My experience of commissioning Telehealth in Dorset
Nichola Arathoon, lead commissioner for telehealth in Dorset, explores some of the challenges experienced locally in embedding telehealth in practice and the successes achieved so far. She highlights areas for development in the future, and further challenges for both key health workers and their patients, and for commissioners.
Telehealth in Dorset enables patients to monitor their own health by using electronic devices in the home; supporting appropriate patients with Chronic Obstructive Pulmonary Disease and Chronic Heart Failure to self-manage their health condition. Patients can monitor their temperature, weight, blood pressure, pulse rate and oxygen saturation – depending on what has been agreed – and the frequency is determined by consultation between patient and key health worker. If the readings are ‘outside’ the pre-determined parameters for the individual patient, an alert is raised for the Key Health Worker to take action, such as a change in medication, which could lead to the prevention of an emergency admittance.
When I was asked earlier this year to take over as the lead commissioner for Telehealth in Dorset, I leapt at the chance. Supported Self-Management has always been at the heart of my practice whether it has been as a Physiotherapist working for 22 years with patients with long term conditions or as a commissioner for the past 7 years with the responsibility for commissioning services for patients with Long Term Conditions.
As commissioners we have been tasked to ‘support and encourage the innovative use of technology to improve health outcomes for patients with long term conditions and deliver more cost effective services to empower millions of patients to own their own care.’ Recent results from a review of Telehealth in Dorset are proving this to be the case for patients with Chronic Obstructive Pulmonary Disease (COPD) and Chronic Heart Failure (CHF).
However, the road to embedding Telehealth into practice has not been easy. Early findings across the country delayed the uptake locally, hence the decision was made that commissioners would lead the project and study it’s outcomes with clinicians and patients prior to the service being transferred to a provider organisation.
Telehealth users, their families and carers have been instrumental in adapting the service to meet their needs with many improvements being made locally. Users and carers have highlighted areas for improvement in making the technology user friendly and effective for them personally. This has had a positive effect for other Telehealth users e.g. the development of patient specific protocols for the sight impaired; development of a yellow sticker to be placed on the (very small) on/off button; messaging to the key health worker when the Telehealth user is on holiday and a conversion table for weight from kilograms to stones.
Key Health Workers have also been actively involved in service design and development e.g. agreeing criteria for referral to Telehealth, agreeing Care Plans with timelines for patients using Telehealth, consolidating the referral form for ease of use and developing top tips for colleagues and Telehealth users. This has led to positive feedback from Key Health Workers who have told us:
“Telehealth has freed up time for me to see new referrals quicker both at home and in the clinic setting, thus potentially improving patient care and reducing unnecessary admission to hospital.” Heart Failure Specialist Nurse
“Telehealth equipment can have real benefits to patients and the health community as analysis of patients’ use of the health system before and after the installation of Telehealth shows a significant reduction in the number of admissions and visits / calls from GPs and nurses.” Practice Nurse
Telehealth users and their carers report that using Telehealth has given them peace of mind, reduced anxiety and made them more relaxed about their condition. Some felt they had learnt more about their conditions, especially about their vital signs and what was considered a normal range for them. For example, if they were feeling unwell and took their BP and this was 'normal' they would not panic about having an exacerbation or becoming ill.
Although set times are agreed for Telehealth users to take their tests, it has proved flexible to users’ needs; one gentleman reported that he has recently been diagnosed with a renal problem and finds taking the home pod results for his BP to the Renal Consultant very helpful –“ the clinician is very impressed.” Another gentleman reported that since using the Telehealth home pod he has bought an iPod and now skypes his family in Australia.
Carers have also been instrumental in supporting Telehealth users. They report that not only have the users quality of life improved but so have theirs. One lady reported that not only had she benefitted from her husband taking more responsibly and control over his health but also had their dog who was receiving more walks and attention as she had been freed up from the worry of leaving her husband at home alone or from long periods of hospital admissions and visiting. Having the time and freedom to walk their dog had a positive effect on her health, wellbeing and coping strategies.
Receiving regular input from Telehealth users and carers has enabled us as commissioners to move the service even closer to the patient so that not only do they feel more empowered to manage their health but also they are empowered to make changes to the service.
Over 600 patients have used Telehealth in the past three years with a running total of 250 users at any one time. 231 patients were studied over a period of 12 months prior to Telehealth and 12 months post installation. 80% of these patients demonstrated a reduction or no change in the cost of hospital admissions with 43% demonstrating a reduction in cost. 81% demonstrated a reduced or no change in length of stay with 41% demonstrating a reduction in length of stay.
Although the main objective of Telehealth is to support patients to self-manage by understanding their condition more fully and thereby coming off Telehealth, 53 patients (9% of the total) have used Telehealth for more than 18 months. Of these, 41 patients demonstrated a reduction or no change in their length of stay in the 12 months following Telehealth installation, and 12 patients demonstrated a reduction in length of stay. There is some evidence here to support the theory that patients continue to benefit from Telehealth in the long term. In order to progress this theory, and enable patients to fully self-manage without close support, we will be looking at procuring a self-monitoring system e.g. App which will alert patients to when they should seek help from their Key Health Worker once the relatively expensive Telehealth devices and the close clinical monitoring are no longer required, thereby freeing up the technology and close monitoring for other users.
The challenge for key health workers and patients/carers is to find the balance between creating dependency and using Telehealth as part of a specialist nurse toolkit and a proactive route to self-management.
The challenge for commissioners is to embed Telehealth into the community service and to increase uptake by Primary Care for patients with COPD and CHF.
Principal Programme Lead, Long Term Conditions,
Frail Elderly and End of Life Clinical Working Group,
NHS Dorset Clinical Commissioning Group.