Patient Orchestrated
Care
Bridget Fletcher, Chief Executive
Dr Richard Pope, Hon Consultant Physician
overwhelming
need for
change
“Trabant Care”
“…I am scared to say something in case there are consequences…”
Through their eyes…
“…I know you are busy but I am important too…” “…Make me feel I matter…”
“…I am not a disease – I am a person…” “…This may be routine for you – but for me it
is the first time…”
“…I may be old – but I have a brain…”
“…Different professionals are telling me different things – who is right?...”
“
“Apple
Care”
Incremental vs Disruptive
Innovation
“Our NHS does a superb job
for millions of people, day in, day out,
but it cannot stand still
– it needs to adapt to survive” Sir Bruce Keogh
Traditionally….
Potentially…..
How can a person
orchestrate their own care?
Teleconsultation - Airedale
8 year journey
Initially prison healthcare
Today work with prisons
across England
~ 800 cases/year
Wide range of specialties
Have extended services……
Current applications
Telehealth Hub 24/7 working
Experienced nurses
2nd tier - physician
Range of technologies
Shared EHR
Resilient infrastructure
Opened September 2011
Nursing
& Residential
Care homes
n=96 live today
deploying to 190
Cumbria to Kent
Care home
caseload audit (Feb 2014) Current care homes
Mix of Residential /
Nursing
Total 2500 residents
Aged 26-106
Looking only at those
homes that refer into
Airedale hospital ….
Call outcomes
Care Homes - summary
0
100
200
300
400
500
600
700Acute Admissions 1Year Prior toDeployment ofTelemedicine
Acute Admissions 1Year PostDeployment ofTelemedicine
-35%
Care Homes continued
0
200
400
600
800
1000A&E Attendances 1Year Prior toDeployment ofTelemedicine
A&E Attendances 1Year PostDeployment ofTelemedicine
0
2000
4000
6000
8000
10000Acute Beds Days 1Year Prior toDeployment ofTelemedicine
Acute Beds Days 1Year Post toDeployment ofTelemedicine
-53%
-59%
Results: 24 hr teleconsults to 26 COPD patients
at home – 1 year pre/post
-45%
ED attends
-60%
Feedback…
“I would like to express my
gratitude and thanks for the level of care you have
provided my husband, in particular the consultation at the weekend – the service is
marvellous.”
“The Doctor was fantastic when one of our dementia patients fell and hurt
herself. I would have called an ambulance and she would have endured an A&E visit which would have terrified
her. Your consultant saved her from this and reassured me that the cut was
superficial and she was fine…”
“A very good service. It made me confident within my job so I could do the best I can for our
residents. This service taken the pressure off us as we have
access quickly to a health professional.”
“I have only one word to describe Telehealth –
excellent.”
“ The Telehealth Hub came into its own last winter when snow and ice brought traffic to a halt. My Husband’s condition deteriorated suddenly and having visual, instant contact with the team was very
reassuring. A wonderful service.
People want to “live” with their LTCs
The NHS needs increased Quality
and Improved Efficiency These seemingly conflicting demands can be resolved by
A different Patient Clinician
Engagement making it personal, not simply clinical
Scale - to thousands of HCPs, millions of Patients
People with LTCs - owning their plans and
defining their support
First tried it ‘on paper’ – cohort of 50 carefully tracked
0
10
20
30
40
50
60A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
AA
BB CC DD EE FF
GG
HH II JJ KK LL
MM NN
OO PP QQ RR SS
TT
UU
VV
WW XX
Nu
mb
er
of
visi
ts
Patient code
Practice visits
Pre-care planning
Post care planning
0
5
10
15
20
25
30
A B C D E F G H I J K L M N O P Q R S T U V W X Y ZA
AB
B CC DD EE FF
GG
HH II JJ KK LL
MM NN
OO PP QQ RR SS
TT
UU
VV
WW XX
Nu
mb
er
of
atte
nd
ance
s
Patient code
Outpatient attendances
Pre-care planning
Post care planning
0
0.5
1
1.5
2
2.5
A B C D E F G H I J K L M N O P Q R S T U V W X Y ZA
AB
B CC DD EE FF
GG
HH II JJ KK LL
MM NN
OO PP QQ RR SS
TT
UU
VV
WW XX
Nu
mb
er
of
atte
nd
ance
s
Patient code
A&E attendances
Pre-care planning
Post care planning
0
0.5
1
1.5
2
2.5
3
3.5
A B C D E F G H I J K L M N O P Q R S T U V W X Y ZA
AB
B CC DD EE FF
GG
HH II JJ KK LL
MM NN
OO PP QQ RR SS
TT
UU
VV
WW XX
Nu
mb
er
of
adm
issi
on
s
Patient code
Acute admissions
Pre-care planning
Post care planning
Published in HSJ Dec 2010: “QIPP and Care Plans for long term conditions”
© Dynamic Health Systems
Example - engaging with own action plan
0.00
1.00
2.00
3.00
4.00
5.00
6.00
Exercise sessions per week
Starts using SSC here Patient generated data
Patient generated data
Feeling better – motivated by results
73.00
74.00
75.00
76.00
77.00
78.00
79.00
80.00
81.00
82.00
12/23/11 0:00 2/11/12 0:00 4/1/12 0:00 5/21/12 0:00 7/10/12 0:00 8/29/12 0:00 10/18/12 0:00 12/7/12 0:00 1/26/13 0:00 3/17/13 0:00 5/6/13 0:00
Weight (kg)
Starts using SSC here Patient generated data
Clinician generated data
Achievement confirmed by clinical results
0
20
40
60
80
100
120
1/22/10 0:00 8/10/10 0:00 2/26/11 0:00 9/14/11 0:00 4/1/12 0:00 10/18/12 0:00 5/6/13 0:00
Haemoglobin A1c level - IFCC standardised
Starts using SSC here
QoF
Clinician generated data
In control – aged 80 and happy!
In control,
80 & happy
Initial Cohort - age profile
yrs
Patient No.
BP before and after 6 months use of supported self care
BP before and after 6 months use of supported self care
Patient No.
mm Hg
Ave reduction SBP=19mm DBP=13mm
HbA1c change over 6 months following introduction of
supported self care
Ave = -16 mMol/ Mol
Weight change (Kg) over 6 months following the
introduction of supported self care
Ave loss = 4.5Kg
The person orchestrating their own care with clinicians working by exception
Technologies
converge….
signalling
choice
& needs
near the
end of life