Transformation Directorate

Technology-enabled remote monitoring is enhancing long term condition care in Surrey Heartlands

Delivered in partnership with the AHSN Network.

Empowering people in Surrey Heartlands: how a multi-disciplinary team approach to technology-enabled remote monitoring is enhancing long term condition care and inspiring healthier living.

People with long term conditions in Surrey Heartlands are being supported to manage their health and wellbeing at home with greater choice, knowledge, and confidence thanks to a multi-skilled collaboration of professionals enabled through digital innovation.

Together they are harnessing technology-enabled remote monitoring to help an increasing number of people better manage their health, make beneficial lifestyle changes and access more personalised care.

People

Surrey Heartland’s Digital First Primary Care team, established by the ICS which serves a population of 1.1 million, is working to scale and support around 125,900 people in the region estimated to be living with poorly-controlled diagnosed or undiagnosed hypertension.

Building on a successful pilot in March 2021, the team’s BP@Home hypertension remote care service is led by pharmacists and care coordinators working alongside GPs, other clinical and non-clinical specialist roles and a team of ‘tech angel’ volunteers who offer one-to-one digital support and training to patients.

This approach, interlinked with strong patient engagement, is maximising skills and resources across the region as the service scales to support people according to greatest clinical need.

"Technology-enabled remote monitoring of patients’ blood pressure helps us to use time productively, allowing us to focus on patients’ clinical needs, optimise medication and work with them to achieve their health goals. I think patients feel quite empowered to manage their own health in a familiar environment, knowing we are there to support them."

Ameeta Rajendran, senior clinical pharmacist for North Tandridge Primary Care Network

“The workload of managing high blood pressure that used to fall on GPs and practice nurses has very much been taken over. Our relatively new role within the primary care network is about liaison with the clinical pharmacists who manage the service on subjects like medication.”

GP Richard Wright, clinical director for North Tandridge Primary Care Network

Process

Embedding strong information governance has been an intensive but essential process in developing the service, ensuring the secure upload of blood pressure readings from patients to GP systems.

Supported by a team of care coordinators, the service operates with pharmacists as the first point of clinical triage for assessing blood pressure and heart rate readings typically reported twice-daily by patients over a four-day period.

"This is all about early intervention and picking up and identifying that there is an issue before something goes wrong. We do whatever is necessary, take whatever path that needs to be taken, in getting a patient into whatever service is required quicker than what they would do by their own means.”

Gillian Kneale, Surrey Heartlands patient care coordinator

Assessments are informed by a tailored traffic light red, amber, green (RAG) system, where red and amber readings mean the patient’s readings are outside of their ‘normal’ parameters and require appropriate clinical intervention.

Ameeta said:

We’re finding cases where we need to intervene promptly, in situations we previously may not have been aware of where an individual may be at risk. Not only do we feel clinical management has improved because of technology-enabled remote monitoring, our confidence in proactive case-finding and picking up undiagnosed cases of hypertension has also been a positive experience.

The service prioritises patient cohorts by using a needs-based pyramid model to stratify risk, and aims to support additional, lower risk groups as it continues to scale up.

Ameeta added:

As we work through the cohorts the way we will contact them will change. Care coordinators contact those most at risk by email, phone and text, but when we get to wider community numbers, people will receive texts.

Culture

By operating as a multidisciplinary team, the service is fostering a workforce culture that empowers different health, care and engagement roles to work together, with technology and data at the heart of decision-making and triage.

Together, they are fostering a culture where people have greater understanding and choice over accessing digital, face-to-face or hybrid support that’s right for them.

Patient and public engagement remains key, ensuring innovations like technology-enabled remote monitoring are inclusive and understood as voluntary not mandatory, and in recognising that some people may always prefer to see their GP in person.

The team’s digital inclusivity work includes a ‘library loans’ system for blood pressure monitors and the option for people to have their blood pressure tested at a community pharmacy.

They run a Tech to Connect partnership that supports digital literacy, loans digital devices and links people to ‘tech angel’ volunteers for one-to-one support.

"It’s been revolutionary for me. It’s reawakened for me the benefits of physical training and got me to look after myself, and hopefully some of my friends and colleagues to do something similar. That’s all come from this process.”

Surrey Heartlands BP@Home patient Jeremy Clarke

Digital First primary care communications and engagement manager Debbie Bacon said:

Discussions with patients during the pilot highlighted some patients didn’t understand what their blood pressure readings meant or, aside from taking medication, other things they could do to help their health such as exercise, diet, and work-life balance. Engagement is key and discussions with our patients about the service helps us develop information for them on things like how to take readings, what they mean and potential lifestyle changes they could make.

Tools and technology

Patients most at risk of hospitalisation or stroke, according to the risk stratification pyramid, are actively monitored by the service using Inhealthcare software.

The patient uses a blood pressure monitor to take their reading and submit it to the service via an app, email, text message, or phone call to the long-term conditions digital care coordinator, whose post, along with Inhealthcare licenses, has been supported through NHS England funding.

Taking a needs-based approach, the team use blood pressure monitors, procured centrally and distributed regionally by NHS England, to offer the service to patients who may not be able to acquire their own device and therefore could have been excluded from the service.

Those at risk according to the risk stratification pyramid can submit average readings as directed over four, seven or ad-hoc days if they have access to a validated blood pressure monitor. Data is submitted via an online questionnaire, a link to which is sent to the patient’s phone or device.

Richard said:

As a GP, there’s a sense we have a greater degree of confidence in the way this cohort is being managed. It’s a good level of supervision they are being managed with, and the way the monitoring occurs using the traffic light system provides a great deal of reassurance.

The team, which also supports people living in care homes, is expanding its long-term condition support, including using technology-enabled remote monitoring to identify and support people with atrial fibrillation and heart monitoring, and supporting people with diabetes to carry out annual urine tests at home to highlight signs of chronic kidney disease.

Benefits and impact

More than 2,100 patients from high-risk cohorts engaged with the BP@Home service between October 2021 and December 2022.

Within this group:

  • The average age was 65.
  • A small number (14) initially submitted a very high-risk ‘red category’ blood pressure reading, meaning they needed immediate intervention by their GP practice.

Readings for 11 of the 14 are now in the ‘green category’, meaning both their systolic and diastolic blood pressure readings are being treated within target parameters.

  • Just over half (1140) initially submitted a higher-than-recommended ‘amber category’ reading, meaning they were at greater risk of stroke or cardiac arrest.

Within this group, 440 have now recorded either a ‘green category’ diastolic or systolic blood pressure reading, while 340 have recorded ‘green category’ readings for both.

  • Just under half (980) initially recorded a ‘green category’ systolic blood pressure reading.

Almost 65 per cent (640) are now being treated within the ‘green category’ target parameters for both systolic and diastolic readings.

Overall, this means that nearly half of all of the patients within the cohort, or just under 1,000, are now being treated to target.

**Please note numbers above 100 have been rounded to the nearest 10.

Surrey Heartlands BP@Home patient Mr Gurmit Bhamra said:

As a result of monitoring and submitting my results, my medication has been changed, and I have also made some lifestyle changes to help manage my blood pressure better. These small changes are already helping me feel in control and have had a positive effect on reducing my blood pressure. I feel supported and encouraged to make the right decisions, and I know that there’s help at the end of the phone if I need it.

Find out more

You can read the full case study on our Innovation Collaborative workspace at FutureNHS.

Join the National 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.

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