Transformation Directorate

Remote intelligent monitoring and predictive analytics to support people in their optimal care setting

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Problem to be solved

Rapid deterioration in a person’s health and social condition can often lead to a step-up to more intensive care settings or packages of support - such as premature admission to a care home - which is a significant change for the individual and their families, and frequently more costly.

With the right interventions early on, incidences of people deteriorating rapidly can be reduced - thereby maintaining an optimal level of care whilst they remain in a lower intensity setting or package. The London Borough of Bexley wanted to explore how to prioritise this in ways that promote individuals’ independence and person-centred approaches to their care.

The project - part 1

The goal

In partnership with Docobo, the Council piloted implementation of Docobo’s DOC@HOME technology in one of the borough’s care homes with the goal of:

  • supporting residents to connect more easily with their GP
  • managing residents’ health and wellbeing in their current care setting
  • reducing the likelihood of escalations in care or emergency hospital admissions

Healthcare question sets

The DOC@HOME platform can be used to develop different kinds of question sets loaded up onto everyday devices, for recording and submitting personal healthcare data to clinicians using a secure web interface. This pilot involved two types of question sets.

The first was for cases where a resident themselves or a staff member felt that the resident required a doctor’s consultation. Submitting answers to the questions provided comprehensive information to the GP, who could quickly determine if a visit was necessary or not, and in turn respond within 2 hours with a call to the home. This cut out the wasted time of returning several telephone calls.

The second question set was used to conduct routine monthly wellness checks. Following submission, the resident’s GP or pharmacist would be alerted if the health observations exceeded previously agreed parameters. The technology solution incorporated an AI model trained to identify atrial fibrillation from electrocardiogram (ECG) observations. 

The impact

Since implementing DOC@HOME, there have been fewer transfers to more intensive care settings. Care home residents have benefitted from more timely prescription of medicines by the community pharmacist. When comparing the period April toJune 2018 (pre-implementation) with April to June 2019 (post-implementation), there were:

  • 71% fewer visits by GPs to the care home
  • 36% fewer visits by residents to A&E

The project has upskilled care staff to identify common signs and symptoms of ill health, and gave them reassurance that the GP had the data they needed rather than being solely reliant on a description of the resident’s condition. Care staff also saved significantly on their time, not only from a more efficient communication channel with the GP but also from a lower administrative burden associated with 999 calls and ambulance attendances. 

Scaling up the project

With support from an NHS Digital pathfinder grant, the council plans first to scale up this project to 20 care homes across the borough. It will then make the project available more widely to:

  • vulnerable individuals who live at home and their carers 
  • other professionals from hospital discharge, reablement and community health teams

The project - part 2

Using another Docobo product, ARTEMUS, the Council and Bexley Clinical Commissioning Group (CCG) are together developing a risk stratification platform to:

  • predict the needs of citizens
  • support intervention planning with them
  • evaluate the outcomes of interventions, for example, by monitoring the health and wellbeing of individuals before and after admission to a care home

The platform is currently pulling data from GP practices and the DOC@HOME system. Next steps are to incorporate:

  • Secondary Uses Service (SUS) healthcare data
  • adult social services data
  • other contextual geographically-based council data 

This analytics and decision support platform will support a more holistic approach to health and wellbeing at the individual level by predicting likely causes of deterioration and route to referral for higher levels of care and provide better evidence for understanding how to promote independence and self-management.

Benefits for strategic commissioning

At a strategic commissioning level, there are many potential benefits. The project will help with predicting future demand for social care services. Primary Care Networks will be able to stratify their service users and design interventions to manage population health. Commissioners will be able to identify early interventions which are most effective at preventing long-term escalations in people’s care needs. The data will also help to develop better understanding of comorbidities, such as the relationship between dementia and frailty, and inform more integrated support.

Lessons learned

As with several similar projects, securing access to data from across several organisations and putting in place robust data sharing agreements has been a challenge.

On the DOC@HOME initiative specifically, helping to broker a new kind of relationship between the care home and its residents’ GP practices has taken time and energy. Traditionally, care homes have sometimes felt like they are lower down the priority list for GPs, whilst GPs may have felt frustrated by care homes raising what they considered to be minor concerns about residents. The DOC@HOME initiative has been designed to address this historic tension through improved communication and responsiveness, though changing perceptions will not happen overnight.

Through this project, the council has appreciated the value of Docobo’s implementation approach of ‘getting up close and personal’. Technology suppliers need to commit time and resources to working with the staff who will be using their products on the ground.

To find out more about this project, contact Rebecca Watson-Morse by emailing:

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