Kent and Medway prehabilitation telehealth delivered home-based patient optimisation

Prehabilitation, or ‘prehab’, involves identifying and promoting health-optimising behaviours to reduce the unwanted consequences of cancer treatment. This often happens in the preoperative setting to improve postoperative outcomes.

The effects of in-person supervised programmes and the benefits of prehabilitation for cancer patients have been well documented. The benefits include:

• improved functional capacity
• clinical outcomes
• adoption of healthy lifestyles

Situation

Before the COVID-19 pandemic, the Kent and Medway team provided cancer patients centre-based, or face-to-face, prehabilitation interventions.

When the pandemic hit and high-risk and medically vulnerable patients were advised to shield. The team looked for digital technology and telecommunication methods to deliver prehabilitation remotely.

Aspiration

The team wanted to provide a prehabilitation service for patients that's:

• a high standard
• personalised
• quality-assured
• home-based

They wanted the service consistently support health optimisation and preparation for treatment. This includes before surgery, during non-surgical cancer treatment, or both.

The team wanted to consider sustainability and cost to ensure longevity of the service.

They wanted to explore how digital health tools can help the programme expand and breakdown geographical barriers.

Solution

Eligible patients are referred to a regional prehabilitation unit that provides home-based prehabilitation from:

• multiple centres
• NHS acute Trusts
• GP practices

Referrals are completed using the service’s webpage.

The patients are then examined and streamlined based on initial questionnaire screening.

Prehabilitation specialists and counsellors then have a remote consultation with the patient. This is where the patient is assessed on their psychological and physical needs.

The team then uses a platform called Craetus to create a supervised, targeted plan based on their functional capacity and clinical need.

The programme consists of 4 key interventions:

• exercise
• nutritional advice
• lifestyle optimisation, for example, stopping smoking
• psychosocial support

The referring healthcare professional is communicated with as often as needed. After treatment is complete, patients receive calls at:

• 6 weeks
• 6 months
• 1 year

Impact

The service provides prehabilitation teams a powerful tool to actively support their patients through their treatment journey. It also empowers patients during a difficult and confusing time in their lives.

Results from a focus group showed patients welcomed the telehealth method. They liked the flexibility, accessibility, and social support it offered.

One patient described the fear of embarrassment of having to exercise in front of others and welcomed exercising at home.

The programme also reduced the need to travel to the prehabilitation unit, which gave patients flexibility around medical and personal commitments. This resulted in increased access for patients who were otherwise unable to attend face-to-face in-hospital sessions due to:

• unavailable hospital transport
• being unwell to drive
• time and distance to travel for those outside of the region

The team has expanded the service to non-surgical oncology management and now around half of the patients are from that pathway.

After the 1st year, the team investigated and found positive results.

• They surpassed the goal of patient recruitment by over 250% in a time when most other services were paused.
• They were able to expand the service from 3 centres clustered together and are now a cross-country service. They receive referrals from 9 NHS acute Trusts and GP practices in the Primary Care Networks.
• There was a positive association between the programme and patient reported outcomes.
• There was a high acceptance rate (76%), a high adherence rate (72%) and positive patient feedback.
• There was an increased number of patients in the “no problems” category for all the dimensions after completing prehabilitation.
• When reviewing the available data, the 90-day readmission rate for patients undergoing colorectal and urology surgical oncology management is 16%. The readmission rate at Kent and Medway Prehab is 12%, which is lower than published literature.

Functionality

Craetus is a cloud-based platform and app. It’s easy to deploy and is built on Google Cloud Platform to ensure the highest level of flexibility, operational reliability and data safety.

The 3 main functionalities are:

• prehab programme personalisation and provisioning tool
• a patient navigator which provides information, guidance and signposting to relevant third-party services
• a data analytics tool for programme optimisation and improvement

If patients need additional support during the initial screening or the prehabilitation sessions, they’re offered a referral for wellbeing navigation services. These can include at home access to services for:

• befriending
• home safety
• financial support
• housing
• domestic support
• shopping
• transport

Patients are also invited to:

• group counselling sessions led by professionals over video link
• mind body therapies like tai chi and pranayama
• e-peer support groups

Capabilities

• The digital service enables seamless delivery of personalised prehabilitation services at scale.
• The digital service is a fraction of the cost when compared to traditional provisioning.
• Clinical teams can design, adjust and deliver personalised prehabilitation programmes.
• An app is used to encourage patients’ progress and compliance.
• Clinical teams can monitor results on the platform through the built-in progress tracker and can nudge patients into better compliance.

Scope

Craetus is designed to complement and support telehealth-delivered prehabilitation after initial remote screening and programme design.

Key learning points

COVID-19 made telehealth more acceptable and the team has learnt the value of being pragmatic and agile.

There needs to be a strong focus on rapid adaptability of systems within organisations delivering the programme.

There also needs to be robust governance structures to support:

• implementation of ideas
• clarity in communication

Having a flattened hierarchy and working towards a shared vision of benefitting population health is an important founding principle. Empowering patients to use digital technologies is also important.

Key quotes

“Telehealth has the potential to enable accessibility, flexibility and sustainability for the providers and our population group. It does so whilst lowering delivery costs for healthcare providers and opportunity costs for our patients and we’re delighted they have an overwhelmingly positive experience. Keeping our patients at the heart of all innovation, from conception to delivery and review has been the guiding force responsible for our success.”

Tara Rampal, founder of Kent and Medway prehab

Find out more

Case study on the feasibility and effects of a telehealth-delivered home-based prehabilitation program for cancer patients during the pandemic

Case study on patients' experiences of virtual prehabilitation during the COVID-19 pandemic

Virtual prehabilitation programme launches for Kent and Medway cancer patients media release

Key contact

Claire Mallett, Programme Manager, Kent and Medway Cancer Alliance

claire.mallett3@nhs.net

Tara Rampal Kent and Medway Prehab Clinical and Strategy Director, Consultant Anaesthetist, Senior Clinical Lecturer

t.rampal@phb.community

Alex Agrapine, Director of Technology, C Digital Healthcare Ltd

alex@craetus.healthcare