Self management of long term conditions can ease the burden on NHS resources and increase patient independence. A pilot aimed to assess the benefits of telehealth
Tony Paget, MSc, RGN,RMN, is a lecturer in health informatics, College of Human and Health Sciences, Swansea University; Craig Jones, RGN, is chronic conditions management team leader; Michelle Davies, RGN, is chronic conditions management case manager; Caroline Evered, RGN; Clare Lewis, BSc, RGN, are chronic conditions management case managers; all at Abertawe Bro-Morgannwg University Health Board, Swansea.
Paget T, Jones C, Davies M Evered C, Lewis C (2010) Using home telehealth empower patients to monitor and manage chronic conditions. Nursing Times; 106: 45, early online publication.
This article describes a pilot telehealth project in Swansea where patients with heart failure and chronic obstructive pulmonary disease were provided with telehealth monitoring equipment. Early evaluation points to some potential economic benefits, but supporting patient empowerment was a significant outcome.
Keywords Telehealth, Patient empowerment, Long term conditions
- This article has been double-blind peer reviewed
- Reluctance within the healthcare team to refer patients to the telehealth service can be overcome through training and by sharing its benefits.
- Patients need to understand the role of monitoring and that it is not an emergency response system.
- It is important to evaluate the effectiveness of telehealth using a variety of tools including validated health questionnaires and user questionnaires
The increasing burden of chronic disease on health care resources and costs provide a powerful incentive to find more compelling ways to care for patients with chronic illnesses (Pare et al, 2007). Our current health care systems continues to focus on acute care and neglect the patient’s role in managing their own health (Bensink et al, 2006).
One way of addressing these issues is through home telehealth. This provides a means to monitor, educate and counsel patients within their own home. Wootton et al, (2006) identified that home telehealth has the potential to collect monitoring information, give patients access to their own data, improve self management, reduce the need for home visits and ultimately the cost of home care.
Telehealth technology incorporates home monitoring technology designed to enable people to stay in their own homes and to take greater responsibility for their own care. The main aim is to empower patients, and in doing so prevent them from having frequent unplanned admissions, while allowing them to maintain their independence (Furrse et al, 2008; Dale et al, 2003).
Development of a telehealth service in Swansea
The chronic conditions management (CCM) team at Abertawe Bro Morgannwg University Health Board, Swansea set up a pilot of telehealth. The aim of the pilot was to allow patients to monitor their vitals signs and become more proactive in managing their condition.
Funding was secured as part of a grant from the Welsh Assembly Government to purchase 11 telehealth packages to be piloted by the CCM team. The Genesis monitor is a small device that looks like an alarm clock, which has a blood pressure cuff and pulse oximeter finger probe attached. It also has an option to attach other peripheral devices including glucometers, INR monitors and weighing scales. For the pilot, weighing scales were the only extra peripheral device used.
The pilot started in March 2009, and a total of 22 patients enrolled to take part up until March 2010.
Every day, the monitor comes on at a preset time and instructs the patient to take their blood pressure, oxygen saturations and weight, as required for their long term condition. In addition, the device prompts them to respond to a number of condition specific questions, which are presented on the screen of the device. The questions are simultaneously presented in an audible format, and are set by the CCM nurse who can tailor them to the patient’s specific needs. The patient can only answer “yes” or “no” by pressing the appropriate button. While this can limit the range of detail available from the patient, it has the advantage of making the user interface very simple as there are only two buttons to choose from. The patient can also opt to request a visit by the CCM nurse at this point.
The monitor is connected to a home telephone line and sends information to a secure web-based server. This information is then accessed via the internet by the patient’s CCM nurse who in turn can assess whether or not they need any intervention on that particular day. Reports can be printed at the patient’s request for them to take to outpatient appointments in secondary care.
The pilot study
Patients diagnosed with heart failure and/or COPD were included in the pilot study. Both these conditions were common in the CCM caseloads, accounting for a significant amount of hospital admissions and place the greatest demand on the service (Box 1). Patients invited to join the pilot had to meet inclusion and exclusion criteria (Box 2).
Box 1. Background of conditions chosen for the pilot study
This is a major public health problem in industrialised countries and its increasing prevalence has both clinical and socioeconomic implications (Biddis et al, 2009; Martinez et al, 2006; Antonicelli et al, 2008). Gambetta et al (2007) suggest there needs to be cost effective strategies that improve patient outcomes in the heart failure population.
This is one of the most common respiratory conditions in adults in the developed world and it poses an enormous burden to society, both in terms of direct costs to healthcare services and indirect costs to society through loss of productivity (Davey, 2008). In England and Wales, nearly one million people are diagnosed with COPD and half as many again are thought to be living with undiagnosed disease (National Institute for Health and Clinical Excellence, 2004).
Box 2. Inclusion and exclusion criteria
- Be registered with a Swansea GP;
- Have a basic literacy in English;
- Be willing and able to consent to be monitored using telehealth in their home;
- Have a landline telephone installed, with plug in type sockets.
- Physically unable to carry out the process of monitoring and has no care giver to assist;
- Known to be at the end of their disease process where intensive monitoring would not be appropriate;
- Unwilling to consent to have telehealth installed in their home or do not have a landline telephone installed with a modern plug in socket;
- Living in an unsafe environment for telehealth monitoring.
The aim was to monitor individual patients for a 12-week period, although this could be extended or shortened due to individual needs, with the pilot study running for one year. The first patient began monitoring on March 2 2009 and 22 patients had been monitored by March 2010.
Patients were informed that the monitoring process was not an emergency response system and this was reinforced on the consent form signed by patients before the system was installed. This was because readings were checked by the CCM team from Monday to Friday, 9am to 5pm. Patients were advised that although they could record outside these hours, the readings would not be viewed by the CCM nurse until the following working day.
They were instructed not to rely on the machine if they felt unwell and to contact the GP or out-of-hours service. It is technically possible to have the readings monitored by a 24-hour call centre, which would avoid this problem, but this option was not available to the team.
Evaluation of pilot
Data has been collected using the following tools:
- Minnesota heart failure questionnaire pre and post monitoring (Reigel et al, 2002);
- St George’s respiratory questionnaire (Jones, 1991) pre and post monitoring for patients with COPD;
- Patient experience questionnaires provided by ther manufacturer at the end of monitoring;
- Data relating to number of CCM/surgery consultations/visits and hospital admissions prior to commencing and during monitoring;
- Anecdotal evidence was gathered from CCM staff, patients involved in pilot and other members of the multidisciplinary team.
The pilot is being formally evaluated in conjunction with Swansea University and the outcomes will relate to both qualitative and quantitative data. Although patients consented to be part of the study, all data was anonymised before being exchanged with co- researchers.
The telehealth team which is part of the chronic conditions management team, encountered several problems due to equipment failure and reluctance of staff to adapt to new practices. Over half of the original monitors and peripheral devices supplied were faulty resulting in the company replacing all the monitors, and subsequently some of the new monitors had to be replaced for the second time. Some of the faults reported included failure of monitors due to electrical faults and which also affected some peripheral devices. Failure of the monitor screen to prompt questions was noted on some of the devices and some did not produce the audible versions of the questions.
A major obstacle to implementation occurred when the original devices were withdrawn for upgrading and staff already trained in to use this device required re-training.
Technical problems included overcoming apparent incompatibility of the device with some telephone exchanges and a delay when an unanticipated need to provide ADSL filters for patients’ homes with broadband installed was identified. This led to gaps in the monitoring of some patients and others refusing to have the monitors reinstalled in case further problems occurred.
At first there was some reluctance within the team to refer patients due to fear of increased workload and difficulty in identifying suitable patients. Initially staff were only given basic training and so found it difficult to anticipate the benefits for patients and felt that the software appeared complicated. Once staff started to use the software they found it user friendly and following provision of extra training, their initial reluctance to refer improved.
The telehealth team have undertaken this project in addition to their original workload. Initially the team checked the daily monitoring data but this role had to be transferred to individual case managers. This has caused a problem as some staff forgot to check data and they needed to be prompted by the telehealth team. Installations of the telehealth system in patients’ homes are currently being undertaken by the telehealth team, but this is time consuming and needs to be transferred to the CCM team.
A detailed analysis of the full range of data is underway, but there are some positive early indicators.
There are signs the pilot has achieved its aim to reduce unplanned hospital admissions. A comparison of admission rates before and after installation of the telehealth equipment show a reduction for most of the patients involved. Similarly, there appears to have been a reduction in the number of GP consultations following installation. In respect of visits by CCM nurses, the results are more equivocal, and have gone up in some cases. This may reflect an improvement in the detection of early signs of deterioration and extra visits may help prevent a hospital admission.
Feedback from patients via a consumer questionnaire is positive. As Kobb et al (2008), suggest the views of patients using telehealth systems maybe of some significance and positive perceptions could have a direct impact on health and health behaviour.
Patients find that having a “hotline” to the health professionals allows them to feel more secure and less anxious. Other responses point to an increased confidence in dealing with their symptoms and greater independence.
One of the main drivers for the use of telehealth equipment is to support professionals to monitor signs and symptoms, allowing them to intervene (Wootton et al, 2006). This assumes an almost passive patient who is uninterested in their own monitoring. Early on in the project, the team recognised that the patient benefits directly if involved in self-monitoring.
Feedback suggests patients see positive outcomes from being made aware of their own vital signs. Being able to associate how they feel with their vital signs empowers them to recognise early indicators of deterioration. One patient explained how he associated the feedback on his lowering oxygen saturation with very early symptoms. He was also able to identify when his oxygen therapy was effective. Most patients said they felt more involved in their care and more able to manage their own care during the telehealth pilot.
The ability to manage their care within their own home was another positive outcome identified by patients. Most said they would be more comfortable with an early discharge from hospital if they had telehealth monitoring and that being at home had other advantages. They felt that, as well as preferring their home environment it would promote better recovery, avoid hospital acquired infections and be easier for their family and carers.
The majority of patients taking part in the pilot found the equipment easy to use and were happy with the user interface. Some patients became so confident in using the system that they were able manually to check their blood pressure or oxygen saturations on an ad hoc basis. Suggested improvements from patients included extending the service for a longer period, and to cover weekends.
The early indications are that the pilot has been successful and was worth extending. Most respondents found the service helpful and were willing to recommend it to others. Most patients at the end of their twelve weeks on Telehealth monitoring did not want the system to be removed from their homes. One patient stated that “Telehealth has become a part of my everyday life”. However the majority of patients had become so dependant on the system that the team had to remove it gradually.
Telehealth is a relatively new idea in the management of chronic conditions and there is little evidence based research to support its use. However, it is developing rapidly and information on its costs and benefits is of increasing interest to decision makers in healthcare (Hailey et al, 2002). This view is echoed by Wootten et al, (1998) who added that in Britain, telemedicine systems have been proposed as a cost effective means of responding to structural problems in the NHS.
This small pilot scheme has shown there is some evidence of positive outcomes, which may be as much psychological as economic. The feeling of security that comes with the notion that someone is “watching over me” may be significant to someone worried about their health status and can have a positive health benefit as patients feel more relaxed.
The equipment provides a form of biofeedback, whereby the patient is made more aware of their own physiology via the readings that the machine provides. This is interesting, as being made aware of their own physiological readings on a daily basis is a relatively new experience for most of them and traditionally an area from which they are often excluded by professionals. Patients begin to associate the bio-feedback with how they are feeling at the time and become experts at understanding and then predicting their health status.
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