How to sustain, scale and expand technology-enabled care across pathways and providers: supporting people to be at home and outside of hospital in Leicester, Leicestershire and Rutland.
Teamwork between health and care providers in Leicester, Leicestershire and Rutland (LLR) means an increasing number of patients have the option of accessing digitally-enabled support from the comfort of home.
Professionals from different settings and specialisms across the region have not just sustained a technology-enabled remote monitoring service since 2020, but are growing and diversifying this innovation across acute, community and primary care.
Their work includes the provision and development of technology-enabled virtual wards to support patients along pathways including:
- asthma
- covid
- chronic obstructive pulmonary disease (COPD)
- heart failure
- atrial fibrillation (AF)
- pneumonia
A virtual ward is a safe and efficient alternative to NHS bedded care that is enabled by technology. Virtual wards support patients who would otherwise be in hospital to receive the acute care, monitoring and treatment they need in their own home. This includes either preventing avoidable admissions into hospital or supporting early discharge out of hospital.
The LLR team intend to evolve their services beyond a predominantly step-down model, where the focus is on helping patients to safely leave hospital as early as possible, to provide further preventative ‘step-up’ pathways aiming to reduce avoidable acute exacerbations and hospital admissions.
People
A diverse population of 1.1million people is served by both Leicestershire Partnership NHS Trust (LPT), which provides community and mental health services, and University Hospitals of Leicester (UHL) NHS Trust, which operates three hospitals.
Teams from both providers have formed a strong partnership to advance the increasingly integrated delivery of technology-enabled services, supported by NHS Leicester, Leicestershire and Rutland (LLR) Integrated Care Board (ICB).
Multidisciplinary teams including specialists from all involved providers sit at the heart of each digital pathway from the outset. Each brings together a diverse range of healthcare professionals underpinned by a consultant-led model.
This collaborative approach originated in 2020 with the introduction of two covid virtual wards, with a fully technology-enabled step-down ward running alongside a non-technology enabled step-up ward.
UHL Advanced Nurse Practitioner Sue Armstrong is one of the clinical leads for the technology-enabled AF virtual ward, which went live in January 2022.
Sue said: “It’s a very challenging pathway, as the patients have fast heart rhythms and can become unstable quickly. We work very collaboratively as a team supporting these patients until they are more stable, delivering hospital level treatment in the home.”
“It's important to make sure you've got the consultants and clinicians you're working with on board and, for AF, that patients are all under the care of an electrophysiology consultant for further support and advice.”
Emerging pathways
Prof Gerrit Woltmann, UHL Head of Service for Respiratory Medicine and Allergy, is the lead clinician for the recently established technology-enabled pneumonia virtual ward that became operational in late November 2022.
He explained how the work of specialist nurses within the acute trust has led to the development of the digital pathway.
Gerrit said: “The specialist pneumonia intervention nursing (SPIN) team in UHL see several thousand people every year in the acute hospital wards. They confirm and validate CURB65 risk scores, which help determine the severity of pneumonia.
“The team also aim to bring antibiotic prescribing in line with NICE and UHL guidelines and offer to undertake the repeat chest x-ray six weeks later.
“It was obvious for us to engage with this virtual ward piece and extend into the community. I think that's absolutely the trajectory and direction of travel for all specialist nurse teams.
“The virtual ward is supported by a weekly MDT that I attend with the UHL SPIN nurses and a microbiologist. We look at all the inpatient nerve centre records and radiology and decide whether any further imaging may be required other than routine follow-up chest x-rays.”
Process
Demonstrating value to commissioners, executive colleagues and staff, has been key to sustaining and expanding technology-enabled remote monitoring provision in the region.
The team behind the region’s inaugural technology-enabled virtual ward, which initially supported COVID-19 patients before evolving to help people living with respiratory conditions, successfully made the case for continued and further investment by evidencing how such services meet the evolving needs of patients.
This includes providing regular qualitative and quantitative updates, including reductions in avoidable acute admissions and primary care appointments, and positive patient and staff feedback.
Ali Shaw, LPT Cardio-Respiratory Lead, was involved with the initial virtual ward programme and now manages the cardio-respiratory digital service, which includes a technology-enabled COPD virtual ward.
The service also operates a non-technology enabled Enhanced Respiratory Assessment Service, which offers home support from specialist nurses and health care professionals (HCPs) to patients experiencing an exacerbation.
Ali said: “We've got a great integrated team and work and communicate really closely. It is an iterative process where things do need to be adapted and tweaked and that's absolutely fine.
“It takes a while to get virtual wards set up. You need to make sure that your team are on board and offer training support to make sure they're happy and confident in using the equipment and in teaching patients how to use it.
“Make sure you have got your Standard Operating Procedure (SOP) up-to-date, that it’s relevant and easy to use for reference, and communicate it well with partner organisations in primary and secondary care.”
Bespoke criteria
Each pathway has a bespoke criteria for onboarding, ensuring patients have been assessed by the clinical team as safe and suitable to be monitored at home.
The technology-enabled AF virtual ward was originally designed as a step-down model from acute inpatient care, with onboarding criteria for patients with AF and atrial flutter and a fast ventricular response, heart rates between 100 to 150 beats per minute.
The team successfully secured local CCG funding to undertake a proof-of-concept study for the ward, followed by a successful funding application to NHSX, now part of NHS England, that enabled them to recruit advanced nurses to run the service.
Sue said: “The initial plan was to focus on patients presenting to our clinical decisions unit. We aimed to expedite discharge for patients who were otherwise well and relatively stable and didn't have any other factors driving their atrial fibrillation, for example sepsis or heart failure.
“What surprised us was we started to get referrals from our outpatient department for patients that were presenting for an ECG or a 24-hour heart monitor with a fast heart rate and patients after other investigations, were also found to be meeting our criteria.”
The service model and leadership of advanced nurses has enabled the AF team to manage this additional demand.
In respect of the new pneumonia ward, which has supported more than 100 patients since launch, Gerrit explained the initial criteria for onboarding includes patients with a CURB65 score of between zero to two and excludes any patient with severe pneumonia.
A CURB65 score is used by health professionals to assess the severity of a patient’s pneumonia.
Gerrit said: “We are not including patients who are still on intravenous antibiotics, but moving forward there is a plan to involve the Community Intravenous Therapy Team. We also aim to expand from pure pneumonia cases to lower respiratory tract infection (LRTI) cases to promote earlier discharge.
“There’s the vision at some point to have a step-up system connected to the infection hubs in the primary care centres.”
Culture
The cross-provider partnership, supported by LLR ICB, is underpinned by a culture centred on supporting individual patients with a personalised approach throughout their journey, above and beyond traditional organisational barriers.
Each patient is in receipt of a personalised care plan as part of their respective virtual ward onboarding process, with some plans also including family, friends or carers depending on individual circumstance and need.
An educated and empowered patient culture is also being fostered, particularly among those living with chronic conditions, through the provision of digital learning and support modules. This includes a new digital pulmonary rehabilitation programme.
The team have an “inclusivity with no exclusions” philosophy and are careful to avoid making any assumptions about who might want, or be able to use, the technology-enabled pathway.
iPads can be loaned to patients that don't have access to a smartphone or tablet, ensuring equitable access for all.
The service is also offered to patients as an alternative or hybrid option, not a replacement, for face-to-face care.
Ali said: “Technology-enabled support is not a replacement for face-to-face nursing care or clinical care. It's a tool to work alongside that patient care as an extra method of monitoring patients closely.”
Tools and technology
Leicester-based supplier Spirit Digital has developed the CliniTouch Vie platform for virtual ward patients to input the data specified as part of their respective pathway, with this information made available via a digital dashboard for clinical teams.
Patients, all of whom are offered technical support at home upon being onboarded to the service, have both messaging and video call options if they want to contact their clinician via smartphone or tablet. They also have anytime access to educational modules designed to help them learn more about and manage their condition.
Ali said: “We spend a lot of time talking to patients and teaching them about the software, going through exactly how to use the equipment just to give them that reassurance and offer that support.
“Sometimes there have been blips with equipment not connecting, such as trouble with the Wi-Fi and the Bluetooth connections, but on the whole it seems to work really well, and we've had positive feedback and some lovely letters from patients that have really found it supportive and reassuring.”
Patients on the AF virtual ward use the MyDignio platform and are provided with a Bluetooth enabled blood pressure monitor, pulse oximetry and a single lead ECG device.
Sue explained how patients send results via their smartphone or tablet to the dashboard twice a day, or three times daily if they require closer monitoring, and also complete a symptom-based questionnaire.
Sue said: “We have the option to be able to message the patients directly via the platform or we can do video as well as phone consultations.
“The service we're offering is not just about measuring and monitoring their cardiovascular condition along with their rate and rhythm control, we are also giving them support and advice. We hope to give them the tools they need to manage their condition in the long term.
“By providing acute medical care for these patients by either controlling their heart rate or rhythm, we are improving their care pathway and getting them to their destination therapy sooner than the traditional pathway.”
On the pneumonia virtual ward, patients report daily observations through the platform including temperature, blood pressure and pulse alongside a symptom questionnaire developed by Gerrit and the MDT.
The on-shift team of two pneumonia nurses, supported by at least one senior healthcare assistant, assess the resulting data via the clinical dashboard as they conduct their daily round on the virtual ward, which has a current capacity of 15 virtual beds. In addition, the team are alerted to any red flag readings on the system.
Gerrit said: “I think it's a very safe system. We have a trajectory of improvement before patients are sent to the virtual ward and the vast majority continue to improve and fully recover after about 10 days or so and then they are discharged.”
Benefits and Impact
- 96 per cent of people using the respiratory pathway felt more knowledgeable and motivated to make behavioural change and manage their conditions.
- 173 patients were onboarded to the AF virtual ward between 31 January 2022 and 20 April 2023, saving approximately 500 bed days.
- Half of all AF virtual ward patients onboarded to the step-up pathway via the outpatient department did not subsequently require a hospital admission or use of the step-down pathway.
- 106 patients were onboarded to the pneumonia virtual ward between late November 2022 and late June 2023, with a 10-day average length of stay (LoS). To date the ward has received 100 per cent positive feedback from patient satisfaction questionnaires.
Ali said: “Some of the feedback we've had from patients has been absolutely fantastic. They felt really supported knowing they are in the comfort of their own home. They have the equipment, they are monitored daily, and they have the assurance that a trained, qualified clinician is there monitoring them data and we'll contact them to offer any support, advice or treatment as and when needed.”
Sue said: “We've been able to expedite patients needing cardioversion or even ablation procedures to enable them to get to their endpoint in their treatment pathway sooner, and more definitive treatment for their atrial fibrillation rather than just undergoing rhythm and rate control.
“We've had 100 per cent satisfaction on our friends and family tests and some really valuable feedback from patients. They feel very reassured and supported while they've been on the platform.
“The great patient feedback has been what has motivated us and drives us to take the service forward, we've got further phases we want to roll out. It’s a very challenging pathway but it has a lot to offer, and patients really appreciate being at home.”
Gerrit said: Patient satisfaction is very good. On a small-scale audit that we've done, we've only had one returner who had to be reassessed in the hospital, but they were not admitted as a result.”
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