Leading change

Nurse leaders at Airedale NHS Foundation Trust led the implementation of a telemedicine service to remotely provide care at home or in nursing and residential homes. This has significantly reduced avoidable admissions to hospital, supported individuals to remain in their place of residence without needing to travel to receive care and improved overall patient experience.

Where to look

The Long-Term Plan (2019) highlights that digital technology can support the NHS to deliver high quality specialist care more efficiently. There are numerous examples where telemedicine services has been successfully used in practice for remote consultations in perceived ‘hard to reach’ communities.

Nurse leaders at Airedale NHS Foundation Trust identified rising numbers of acute admissions and Emergency Department (ED) attendance from care home residents. This was unwarranted variation, some of which, upon reflection, could have been avoided had services been available within the home. By wrapping services around the individual in the home, the team aimed to eliminate the need for people to be transported to and from healthcare services, recognising that this can often be distressing when people are unwell.

What to change

The nursing leads considered the reasons why care home residents were accessing urgent and emergency care services and it became clear that staff within the homes needed better communication channels with clinicians traditionally housed within NHS hospitals. This could increase the opportunity to provide care at the home for residents at the end of their lives, as well as support them with day-to-day management of long term conditions such as chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), diabetes, Parkinson’s disease. A different way of supporting residents was needed and nurse leaders recognised that the telemedicine service being used across prison services could be applied to support nursing and care homes as well as individuals at home.

How to change

Using learning from the prison healthcare work, nurse leaders developed the care home model in collaboration with clinicians and specialists in the local acute Trust.

A telemedicine hub model was adopted and rolled out to care homes across the locality. Staffed 24/7 by acute care nurses with access to specialists as required, the hub provides instant support, advice and clinical guidance to staff within the residential and nursing homes. This supports residents to remain well and within their home environment.

The telemedicine system works as a two-way secure video link between patients/residents and a clinician – in the first instance a senior nurse – which can then be escalated to a doctor as required. Nurses can remotely provide advice and support to staff in residential homes who are caring for residents.

There are two technology platforms available:

• A bespoke set-top-box on a television at home – if residents feel unwell or concerned they can access the box via a button which links them to the nurse-led monitoring centre. It is also possible for a clinician to contact the patient through the same channel if they are concerned for any reason.
• An instant messaging and video conferencing software package that allows secure two or multi-way contact on mobile devices such as tablets or laptops.

All nursing staff in the hub have experience and skills in caring for people towards the end of life and palliative care consultants from within the hospital provide specialist advice and support where needed. The hub also hosts a GP triage service and intermediate care hub where health and social care work in partnership. Colleagues can escalate to community teams out of hours if required.

Adding value

Better outcomes – As of February 2018, the telemedicine system of assessment has been implemented in 534 nursing and residential care homes, with 50 currently in progress, supporting over 20,000 residents. The hub also supports more than 30 prisons and thousands of patients with long-term conditions living in their own homes. In February 2017, there had been a total of 21,592 clinical video consultations. Between April – July 2017, 90% of patients (8,626) using the service remained in their place of residence (including reported deaths) and only 10% (924) needed an ambulance request. During this period, 45% of calls (2,997 patients) would have originally contacted their GP but did not need referring, 7% (441 patients) would not have called their GP but were referred, and 48% (3,148) would have contacted their GP and were referred. Airedale became an NHS England Vanguard for Enhanced Health in Care Homes and evaluation of Vanguard data has demonstrated lowering demand for GP primary care services by 40%, reduction in ED attendances by 33% and a reduction in non-elective hospital admissions by 25%.

Better experience – Positive feedback has been received from residents, who report that they like that they can reach someone always and speak to someone if they’re feeling low, unwell or anxious about their illness. Good feedback has also been received from carers and families of residents. A daughter of a lady coming towards the end of her life fed back that despite being quite unwell, her mother hadn’t had to be admitted back into hospital and the team had managed to put care in place to make that happen.

GP feedback includes “Of all the changes in the 15 years I have been working, this is the greatest change which has reduced workload… I don’t mind the extra “late” duty doctor visit as this is more than made up in the drop in other visits. A big thank you to all involved”.

A care home manager reported “Telemedicine is brilliant, the staff are always using it, I hardly get any phone calls during the night, as I used to, staff would be lost without it.”

Better use of resources – Individuals are now able to access remote consultations reducing their need to travel to their GP or hospital, or for staff to visit patients’ homes or residential homes. This has released time that can now be spent providing care and achieved significant cost savings. The latest analysis has revealed that for every £1 invested in the service, there is a return of £1.21. Airedale have collected information about the clinical reason for each call and the top ten purposes of calls include falls, suspected urinary tract infections (UTIs), suspected chest infections, skin complaints, pain management and medication issues. These accounted for 79% of all calls and GPs confirmed that these conditions mirror their traditional case-mix.

Challenges and lessons learnt for implementation

In terms of the leadership role for staff at the hub, it doesn’t matter what role or band they are, everyone has a part to play. For example, some support staff and call handlers have developed things such as a directory of service and supported in developing pathways.

For more information contact

Rachel Binks
Nurse Consultant, Digital and Acute Care
Airedale NHS Foundation Trust
rachel.binks@anhst.nhs.uk