Protecting care home residents from the impacts of frailty: digitally-enabled innovation in the Black Country.
Staff who care for over 1,400 residents in more than 30 Black Country care and nursing homes are embracing the potential of technology-enabled remote monitoring and digital care pathways to support planned and unplanned care needs.
This includes the team at Woodlands Quaker Residential Home in Wolverhampton, which has 35 beds for people who are elderly, frail and living with early to mid-onset dementia.
The home, which features as part of this case study, also has a separate nine-bedded Elderly Mentally Infirm (EMI) residential unit that supports people with advanced onset dementia.
People
Zoe Taylor is Clinical Lead for the Enhanced Health in Care Home (EHCH) Team based at the Royal Wolverhampton NHS Trust.
The nurse-led team is at the heart of technology-enabled remote monitoring implementation, training and response for care homes.
Zoe said: “We have worked together with our Integrated Care System (ICS) quality team to upskill staff in care and nursing homes to successfully implement the system.”
Together with the ICS’s quality nurse, Zoe has worked with care home staff to ensure they are trained to confidently take and record vital signs information including blood pressure, oxygen saturation, respiratory rate and temperature.
Debra Evans is Deputy Care Home Manager at Woodlands Quaker Home, one of the first homes in the ICS to go live with technology-enabled remote monitoring in May 2022.
Woodlands staff take residents’ baseline observations and input the information into a specialist application on digital tablet. This data supports nursing handovers, technology-enabled remote monitoring and the ICS-wide focus on clinical safety and data quality.
Debra said: “Our staff find it so much easier to record the observations digitally compared to the previous approach of filling in charts manually.
“We get in touch with EHCH representatives to tell them who we need them to see, why we need them, and when we need them. The information we input also goes directly on to the residents’ GP record, which our staff are finding invaluable.
“We add in monthly observations, so if there's any change to our resident’s baseline observations the EHCH team can see the changes and act appropriately. They help us to make sure that the resident isn't deteriorating, that there's no underlying cause, or if medication might need reviewing.
“Our staff use it for their weekly ward rounds and also daily if they think a resident is unwell and need advice.”
GP Dr Zishan Yousef is Chief Clinical Information Officer and Remote Monitoring Clinical Lead for Black Country Integrated Care Board (ICB).
He said: “Before this system, we simply didn’t have the means to monitor vulnerable people in care homes intensely and actively.
“We are starting to see a lot of positives. The introduction of a technology-enabled monitoring system means clinical staff are able to look into any concerns the carers have and support early interventions.”
Process
Technology-enabled remote monitoring is a core component of strategic digital transformation in the Black Country.
Jim McDonald is Remote Monitoring Programme Lead for Black Country ICB and Digital Transformation Senior Programme Manager at NHS Midlands and Lancashire Commissioning Support Unit (CSU).
Jim said: “This service enables our clinicians and care staff to provide residents with earlier interventions, which lead to better outcomes at an increased efficiency. It also supports our work around clinical safety and data quality.
“Zoe and Debra have been at the forefront of developments, combined with Royal Wolverhampton NHS Trust’s Care Coordination (CareCo) and Rapid Intervention Team (RIT) services, which provide the Urgent Community Response element, a key part of keeping residents out of hospital where appropriate”.
Shaped by risk stratification analysis, the Black Country team developed five different digital care pathways for care homes that aim to prevent avoidable harms and deterioration often linked with frailty.
Three pathways cover planned care; weekly home round requests, monthly wellness and care plan reviews, and pre-falls assessment, with data routed to the EHCH team.
Two pathways cover unplanned activity; supporting a deteriorating patient, and post-falls assessment and management, with data routed to CareCo and RIT services.
Planned and unplanned pathways operate within a clear information governance framework supported by two respective specific standard operating procedures (SOPs).
Care home staff use 4G SIM-enabled digital tablet devices, provided by the ICB as part of its contract with its supplier, Docobo, to input a resident’s observations covering physiological, symptom-based and soft sign data.
The data is then made available in near-real-time to authorised professionals like Zoe on a digital dashboard via a secure online portal, and via the electronic patient record.
Additional email notifications can be triggered by some aspects of the data, such as low or high blood pressure, pulse or respiration rates, while the system also supports secure data-sharing into the respective primary care electronic patient record (EPR) via the nationally-recognised Message Exchange for Social Care and Health (MESH) solution.
Zoe said: “We can look at the electronic patient record, dashboard or email and get in touch with the care home straight away and this is helping reduce the queues existing across all sites. It’s well known that when you're ringing a GP surgery you can have quite a long wait in the queue, but this technology reduces the wait and patients get seen sooner.”
Culture
Community, primary and secondary care professionals are harnessing digital innovation as an enabler of collaborative working between settings to help effectively support safe, integrated, personalised care.
Dr Yousef sees technology-enabled remote monitoring as an important step towards building a strong intermediate service between primary care and secondary care.
He said: “Community care has done an admirable job to fulfil that gap, but there's so much more that can be provided and used with community care that allows a much more holistic approach and a much better patient experience.”
Ensuring adult social care and health staff feel supported and empowered to confidently use technology, from taking observations to inputting and reviewing data, is a key element of the ICS strategy and reflective of an absolute commitment to quality and safety.
Jim said: “Instilling and normalising regular educational training for professionals within care homes, where staff turnover is high, is vital if we are to make technology-enabled support sustainable and successful.”
His team is developing a suite of staff training tools, such as animations and short films, to help with this direction of travel, each step rigorously underpinned by quality and safety.
This work is seen as an essential element of successfully shifting the dial from cure to prevention and supporting early intervention, while preventing deterioration and avoidable admissions to hospital.
Dr Yousef said: “Admissions from care homes can often be a signature of persistent decline. Early intervention prevents what can be a completely unnecessary admission that can be detrimental to a patient, who will usually do a lot better in their own preferred environment.”
One example of this shift is how homes are already starting to use the digital technology to securely send photographs of wounds they are concerned about to the EHCH team.
Zoe said: “We're now receiving pictures, which helps us to diagnose and support the patient even before our weekly ward round. We want to put training in place to make sure all the homes are using the technology to take photographs, as it’s a safe way to transport that data with the patient’s consent.”
Tools and technology
Using a remote monitoring solution supplied by Docobo Ltd, data is securely transmitted to a clinical server for processing and made accessible to authorised clinicians via an online portal.
The system allows clinicians to set tailored data thresholds to reflect what is “normal” for individual residents, with an alert generated automatically if a threshold is breached.
The Black Country team work closely with the supplier and clinicians to create structured clinical and non-clinical question-sets that underpin data entry, which are updated as part of a Plan-Do-Study-Act (PDSA) cycle.
Zoe helped to customise the questions and incorporated standardised nursing tools including National Early Warning Score (NEWS2) questions, which help recognise the deterioration of a patient.
Zoe said: “The scores help us to understand whether the patient can wait for a weekly home round or needs more urgent support from our team.
“We’ve also incorporated the Stop and Watch tool, which looks for such soft signs of deterioration, such as the patient has stopped eating and drinking, which might mean they are entering the end stages of life.
“The answers inputted by the carer come through to our team, which means we can have important discussions with the family and make decisions before we've even gone into the care home.”
The question-sets also incorporate whether a patient has a Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) document, which is part of advanced care planning and details whether the patient wishes to be resuscitated or not.
The team have also based some of the questions on the iSTUMBLE falls risk assessment framework and a locally-developed mnemonic, NO STUMBLES, (Normal, Osteoporosis, Shoes and slippers, Toilet, Urine, Medication, medical condition and mobility, Beds, bells and blood pressure, Lighting, Eyesight, exercise and environment, Support and supervision).
Integration, safety and efficiency
The data platform also provides clinicians and other system professionals like commissioners and decision-makers with secure, integrated access to other information, such as Secondary Uses Service data, which helps to build a more complete picture of care to support caseload management.
Both electronic patient record (EPR) systems used by the majority of Black Country primary care and community providers, SystmOne and EMIS Web, have been incorporated to the platform along with the Black Country’s shared care record solution, Care Centric, supplied by Graphnet Heath Ltd.
Dr Yousef added: “This will help us make future care even more holistic. Essentially all the information that a clinician will need is there in one place, which significantly reduces the possibility of clinical error and allows a much better and in-depth review of that patient.
“It will make clinical judgment and decision-making so much easier with the level of clinical detail at your fingertips.”
Such innovation is already helping to support people with complex needs in the region to receive the care they need.
Zoe’s team have already been able to work with care staff who are supporting residents with complex mental health needs to identify where mental health reviews have been requested elsewhere in the health and care system, allowing them to liaise with the relevant team prior to visiting a care home and ensure the review takes place.
Digital integration is also helping to streamline processes, making them faster and more effective while alleviating administrative burden.
A recent achievement includes digitising the GP registration process for care homes.
Jim said: “We have been able make the process of registering a new resident with a GP something that happens at the click of a button, rather than a manual, paper-based approach that can take much longer.
“The care home can now complete an electronic version of the GMS1 registration form on the system, which is integrated with both primary care EPR systems in use on our patch. This might appear a simple change but for some care homes it is an absolute game changer.”
Benefits and Impact
Jim and the Black Country’s Business Intelligence (BI) team regularly assess the impact of technology-enabled remote monitoring to residents and services within the ICS geography.
Care homes are complex environments, remote monitoring is just one contributing factor to any improvement or decline but when they have compared activity relating to more than 900 beds in care homes that were live with the service, compared to beds in care homes yet to go live the following benefits were found.
Analysis of data from March 2022 to December 2022 inclusive found that beds in care homes that were part of the service had:
- 62.8% fewer accident and emergency attendances
- 13.7% fewer emergency in-patient admissions
- 3.9% fewer in-patient hospital admissions caused by falls
- 6.1% fewer hospital re-admissions
- 6.3% fewer 111-service calls
- 14.6% fewer ambulance conveyances
Anecdotal feedback from adult social care providers suggests increased staff confidence in taking observations and using digital tools.
Zoe said: “We've reduced waiting times for busy care staff in a nursing home when they're trying to get an appointment for their patients through the doctor's surgery.
Dr Yousef said: “There is significant benefit to patients from being closely monitored. Regular observations like blood pressure, heart rate and respiratory rate are incredibly useful in helping us provide early interventions, which we know leads to prompt clinical reviews and a reduction in hospital admissions and ambulance call-outs.
“These are all tools which I think if used correctly are incredibly useful to making a patient’s journey better and helping a lot of clinicians provide the best care.”
Find out more
You can read this case study and more on our Innovation Collaborative workspace at FutureNHS.
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