Remote Support for Patients with Multimorbidity

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The project aims were: to expand the use of technology to support long-term conditions; to develop local staff expertise to use remote monitoring in patient care; to expand the specialist knowledge available by developing practitioners with a special interest in the project areas; to assist patients to manage their long-term conditions; and to link this work to reduction in crisis admissions to hospital.

The steering group wished to pilot home monitors for COPD and surgery and community telehealth monitors in accessible locations. A delay in implementation ensued as the commercial supplier initially chosen was subsequently de-selected due to concerns regarding procurement. A new supplier (Telehealth Solutions Ltd®, Watford UK) was engaged to provide equipment and logistical support for the initiative. Time lost in negotiations with the original supplier was significant, as discussed later.

Three types of systems or “Pods” were installed: home monitoring, surgery monitoring and community monitoring. Home Pods were installed for 17 COPD patients in March 2009 with touch screen facilities to enable daily clinical monitoring. Symptom reports and measures such as oxygen saturation were sent by wireless or broadband to the Telehealth Solutions® secure server, maintained behind the NHS firewall. Nominated community nursing teams checked a website daily and were alerted to changes in the patient’s condition.

Touch screen surgery Pods for general health monitoring were installed in general practices in Oban and on Bute, configured to transfer patient data instantaneously into the surgery’s electronic patient record (EPR). Community Pods were installed in sheltered housing in Oban and in a community hall on the Isle of Luing. The Pods enabled patients to record their own physiological measurements including weight, body mass index (BMI), oxygen saturation, pulse and blood pressure. Each patient had swipe card access to their own protocol. In the sheltered housing complex, the protocol gathered responses about general health as well as hypertension. Data was transferred onto a secure, NHS firewalled website for health professionals (primarily community nurses) to review. Results outwith set parameters alerted community nursing teams. Community and surgery Pods became operational in October 2009, but full connection to the EPR had not occurred at evaluation.

Northern Ireland

TelemonitoringNI Managed Service was procured by CCHSC on behalf of the 5 HSC Trusts in Mar 2011. This regional service is capable of providing telehealth monitoring for up to 3,500 patients over a 6-year period. It will enable the collation of patients' vital signs from their home, for conditions such as diabetes, COPD, CHF and secondary prevention of stroke management.

A dedicated nursing triage team will provide first line support to the patients when their vital signs exceed set thresholds which trigger an alert. During the triage process the nursing team will make contact with patients to discuss their readings, as well as provide them with relevant support and patient education. The triage team will also use their clinical judgement and, where appropriate, pass on the results of their assessment to local response teams based in the Trusts. The patient’s nurse and/or doctor will have access to these readings and other information and will be able to view them on their computer screens. They will then make contact with the patient and take appropriate actions.

Previous patient evaluation/study indicated that patients feel that the service is of benefit to them as it provides:

  • Added peace of mind that their condition is being monitored
  • Greater understanding of their condition and how to manage it
  • Greater freedom to get on with their day-to-day lives without the fear that their condition is deteriorating
  • Less risk of unplanned admissions to hospital
  • Less need to have contact with a clinician if their condition is stable
  • Reduced anxiety for their carers and family

Patients/carers will also be able to review the readings via a portal which will also have links to relevant websites pertaining to their condition.

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Demonstrator Project team leader: Matti Matero


Return to demonstrator project matrices


Further information on home based service delivery