Leo Lewis Project Manager

1. How is Carmarthenshire promoting independence, interdependence and self care for its citizens living with chronic conditions? Leo Lewis Project Manager

2. Presentation outline Telehealth and telecare COPD electronic pathway Lifestyle advisor Community Oxygen Service Other initiatives

3. Better Breathing Project Funded through the EU eTen programme Hywel Dda Health Board Carmarthenshire Council Telecare team Welsh Health Informatics Service Telehealth and Telecare HOSPITAL resp nurses Consultant registrar COMMUNITY resp nurses resp physio clinical manager TELECARE team manager telecare assessors

4. Aims of the projects Better Breathing To assess the safety and feasibility of telehealth home care in COPD in a UK healthcare system Secondary objectives (usefulness): Does telehealth reduce healthcare contacts? Does telehealth reduce hospital admissions? Does telehealth improve quality of life? Telehealth and Telecare Does home telemonitoring reduce healthcare use in recurrent hospital attenders with COPD? Secondary objectives: Does telehealth reduce primary and community healthcare contacts? Does telehealth reduce secondary care contacts and duration? Does telehealth improve quality of life? To record telehealth usage / concordance during the 12 month monitoring period To determine cost-effectiveness of telehealth using changes in EQ5D, CAT scores and healthcare contact information

5. Study design Better Breathing – 6 months, RCT 40 patients who had: established (usually severe) COPD completed pulmonary rehabilitation were known to Chronic Disease Management (community) COPD Team Monitoring undertaken by nurses Telehealth device - Docobo HealthHUB Telehealth and Telecare – 12 months & crossover RCT 240 patients with COPD of any severity of airflow obstruction who have been admitted to hospital once in the last 2 years Monitoring undertaken by Telecare assessment team Only alerts responded to by nurses Telehealth devices – Docobo HealthHUB Tunstall RTX3370

6. Learning from Better Breathing Feasible model for delivering care Patients found technology easy to use Reduced number of GP contacts Trend towards reduced hospital admissions Unsuitability of wired devices for some patients Quality of Life was not improved Patients may fail or forget to take daily readings Telehealth may increase patient anxiety

7. Learning to date from large study Study design: Accuracy of number of patients with multiple admissions Recruitment: Nurses are more effective in recruiting patients compared to the researcher Training patients: Approach needs to be individually tailored to meet the patient’s ability to learn and understand Patients sometimes need reminding to monitor daily More emphasis on level of service, eg not 24 hours Technical issues: Potential problems with different telephone landline providers Positioning of electrical and telephone sockets ‘Immobile patients’ Tunstall device generates alert for single exceeded parameter responses Increasing number of patients without landline Operational issues: County Council staff are not routinely insured to deliver services in other counties Clinical alerts are required by text messaging as well as Email Timing of back-end system training for staff

8. COPD electronic care pathway Structured template to collect, record and manage patients with COPD in primary care: Optimises a patient’s ability to self manage Enables delivery of high-quality, evidence-based care Reduces unnecessary variation in practice Structured documentation to support better information sharing Colour coded sections for different care practitioners Facilitates communication between practitioners & audit Data collection, eg exacerbations, medication, chest related GP practice contacts and hospital admissions: 6 months prior to pathway commencement 6 months implementation stage 6 months post pathway

9. What information does the pathway include? The key areas are: QOF requirements Demographics Smoking Body measurements Lifestyle advice Tests and investigations Symptom severity Examination findings and test results Referral templates Self management plan Medication and review Signposting to services Based on NICE COPD guidelines: All data entry on pathway is Read coded and automatically updates the patient’s clinical record – no duplicate data entry

10. Evaluation and learning 86% of patients had fewer exacerbations 57% fewer exacerbations post pathway 43% patients received a change in their management plan as a direct result of starting on the pathway Clear pathway definition Realistic approach from the outset Innovate ways to gain appropriate participation from nurses and GPs working in primary care Determine pilot site early on as its practitioners are key stakeholders Plan for success and identify appropriate local service improvement programme to facilitate roll out

11. Lifestyle advisor Provides primary prevention and health promotion for those who are at risk of developing chronic conditions, offering targeted interventions and lifestyle support: Self referral and care professional signposting Up to 6 face-to-face sessions Healthy Eating/Diet Alcohol Smoking Physical Activity Emotional Health Sessions held in GP practices and community settings Evaluation includes: Patient satisfaction GP surgery staff views Patient outcome data Specific tools relating to lifestyle aspects e.g. Hospital Anxiety and Depression Score (HADS), Lifepsychol Lifestyle Advisor journals evidence base review

12. Learning to date from Lifestyle Advisor Early and ongoing engagement with GP practices is essential A tailored communications and marketing plan is required Little interest in small affluent rural practice population Enhanced role of NHS Direct Wales Information Specialists has been welcomed Less intensive training required for Information Specialists Positive experience for patients: “I’ve been waiting for something like this” and “This service has enabled me to change my life”.

13. Community oxygen service Established in Nov 2008 initially targeting highest cost users of the 550 on Air Products contract database GPs were contacted for additional clinical information about patients to inform reviews Database reviewed and updated Patients seen in clinics or visited at home Oxygen prescriptions are adjusted to lowest cost within patients’ needs where appropriate Over past year a period of stability has been reached

14. Learning from oxygen service Carmarthenshire Oxygen spend 08/09 £386,408 Duplicate, dead patients and incorrect details in Air Products contract database Thorough understanding of Air Products charging mechanism, eg selecting <2hours/day = up to and including 2 hours/per day Locally held database now managed by Hywel Dda co-ordinator Number of patients now on database is 424 – reduction of 126 Estimated saving of approximately £114,534 in 09/10 Oxygen service model roll-out across Hywel Dda

15. Learning from additional initiatives GP systems access to Health, well-being and support directory Communication through practice managers not entirely effective Lack of robust evaluation methodology IT System access for CRT co-location Simple solution but complicated to implement Simultaneous involvement of 4 IT support teams Little knowledge or understanding of IT by clinicians Information sharing Information Sharing Protocols using WASPI are required for the CRTs Co-location has enabled clients to move along pathways more quickly Trust and confidence has been quickly established in most cases Developing, aligning and sharing the vision Senior Management Leadership Groups Staff – particularly those in primary and community