North Yorkshire and York

1. Practice experience of TelehealthDr David Geddes GP &Medical Director NHS North Yorkshire and York

2. North Yorkshire and York 3,200 sq miles 760,000 people 4.9 million tourists

3. Introduction to LTC and Telehealth • National 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

4. Introduction to LTC and Telehealth • North 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

5. 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.

6. 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: Patient centred Conforms to NICE Guidelines (published this summer for CHF and COPD) Uses innovation and technology (particularly telehealth) appropriately to support the patient Care is provided as close to home as appropriate Focus on self management Focus on education and prevention Outcomes focused Integration of Care across the Health Economy Uses resources efficiently Delivers national COPD strategy and diabetes national service framework

7. Map of MedicineLocalisation

8. Telehealth refer to telehealth where patient would benefit from being supported by a telehealth device Patients 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.pdf Referral Process: http://www.nyypct.nhs.uk/adviceinformation/referraltoolkit/_mom_docs/Tele-3a-SystemProcessMap.pdf Referral Criteria: http://www.nyypct.nhs.uk/adviceinformation/referraltoolkit/_mom_docs/Tele-3b-PatientSelectionCriteria.pdf Referral Form: http://www.nyypct.nhs.uk/adviceinformation/referraltoolkit/_mom_docs/Tele-3c-ReferralForm.pdf Amendments: http://www.nyypct.nhs.uk/adviceinformation/referraltoolkit/_mom_docs/Tele-3d-Amendments.pdf

9. York city centre practice 5200 patients Deprived High ‘GP footprint’ High prevalence of respiratory / cardiovascular and mental health illness Clifton Medical Practice

10. Clifton Medical Practice

11. Clifton Medical Practice • Mrs JT • 60 years old • Lives with her son • Diagnosis • COPD • Hypertension • Depression and anxiety • Arthritis

12. 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

13. Investigations FEV-1 = 0.84 38% predicted FVC = 1.75 CXR – no significant abnormality Pulse Oximetry 90% (on air)

14. 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?

15. 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!

16. Process for managing ‘alerts’ in Practice (Calder & Partners Practice) 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. Service desk Triage 10am to 11am Practice reception fax 11am 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 Patients take vital sign readings (telehealth) 5 days or 7 days – 6am to 10am Patient alerts passed to nursing team after morning clinic 11:30am Telephone Advice Discussion with Triage Doctor on call Patient • vital signs; • Blood pressure • Pulse • Oxygen saturation • Temperature Same / next day clinic appointment • 5) Weight • 6) ECG • 7) BG • 8) INR Nursing team makes a clinical judgement as to what intervention is needed Afternoon GP Visit

18. Does it work in practice? • Individualised care • Variation in PO2 • Monitor trends over time • Audit the care you provide • Evidence your outcomes PO2% severity

19. Audit / evaluation in practice Auditing a year of care Review 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)

20. Infection treated

21. 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.”