NHS England - Transformation Directorate

Remote monitoring for patients with chronic conditions in the Midlands

What was the aim?

Across Leicester, Leicestershire and Rutland the COVID-19 pandemic has driven forward a rapid expansion of remote monitoring schemes which is allowing clinical teams to keep track of patients with chronic conditions safely and in the comfort of their own home.

It forms part of a wider plan to improve digital health services for people with long term conditions, aiming to reduce the pressure on hospital services and improve outcomes by detecting and addressing signs of deteriorating health earlier among recently discharged and chronically ill patients.

The project aims to:

  • protect clinically vulnerable patients by reducing the need for community clinics and home visits
  • reduce unplanned hospital admissions involving people with long term conditions, including those recovering from an admission with COVID-19
  • provide patients with better information and support to help them manage their condition and wider health and wellbeing
  • provide a viable blueprint to expand the use of digital technologies across the region and other care pathways in the future

What was the solution?

Technology is set up to help patients self-manage their condition at home. Giving them support and reassurance that the monitoring equipment ensures their clinical teams can act swiftly if their health deteriorates.

Patients capture relevant clinical data according to an agreed management plan. They then upload this using a computer, tablet or smartphone which connects to a web-based remote monitoring platform called CliniTouch Vie.

This data allows health professionals to spot long-term trends in a patient’s condition and identify early signs of deterioration before they require hospital admission. The technology enables patients to have an assessment by video call with their health professionals, if required, and clinicians can send direct messages to their patients. The remote monitoring service is offered to all suitable COVID-19, COPD, heart failure and pulmonary rehabilitation patients and a tablet is provided to any patient who needs one, which they can keep for as long as they need to use the service.

Any changes to a patient’s care and condition are documented in Electronic Patient Records. The potential of interoperability across a wider range of systems is being assessed.

What was the impact?

Over 1,000 patients have been supported across the 4 pathways.

Over 725 patients with heart failure and COPD were supported between 1 April 2020 and 20 May 2021.

In all 288 hospital bed days were saved between January and the end of April 2021.

218 COVID-19 patients were discharged after a hospital admission with remote monitoring at home between 2 November 2020 and 20 May 2021. Only 10 people were readmitted to hospital during their 14-day monitoring period. This resulted in a 50% reduction in readmissions among patients supported by COVID virtual ward.

Key actions and insights

We asked the core project team to highlight the key actions that helped them make progress on implementation and adoption by patients and practitioners. Here are their 3 reflections.

Working across boundaries through clear governance structures

“A particular challenge for us was working across different STPs to define accountability and quickly develop a robust but straightforward governance and operational framework that we could then apply and adapt quickly and easily to future complex services. Working as a system rather than a single provider made this happen.

“Within this framework, we were able to bring together the right experts to predict potential issues and manage them head on, such as how we calculate and weight patient data calculations to a defined RAG status for the dashboard or the incorporation of data protection principles.

“We took the time to get these governance principles right and the solid foundations we laid in the very early days are now yielding success. This is demonstrated by the speed in which we’ve implemented successive projects, sometimes in just as little as one week. We’re now in the position where we can expand our care offering at real speed.”

Nisha Patel, Senior Elective Care Services Manager, Leicester, Leicestershire and Rutland CCGs

Active listening to put the end user at the heart of the process

“We’ve never shied away from listening to our clinical team’s feedback, who act as our ‘critical friends’. For us it’s the natural thing to do, as we are all invested in the project’s success – and their clinical insights have helped to create a service that really does embody the care principles that we set out to achieve and reflect in this new pathway putting the patient at the centre of all our decision making.

“Throughout the project we’ve made a conscious point of using the ‘You said, we did’ model in regular meetings, forums and training sessions to demonstrate that feedback is listened to and incorporated throughout the project stages.

“Within any project there’s a lot for colleagues to take on board and adapt to, but our active listening approach has also supported the emergence of ‘champions’ who’ve supported colleagues to culturally and practically adopt the various pathway processes.”

Zoe Harris, Cardio-Respiratory Service Lead, Leicestershire Partnership NHS Trust

Creating ‘front of house’ ambassadors for technology

“We realised that creating new, dedicated roles or adapting existing administrative

roles within our hospital wards to support the virtual ward process was, and continues to prove to be, critical to the success of the patient onboarding process.

“The unpredictable nature of the pandemic meant we needed a group of colleagues,

with the capacity protected within their roles, to talk to patients about the positive impact remote monitoring could have on their physical health and emotional well-being while providing the context for the rationale of using technology in this way.

“These colleagues work closely with frontline practitioners and as ‘virtual ward ambassadors’ they are on hand to offer the opportunity to any patient who wants to be cared for in this way while providing vital administrative support.”

Irene Valero-Sanchez, Consultant Respiratory Physician and Clinical Lead for Integrated Care, University Hospitals of Leicester

How is the technology working in practice?

We asked a selection of health professionals working within the virtual wards to describe the real-world impact of the technology on their patients and their own working practices. Here are their personal experiences.

“They know someone is keeping an eye on them”

Daisy Savage, a rehabilitation technical instructor, talks about how the technology is reducing demand on other services by lowering hospital readmission rates and giving patients’ confidence that their health is being safely monitored from home.

“You can identify patients about to have an exacerbation or flare up”

Mani Moodley, a respiratory specialist physiotherapist, describes how the technology is improving different aspects of patient care, from helping to identify patients with undiagnosed high blood pressure to allowing observations to be performed remotely via video consultation.

“It’s become embedded as a normal way of delivering care”

Joanne Szymkowiak, a heart failure specialist nurse, and Tanzeem Adam, a heart failure and respiratory rehabilitation team leader, reflect on how the technology has changed their ways of working and why it is now an established way of delivering care.

Key lessons and next steps

Looking ahead, how might this project help to shape the future direction of health services in the region?

We asked members of the project team to outline the four key lessons that are shaping their priorities for the future.

1. Engaging patients on their terms

Using digital platforms has strengthened the connection with our patients, and we have always been clear that the technology should enhance the patient-clinician relationship, rather than replace it.

We know there is more we can do to improve how clinical teams explain the technology and the support available to them, doing so on their terms, without prejudging their capacity to embrace technology. This is particularly important for older patients, many of whom are increasingly confident using digital services.

2. Diversifying our offer to attract wider uptake

It is important that technology helps to close the health gap rather than widen

it, and that means thinking creatively about how to ensure the digital services and support we’re offering fully represent the communities we serve. Leicester, Leicestershire and Rutland has a diverse population, and we’re already exploring how we can develop the technology to take account of different individual needs as a way of improving accessibility and reducing health inequalities.

3. Extending digital support beyond discharge

Our goal is to embed digital solutions at the centre of how we enable our patients to manage their own health ‘digitally by default’.

This includes thinking about how patients can access digital support after discharge to help them self-manage their condition.

We’re hoping to develop new solutions, including Facebook groups and new apps, that can help them maintain good habits and hence stay healthier for longer.

4. Acting as a stepping stone for wider service change

The progress we’ve made to date is now unlocking conversations about how similar technology can enhance other care pathways.

As the integrated care system takes shape, further opportunities will emerge and we hope the learnings from our work can be applied at a system level in the future.

We will continue to deliver our current virtual ward models and look to widen our digital offer into other cardiorespiratory pathways.

Find out more

You can read the full case study on the work across the region on our site at FutureNHS.

Join the Innovation Collaborative

The Innovation Collaborative is open to all NHS, social care and local authority staff with an interest in remote monitoring, providing access to peer-to-peer support, guidance and tools designed to help you implement a remote monitoring service.

Existing members can access the Innovation Collaborative Digital Health workspace on the FutureNHS platform. Alternatively, to join or ask any questions email innovation.collaborative-manager@future.nhs.uk.

Listen to our podcast

Listen to our Innovation Collaborative podcast series on how innovative technologies are being used to provide safe, personalised and more convenient care.