Remote monitoring for patients with chronic conditions in the Midlands

What is 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 is 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 is the impact?

Patients have been supported across four pathways including:

  • over 700 patients with heart failure and COPD (1 April 2020 to 5 March 2021)
  • 50 patients with heart failure and respiratory conditions have been supported so far through the digital rehabilitation pathway (1 September 2020 to 5 March 2021)
  • 172 COVID-19 patients have been discharged after a hospital admission with remote monitoring at home, with only eight people being readmitted to hospital during their 14-day monitoring period (2 November 2020 to 5 March 2021)
  • 20 oxygen weaning patients accessed the COVID-19 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 three 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 the vital administrative support.”

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

Find out more

You can read the full case study on the work across the region to use digital innovations to improve the health and wellbeing of people with chronic conditions on our site at FutureNHS. Alternatively email: innovation.collaborative@nhsx.nhs.uk

Join the Innovation Collaborative

Existing members can access the Innovation Collaborative Digital Health workspace on the FutureNHS platform.

Please e-mail innovation.collaborative-manager@future.nhs.uk to request to join.