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1
RECAP
Heart Failure Team
Telehealth Benefits Realisation
(Essex & Thurrock)
Hub 3
By NELFT: Jan Minter, Nurse Consultant Beverley Hoyte, Transformation Project Manager Julie Price, Associate Director of Performance Tanya Spencer, Service Accountant In partnership with E-Ucare Connecting Health Solutions project partnership
18th December 2014
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Version Control/Quality Assurance
Issue Date Author/Reviewer Reason 0.1 9.6.14 Bev Hoyte First Draft 0.2 5.8.14 Bev Hoyte
Julie Price (Reviewer) Second Draft
0.3 23.9.14 Bev Hoyte Third Draft 0.4 2.10.14 Bev Hoyte Fourth Draft 0.5 14.10.14 Bev Hoyte
Julie Price (Reviewer) Fifth Draft
0.6 4.11.14 Bev Hoyte Julie Price (Reviewer)
Sixth Draft
0.7 24.11.14 Bev Hoyte Tanya Spencer (Reviewer)
Seventh Draft
0.8 27.11.14 Bev Hoyte Eighth Draft 0.9 11.12.14 Bev Hoyte
Julie Price (Reviewer) Tanya Spencer (Reviewer)
Ninth Draft
0.10 15.12.14 18.12.14
Bev Hoyte Julie Price (Reviewer) Jan Minter (Reviewer)
Final Draft
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Contents Page
1 Introduction 4
2 Aims and objectives 5
3 Telehealth Heart Failure Programme 5
3.1 Background 5
3.2 Project set up and implementation 5
3.3 Stakeholders 6
3.4 Patient inclusion criteria 6
3.5 Patient exclusion criteria 6
3.6 Telehealth equipment 6
4 Data collection methodology 7
5 Data analysis/results 7
6 The benefit of telehealth to patients 7
6.1 Education/management of condition 7
6.2 Anxiety 8
6.3 Depression 8
6.4 Quality of life/ability to perform normal
activities
8
6.5 Quality of life/feelings of being worried,
sad or unhappy
8
6.6 Telehealth patient survey 8
6.7 Discussion of benefits 8
7 Patient challenges with telehealth 8
8 The benefits to staff and service delivery 9
8.1 Telehealth within the Heart Failure
Team
9
9 Investment Costs 11
9.1 Telehealth equipment cost comparison 11
9.2 Staffing 12
10 Savings 12
10.1 Impact on hospital referrals and
admission
12
10.2 Nursing contact time 13
10.3 Change in skill mix 13
10.4 SOS (emergency) call outs 14
10.5 Telephone consultations 14
10.6 Travel time 14
11 Financial return on investment 14
12 Conclusions & Recommendations 15
Appendices 1 - 7 17
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1. Introduction
Evidencing the benefits of Telehealth
NELFT’s objective is to increase our use of technology to deliver efficiency and productivity and
provide a more modern innovative service for patients. This links strongly with NHS England vision for
3million lives initiative which seeks through service transformation and integrated care to empower
patients to better self-manage their condition with the use of technology. It also reflects Digital First’s
aim to reduce unnecessary face-to-face contact between patients and healthcare professionals by
incorporating technology into these interactions.
What is Telehealth?
‘Telehealth is the remote exchange of data between a patient at home and their clinician(s) to assist in diagnosis and monitoring typically used to support patients with Long Term Conditions. Among other things it comprises of fixed or mobile home units to measure and monitor temperatures, blood pressure and other vital signs parameters (and the answering of targeted questions) for clinical review at a remote location using phone lines or wireless technology.’
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Telehealth uses technology to provide services that assist in the management of long term health conditions, including Chronic Obstructive Pulmonary Disease (COPD), Chronic Heart Failure (CHF). Patient vital signs such as blood pressure are taken and data transmitted via a telephone line, or broadband, to a telehealth monitoring centre or a health care professional, where it is monitored against parameters set by the individual's clinician. If there is evidence that vital signs are outside of 'normal' parameters, which may indicate deterioration in health this instigates an appropriate response. Telehealth enables individuals to take more control over their own health, and becomes an intrinsic part of the individuals care pathway, with information about their health condition being monitored regularly to flag up issues before they become ‘care critical’.
The benefits of telehealth were published by the Whole System Demonstrator programme2 (WSD)
launched by the Department of Health in 2008. Initial findings showed that when used correctly, telehealth can benefit a patient’s health and quality of life. The early findings from the WSD trial indicated:
15% reduction in visits to A&E 20% reduction in emergency admissions
The Nuffield Trust published separate research which reiterated the interim findings but urged caution because of the uncertainty over costs
3.
In 2011 NELFT joined an EU RECAP telehealth research project specific to heart failure (HF) patients in the community. Patients on telehealth were monitored (physiological and psychological) for 6 weeks mainly following discharge to community HF nursing team after an acute admission. The original aim was to analyse the anonymised dataset sent to Leuven University in order to develop a decision support tool. Additionally, HF team nurses wanted to analyse the impact of telehealth on patient care. This document explores some of the outcomes of telehealth with patients in the Heart Failure Team (as part of EU RECAP project) referencing comparisons with the WSD. We will also consider additional organisational evidence in order to make a more informed decision on the benefits of this technology.
1 The Telecare Services Association definition 2 NELFT Telehealth Literature Review 3 Nuffield Trust 2012: The impact of Telehealth on use of hospital care and mortality: a summary of first findings from the WSD trial
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2. Aim and objectives of document
The purpose of this document is to produce a benefits realisation of the implementation of telehealth
within the North East London Foundation Trust (NELFT) Basildon, Brentwood and Thurrock Heart
Failure team. It will illustrate the outcomes of an evaluation of the benefits and challenges of using
telehealth and provide information that will be used to create a business case for the proposed
continuation of this technology with heart failure patients once the EU RECAP project is complete, and
to consider the potential benefits of using it with other long term conditions.
The benefits realisation objectives are to:
Review qualitative and quantitative impact on patients, carers, staff and service delivery of implementing telehealth in the Heart Failure team.
Review of financial impact of implementing telehealth
Carry out a short comparison/review (not random control study) of implementation within two additional NELFT services using telehealth.
Evaluate the impact on hospital admission or referrals
This document is not an evaluation of the overall EU RECAP project but does show links with the
findings of the EU RECAP project. This report includes a short comparative service review of the use
of telehealth in NELFT Havering Respiratory team who have used telehealth with COPD patients and
NELFT Thurrock Day Hospital who are using the device for patients with other long term conditions.
The aim of the service review is to learn lessons which can be used to inform this benefit analysis and
the proposed business case.
3. Telehealth Heart Failure Project
3.1 Background In 2011 NELFT joined the EU RECAP heart failure research project in partnership with Health Enterprise East and KU Leuven. NELFT’s responsibility within the project was to provide heart failure patient datasets, captured using telehealth, which would be used to create clinical decision support software. Additional objectives that clinicians wished to include (but were separate from the EU Recap objectives) were:
• To monitor (using telehealth for 6 weeks) new and existing patients within the Heart Failure Service to better understand benefits to patients and clinicians
• Improve patient understanding and management of condition • Reduce patient anxiety • Improve prioritisation of patients by clinicians/ increased visibility of patient vital signs • Create clinical capacity through saved visits • Increase information to clinicians to improve titration of medication • Reduce hospital admissions
3.2 Project Set Up and Implementation The project commenced with an initial scoping workshop with stakeholders. Stakeholders included NELFT staff (both clinical and performance) and GPs from Basildon, Brentwood and Thurrock. It also involved Health Enterprise East (HEE) and KU Leuven representatives, together with some telehealth vendors.. The aim of the scoping workshop was to provide a project introduction to participants and allow the group explore what needed to be done within the project to create a decision support tool for heart failure. As this is a research project the group also discussed protocols and ethics requirements.
An implementation plan was created and included:
- Patient criteria - Identification of patients - Ethics - Telehealth co-ordination role and identification of support for this role
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- Telehealth equipment and education Ethics committee authorisation was subsequently obtained and resulted in the use of evidence based questionnaires and patient consent forms (Appendix 1). The patient criterion was agreed and local protocols were developed by the team. A full-time dedicated Telehealth co-ordinator was employed as it was recognised this was a new way of working for the heart failure team and dedicated resource was important to success. The project team selected Docobo telehealth equipment initially, and subsequently also included Philips telehealth equipment (following a telehealth provider marketing event, organised by HEE and hosted by NELFT). 3.3 Stakeholders Key stakeholders involved in the project are NELFT executive team, NELFT Basildon, Brentwood and Thurrock Heart Failure Team, NELFT Performance Team, Katholieke Universiteit Leuven, Leuven
Innovation Networking Circle, Health Enterprise East Limited (Ltd), Philips Ltd, Docobo Ltd, Brainport (EU project co-ordinators) and Heart Failure patients, GPs.
3.4 Patient inclusion criteria To enter the study the patient must be 18 years or above, have a valid diagnosis of LVSD (left ventricular systolic dysfunction) supported by a positive Echo and has access to a telephone. They must also present with any ONE of the following:
• Sudden increase in weight > 1.5kg in 24 hours • Blood Pressure <90 systolic • Sudden increase in shortness of breath • Episodes of palpitation/tachycardia without collapse • Change of medication within 48 hours of discharge from acute • High Hospital Anxiety Depression Self-Assessment (HADS) score
3.5 Patient exclusion criteria Service user may not enter the study if ANY of the following apply:
• Unconfirmed diagnosis (without Echo) • Clinically Stable – NYHA I to II classification (New York Heart Association) • Patient has a normal blood pressure (120/80) • Nil Oedema (no fluid retention/swelling) • Insufficient cognitive understanding to use the Telehealth equipment/complete questionnaires
3.6 Telehealth Equipment The Heart Failure Telehealth devices and peripherals used with the Recap project have been purchased from Docobo and rented from Philips.
Docobo Health Hub Bluetooth BP Monitor Bluetooth Nonin Oximeter (SpO2)
Philips Telehealth Television technology
Docobo and Philips Telehealth monitor BP, pulse rate, SpO2 and body weight. Philips has an
interactive telehealth platform with personal healthcare channel and patient educational information.
Docobo is a stand-alone unit but does not have video streaming or education information on the model
purchased by NELFT (subsequent models to market do).
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4. Data Collection Methodology A mixed methods approach was adopted for the evaluation, including both quantitative and qualitative data collection. Quantitative Methods The project quantitative data collection method was designed to obtain information on user satisfaction and on the impact of providing the telehealth devices. The primary data collected was clinical physiological measures including BP, pulse, and oxygen (Sp02) which patients measure twice daily and weight (which patients measure once daily).
Qualitative Methods Case studies of NELFT patient experiences were used to capture the benefits of the telehealth service. The benefits realisation included additional qualitative interviews with staff using telehealth within NELFT. Questionnaires at the beginning and end of the service used were agreed by the ethics committee and NELFT Research & Development team and include:
- Hospital Anxiety and Depression (HAD) Scale - Quality of Life - Behaviour Questionnaire (EQ-5D-Y) - Patient Telehealth Survey (end of service only)
5. Data Analysis/Results Data was analysed by NELFT Performance team and the Transformation team. Data sources include patient questionnaires, interviews and data extracted from NELFT SystmOne patient record system (Data presented in Appendices 2, 3 and 4). In order to use the East London Foundation Trust skill mix model of 200 telehealth patients, this report also uses two hundred telehealth patients when calculating investment costs and savings. Relevant findings from the EU RECAP project analysed by Leuven is also referenced (section 6.7 and 7) within the document
4.
Data Challenges The SystmOne analysis presented problems due to the method of recording incoming referrals on SystmOne within the Heart Failure Team. It provided challenges with comparison between non-telehealth and telehealth patients for face to face visits and telephone consultations/contacts. Thus the analysis presented in Appendix 4 reflects changes in whole team activity after the implementation of telehealth rather than reductions/changes or improvements in these areas for telehealth patients.
6. The Benefit of Telehealth to Patient EU RECAP project data was analysed from questionnaires completed by each patient at the beginning and end of the telehealth 6 week period and a telehealth patient satisfaction survey completed by the patient at the end of the period. The results show: 6.1. Education/Management of Condition (Appendix 2 - Figure1) There was an increase in the average number of people who manage their condition better when for example taking medication, weighing or contacting the GP when legs become more swollen. The highest improvement was in the increase in the number of people weighing and limiting the amount of fluids taken . The lowest increase was in taking regular exercise and taking prescribed medication.
4 EU RECAP symposium presentation
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6.2. Anxiety (Appendix 2 - Figure 2) Evidence revealed that 43% of telehealth patients had a reduction in anxiety (improved wellbeing) and 38% had an increase in anxiety (decreased wellbeing) during that period. 18% stayed the same.
6.3. Depression (Appendix 2 - Figure 3) 38% showed reduced depression levels, 22% stayed the same and 40% increased.
6.4. Quality of Life/Ability to perform usual activities (Appendix 2 - Figure 4) 60% had no change in their quality of life. 16% had an improvement and 24% had a reduction in their ability to do usual activities.
6.5. Quality of Life/Feelings of being worried, sad or unhappy (Appendix 2 - Figure 5) 24% had reduced feelings of being worried, sad or unhappy, 58% stayed the same and 18% felt worse. 6.6. Telehealth Patient Survey from 9.4.13 to 28.5.14 (Appendix 3) 25 patients completed the patient survey. A summary of the findings were:
72% of the surveyed patients were between aged 55 and 65.
69% said that the thing they like most about telehealth was that it enabled the care team to manage their condition.
59% believed that telehealth helped them avoid a hospital admission
40.32% felt it stopped them calling out an emergency service
65% believed their families benefited from them having telehealth
22.3% believed telehealth had highly improved their quality of life and 58.7% said it had stayed the same
96.8% would recommend telehealth to family or friends with long term conditions
82.5% rated the service as very good 6.7 Discussion of benefits
The EU RECAP project data analysed by Leuven demonstrated that telehealth patients were more
self-aware and managed their condition better. The WSD Telehealth Questionnaire study findings5
show that there are no differences found between telehealth and usual care groups in quality of life or
psychological wellbeing (anxiety, depression). It did not consider other measures of health gain such
as activities of daily living and impact on levels of self-care as reported in point 7.1 and 7.4 above. It is
well evidenced that health related quality of life is reduced and anxiety and depression elevated for
patients with diabetes, COPD and Heart Failure.
7. Patient Challenges with Telehealth
Initial Common Patient Issues According to EU RECAP findings patients using the Docobo units had initial issues with adhering to monitoring times and problems with entering data on a daily basis. The impact of these difficulties reflected in more missing data and 15% withdrawals from the scheme compared with 1% withdrawal for Philips users. Philips users had issues with the lack of portability of the unit and signal issues. Over monitoring is also an issue although the reason for this was not explored.
Refusal Data Data evidencing patient challenges with telehealth were captured from reasons why patients refused telehealth but did not capture challenges experienced whilst using the devices although we do know that there have been issues with difficulty in replacing batteries (see Appendix 4). There is also statistical evidence (see section 9.2) that some patients withdraw from using the devices only after a few days but we have not captured hard evidence of the reason for this in this report. Anecdotally (from the Telehealth Co-ordinator) the suggestion is that equipment is removed for the following reasons:
Equipment failure
5 WSD- Effect of telehealth on quality of life and psychological outcomes over 12 months. Cartwright et al, Feb
2013
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Patient finds the equipment too difficult to operate
Use of the equipment is voluntary so patient decides not to continue with usage
Patient is due to be admitted to hospital and thus unable to use it within the 6 week period
Review of 14 refusal forms revealed that 43% of patients refused the telehealth service due to being
anxious. 14% did not feel they could manage the equipment and 43% gave other reasons or changed
their minds.
Similarly findings from a WSD trial qualitative study 6 revealed that some patients declined the trial
because of uncertainties about the technology, thinking that they needed special skills to operate the
equipment. Patients believed that the technology would undermine their ability to self-care and cope
with their condition. It concluded that more time and information should be available to discuss
telehealth and potential recipients to have the time to discuss their expectations and views.
The recommendation that more time could be spent with the patients on introduction of telehealth
can be justified as a NELFT review of telehealth costs (section 10.2) revealed that there was
wastage, as a percentage of patients had the equipment installed but had it removed again after 1 to 3
days incurring financial costs/losses to NELFT. This suggests that they may not have fully understood
the benefits of telehealth in their health care management.
8. The Benefits to Staff and Service Delivery
This section demonstrates the benefits of telehealth implementation to staff and service delivery within
NELFT Heart Failure Team.
8.1 TELEHEALTH WITHIN THE HEART FAILURE TEAM Interviews were undertaken with the Heart Failure Nurse and Senior Healthcare Assistant, the Telehealth Co-ordinator and a Clinical Manager within the Heart Failure Team.
Benefits
This Team have a dedicated Telehealth Co-ordinator who is responsible for introducing the patients to telehealth through home visits and ensuring that the patient understands how the technology works and the terms and conditions to the patient being involved in the EU RECAP project. The Co-ordinator is very knowledgeable in telehealth and has developed clinical competencies allowing her to effectively monitor the recordings in close liaison with the Heart Failure nurses. There is a high level of staff confidence in her ability to perform the role.
The Co-ordinator visits the patient within 2 weeks of referral which is before the nurse is able to visit patients thus providing a quicker response time from referral date. It is believed that this presents a professionally run organisation to patients and their carers.
Staff are able to monitor patients following changes in medication eliminating any unnecessary alarm caused by changes in vital signs.
Issues
The nurses recommend that ideally they would prefer the nursing staff undertake the initial
assessment and then, if appropriate, recommend telehealth to patient. The staff appreciated
that clinical capacity in the team did not at present allow for this process. According to the
Heart Failure Nurse Consultant this approach is not necessary as there is a set clinical criteria
for patient eligibility and the role of the Telehealth Co-ordinator is to assess the patient’s ability
to use the device.
6 Exploring the barriers to participation and adoption of telehealth and telecare within the WSD trial: a
qualitative study Sanders et al 2012
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Recommendations
1. The team recommend that patients are on telehealth for 3 months maximum rather than the 6 weeks EU RECAP project criteria as they have found that patients would benefit from longer periods of monitoring particularly those who after a few weeks had a change in medication and thus required longer monitoring before being stabilised.
2. The Consultant Heart Failure Nurse was interviewed regarding her view on the length that patients should be on telehealth. She said that 6 weeks is sufficient for patients who have been discharged after a crisis. This period allows nurses to monitor vital signs and stabilise the patient. She recommended a longer period of 3 months in order to provide enough time to increase their knowledge of their condition by using the educational information on the device and encouraging the patient to effectively use the machine.
3. She does not recommend patients stay on telehealth longer than 3 months as it might cause dependency and not improve patient self-management of their care. Although, this decision would be made on an individual basis.
NELFT has also implemented telehealth in other service areas. A discussion on the issues and recommendations can be found in Appendix 4.
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9. Investment Costs
Outlined below are the cost of equipment and staffing.
9.1 Telehealth Equipment Cost Comparison The Heart Failure Telehealth project uses 2 types of devices (Docobo and Philips). The Philips device has the facility to be used via the patient’s television (though the patient must meet technical criteria in order to be eligible). Unfortunately the device is not portable and thus is not a good choice for patients who are going on holiday regularly. It has the advantage of providing educational streaming through the television on heart failure so that the patient can learn how to manage their condition. Philips completes the installations within the patient home and NELFT pay a fee for this service (see Table 9.1a below).
Philips Costs – Rental – Table 9.1a
1 month (Cost per patient)
3 months costs (per patient)
Installation (and servicing) per patient
£150 £150 (first month only)
Domain usage per patient per month
£64 £192
Total £214 £342
The yearly telehealth cost for 200 patients using Philips equipment is £273,600
Challenges during installation
During period May 2013 to January 2014 the Heart Failure Team installed 154 new Philips devices
within patient homes. 16 patients (10.4%) had the Philips equipment de-installed after 1-3 days and
NELFT forfeited their installation charge of £150 per patient despite the patient not continuing with the
6 week period.
Docobo Costs – Purchase
The Docobo units (Table 10.1b) have been purchased by NELFT and are installed by NELFT
Telehealth Co-ordinator. The current Docobo equipment in use is old and does not have educational
information. The advantages of this equipment are that it is portable and so can be taken with service
users even when they are away on holiday or on the move. Units are also upgradable at a cost to
NELFT which ensures that we are using up to date technology.
Table 9.1b
Purchase cost per unit
1 month (Cost per patient)
3 months cost (per patient)
Docobo Units
£1,000 (3 years usage)
£27.77 £83.33
Domain usage £36(£1.20p/day) £108
NELFT ½ day installation
£50 (£13.33 Band 4 per hour)
£50
NELFT 1 hour de-installation
£13.33 £13.33
Comms fee £6.20 £18.60
Servicing & upgrade costs
£33 per year £2.75 £8.25
Total £136.05 £281.51
The yearly telehealth costs for 200 patients using Docobo telehealth is £225,208
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Device Cost Comparison Using the above Philips (rented) and Docobo (purchased) device costings we can conclude that it is cheaper to purchase our own devices with a yearly saving of £47,592 per 200 patients. With the advancement of technology it is recommended that an options appraisal be carried out as part of the business case before choosing a model to use for the future. 9.2 Staffing Costs . The Heart Failure team has the advantage of employing a dedicated Telehealth Co-ordinator who is able to see the patient sooner than the nurse following referral and introduce telehealth. She is also able to monitor the reports and liaise with clinical staff. Staff bandings and costs are outlined below (Table 9.2a). Table 9.2a
Telehealth Co-ordinator Band 4 1.0 wte £26,060
Heart Failure Nurse Band 7 1.0 wte £45,340
Staffing costs compared to Device Costs Table 9.2b
Device Annual device cost per 50 patients (eg 1 wte caseload)
Band 7 nurse Annual salary
2 Band 4 practitioners Annual salary
Docobo £56,302 £45,340 £52,120
Philips £68,400 £45,340 £52,120
If we calculate the yearly cost of managing a caseload of 50 patients we can see that it is cheaper to employ one Band 7 nurse or two Band 4 practitioners compared with the cost of purchasing and utilising 50 telehealth devices.
10. Savings Detailed below is a review of savings incurred through reduction in hospital referrals and admissions, nurse to patient contacts, change in staffing mix, SOS call outs and telephone consultations. 10.1 Impact on hospital referrals & admissions
Referral to Acute Hospital (Appendix 5 - Table 4) The impact on referrals to acute hospital in the pre-telehealth period and post telehealth period shows a percentage decrease of 9% in referrals to acute hospitals. Average number of referrals to hospital per month pre-telehealth is 140 (based on the 25% increase in caseload and average number of referrals to acute hospitals in the period) and post-telehealth the average number of referrals per month is 128. Admission Costs
7- Table 10.1a
Type of admission
5 days Over 5 days – per day
18 days Over 21 days – per day
Non elective £577 £208 n/a n/a
Assuming that the referrals to acute were non elective (5 days) the cost per admission would be
£647.85 (including market force factor costs of x1.1228). If 200 patients were on the active caseload
we can calculate that there would be 17 pre-telehealth and 15 post telehealth
7 The 2014/2015 National Tariff Payment System – National Tariff Information Workbook (including non-
mandatory prices) updated 26.2.14
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average number of referrals to acute per month. This would equate to 2 hospital referral savings per month. The total annual saving for non-elective admission savings equates to £15,548. Telemonitoring Heart Failure Patients in Hull - Appendix 6 Further evidence regarding cost savings from reduced hospital admissions due to telehealth can be found on review of studies carried out by David Barrett, Nurse Lecturer in Telehealth at the Centre for Telehealth at University of Hull. The savings estimate compares expected hospital admission rates for heart failure patients (based upon published historic data) against reported admission rates in the tele-monitored group. They have seen net savings of £118k in 2011/12.
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10.2 Nursing contact time Table 10.2a
Number of patients
Average number of Face to Face contact per person per month*
Visit Time = 1 hour Travel Time 0.5 hour
Home Visit cost per hour (Band 7 hourly rate)
Total cost per month
Telehealth patients
200 0.5 1 .5 £23.19 £3,479
Non telehealth patients
200 0.9 1 .5 £23.19 £6,261
Total monthly
saving
£2,782
*The average face to face contacts were calculated using data from 30 telehealth and 30 non telehealth patients. If we make an assumption that a 1.5 hour face to face visit costs £34.79 (£23.19x 1.5) we can calculate that 200 patients on telehealth require less face to face contact than non-telehealth patients and thus produce a saving of £2,782 per month. The total annual saving for a caseload of 200 telehealth patients would be £33,384. 10.3 Change in Staff Skill Mix If NELFT decided to change the clinical skill mix we could use East London NHS Foundation Trust
9calculations. They propose that 4 Community Matrons are able to deliver care for 200 patients
(50 patients each) and with telehealth one Community Matron and two Telehealth Assistant Practitioners are able to manage 200 patients. Using a Band 7 Community Matron on a salary of £45,340 1.0 wte and Band 4 salary of £26,060 1.0 wte the following calculations can be made:
- 4 Community Matrons total cost is £181,360 - 1 Community Matron plus 2 Telehealth Assistant Practitioners cost £97,460
The total annual saving achieved by changing the type of staff managing the caseload is £83,900
8 Telemonitoring savings report update 2012, David Barrett, University of Hull
9 Padmanabhan & Stubbs. “Newham Telehealth Services2 PowerPoint Presentation, East London Foundation
Trust, Stratford, London, July 2014
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10.4 SOS (emergency) call outs in Heart Failure Team (Appendix 5 - Table 1) Post telehealth implementation we can calculate a decrease of 0.1 of a visit in SOS (emergency) call outs per 200 patients per month. The total annual saving using a 1.5 hour hourly home visit rate (including travel) of £34.79 for 200 telehealth patients caseload is £41.74 (0.1x1.5x23.19 x 12 = £41.74) i.e. a negligible saving. 10.5 Telephone Consultation’s (Appendix 5 - Table 2) Post telehealth implementation we can calculate a decrease of 2 telephone calls per month per 200 caseload. The total annual saving using non mandatory tariff of £23 (£25.82 including market force factor of 1.1228). for 200 telehealth patient caseload is £619.80 10.6 Travel Time (Appendix 5 - Table 3) The data shows no impact on patient related travel time pre-telehealth period and post telehealth period. The calculation is a percentage of the total clinical time spent in the periods. It is expected that there would not be any savings in staff travel time as any time saved in visiting a patient would be redirected into visiting another patient on the case load.
11. Financial Return on Investment The tables below (Table 11a and 11b) totals the cost of investment in the two types of telehealth devices and the total annual savings outlined in this document. We have found that financial savings are gained via change in skill mix, reduction in face to face contact time, and reduced admissions. We have not included reduced telephone or SOS contacts as the savings are negligible. Table 11a Non-Elective Admission
Device Investment in Devices (Annual cost for 200 patients)
Savings10
Financial Return on Investment
Docobo (Purchased)
£225,208 £132,832 -£92,376
Philips (Rental)
£273,600 £132,832 -£140,768
When considering the figures within this document we can see that overall there is not a financial return on our investment. Although the financial return on investment is not positive, it is important to consider the qualitative benefits captured within this report. It is worthwhile noting that if the daily costs of monitoring telehealth were reduced this would improve our return on investment.
12. Conclusions This report has reviewed the qualitative and quantitative impact on patient, carers, staff and service delivery of implementing telehealth. The case for the qualitative benefits of the programme is clearly evidenced. Patients believe that their
carers benefit (gaining peace of mind) from them having telehealth and they would recommend it to
family and friends. Patients have improved self-management of their condition by using the
educational aspects of the telehealth device. This improvement is due to their increased knowledge of
their condition demonstrated in an increase in undertaking certain activities such as recording weight.
This improved self-management of care could help patients take preventative measures before their
condition escalates. In line with national evidence there is no significant change in quality of life as a
result of using telehealth.
10
Savings referenced include 10.1 (Admissions), 10.2 (Face to face visits), 10.3 (Skill mix),
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Evaluation of the cost savings of using telehealth revealed savings from the reduction in face to face clinical contact time with patients who are using telehealth thus reducing costs to the organisation and increasing time for clinicians to care for patients who need their intervention. Time to care could also be released if NELFT review the skills mix within the teams who are using telehealth. Other evidence based research (University of Hull) suggests potential cost savings in the introduction of telehealth due to reduction in hospital admissions. It is also suggested (East London Foundation Trust) that potential savings could be achieved if there is a review of skill mix in the clinical teams. The report compared the cost of purchasing telehealth equipment compared to rental demonstrating that it is cheaper to purchase telehealth units, however NELFT would need to be mindful of both procurement and device management in the long term (calibration/asset management etc.) A review of monthly rental costs has revealed financial losses/wastage which can be addressed in order to ensure we are getting good value from the existing contract. It is likely that investigation into the reason for the early withdrawal of service users using purchased units would also reveal wastage. Despite the qualitative benefits to patients using telehealth the financial return on investment of implementing telehealth in NELFT is not evident. On further analysis we can see that the domain usage cost of £1.20 per patient per day (equating to £432 per patient per annum) is making the equipment cost prohibitive. Since the domain usage cost is actually simply provision of the data exchange between patient and NHS provider, it is hoped that market forces will drive these costs down through competition in much the same way as with internet and mobile providers in recent years. If the daily costs halved (0.60p per patient per day) the costings would allow NHS providers a realistic return on investment. Although not discussed within this document, when considering the future implementation of telehealth within NELFT It is helpful to reference and consider how telehealth has been implemented within other NELFT teams (outside of the EU Heart Failure project). As the EU Recap project criteria has restrictions on the length of time patients could use telehealth it prevented us from learning from the benefits of our patients when using telehealth for a longer period.
Recommendations It is recommended that if telehealth is taken forward across the organisation the following should be in place:
Clear and co-ordinated project management approach to implementation across the organisation.
Each service should have access to dedicated telehealth co-ordination, which would be affordable via skill mix reviews.
Clear criteria for telehealth outlining suitability of telehealth for particularly clinical groups e.g. Heart Failure, COPD.
An approach to be agreed organisationally to either purchase or rent (procurement review). This should include negotiation around the daily ‘per patient’ costs charged by telehealth providers.
Clear protocols to be implemented for infection control, calibration, asset management etc.
If we consider other service implementation of telehealth (Appendix 4) evidence suggests that when taking this project forward it is important to spend time with teams ensuring that telehealth is implemented and co-ordinated well, with clear processes, patient eligibility and staff accountability in place This will ensure that devices are issued to the correct client group who will benefit from its use together with the professionals delivering the service.
16
Appendix 1
Patient Observation Sheet
Scanned from a Xerox multifunction device.pdf
Hospital Anxiety and Depression Scale
Scanned from a Xerox multifunction device.pdf
EQ5DY Questionnaire
Scanned from a Xerox multifunction device.pdf
Community Heart Failure Telehealth Service Patient Survey
Scanned from a Xerox multifunction device.pdf
17
Appendix 2 Figure 1 Self Behaviour Questionnaire
Data - Question First time
Last time
% decrease
Average of I eat a low salt diet 1.96 1.54 21%
Average of I exercise regularly 1.94 1.85 5%
Average of I get a flu shot every year 1.79 1.67 7%
Average of I limit the amount of fluids I drink (not more than 1.5 - 2 litres per day) 2.60 1.68 35%
Average of I take my medication as prescribed 1.12 1.07 4%
Average of If I experience increased fatigue, I contact my doctor or nurse 2.39 2.01 16%
Average of If my feet legs become more swollen than usual, I contact my doctor or nurse 1.85 1.55 16%
Average of If my shortness of breath increases, I contact my doctor or nurse 1.95 1.67 14%
Average of I weigh myself every day 3.05 1.52 50%
Average of If I gain 2 kg in 1 week, I contact my doctor or nurse 2.47 2.01 19%
Average of If I get short of breath, I take it easy* 1.50 1.38 8%
Average of I take a rest during the day* 1.53 1.66 -8%
Based on 23 patients that have first and last score recorded Likert Scale was applied to answers eg Strongly Agree = 1 point, Disagree = 5 points * Would we expect to see an increase or decrease in the scores?
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
Education (Management of Condition)
First time
Last time
18
43%
18%
38%
0%
10%
20%
30%
40%
50%
Improved Same Worse
Reduction in Anxiety
38%
22%
40%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Improved Same Worse
Reduction in Depression
16%
60%
24%
0%
20%
40%
60%
80%
Improved Same Worse
Quality of Life (Reduced problems
doing usual activities)
24%
58%
18%
0%
20%
40%
60%
80%
Improved Same Worse
Quality of Life - (Reduced feelings of being worried, sad or unhappy)
Figure 2
Based on 260 patients that have first and last score
recorded in the report period
Figure 3
Based on 268 patients that have first and last score
recorded in the report period
Figure 4
Based on 25 patients that have first and last score recorded in the report period
Figure 5
Based on 25 patients that have first and last score
recorded in the report period
19
Appendix 3 – Telehealth Patient Questionnaire
18-25 25-35 35-45 45-55 55-65
Age range 0 1 0 6 18
0
2
4
6
8
10
12
14
16
18
20
Nu
mb
er
of
pat
ien
ts
Age of patients
58.73%
69.84%
46.03%
34.92%
Peace of mind/reduced anxiety
Enabled my care team to better managemy condition
Enabled me to better manage mycondition
Reduced my need to see my GP
What do you like most about the telehealth service?
59.02%
40.98%
No
Yes
Do you feel telehealth has helped you avoid a hospital admission?
20
40.32%
59.68%
Yes
No
Has telehealth stopped you from calling out an emergency service (eg ambulance, GP
emergency line, community heart failure SOS line)
65.08%
4.76%
30.16%
Yes
No
Not sure
Did you feel like your family/relatives have benefited from you having telehealth?
22.22%
58.73%
19.05%
High Improvement
Some Improvement
No Improvement
Do you think telehealth has improved your quality of life?
21
96.83%
3.17%
Yes
No
Would you recommend telehealth to family or friends with long term
health conditions?
82.54%
12.70%
1.59%
3.17%
Very Good
Good
Average
Very Poor
How would you rate the service?
22
Appendix 4 TELEHEALTH WITHIN THURROCK DAY HOSPITAL (separate to EU heart failure project) Interviews were carried out with the Clinical Lead, Specialist Nurse and the Administrator within the Thurrock Day Hospital and a Community Matron. Community Matron who is responsible for introducing telehealth to the patient and for reviewing and updating parameters on the units. Benefits
Community Matrons benefit as they are able to see the trend in blood pressure and this information is reviewed at the patient’s monthly visit enabling staff to be more informed about the progress of the patient.
Issues
Community Matrons are now managed by the ICT and unfortunately do not carry out the review of the parameters. This has resulted in devices being left long term within patient homes and units are not serviced yearly as per the guidance.
Batteries for the oxygen finger monitor lasts only 2 weeks. Often patients find it difficult to fit the new battery provided and thus cease using the machine.
Thurrock Day Hospital does not have the capacity or the time to monitor alerts and believe they are an unnecessary stage in the patient pathway.
The frequent unnecessary alerts could be avoided if devices were serviced and parameters updated.
Recommendations The Team recommend that:
1. Telehealth would also be beneficial if used for respiratory, diabetes, falls patients where monitoring could prevent escalation of the condition to hospital etc.
2. It is advisable that the service uses a dedicated telehealth co-ordinator for monitoring devices and liaising with the nurse.
3. Review of patient parameters should be carried out by the clinician responsible for patient care.
4. Devices should be PAT tested and serviced regularly and training on triage should be provided
5. A review of telehealth in the Thurrock Day Hospital service is carried out by senior management
.. TELEHEALTH WITHIN HAVERING COPD SERVICE (separate to EU HF project.) Interviews were undertaken with the service lead and the senior healthcare assistant. Docobo units were implemented in 2010/2011. Benefits
The team did not identify any benefits of the current use of telehealth within their service. Issues
There was no selection criteria for patients going on to telehealth and no defined time frame identified.
There was a lack of training and the team who install the devices have no clinical knowledge.
Questions on the units could not be customised to desired specifications so team do not think telehealth is appropriate for COPD or patients with comorbidities.
Recommendations The team recommend:
1. If telehealth is rolled out within other long term condition areas, there should be clear eligibility criteria.
2. It is introduced into services where it will be of benefit and enhance clinical practice
23
3. Education on the use of the devices and triage training should be in place. There should be a dedicated telehealth co-ordinator and teams should be able to access other services outside normal hours in order to action the alerts.
24
Appendix 5 Table Data source: Performance Team
10.1Referral to Acute Hospital – Table 4
Time Frames Patients on
Active Caseload*
Ave no of refs to hosp per month
increase to11
Pre - Telehealth Dec 2011 - Nov 2012 (12m) 1342 112 140
Post - Telehealth Dec 2012- April 2014 (17m) 1674 128
Percentage decrease (approx) 9%
Calculations of savings for 200 patients 112/1342 x200=17 128/1674x200= 15 17-15=2 referral to acute hospital savings per month
10.4 SOS (Emergency) call outs in Heart Failure team – Table 1
Time Frames Patients on
Active Caseload*
Average of SOS Call outs per month
increase to
Pre - Telehealth Dec 2011 - Nov 2012 (12m) 1342 11.08 14
Post - Telehealth Dec 2012- April 2014 (17m) 1674 13
Percentage decrease (approx) 7%
Calculations of savings for 200 patients 11.08/1342 = 0.008 x 200 =1.65 13/1674 = 0.007 x 200 – 1.55 1.65 – 1.55 = 0.1 average SOS call outs savings per month
10.5 Telephone Consultations – Table 2
Time Frames Patients on
Active Caseload*
Average telephone consult per month
increase to
Pre - Telehealth Dec 2011 - Nov 2012 (12m) 1342 77 96
Post - Telehealth Dec 2012- April 2014 (17m) 1674 78
Percentage decrease (approx) 19%
Calculation of savings for 200 patients 77/1342 = 0.06 x 200 =12 78/1674 = 0.05 x 200 = 10 12-10= 2 average telephone consult savings per month
10.6Travel Time – Table 3
Time frames Total
Clinical time spent
Hours of patient related travel
%
Pre - Telehealth Dec 2011 - Nov 2012 (12m) 6169 492 8%
Post - Telehealth Dec 2012- April 2014 (17m) 8562 680 8%
Percentage decrease (approx) 0%
11
Figures in ‘increase to’ columns allow comparison of data pre and post telehealth against an equal caseload
25
Appendix 6
Hospital Admissions – Hull Telehealth Study
Telemonitoring savings report 2012 update.doc
Cost of avoided admissions In order to demonstrate the potential savings through avoided admissions we can look at Hull University evidence base study methodology below and apply this to NELFT admission data. Calculations: Formula below: (HP) predicted hospital admissions for Heart Failure Team per month minus (HA) actual all cause hospital admission from this cohort of patients per month multiplied by (C) the average cost of admission: (HP – Ha) x C = monthly cost savings
Re-admissions According to Hull six to nine months following diagnosis 60% of patients have 1 or more readmissions (average of 2.2 re-admissions per patient). Formula below: (HP) predicted hospital admission for heart failure team per month is equal to the number of telehealth patients (n) multiplied by 60% multiplied by 2.2 average readmission rate divided by 9 months: HP= ((n x 0.6) x 2.2) / 9
26
Appendix 7 NELFT Case studies
Heart Failure Telehealth Case Study – Mr Case
The problem
67 year old Mr Case suffers from Left Ventricular Systolic Dysfunction (Heart Failure) which is a
condition where the heart can’t pump enough blood to meet the body’s needs.
The need
Mr Case was recently admitted to hospital where he was diagnosed with Heart Failure, complicated
by Atrial Fibrillation (irregular heart beat). Part of his management plan is to monitor his
physiological parameters to observe for any changes presenting in increase in symptoms.
The answer
Mr Case lives alone and had telehealth fitted into his home upon his discharge from hospital and
referral to the Heart Failure Service. Both BP and pulse were being monitored remotely and any
changes outside of set parameters will be picked up on the Alert system. Mrs Case’s Blood
pressure showed dangerously high reading, picked up on telehealth as an Alert and followed up by
the Co-ordinator and the Heart Failure Team.
The method
Using telehealth Mr Case is able to take his blood pressure, weight, pulse and oxygen levels each
day. Following the alert from telehealth, Mr Case is contacted and asked if he is unwell and to take
his readings. If blood pressure readings remain high, Mt Case will be reviewed and assessed by a
qualified member of staff.
The outcome
Mr Case can monitor his BP from home. “I feel a lot more confident knowing that a healthcare
professional is checking my readings daily” For the healthcare professional it allows a clinical
decision to be made to increase his cardiac medication and monitor the effectiveness of this change
on his blood pressure.
Heart Failure Telehealth Project Case Study
The Method
Using telehealth Mr Heart is able to take his blood pressure, weight, pulse and oxygen levels each day. The results of which are automatically uploaded and monitored remotely. A team of healthcare professionals will review these results daily and respond to Alerts or changes outside of any individually set parameters. The Outcome
For Mr Heart, monitoring his fluid intake and any weight gain from home, has provided him with the tools to help him learn how to manage his own condition. “I am now able to understand why I have been told to restrict my fluid, I understand it is for my benefit and also helps me in getting me better”
For the healthcare professional it allows a clinical decision to be made about the need for a change in medication management and monitors the effectiveness of this change.
NELFT Promotional DVD NELFT have produced a Telehealth DVD which effectively captures the patient experience of using telehealth. Information can be viewed by contacting the Heart Failure Team.
