NHS Stoke on Trent • 270,000 registered patients, 54 GP practices • 2 new GP practices and GP led Health Centre planned for 2009 • Some of the most deprived wards in England, • 5 PBC clusters closely aligned with the Local Authority neighbourhood areas Technology enabled care is a must- now! Dr Ruth Chambers OBE GP Stoke-on-Trent; Clinical lead for WMAHSN LTC priority; Clinical telehealth lead for Stoke-on-Trent CCG Clinical lead WMAHSN TECS exemplars
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Professor Ruth Chambers OBE, GP and Clinical Telehealth Lead, NHS Stoke-on-Trent Clinical Commissioning Group
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NHS Stoke on Trent
• 270,000 registered patients, 54 GP practices
• 2 new GP practices and GP led Health Centre planned for 2009
• Some of the most deprived wards in England,
• 5 PBC clusters closely aligned with the Local Authority neighbourhood areas
Technology enabled care is a must-
now!Dr Ruth Chambers OBE
GP Stoke-on-Trent;
Clinical lead for WMAHSN LTC priority;
Clinical telehealth lead for Stoke-on-Trent
CCG
Clinical lead WMAHSN TECS exemplars
The challenges
Number of Conditions1 % self reporting
1 30%
2 13%
3+ 10%
The 15 million people in England with long term conditions have the greatest healthcare needs of the population (50% of
all GP appointments and 70% of all bed days) and their treatment and care absorbs 70% of NHS and social care
budgets in England
1. The percentage of people aged 18 and over self-reporting experiencing long-term conditions in the GP Patient Survey
GP practices + other independent contractor practices
(including dentistry, pharmacy, optometry)
Patient
CCGCommissioning
Support Unit
Local Area Team/NHS
England
Public Health
Social Care Loca
l au
tho
rity
End of life care
Emergency services
Ambulance service Community
services
Partnership Trust
Community District Nurse
team
Mental HealthOut of Hours
services (SDUC/ NHS111)
Secondary care Elective referral
Direct
Discharge
Emergency portal
Home GP
Social care
Community services
Other initiative
Public Health England
People with multimorbidity do not feel enabled by
healthcare encounters
In a study of over 3,000 GP consultations, patients withmultimorbidity (compared to those without) had :• More problems to discuss, which were more often
complex (a mix of physical, psychological, and social);Yet• Consultations were not longer for people with multi-
morbidity; and• Patient enablement was lower;• These findings were worse in deprived areas, and
GPs in deprived areas reported more stress in and after the consultations
General practice focus on LTCs: practice nurses, HCAs, GPs
Level 3: High Complexity
Case Management
Level 2: High risk
Disease/Care Management
Level 1:
70-80% of LTC population
Self care support/management
Low cost, large-scale: ‘simple telehealth’
Personal responsibility & self care
Right treatment for LTC, right delivery, right time, right team, right intensity
Technology enabled care services - meaning and scope
Focusing technology enabled care –along pathways
End of lifeSeveredisease
Early onset of disease
Unhealthy lifestyles
Poor life chances
Unemployment
Poor housing
Education
Smoking
Obesity
Diabetes
Hypertension
CHD
COPD
Heart Failure
Prolonging life and quality of carePreventing ill health
Frailty
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Community Care
Primary Care
University/ Specialist Facilities
Social Care
GeneralHospital
ICare
The Future: co-ordinating TECS
TECS
LTC reviews
Home visits
Reminders
for
interventions
Skill mixAcute care
Patient groups
Incentive schemes
PV-områden (6)
Social care
teams
Patient
empower-
ment/ Better
clinical
outcomes
People
with
LTCs
apotek
How NHS and
social care
professionals can
provide LTC care
Patient focused: TECS
Integrative and innovative
PharmaciesCommunity Trusts
Practices
Trusts –
acute/mental health
Clinical
pathways/
protocols
Other service
providers
Supporting people at
home
Enhanced support at
home
Manage Crisis Effectively
Specialist acute input
How Flo Simple Telehealth can support the whole patient pathway
Enhanced support at
home
Supporting People at
Home
Manage step down from acute
effectively
Crisis Acute Trf of care
Home HomeSupport* Support
Long term
hypertension
Smoking
Cessation
Long term vital
signs monitoring
Care Homes
Pain Mment
Medicines
Management
“Worried Well”
INR
Weight loss
motivational
messages
Health self
assessment
Sexual health
Unstable
Hypertension
Newly diagnosed
hypertension
Medication
Reminders for: -
Hypertension /
Ashma inhaler /
pain management
Paediatric ashma
COPD
Diabetes (type1& 2)
Heart Failure
Palliative care carer
support/wellbeing
Falls prevention
Virtual Wards
Intermediate
care
Step down
facilities
Unstable vital
signs monitoring
Medication
management
As *Pregnancy induced
hypertension
Gestational diabetes
COPD
CHD
Diabetes
physiotherapy
Monitoring of pre op
patients to reduce
cancelled operations
Out patient acute
specialist follow up
DNA management
Support early discharge
EMAS unstable vital
signs monitoring
Oncology
Neurology
Speech therapy
Alcohol support
Learning disabilities
Mental health behaviour
Mental Health appt &
medication reminders/
supportive messages
Daily living/ medication
reminders for people
with Aspergers/autism
Long term
hypertension
Smoking
Cessation
Long term vital
signs monitoring
Care Homes
Pain Mment
Medicines
Management
“Worried Well”
INR
Weight loss
motivational
messages
Health self
assessment
Sexual health
5. Person selects and purchases own technology to support or improve their own health
and/or social care and/or lifestyle habits: they may include goal setting, reminders, records of
feelings/bodily measurements etc, action plans, information about best practice. They may or may
not share their personal information/record keeping generated by the technology (eg health app)
with a health/social care professional.
4. Shared delivery by individual professional with patient/carer: TECS initiated & delivered
by health /social care professional who updates other health/social care professional(s) or teams
involved in the patient’s care (ie giving information rather than interactive decision making
between professionals). It might be that a patient requested the inclusion of their personal
technology such as an app in their health or social care, that the initiating health/social care
professional has adopted; with shared care plan agreed by patient, that optimises patient
responsibility for their own care.
3. Shared multidisciplinary protocol with one TECS operator: ≥2 clinicians/ social workers, of
different disciplines, in same organisation or setting; sharing (delegated) responsibility for providing
TECS directly (≥1 mode of technology) for continuing care of same patient/≥ 1 conditions via
agreed care plan. (This might be by the most senior/expert defining patient pathway and endorsing
TECS protocol(s) for others to provide with real time support eg advice in person/by email; with
shared care plan agreed by patient, that optimises patient responsibility for their own care.)
2. Shared sequential responsibility: ≥2 clinicians/ social workers, in different
organisations/settings interface; so one hands over responsibility to the other for providing TECS
directly (same mode of technology or different) for continuing care of same patient/same condition
via agreed care plan.(This might be by the most senior/expert defining the patient pathway and
endorsing the TECS protocol for others to provide with real time support eg advice in person/by
email; with shared care plan agreed by patient, that optimises patient responsibility for their own
care.)
1.Shared real time responsibility by ≥2 clinicians/ social workers, in different
organisations/settings share TECS directly (same mode of technology or connected if
different) for delivery of an agreed shared care plan of same patient/ same condition at
same treatment phase (clinicians/ social workers have agreed responsibility via shared
care plan agreed by patient, that optimises patient responsibility for their own care)
Extent of responsibility for delivery of integrated & connected care via TECS
Implementing TECS in primary care
• skype
• encrypted video
consultation
• apps
• telehealth
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The importance of self care
Enriching self care as agreed dual management
Helping people to help
themselves – as agreed with their
clinicians
It’s about the basicsimproving delivery of best practice care for long term conditionsvia patient empowerment, integration & innovation
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Best clinical practice &
shared management
Tech
Improved QUALITY of clinical
care
Your blood pressure is under control when the top (systolic)
measurement is less than 135mmHg and the bottom (diastolic)
measurement is less than 85mmHg.
We hope your blood pressure readings will be below
135/85mmHg when you take them at home.
Follow a healthy lifestyle.
Take plenty of exercise – half an hour walking each day, if you can.
Eat sensibly – 5 portions of fruit and vegetables every day, and cut down
on fat, sugar and salt.
Keep your weight down, and aim for a body mass index of less than 25.
If you smoke, stop now.
Sometimes your blood pressure may be raised, and your reading
may be as high as 175/105mmHg. Although this is a high reading,
it might settle without any further change to your medication if this
is an unusual reading.
Keep taking the tablets every day as your doctor has prescribed.
Think if there is anything which has made your blood pressure worse, and
if you can identify it, take action to alter what has taken place.
Were you angry or stressed?
If your blood pressure remains as high as 175/105mmHg, make an
appointment with your GP or practice nurse in the next few days. If it is
only just above 135/85mmHg, wait and see if it settles and go for your
next usual blood pressure review.
If your BP reading rises further:
above 175/105mmHg (that is above either 175mmHg and / or
105mmHg)
Very high blood pressure could trigger a stroke, so it’s important