Urgent Care at Home - 5 ways that Digital Home Care can help

One of the toughest winters ever?

We all remember how tough last winter was. Whether because we work in healthcare and saw for ourselves or a loved one needed care or because we couldn’t escape the coverage on the news and in the media. I’ve just listened to episode 2 of the excellent podcast series “The NHS: Who Cares” hosted by Dr Kevin Fong which brings it back all too vividly.

Called “No Ordinary Crisis” It focuses on the pressure ambulance services are under with paramedics of 25 years’ experience saying last winter was the hardest they had ever known, with hundreds of calls for an ambulance not being responded to, despite best efforts. Hats off to South East Coast Ambulance Service staff for telling it as it is in this episode as well as Nigel Edwards and Anita Charlesworth busting several myths.?

It is well worth a listen if you do very much care about the NHS, although it is distinctly uncomfortable spending time in the shoes of deeply committed staff trying to deliver care when demand has outstripped capacity so markedly.

So, how can we avoid another winter like that??

Across the country, there are a number of areas providing local leadership and investment into remote monitoring that goes well beyond the Virtual Ward model and in this blog I will highlight some examples that are making a real difference to people with urgent care needs and the NHS services supporting them. I think these models are totally replicable elsewhere and if you are in a position to do something about that in the NHS where you are, I would urge you to do so.?

Context

Emergency Departments across the NHS in England have experienced another record-breaking year both in terms of increased volumes of patients attending - over 24 million emergency attendances - and decreases in performance against waiting time standards. Identical pressures are seen in Ambulance services where, across the country, ambulance response times have worsened severely over the past year with waits increasing for all categories and a doubling in waits for less urgent cases to an average of 3 hours. One in 10 ambulances is waiting over an hour outside hospitals. Demand has increased with more calls being for life threatening emergencies now 78% of all calls, from 69%. More than half of emergency admissions - 60% - relate to a Long Term condition that has got out of control.??

• Source: Health Foundation - Reducing emergency admissions: unlocking the potential of people to better manage their long-term conditions 2018 - link to full report below

Despite the introduction of new services including Same Day Emergency Care for ambulatory sensitive conditions, and Urgent Clinics, in many areas these as well as ED services are receiving an overwhelming level of demand. As President of the Royal College of Emergency Medicine Dr Adrian Boyle put it in The Times on 30th May

 “We still have lots and lots of nasty corridor care, and [also] people waiting for more than 12 hours”         

in an article describing that some ED departments are now spending 80% of their pay budget on agency staff.

It is time to think differently about how we support urgent care at home.?

Here are 5 ways it can help.

1. Remote monitoring available to community urgent response teams

Hertfordshire Community NHS Trust has an excellent Hospital at Home service and remote monitoring hub that has successfully cared for 4,000 patients led by their inspirational medical director Dr Elizabeth Kendrick and CEO Elliot Howard-Jones. This includes a large virtual ward supporting patients to leave local hospitals early, for a wide range of conditions, from acute respiratory infections to early discharge post knee replacement. The team recently won a Parliamentary Award for their great work.?

Hertfordshire has now taken this expertise into urgent care equipping its very active community urgent response service with remote monitoring boxes so they can have an additional tool to support people to stay at home. Working with East of England Ambulance service they have implemented a system on pilot weeks, where their community clinicians take direct responsibility for the assessment of patients where the ambulance service has been called and the most likely alternative outcome is conveyance to hospital.?

Instead of the estimated 100% conveyance rate, this has been reduced to 33% when the service was provided. Two-thirds of the circa 100 patients on pilot weeks were supported to stay at home. Patients were offered a range of services in the home, including remote monitoring. It also made a statistically significant and much needed reduction to ambulance handover delays outside hospital, and time lost by crews that could otherwise be responding to calls, and led to an 18% reduction in ambulance attendances at East and North Herts NHS Trust during the pilot weeks.?

I am aware of a good number of other ICS and Trusts currently exploring this model and it is being encouraged nationally which is great, but it would be superb to see it scaled up in time for winter so that most rapid response services could offer this to the patients they attend to. In order to achieve that, and have services well in place by the end of October, the pace needs to accelerate.

2. Remote monitoring available to ambulance teams?

To complement it, imagine paramedic crews having the ability to offer remote monitoring for any patients they are concerned about, instead of the very binary decision they are forced to make of either leaving at home or conveying to hospital. Remote monitoring provides the opportunity to keep a close eye on someone who may be fine at home, safe in the knowledge that clinicians are viewing their readings.?

If all progresses well, they recover in the comfort of their own home, and if any readings are concerning action can be taken. This can include video consultations, changes to medication, visits in the home for assessment and treatment, and where needed escalation either to a virtual ward or to a physical ward.?

In the meantime crews are rapidly back on the road to support the next call much more rapidly.?

3. Preventing emergency admissions due to asthma attacks through remote monitoring?

At Northampton General Hospital NHS Trust they now have a completely different pathway for asthma which has markedly reduced emergency admissions in this patient group. It is fully replicable by respiratory teams across the country.?

Their results have been impressive - within 6 months the use of remote monitoring had meant that three quarters - 76% - asthma patients had avoided being admitted and additionally of those admitted 24% were then discharged early thanks to this support.?

In its first year the service reached 300 people living with asthma and kept the vast majority at home. The CEO of Northampton General is Heidi Smoult and the lead clinician for the new asthma service is Respiratory Medicine Consultant Dr Fiona McCann.?

In this podcast, Fiona and team talk about how they set the service up within Integrated Care Northamptonshire. Fiona is joined by Asthma and COPD nurse specialist Frances Mulligan-Evans and GP Dr Rob Gale of Langham Place Surgery, Northampton as well as retired teacher and grandfather Ian Mcllroy, who has asthma and was one of the first to be supported at home virtually by the trust’s specialist respiratory team.

A transcript is also available below, this is episode 9?-

4. Remote monitoring preventing emergency admissions for exacerbations of chronic disease?through proactive Health Hubs

In Airedale NHS Foundation Trust in Yorkshire, their goal has been on prevention of hospitalisation in those with long term conditions. They have had a particular focus on Chronic Obstructive Pulmonary Disease, (COPD) a disease that nationally has a 42% readmission rate at 90 days, and is highly seasonal, playing a major role in the creation of “winter pressures”.?

Because of the impressive results they achieved with the first 50 patients on the pathway last winter - written up in Thorax and an NHS England case study - the team at Airedale is now expanding this offer to all their patients and now have 5,000 patients on a remote monitoring pathway. They have demonstrated up to a 50% reduction in emergency readmissions in the cohort of COPD patients who are supported by a simple digital tool and clinical support.?

Other areas, Imperial College Healthcare NHS Trust in North West London for instance, have achieved similarly stunning results in Heart Failure.?

This great video explains how it works -

I’d love to see other ICSs and NHS Trusts do the same and boldly go after some of the results the LTC Health Hubs are achieving so that these improvements could be available to all who could benefit and keep them out of hospital this winter. We know hospital admission is particularly punishing for the elderly, and I feel there is much more we can do to “winter proof” and protect those living with progressive LTCs that will otherwise see them regularly spend time in hospital as their condition goes out of control.?Proactive, personalised care combined with remote monitoring is a terrific way to do this, as these leading examples demonstrate.

5. Virtual Wards

Virtual Wards also have a role to play of course, and they need to expand further. That is when they will really impact flow and reduce overall bed occupancy, which remains far too high, making it impossible for the NHS to absorb even small peaks in demand. They feature as part of the Urgent and Emergency care plan with a commitment to reach 50,000 virtual ward beds by winter 2023.

How we use Winter Funding to best effect

Winter funds are being spent in many directions; extending Emergency departments, ambulance bays, receiving areas, building more physical beds, seeking to recruit more staff, and much of this is of course needed. It may mean people wait more comfortably and are in a more suitable place for care. But none of this will actually stem the flow, or tackle the root causes.

Most people in hospital are there because they have a long term condition that is out of control, this represents 70% of hospital bed use (and NHS expenditure) and 60% of emergency admissions.

We’ve seen dramatic results in both the Health Hub model and by equipping community teams with remote monitoring in helping keep people in control of their condition, and getting support when readings suggest something is up, ahead of the issue escalating such that obviating admission becomes impossible.

Isn’t it time we made this the standard of care for long term condition management across the NHS?

So these are five things I would be delighted to see adopted at scale across the NHS to help us all have a much better winter.?

Tell me about your results?

If you have examples of remote monitoring working in this way locally, or in other ways to benefit the urgent care pathway do let me know, as I would love to hear about them and to help spread the word about schemes that are doing well, spotlighting the teams that are thinking differently about how we support people to stay well over this winter, and beyond.

Please send details through a Linkedin message or in the comments as I’d be keen to share some further examples in a second blog on urgent care coming out in August.?

Finally, if you are in a position to introduce these types of services locally, please crack on. If me or the team can help in anyway, just shout.