Transformation in practice: an exploration of the large scale implementation of telehealth monitoring in Bristol

Abstract

Background: Telehealth monitoring, introduced in Bristol in 2011, offered a new approach to home management of people with long term conditions. The three year scheme was ambitious, focussing on the Quality, Innovation, Prevention and Productivity (QIPP) and Care Closer to Home agendas. This was not a pilot but a commissioned service to support different ways of working. The aim was to reduce use of NHS resources through anticipatory clinical practice and improved self care behaviours. Aims: It was intended that 600 Telehealth units would be introduced during 2011 to pathways for chronic obstructive pulmonary disease (COPD) and heart failure (HF). Expected outcomes were: improved patient self care and reduced hospital admissions and primary care consultations. Also, any reduction in community nurses’ patient contacts, resulting in improved productivity. This depended on effective system integration and redesign and staff engagement with the change. Approach: Telehealth implementation required a partnership between commissioners and providers. As one of the largest Telehealth initiatives at the time and still an evolving area, it offered significant challenges for all. During year 1 the project plan took longer than anticipated to deliver; reorganisation within the community services provider was imminent and the teams were being restructured. Patients were recruited from referrals to community nurses and the way in which nurses worked was impacted on as processes changed. This led to resistance to Telehealth and poor engagement; therefore nurse champions were identified to support implementation. Commissioner expectations were high, to ensure deployment targets were met. The Telehealth Support Team was introduced to manage installations and issues. Targets meant a move to numbers deployed, rather than appropriate selection. Attempts made to recruit patients managed by Primary Care failed due to lack of incentives and quality evidence. Outcomes: Since 2011, 1012 patients have been selected for Telehealth (COPD 51%; HF 46%; both 3%). Over 400 are active on the system. Patient experience is overwhelmingly positive: it reduces the need to for them to contact their doctor and improves independence and confidence. Nurses believe Telehealth reinforces patient’s role in self care and has led to improvements in productivity in the teams, through new ways of working. Nurse phone calls have reduced by 40% and visits by 18% compared to before Telehealth. Fewer contacts with GP practices have occurred: an average of 83% fewer phone calls, 57% less visits. LTC6 results show 91% were ‘somewhat’ or ‘very confident’ managing their condition before Telehealth, 100% afterwards. A International Digital Health and Care Congress, The King’s Fund, London, September 10-12 2014. International Journal of Integrated Care – Volume 14, 01 November – URN:NBN:NL:UI:10-1-116557– http://www.ijic.org/ statistical significant reduction in unplanned admissions was seen for COPD (<0.05); some had fewer admissions, but those that were admitted had more. Unplanned activity for HF was small. Community staff engagement in Telehealth is now good; most teams have adapted positively. Learning:The findings are encouraging, considering challenges faced. Key points of learning highlight the need for: • Incremental implementation at a pace that supports local adjustment. • Identification of champions to provide peer to peer support • Effective patient recruitment, monitoring of progress and clear ‘discharge’ criteria to maximise benefits • Identify incentives for GP practice involvement, eg reduced demand