating remote monitoring, access to specialist COPD expertise, pulmonary rehabilitation and medicine usage reviews.
Tied in with the remote monitoring, and to add to the whole system change, the nursing staff were also introducing regular pulmonary rehabilitation classes with a particular focus on those that are being monitored remotely.
Another important innovation is that as the nearest specialist respiratory nurse, in Oban, is two hours away from Bute plus a ferry ride and the Isle of Luing is even harder to get to, the use of remote monitoring enabled us to establish a review mechanism for that nurse to oversee all the patients’ progress and be on hand to give advice when required.
A particularly valuable service she provided was carrying out a full medicine usage review which in itself delivered significant benefits; she has subsequently been able to advise on fine tuning of medication that has also ameliorated patient conditions.
This overseeing role has resulted in a further – planned – benefit: the Bute community nursing team has now become far more skilled in COPD management, including the use of COPD modules at the local university and the introduction of nurse prescribing. As a result, there is now scope for the specialist nurse to begin a new project elsewhere, so fulfilling the need to make the changes self-sustaining.
The equipment itself is also an innovation being standard hardware with custom software added. This has meant that it is easy to upgrade the functionality of both the HomePod and the CommunityPod as the science of remote patient management advances and as individual patients change in their requirements. In addition, new peripheral equipment can easily be added as the telehealth service is expanded to cover other conditions, such as an INR device for a hypertensive patient having difficulty managing their Warfarin or, when it is unveiled later this year, a BNP sensor for people with CHD. A further innovation is that the kit is entirely wireless and so can be installed or moved by trained nursing staff without requiring installation of for example an ADSL line.
Capturing patient’s experience was also very important, about what the use of telehealth had done for them and how they are affected by their condition. To capture this Argyll and Bute, together with an external evaluation, ran a digital voices workshop and have now published a selection of digital stories about telehealth that only the storyteller can tell. These are very powerful.
The end result of this transformation has been a dramatic reduction in usage of care services, and an equally significant improvement in patient outcomes.
The evaluation, carried out by the University of Aberdeen (Professor David Godden) and completed in mid 2010, was designed to determine progress against the original project objectives and to inform any future rollout of such systems across NHS Highland. A mixed methods approach was adopted including both quantitative and qualitative data collection.
Users of the systems in all areas were generally older people (range 61-102 years). The mean age was 73 years in Bute and 71 years in Luing. In all the feedback received only a very minor few found any small difficulty in engaging with the technology, and this was resolved with further instruction and support.
The evaluation showed that:
• satisfaction with the use of HomePods in Argyll & Bute was generally high
• similar high levels of satisfaction were found with both patients and health professionals
• admissions to hospital fell by 91%,
• attendances at GP fell by 41%,
• inpatient bed days fell by 89%.
• 93% HomePod users said very comfortable/comfortable about their health being looked after remotely
• 78.5% of COPD users said yes generally/yes definitely when asked if their awareness of their condition had changed since using telehealth
• 93% of COPD users said they did not find using the technology difficult.
• 100% of COPD users said yes definitely or yes generally to feeling safe about their wellbeing being monitored in this way
Staff and carers were also evaluated regarding their interaction with telehealth and the same positive benefits and responses were received.
In conclusion this project has taken technology new to this area and patient group, employed it in a remote and rural area with challenges of geography and transport, and successfully managed a group of patients to achieve the overall aims of the original project.
The project was nominated for – and won – every significant Scottish health innovation award.
The evaluation showed the success of the project and recommended further rollout, which is now underway across Argyll and Bute, and NHS Highland as budget opportunities permit.
The project itself continues in the Isles of Bute and Luing with additional patients being added as appropriate. Since the end of the project, there has continued to be a very low level of COPD on the islands which continues the trend identified in the assessment.
Elsewhere there is still concern that telehealth will add to the burden that hard-pressed health staff have to shoulder, but as Sheena Ferguson, who now manages the Isle of Bute telehealth service says: “Caring for these patients does not take much time or effort really which is why everyone should be using Telehealth.”