The increasing ageing population means nurses need to find innovative ways to manage long term conditions. A pilot site found telehealth has many benefits
Helen Lyndon,MSc, BSc, RN, DN Cert, is nurse consultant, older people and long term conditions; Dave Tyas, BA, PRINCE2 Practitioner, ITIL Foundation, is service improvement manager, self care and long term conditions; both at Cornwall and Isles of Scilly Primary Care Trust.
Lyndon H, Tyas D (2010) Telehealth enhances self care and independence in people with long term conditions. Nursing Times; 106: 26, early online publication.
The increasing prevalence of long term conditions will influence all nurses’ practice, irrespective of their particular field.
NHS Cornwall is taking part in a government trial, known as the whole system demonstrator programme, piloting telehealth and telecare to manage long term conditions. This article reports the initial positive results.
Keywords: Telehealth, Telecare, Long term conditions
- This article has been double-blind peer reviewed
- Nurses and other health and social care professionals need to embrace new technology and ways of working to provide care to meet the needs of the ageing population.
- Telehealth and telecare provide ways to enhance service capacity and support patients to self care.
Some 15.4 million people in England live with a long term condition and this number is expected to rise due to an ageing population and lifestyle choices (Department of Health, 2010).
Cornwall has significant problems that contribute to difficulties in developing responsive services that meet identified need.
It is the poorest county in England and has a dispersed rural population of 500,000, with 46% living in settlements of fewer than 3,000. Some 10% are aged over 65 and 21% report having a limiting long term condition, according to unpublished data from Cornwall and Isles of Scilly PCT. This means there are particular challenges in developing capacity in community services to provide care at or close to home in this area.
To address these challenges, NHS Cornwall has needed to think creatively and explore new ideas and technology. We therefore applied in 2008 to become a whole system demonstrator site for implementing telehealth and telecare for people with long term conditions.
Telecare and telehealth
Telecare refers to a range of active and passive sensors and devices installed in people’s homes such as bed occupancy monitors, falls sensors and medication reminders. Alarms are triggered by these devices and fed back to a monitoring centre.
Telehealth covers equipment installed in the home that enables patients to take their own biometric readings such as blood pressure, pulse, weight and temperature, as well as blood glucose and blood oxygen levels. These readings are accompanied by a set of individualised questions about their condition and symptoms that patients answer every day. These results are fed back via their phone line to a computerised system and the key worker who monitors their condition.
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Whole system demonstrator programme
The whole system demonstrator programme is the largest randomised controlled trial in the world to evaluate the effectiveness of telehealth and telecare; it is seen as critical to the future uptake of assistive technology in this country (Department of Health, 2009).
Commissioned by the DH, the trial involves University College London, the University of Oxford, the University of Manchester, Imperial College London, The Nuffield Trust, the London School of Economics and The King’s Fund.
The aims of the two year trial are to:
- Determine the effectiveness and cost effectiveness of the addition of telecare and telehealth, delivered alone or in combination, to whole systems redesign;
- Examine the service user, carer and professional factors associated with their effective use;
- Determine the organisational factors that facilitate or impede their adoption.
Three NHS and social care communities are involved – Cornwall, Newham and Kent. Newham in east London has the second most diverse population in the UK, while Kent has a combination of rural and urban populations.
The trial involves more than 6,000 participants with long term conditions or who meet other eligibility criteria (such as high levels of social care need) for telecare. Some 2,272 people have been identified to take part in Cornwall.
In the trial’s telehealth arm, patients have one or more of three long term conditions: chronic obstructive pulmonary disease; heart failure; and diabetes. Half are randomised into an intervention group and half into the control group.
The intervention group have telehealth installed immediately and the control group have “delayed intervention”, where it is installed after one year. Full evaluation results will be available in 2011.
Experience to date
Implementing telehealth on this scale has not been without its challenges and the logistics and organisation needed should not be underestimated. In addition, a programme of change management needs to take place with patients in this new way of managing their long term condition and with clinicians in this new way of working.
In Cornwall, we decided that patients known to the community matron and specialist nursing services would be monitored by them.
It quickly became clear that many patients who had been identified as suitable for the trial were not known to these services, so we put in place a small team of telehealth nurses and patient support assistants to monitor them. This team also provides cover for the community matrons and specialist nurses in their absence.
Training is offered on a one to one basis for all clinicians, with extra training and telephone support available as they become more familiar with the system.
Initially, clinicians had concerns about using telehealth such as: the time involved in monitoring patients; possible problems using the technology; patients’ ability to manage the equipment; and whether it would lead to increased patient contact and workload.
However, our experience has been extremely positive. Community matrons and specialist nurses have found they can monitor patients from any NHS setting so can be flexible with this. They appreciate the backup from the telehealth nurses who cover their absence and support them as needed.
We involved clinicians in testing the equipment and chose a user friendly system. We produce regular newsletters and bulletins to keep them informed and ensure that any individual concerns are addressed in a timely way.
Concerns about workload and patient issues have not proved to be founded to date. Community matrons have reported that using telehealth has increased capacity, in that they can monitor appropriate patients remotely so free up capacity to visit those who are more acutely unwell. This is extremely valuable given Cornwall’s rural nature.
Clinicians also report that they value the ability to use biometric readings to monitor trends and to spot early signs of deterioration in patients’ conditions. This has provided a new way to manage exacerbations which may previously have led to hospital admissions.
Most importantly, clinicians have highlighted how using telehealth enhances self care and patient independence. One said:
“I get to know patterns with patients’ biometrics which often signify an exacerbation. It backs up phone triage with objective information.”
So far, we have focused on understanding patients’ experiences of using telehealth and its impact on quality of life. As a result, we have encouraged regular feedback in all contacts with patients and a regular newsletter, and set up user groups to provide an ongoing forum for support and information.
The majority of feedback, collected mainly through telephone conversations, has focused on patients’ experience of using the equipment, the monitoring process and what it has meant to patients themselves.
We are planning to use Experience Based Design (NHS Institute for Innovation and Improvement, 2010) methodology to obtain more patient stories.
The main themes from patient feedback were:
- Being able to manage their condition betteras they can see their own readings and relate it to how they are feeling;
- Promoting independenceand peace of mindas their health is being monitored;
- Feeling empoweredto manage their condition;
- A belief that telehealth has contributed to earlier diagnosis, treatment and improved management;
- A feeling for some that it is stopping them from going into hospital.
The case study below demonstrates the positive impact of telehealth.
Eddie Beardsmore (his real name, used with his permission) has COPD, which had placed severe restrictions on his life. “At one point, I was unable to venture out of the house for 112 days – I counted them!” he recalled. His condition had made him feel both anxious and lacking in confidence.
In 2008, he was admitted to hospital several times and visited his GP regularly. This culminated in a lengthy stay in hospital at the start of 2009.
In February 2009, Mr Beardsmore agreed to take part in the trial. He had equipment installed at home to monitor oxygen levels and blood pressure, which were then monitored each day by his community matron. The monitoring device also asked a series of questions about his health and symptoms, and the answers were fed back to the community matron.
In a matter of weeks, he started to notice a difference,” he said. “Being on this programme has allowed me to control my condition, rather than it controlling me. By looking at my oxygen levels, I can see when I am likely to have a potentially bad or good day. I know when I should be using my oxygen or when I need to start taking medication.
“It has given me confidence knowing that I can go outside. I am able to visit family and this has a really positive impact on my life. It is the best I have felt in the last two years.”
Mr Beardsmore has received tremendous support from his community matron and GP practice in Looe in Cornwall. Since being on the programme, he has not had to visit his GP or go into hospital and has gone from seeing his matron every week to seeing her once a month.
The programme is extremely important to Cornwall and the Isles of Scilly due to its geography and demographics. As a result of our success in recruiting people to the trial, after further discussion with the DH, we were able to extend the programme’s scope and work is under way to accept further participants.
The telehealth service has now become part of mainstream community health services and is available to people who were not taking part in the trial and those with other long term conditions. In addition to people with diabetes, COPD and heart failure, there will be a particular focus on those at risk of falls and stroke, as well as those admitted repeatedly with urinary tract infections.
Telehealth is key to our plans to maximise the productivity of community services and improve the experience and independence of people with long term conditions. It forms a key part of our Transforming Community Services programme and self care strategy.
We believe this is just the start of how we can use this technology to improve patient care. While we cannot pre-empt the trial results, we are extremely positive about the benefits of telehealth for both patients and healthcare professionals.
- People with long term conditions account for a significant proportion of health and social care resources and responsive services must be developed to meet their needs.
- Nurses will need to ensure that all people with long term conditions have the opportunity to manage their own care and be as independent as possible.
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