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Switching to telehealth: a masterclass in managing COPD

Fatima Holt
RGN

RGN for the District Nurse Team
Milton Keynes Primary Care Trust

According to the National COPD Audit 2004, the cost to the NHS of treating chronic obstructive pulmonary disease (COPD) is £818m per annum.(1) There are on average 25,000 primary care consultations and 1,000 hospital admissions in a typical trust area, and over 30% of emergency admissions are readmitted to hospital within 90 days.  
COPD kills 30,000 people every year in England and Wales alone, making it the fifth biggest killer. Moreover, it is the only major cause of death whose incidence is on the increase - 95% of all COPD cases are linked to smoking, and given our aging UK population the mortality rate is set to rise.
In the light of this audit, the Secretary of State announced that a new National Service Framework for COPD will be developed for 2008, to improve the quality of and access to COPD services.  
There is clearly an enormous burden on the NHS, both economically and also in terms of primary and secondary care provision, with extended hospital stays and avoidable hospital admissions placing a strain on resources. It's an issue which NHS trusts across the UK are addressing with urgency by finding alternative models of care to treat COPD cases in a more timely way within the primary care setting.

Heads and beds: the cost of COPD
Milton Keynes has a high prevalence of COPD in its local population. The Bletchley area, for example, has a COPD prevalence 4% above the national average, and overall, COPD is the third most common long-term disease affecting individuals in Milton Keynes after diabetes and coronary heart disease. Its burden on the NHS is significant, costing the PCT over £450,000 a year to treat emergency admissions.  
But while the cost to the NHS is high, the effect of COPD on individuals - characterised by difficulty in breathing - is more dramatic, with marked impairment of quality of life in many cases. In severe cases of COPD, patients are totally reliant on oxygen to even walk or talk and they can be wheelchair bound for a large proportion of the time. Constant visits to the hospital for check-ups can be stressful for the patient and eat away at valuable NHS resources. 
It was essential that Milton Keynes PCT addressed the situation and found a long-term solution that would not only lighten the financial load of COPD on the PCT, but would also allow us to continue giving our COPD patients a high level of care and improve their day-to-day quality of life.
New government guidelines were promoting the greater need for care at a community level and the Department of Health had put forward new models, which tailored care to the needs of the patient, while simultaneously reducing some of the burden on the NHS.

Adopting a more proactive and preventive approach with telehealth
With this in mind Milton Keynes PCT and Milton Keynes Community Alarm Service teamed up with Tunstall, the leading telecare and telehealth solutions provider, to launch a pioneering telehealth initiative to reduce avoidable hospital admissions and enable people to better manage conditions such as COPD at home.
During the initial roll-out of the scheme 10 Tunstall Genesis monitors were provided to patients with COPD to support a more proactive and preventive model of care. The monitor allows patients to measure their own vital signs such as heart rate, weight, blood pressure and oxygen levels, and also asks a range of clinical questions to further determine their condition. A total of 51 preset questions are available in 11 different languages, and can be selected as appropriate for each person's specific health issues.
As a result, if patients with COPD experience a change in their health status, proactive medical intervention can be taken at an early stage. Staff at the community alarm centre view patient data using remote client access, and the nursing team is notified if assistance is required - an approach that has the potential to reduce the number of avoidable hospital admissions.
The community alarm team perform first-level response and handle all noncritical readings. The team is also responsible for clinical triage and if a red flag is detected, they call the nursing team responsible to inform them of the situation. Prior to this the monitoring centre will call the patient to ask them to perform a retest to quantify the result to triage.

The nuts and bolts of telehealth and telecare
Patients returning home from hospital and their informal carers are trained on how to use the unit to monitor their condition. They are guided through a process allowing them to take their own measurements, which can include temperature, pulse oximetry, heart and breathing rates, electrocardiogram and noninvasive blood pressure, twice daily.  
The telehealth monitor records the results and sends them over the phone line to a secure server where they are stored as an electronic patient record in a database accessible by both the nursing and community alarm teams.
Prior to monitoring, the necessary clinical information, instructions and escalation process are inputted into the patient's care plan by the nurse, using a web browser and an intranet connection. If the triage software detects any abnormalities or deviations from the individually-set parameters for the patient's results during the vital signs of the monitoring period, eg,  oxygen saturation beginning to drop, it flags up the reading for the community alarm team, who will then contact the patient's nurse.
Telecare complements telehealth in the management of COPD by providing a comprehensive way of managing the risks associated with an individual's health and home environment - automatic sensors and remote monitoring ensure a proactive, preventive approach to care. In this way, telecare provides additional care and support for people returning home from hospital.
Both telehealth and telecare provide dedicated valuable support and the reassurance that expert help is on hand whenever it might be needed, 24/7.

Charting success
Telehealth technology has enabled healthcare professionals in Milton Keynes to manage COPD more effectively and to support patients in their own homes; it has benefited patient and trust alike. 
Valuable NHS resources have been liberated, and most importantly, patients have a higher quality of life.  Since launching the telehealth service, 26 hospital admissions and 10 GP visits have been prevented in just four months, reducing the burden on acute, primary and community sectors.
By allowing people with COPD and informal carers to monitor their vital signs in their own homes, anxiety levels are reduced and patients are empowered by gaining a better understanding of their condition, which in turn has reduced the number of acute exacerbations. 
Research shows that early supported discharge offers good clinical outcomes and is as safe as continued hospitalisation. It does not need to be consultant-led - reducing the burden on primary care resources - and has a high level of patient acceptance, as patients welcome the increased independence and reassurance of familiar surroundings.  
A key benefit of the initiative is educating users to be more aware of their own symptoms and to proactively manage them, as this also reduces part of the burden on healthcare providers.

Telehealth in practice - positive patients
The service has been well received by patients who are as a result able to manage their condition more effectively, as it gives them greater knowledge and understanding of the medical factors that can contribute to the condition. On one occasion, a patient who normally takes her readings every morning, knew she had been too busy to take her oxygen, and phoned the district nursing team to explain the situation, thus avoiding an unnecessary visit.
The community alarm team was delighted by this proactive engagement from a patient and this type of situation has been replicated many times.
An example of an avoidable admission was the case of a patient whose telehealth equipment raised an alert one morning. The team called the patient and asked her to do a retest on the monitor to confirm the results and also asked her how she felt.
It was clear from the results that she was developing a chest infection. From this the team was able to quickly prescribe a course of antibiotics and the infection cleared; the patient didn't need to go to hospital and the GP didn't have to do a home visit. Telehealth helped to ensure proactive and timely intervention; without it the patient may have needed to go to A&E over the weekend or with a seriously developed case the following Monday.

The future's bright for telehealth
These patient stories demonstrate the positive outcomes witnessed on the scheme. Historically COPD patients presented themselves to us in very acute stages of their care. It was not uncommon for them to begin feeling ill, allow this to develop for three or four days, then contact us when they were in a very serious condition. In the majority of these cases we had to admit these patients into hospital.
We have now transformed this situation and because of the telehealth monitors we are able to see the start of an exacerbation in the early stages and take appropriate proactive care. 
Since launching the telehealth service 26 hospital admissions have been prevented in just four months, and we have also found that in the majority of cases after using the monitors the patient's confidence soars. With continued use of the service, a marked difference can be made to the management of COPD  - within the local PCT and within the NHS as a whole. 
This approach needs to be rolled out into all our chronic disease areas, as the results prove just how much of a difference, to patients and the PCT, Tunstall's telehealth service has already made, and will keep on making.
The telehealth monitors have received significant praise from patients and clinicians and it is hoped to roll out further monitors across the city in the coming months.

Reference
1. The Royal College of Physicians and British Thoracic Society. National COPD Audit. London: RCP and BTS; 2004.