With the decline in numbers of doctors and experienced nurses, increasing pressure on the acute sector and increasing patient expectation, the issues around chronic disease management have become problematic. This has led to a move towards providing care at home through multi-disciplinary teams supported by the use of innovative technology and communication.
Through the drive and initiative of primary care trusts (PCTs), such as East Elmbridge and Mid-Surrey, some regions are now witnessing the reduction in the severity of exacerbations, hospitalisations and subsequent quality of life of COPD sufferers. In East Elmbridge, much of this has been achieved through the introduction of AxSys Technology’s Excelicare Direct solution which has enabled the remote assessment and monitoring of patients.
Background to developing COPD services
With over 30 years experience of working within cardio thoracic and respiratory disease related illnesses, RGN community respiratory nurse specialist, Julia Davey, was very much the driving force behind setting up the COPD services at East Elmbridge and Mid-Surrey PCT.
“With a population of 275,000 and a catchment area covering over 50 square miles, I built up a case load of over 150 COPD patients with over 70 requiring home visits on a regular basis,” comments Julia Davey.
“At this stage all patient records were paper based and it was becoming increasingly difficult to monitor patients effectively because of time and lack of up-to-date information on a patient’s condition. We needed a change of approach to help improve the standards of service delivery and patient care so it was fortunate that in 2003 I was introduced to AxSys Technology.”
Objectives and Requirements
A COPD community service was initiated by East Elmbridge and Mid-Surrey PCT in 2004. The aim of the service was to provide high quality personalised care to patients in the home setting therefore reducing the over-reliance on secondary care.
With limited resources the service set the objectives to function in the following way: -
“The key was to promote ‘patient empowerment.’ If patients could be encouraged to take an interest in their own disease and day-to-day care this would help to reduce the frequency of home visits during the year,” comments Julia Davey. “The service also set itself a goal to reduce patient admissions to hospital. This was all good but we needed to find a more effective way to monitor patients and maintain contact without having to actually visit them.
“Following some research into technology solutions, we encountered Excelicare Direct being used at Glasgow Royal Infirmary for the home monitoring of patients with rheumatoid arthritis. Through this computerised telephone monitoring system healthcare staff could detect any deterioration in the patients’ condition without having to physically see them.”
“We didn’t really know what functionality was required from the system,” states Julia Davey. “But AxSys worked with us right from the beginning. They listened to our requirements and came back with a presentation which was almost spot on in terms of what we needed. We only spoke with AxSys as we felt this provided us with an all encompassing solution.”
The system went live in September 2004 and was piloted with 10 patients before it was rolled out. Excelicare now provides a patient-centric, tele-medicine solution for the remote assessment and monitoring of COPD patients and has been set up to ensure that the correct treatment protocols are followed whilst documenting the clinical care pathway for each patient. Of the 150 COPD patients now registered, over 80 have access to Excelicare within their home.
How the system is working
All patients are registered onto Excelicare after an assessment is carried out by a respiratory nurse. This effectively becomes the integrated care record for that specific patient containing all their details and medical history.
Patients can then be monitored at home by placing a call to the system as and when necessary or if their symptoms change. Having dialled a dedicated number the patient is asked to enter their secure PIN and date of birth. This identifies them to Excelicare Direct and opens their individual patient record. The system welcomes the patient by name and delivers a personalised questionnaire script over the telephone relating to their signs and symptoms. The patient responds by pressing the appropriate touch tone keys. All responses are recorded into forms in the individual’s patient record and after the call a report is created and generates an alert if it has detected deterioration in the patient’s condition.
This alert is automatically sent to the respiratory nurse, via a text message, who calls the patient to give advice about what they need to do. After an incident, nurses enter their clinical notes direct into Excelicare and clear the alert.
Management of the care process via the system means that patient notes are available on the desktop where and when required. Excelicare Report Manager is used regularly as it provides a constant record of what stage the patient is at in their treatment plan. This facility also enables data collection on system usage as well as reports for clinical audit and governance.
Results and benefits
Excelicare Direct has empowered patients by allowing them to be more actively involved in their own care and has minimised the inconvenience, cost and time incurred for patients in having to travel to clinics for assessment and treatment. Results published by the community respiratory service have demonstrated that Excelicare has enabled the service to change emphasis from ‘crisis management’ to a proactive ‘preventative partnership’. It has also reduced the severity of exacerbations and hospitalisation by 44% and is helping to maintain lung function and subsequent quality of life.
“The crux has been to keep patients at home and improve the standards of care they receive. The response time for answering an alert is now 15 minutes.” The introduction of Excelicare has saved lives and cut admissions into hospital. Since starting the respiratory service in 2001, hospital admission for patients seen at home has fallen by 40% and the average length of stay in hospital has been reduced to 5.9 days representing a 26 % reduction in bed days. Our target is to save 20% of admissions every month and we are pretty much always there”
By having an electronic patient record it has been possible to implement and monitor ‘best practice’ and has led to cost savings whilst maintaining clinical effectiveness. The benefits to clinicians are that it allows close, accurate monitoring of patients without increasing the load on clinics, and has improved the overall outcome of treatments.
“Excelicare Direct is easily transferable to other disease areas and I believe this is the future of modern medicine, especially for the management of chronic disease. I also think it is important to encourage nurses to embrace the use of technology to help them continue to improve standards of patient care and drive change,” states Julia Davey.
“Our on going target is to remove all patients out of acute and into primary care through administering treatment at home. It’s about moving care into the community. We are currently working on a project in association with the Modernising Healthcare Partnership to set up a COPD Network. Nurses are going to have to learn new skills if the Electronic Health Record is to fulfill its promise so we need to ensure that the Network contains the kind of information that will support nursing practice and improve patient care. I believe Excelicare can go a long way in helping us towards this goal.”
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