A new approach to wound care –improving outcomes, improving

efficiency

Jonkoping Microsystems Festival February 2015Lisa Hilder

Assistant Director for Strategic Planning

N.E. Lincolnshire Clinical Commissioning Group

Roger Young

Managing Director

Longhand Data Ltd

The Commissioning challenge

• Elevated level of problems with tissue viability resulting in serious untoward incidents across care environments

• Limited specialist tissue viability resource

• Ageing population – increased and increasing demand

• N.E Lincolnshire is big – population density low

• Distributed rural community

• 60 residential care homes

• Flat allocation of cash to commissioners for the foreseeable future

Purpose of the project

• To deliver better outcome woundcare to an increasing population of older people within a smaller budget.

• To introduce better measurement of woundcare outcomes

The solution part one:Integration of remote clinical expertise, robust data and local practice

• Healogics – third party tissue viability expertise with national/global

credibility

• Experience in working remotely

• Strong training component

• Ability and willingness to work with range of clinical expertise.

• Able to respond to referrals with

o Corrected diagnosis

o Amended/additional treatments

o Expert tissue viability intervention if necessary

AND

• Local Community Nursing team open to improving outcomes by

working differently

The solution part two:connecting everybody

• A wound referral application that is easy to use

• Exactly meets the agreed demands of the project

• Hosted online and compliant with ISO 27001

• Mobile technology so nurses can refer + take photos

• Strong tiered permissions of access and edit

• Patients grouped by location

• A development team to evolve the care pathway

• Clear care plan listing

• TELER Patient Measured Outcomes

• Robust evidence of the effectiveness of treatment

Developing the project

• Working with local clinicians, Healogics and TELER to

develop the pathway tailored to local needs

• Dealing with Information governance requirements

• Rollout of ipads to support mobile working and

woundcare pathway

• Training on TELER

• Project Launch

The challenges of delivery

• Generating engagement

• Hardware

• Software

• Training

• Change management

• politics with a small “p”

• Patience with a large “P”!

Initial feedback

• Nurses and patients love the application and find it easy

to use

• Remote clinical advice praised

• New treatments advised and adopted locally

• Already opportunities for knowledge transfer have

arisen and been used

• Desire to expand scope of the project to include a wider

range of wounds

Care pathway

Care pathway - continued

• Patient referred into the system

• Triage patient priority

• Schedule appointment

• Clinician confirms/corrects

original diagnosis

• TELER Grid used to specify

treatments and indicators to

measure results

• Grid can even be completed by

a patient!

Use the TELER Grid for:

• Remote monitoring

• Decision making

• Intervention

System features

• Permission-based access

• Referral system

• Patient history

• Current medical information

• Clinical notes

TELER Grid – the patient narrative

• Referral – possible from multiple locations

• Online triage - remote oversight and management

• Easy recording of important steps within referral pathway

• Scheduling of TVN/community nurse visits

• Onward-referral for acute cases

• Monitoring of non-critical patients by acute care teams

• Visibility of all associated files and images (pdf, scans, jpeg, etc..)

• Acute care monitoring of care-plans delivered in the community

• Oversight case-reviews for chronic conditions

• Reporting at discharge

The patient narrative - continued

Thank you

A valid measurement scale of unambiguous clinical statements, in which

each step is clinically defined from the problem to a treatment goal

Indicator title

Recovery from pain induced at dressing changesIndicator library No.WC0048

Code5 Able to do I want to do without pain – Treatment goal4 Able to do what want to do, with pain, but pain does not interrupt3 Able to do what I want to do with pain, pain interrupts, but able to resume2 Pain interrupts what I want to do - not able to resume1 Pain prevents me doing what I want to do0 Unable to even plan what I want to do due to pain - Problem

So what is a TELER Indicator?

• Wound care

• Stroke rehab

• General Physiotherapy

• Paediatrics

• Occupational therapy

• Speech therapy

• COPD

• Mental health

• Palliative care

Over 1,200 in total

TELER library of clinical indicators

• Patient measured outcomes

• Using TELER Indicators

• To deliver TELER indexes via TELER algorithms

• deficit Index

• Improvement index

• Variability index

• Disparity index

• Cost effectiveness index

• In research – clinical and statistical evidence of

change. n-of-1 within an RCT

• In every-day clinical care – tracks treatment

narrative. Strong evidence to back-up clinical

decisions.

The TELER engine

Data collection

Records are more than measurement

• Patient ID methodologies

• Biographic detail

• Co-morbidities

• Referrals

• Triage

• Care Plans

• Contemporaneous notes

• Over-sight notes

• Associated images

• Assessment forms

• Treatment formularies

• Reports

The patient narrative: tele-health via TELER

• Referral – possible from multiple locations

• Online triage - remote oversight and management

• Easy recording of important steps within referral pathway

• Scheduling of TVN/community nurse visits

• Onward-referral for acute cases

• Monitoring of non-critical patients by acute care teams

• Visibility of all associated files and images (pdf, scans, jpeg, etc..)

• Acute care monitoring of care-plans delivered in the community

• Oversight case-reviews for chronic conditions

• Reporting at discharge

• Date of contact

• Duration of contact (mins/units)

• Time-codes vs. actual time

• Wound photos

• Form submissions

• Indicator measurements

• Treatments performed & by whom

• Other measurements – e.g. ABPI, pH, wound

depth

All in chronological order

The patient contact

Indicator descriptions

First form and image

Access notes

Last image

Summary – the TELER grid

• Deficit Index – where 0 is no deficit and 100 is total deficit

against Indicators in use

• Improvement Index – % deficit recovered

• Effectiveness Index – a measure of the loss of function

while under treatment. Relates to quality of care and

therefore a measure of delivery of treatment

• Variability Index – the amplitude of variation of

improvement and deterioration.

• Disparity Index – a measure of comparison between two

runs of TELER Indicators; used in n-of-1 research projects

TELER Indexes

Global Wound reports

• Wound on admission

• New wounds after admission

• Wounds healed

• Average wounds/patient

• Wound aetiology

• Common indicators

Initial Assessment

reports

• Wound details

• Wound durations

• Measurements taken

• Medical history

• Previous treatments

used

Daily Treatment reports

• Indicator scores

• Treatments used

• Index values

Management reports

• Patients seen

• Admitted/Discharged

patients

• Referrals received

• Referrals declined

• Referrals

correct/incorrect

• Average

appointments

We can report on any of the data the system is customised to collect

Clinical reporting

Cost of Treatment Reports

• Cost per wound

• Total patient cost

• Average cost per contact

• Average cost per contact for a specific wound

• Average cost to heal specific wound

• Cost effectiveness – cost per clinically significant change

Bespoke cost reports can be created on request

With the right information collected in our system, we can report on more

than simple ‘estimated’ costs.

Linking Cost to Indicator Scores, compare the clinical results of using different treatments

Identify treatment cost impact against clinically significant improvements in patient care

Health economics - reporting

We found out what patients’ needed – an alternative to

bandages

We involved a fashion designer to design garments to

‘clothe the wounded body’

We involved a knitwear manufacturer with computerised

knitting Research Assistant & Designer acted as

‘surrogates’ and tested the garments, refined by the

designer and manufacturer

N-of-1 design: Patients tested the garments and collected

their own outcomes data

King’s granted a licence to the manufacturer to

commercialise and sell

The data supported an application to Prescription and Pricing

Authority

Drug Tariff Listing May 1st 2013 (adults) May 1st 2014

(children)

http://www.skinniesuk.com/category/web

WEB Summary

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