North Yorkshire and York
description
Transcript of North Yorkshire and York
Practice experience of
Telehealth
Dr David Geddes GP &
Medical Director NHS North Yorkshire and York
North Yorkshire and York
3,200 sq miles760,000 people4.9 million tourists
Introduction to LTC and TelehealthNational strategy - shift in the management of long term
conditions
• Shift from a reactive to a more proactive, organised, preventative and multidisciplinary model of care
• Partnership working between the patient and the healthcare professional associated with regular review, adherence and compliance to treatment, good communication and exchange of information
• A more structured and systematic approach to admission • Promotion of self-management and self-care though education and
training, peer support, tools and devices (such as telehealth), information and healthy living
• An improved design and targeting of clinical interventions • Redesign of incentives schemes and system management
Introduction to LTC and TelehealthNorth York and Yorkshire (NYY) – Changing health needs
• Our aging demographics means the prevalence of LTC is continually increasing
• People with LTC are intensive users of healthcare services. • Non-elective admissions are increasing by 5-10% a year. • Rurality of North Yorkshire leads to issues regarding access to
services• To proactively address this growing demand and to respond to the
shift in the management of LTCs nationally, LTCs were set as priority project within NYY’s Strategic Plan
• The PCT’s strategy for LTCs highlights the benefits of self management and the introduction of telehealth to facilitate patients remaining at home and reducing the need to access NHS services
Long term conditions
• The development of care pathways for Long Term Conditions and the associated implementation of the Telehealth programme is a key priority within the PCT’s Strategic Plan
• The project is planned to make a significant contribution to Q&P savings and the new pathways will underpin commissioning arrangements for 2011/12 with partner acute Trusts.
• As an enabler to this work, the PCT has purchased 2,120 telehealth units from Tunstall, which will be rolled out across all Localities in NYY. – Making NYY the largest telehealth site in the UK
• A Q&P target of £1,400,000 has been set across a range of ambulatory conditions, with a minimum target of £600,000 for CHF, COPD and diabetes. The Telehealth business case suggests that greater savings over and above this minimum can be achieved.
Care pathway principles• The overall focus to redesign the care pathways is to optimise the care of patients with LTCs
• Technology is an enabler for the optimisation but not the whole solution
• The pathways have been developed in conjunction with published NICE guidelines and National strategies for the management of LTCs, where available
• The pathways were further informed by Map of Medicine and have gone through systematic reviews with clinicians across North Yorkshire, where front-line primary, community and secondary care practitioners were consulted in order to draw on their local expertise
• Key principles were followed throughout the process of development of the new pathways:o Patient centredo Conforms to NICE Guidelines (published this summer for CHF and COPD)o Uses innovation and technology (particularly telehealth) appropriately to support the patiento Care is provided as close to home as appropriateo Focus on self managemento Focus on education and preventiono Outcomes focusedo Integration of Care across the Health Economyo Uses resources efficientlyo Delivers national COPD strategy and diabetes national service framework
Map of MedicineLocalisation
Telehealthrefer to telehealth where patient would benefit from being supported by a telehealth devicePatients considered must be able to operate basic electrical equipment (e.g. a TV) and in addition must fulfil ONE OR MORE of the following criteria:•Patients that have had two or more unplanned admissions or emergency department attendances in the last 12 months•Patients that are deemed to be at risk of having an unplanned admission•Patients with additional co-morbidities •Patients that have high anxiety levels that usually defers to unplanned or emergency services and could benefit from this level of support•Patients who access GP services, out of hours services or the emergency services frequently i.e. frequent flyers and frequent callers•Patients who the referring clinician deems would benefit from telehealth•Patients where telehealth would support the optimisation of medication
Please see Telehealth related links below:Guidance:http://www.nyypct.nhs.uk/adviceinformation/referraltoolkit/_mom_docs/Tele-3-Guidance.pdfReferral Process:http://www.nyypct.nhs.uk/adviceinformation/referraltoolkit/_mom_docs/Tele-3a-SystemProcessMap.pdfReferral Criteria:http://www.nyypct.nhs.uk/adviceinformation/referraltoolkit/_mom_docs/Tele-3b-PatientSelectionCriteria.pdfReferral Form:http://www.nyypct.nhs.uk/adviceinformation/referraltoolkit/_mom_docs/Tele-3c-ReferralForm.pdfAmendments:http://www.nyypct.nhs.uk/adviceinformation/referraltoolkit/_mom_docs/Tele-3d-Amendments.pdf
Clifton Medical Practice
• York city centre practice
• 5200 patients• Deprived• High ‘GP footprint’• High prevalence of
respiratory / cardiovascular and mental health illness
Clifton Medical Practice
Clifton Medical Practice
• Mrs JT• 60 years old• Lives with her son• Diagnosis
– COPD– Hypertension– Depression and
anxiety– Arthritis
COPD – a year of care• 9 appointments in primary care• 2 hospital admissions (7 + 4 days)• 3 OOH contacts• 3 A&E attendances• 6 courses of antibiotics +/- steroids• worsening breathlessness (20-30 metres)• reduced smoking from 20/day to 2 daily• unemployed• Increase stress- going through an acrimonious divorce
Investigations
• FEV-1 = 0.84• 38% predicted• FVC = 1.75• CXR – no significant
abnormality• Pulse Oximetry 90%
(on air)
Medical management…
• Have we maximised medical management?• Has she a clear management plan?• Can we minimised infective exacerbations damaging her
lungs? • Are we over or under treat her when she presents with
discoloured sputum / increased breathlessness?• Have we managed her associated anxiety / depression?• Is she aware of her hypoxia ?• Does she need LTOT?
Introducing telehealth in practice
• Getting clinical ‘buy in’– GP lead– nursing lead– receptionist
• Training• Mapping the practice
pathway.• Identify ‘willing
volunteers’ – and give it a go!
Practice reception fax
Service desk Triage
10am to 11am
Patient
11am
11:30am
Patients take vital sign readings (telehealth) 5 days or 7 days – 6am to 10am
Afternoon GP Visit
Discussion with Triage Doctor
on callSame / next day
clinic appointment
Telephone Advice
Nursing team makes a clinical judgement as to what intervention is needed
Vital sign readings are validated and only alerts that are outside of the parameters will be passed to the Practice.
Service desk to fax practice reception at 11am with today's validated patient alerts.
Patient alerts passed to nursing team after morning clinic
vital signs;1) Blood pressure2) Pulse3) Oxygen saturation4)Temperature
Process for managing ‘alerts’ in Practice (Calder & Partners Practice)
A list of patients which haven't been able to perform a retest will be passed to the practice by email or call at 14:00 or rolled over to the following day
5) Weight6) ECG7) BG8) INR
Does it work in practice?
• Individualised care• Variation in PO2 • Monitor trends over
time• Audit the care you
provide• Evidence your
outcomes
PO2%
severity
Audit / evaluation in practice
Auditing a year of careReview COPD patients before and after telehealth • Risk stratification – our most high risk patients• 6 patients currently being monitored • Freq of admissions / high cost• Patient satisfaction• Number of PO2% patient alerts • Number of treatments with antibiotics / steroid dose • Number of unscheduled interventions (OOHs / A&E/
admissions)
Infection treated
Patient feedback
“ It is my new best friend!….I love it….I know what my breathing is doing, so I can get help for my chest before I get into trouble…. I know when I need to start antibiotics and I can see myself getting better with the treatment I get.”