HEALTHCARE. Switch On! The Case for Telehealth ADVISORY

HALTHCAR Switch On! The Case for Telehealth ADVISORY

2 Switch On! The Case for Telehealth Switch On! The Case for Telehealth The case for assistive technologies is growing, with a number of successful pilots and trials across the UK. Telecare is well established, primarily addressing the care needs of the frail elderly, whilst telehealth is not yet as widespread. Telehealth can help monitor people with longterm conditions, enabling timely interventions that reduce the need for expensive hospital admissions, as well as improving overall management of these conditions. However, for many organisations taking a decision to implement telehealth is currently a leap of faith. 2010 KPMG LLP, a UK limited liability partnership, is a subsidiary of KPMG urope LLP and a member firm of the KPMG

Switch On! The Case for Telehealth 3 As the UK population ages, the number of people with long-term conditions (LTCs) is set to increase sharply, intensifying the demands on an already stretched care system. It is no exaggeration to state that the NHS faces possibly its most difficult ever challenge expectations of service quality and availability continue to rise and the system will now have to do more with less. The statistics on LTCs are stark. Almost one in three of the population currently has such a condition. LTCs account for half of all inpatient hospital bed days and 69 percent of the primary and acute care budget in ngland. And as people live longer, the number with a LTC is set to rise by 23 percent over the next 25 years 1. On top of this there is latent demand of those people whose health needs are not being met under current care models. This group may be significant a recent sampling of Quality and Outcomes Framework (QOF) data to identify patients registered with chronic obstructive pulmonary disease (COPD) on a GP practice system found about 25 50 percent of the number one would expect to see given prevalence rates. Definitions are still evolving but for the purposes of this paper, the following are used: Telehealth: equipment and services used to remotely monitor aspects of a person s health in their own home. Telecare: a combination of remotely monitored passive alarms, sensors, other equipment and services to help people live independently. Assistive technologies: any product or service designed to enable independence for people with health and care needs, such as LTCs or the frail elderly. 2010 KPMG LLP, a UK limited liability partnership, is a subsidiary of KPMG urope LLP and a member firm of the KPMG

4 Switch On! The Case for Telehealth Technology can help take the strain The use of technology to monitor people s health remotely is increasing. Telehealth can give an accurate and regular picture of a patient s health. It enables clinicians to identify trends and take more timely action to address issues and prevent exacerbations. Better self management Patient has increased awareness of their condition Greater likelihood of lifestyle changes being adopted Timely and accurate clinical readings More frequent and more regular readings taken Reduced white coat syndrome Improved health Conditions stabilised better health Less likelihood of exacerbations Fewer unplanned interventions Reduction of A& visits and hospitalisation Timely and appropriate care Ability to identify trends Can intervene to prevent exacerbations Can more easily gauge the impact of medication changes 83 year old heart patient Mrs, full-time carer to her husband When Mrs s low pulse reading was received through the telehealth system, a concerned telehealth nurse rang her. She learned that the patient had been feeling weak for a couple of days but had been too busy caring for her husband to see a doctor. The nurse rang Mrs s GP, faxed over her recent vital signs readings, and within an hour, the patient was admitted to hospital where she had a pacemaker inserted. In just a few days Mrs was back home, feeling better and caring for her husband, with a potentially serious situation averted. Improved quality of life Patient feels more in control Patient and carer may experience reduced anxiety Patient remains at home for longer Cost savings Savings through reduction in unplanned interventions and hospitalisation Shift to less costly interventions (e.g. nurse visits instead of GP visits or A& attendance) Savings on medication costs For more information on the Newham WSD trial and further case studies and videos please go to: www.newhamwsdtrial.org The feedback from patients and users has been very encouraging. Some feel it empowers them to manage their own conditions and subsequently address associated health or social care concerns, such as depression over their condition. Others believe that it gives them a better understanding and awareness of their health, which helps motivate lifestyle changes such as increased exercise or better dietary awareness. Informal carers may also benefit. Whilst evidence for carer benefits from telehealth has yet to be published, it is reasonable to draw conclusions from telecare the Scotland Telecare Development Programme 2, and the smaller scale London Borough of Havering Assistive Technology Pilot project 3 claim that 74 percent and 88 percent of carers respectively report a reduction in stress levels. A number of clinicians and care workers involved in clinical trials and pilots have also been glowing in their praise. But there is still a long way to go. Although a number of primary care trusts (PCTs) are beginning to talk about telehealth, only a few have implemented such an approach, typically via small-scale pilots, with just a handful taking the leap to large scale roll-out. 2010 KPMG LLP, a UK limited liability partnership, is a subsidiary of KPMG urope LLP and a member firm of the KPMG

Switch On! The Case for Telehealth 5 A growing body of evidence Through a series of clinical trials, small pilots, systematic and meta-data reviews, the case for telehealth is starting to strengthen. Many of these trials and pilots attempt to measure changes in indicators such as hospital admissions, bed days and quality of life, and some attempt to translate findings into cost savings. The table on the last page of this document, highlights some of the successes of telehealth. The cost savings are typically theoretical, based upon reductions in the number of admissions or interventions, which would be replaced by less costly activity. However, the evidence currently lacks scale, statistical significance or robust cost saving data, something that the Department of Health is eager to address through its Whole System Demonstrator (WSD) programme. What is the WSD programme? WSD seeks to evaluate the potential of integrated health and social care provision, supported by advanced assistive technologies such as telehealth and telecare. It involves over 6,000 participants in three locations (Newham, Cornwall and Kent), with five evaluation themes: Impact upon service utilisation and costs across health and social care Impact upon the lives of participants and carers Cost and cost-effectiveness of the service Views and experiences of users, carers and professionals involved in the programme Impact of change, collaborative working and large-scale programmes on the organisation and individual The results of WSD will help to shape national policy for assistive technologies, but they will not be available until Spring 2011. In the meantime, a small number of healthcare organisations are starting to implement telehealth, encouraged by the findings of pilot studies. We have made a commitment to mainstream telehealth services in order to improve self care and provide services that enable patients to be more informed, keep them out of hospital and enhance their overall well being. This is fundamental considering our demographics and cost of services in an ageing population, 25 percent of whom will be over 65 nationally in the next 25 years. Carol Williams, Director of Service Improvement and Professional Practice at NHS Cornwall and Isles of Scilly 4 The dilemma facing healthcare organisations is whether to lose valuable time by waiting for the full trial results, or whether to push ahead now. Diabetes patient, Mr C Mr C agreed to take part in the Kent WSD programme. He didn t like using the telehealth equipment to begin with but soon got used to it. As a result, Mr C has noticed that his weight has decreased steadily and his blood sugar readings are more consistently lower than before taking part in the programme. He then found that by taking his readings regularly he became more aware of his readings, and his general health. Mr C says his wellbeing has improved and that generally he feels healthy. He is taking better care of himself and taking regular exercise. 2010 KPMG LLP, a UK limited liability partnership, is a subsidiary of KPMG urope LLP and a member firm of the KPMG

6 Switch On! The Case for Telehealth Technology is not a panacea Although telehealth can enhance the quality of care and reduce costs, to realise its full potential, healthcare providers will have to fundamentally change the way they work. Remote monitoring allows the identification of relevant trends through an individual s vital readings and their responses to questions posted on the system. This can lead to more informed decision-making, earlier intervention and improved caseload management, which can both save money and make better use of resources. Prevention and early involvement helps reduce the number of people who require increasingly complex and expensive care services, as shown in the diagram opposite. Prevention and early involvement in tiers of care Focus on prevention and early maintenance Improved health outcomes for patients and population Management of condition in most appropriate setting TI R 1 TIR 2 TI R 3 TI R 4 Self management Active management Improved and managed elective admission Specialist intervention TI IR 0 Crisis management Health promotion Prevention Support services Community intervention Prevention Screening programmes Care planning ducation Lifestyle improvement Movement of resources from Tier 4 towards Tier 0 Reduction of costs and expenditure By redesigning care pathways, telehealth and other assistive technologies can be incorporated to achieve more effective ways of delivering care. The example opposite features patients suffering from COPD. By implementing telehealth for appropriate cases post-assessment in tier two as represented by the orange boxes the provider could reduce the costly treatment required in higher tiers, as well as improving overall management of the conditions. An integrated system which features assistive technologies will help professionals realise the potential of common needs assessment mechanisms, resulting in more informed referrals for a variety of services. It can play a vital role in bringing together a full range of clinical services in a community setting, delivered at a time and place most convenient to the patient or user. 2010 KPMG LLP, a UK limited liability partnership, is a subsidiary of KPMG urope LLP and a member firm of the KPMG

Switch On! The Case for Telehealth 7 Redesigning the COPD process TIR 0 TIR 1 TIR 2 TIR 3 TIR 4 Severe COPD Pulmonary rehabilitation and oxygen therapy Specialist planned assessment lective admission S Population At risk population Screening & spirometry Clinical assessment Moderate COPD Oxygen therapy Pallaitive care 1 Mild COPD Pulmonary rehabilitation Crisis assessment Acute emergency admisison KY S Start nd Admission avoidance/ early discharge Case Study: NHS Cornwall & Isles of Scilly WSD Programme Such a bold step can break down traditional barriers between different parts of the health and social care system, putting the patient firmly at the centre of the care model. The case for integrated care in the UK, including the role of Integrated Care Organisations (ICOs), is made in a companion piece to this publication A Bold Step Forward. COPD patient Mr B, frequently attending A& The patient had a lung problem which meant that he had attended A& five times in the previous six months. He was continually on antibiotics and unable to withdraw from steroids. He recognised that his admissions were probably the result of his anxiety as when he got to hospital he was mainly given oxygen before being sent home. He was afraid to venture out in case he had an attack. He agreed to enrol on the WSD programme and was issued with equipment to measure his oxygen levels and blood pressure and was asked to answer a series of health questions that the equipment monitor would ask him each day. The patient fully believes the equipment has contributed to changing his life. Being able to check his oxygen levels when he is feeling unwell has calmed him and if his levels are low he relaxes and uses his oxygen. He was assessed as suitable for short term oxygen and since being supplied with that he is now venturing out and walking up the steep hill to his cottage a feat he had not attempted in the five years he has lived there. He has to stop six or seven times but he can do it. He has gone two months without antibiotics and has not attended A& since being on the programme. NHS Cornwall & Isles of Scilly programme office e-mail: wsd.prgramme@cornwall.nhs.uk 2010 KPMG LLP, a UK limited liability partnership, is a subsidiary of KPMG urope LLP and a member firm of the KPMG

8 Switch On! The Case for Telehealth Overcoming barriers to implementation Although assistive technologies are making their way on to the agenda of PCTs and local authorities, there is still a general reluctance to bring telehealth into mainstream use, due to the perceived costs, concerns over acceptance by staff and patients, and the complexities of implementation. To some organisations in the UK, telehealth is perceived as relatively expensive, in terms of both set-up and running costs. Some see this as a hindrance to early adoption and are waiting for the kind of rapid price falls associated with most innovations. As this market matures we expect to see an increase in service and solution offerings as opposed to the pure product offerings that dominate the market today. And the potential market size for telehealth is significant. 15.4 million people in ngland have a LTC. Making an assumption that just 20 percent of these people would benefit from telehealth indicates the potential for over three million installations. If one in three of these people has one less hospital admission per year at an estimated cost saving of 2,000 per admission, 2 billion could be saved annually. However, decisions are increasingly taken at local levels and local business cases need to be compelling. In developing a business case, organisations need to feel confident that the investment will lead to realisable savings and demonstrable efficiencies in an acceptable timescale. There are areas of expenditure that must be considered, over and above the cost of the technology; for example the integration of pathways, people and systems, upgrading outdated phone lines at user s homes, monitoring and maintenance costs. These costs are offset by savings and efficiencies in a number of areas such as reduced hospital admissions, avoided referrals, reduced transportation costs, increased caseload and reduced visits. Taking a conservative view and from a standing start, to implement telehealth services for COPD patients in a typical PCT population without the additional costs of integrated care, we would expect the realisable savings from the reduction in hospital admissions alone to pay for the telehealth service within one to two years. Some pilots have demonstrated a much faster ROI and some advocates would predict much more aggressive 6 12 month return. However, the benefits of telehealth are unlikely to be realised instantly. In addition to the initial set-up costs, there is, as mentioned earlier, a need to redesign care pathways and adopt integrated care. Such a move may seem too daunting to some health providers. There are a number of factors which contribute to the complexity of implementing assistive technologies: The engagement of frontline professionals in the implementation of assistive technologies is fundamental. Many may be sceptical and others slow to adopt, seeing it as undermining their autonomy, but those who embrace it will see benefits. With greater emphasis on GPs as commissioners and the possibility of challenging budgets, early adopters will reap benefits through reduced hospital spend and ultimately better outcomes, with likely slowing of progression through the tiers of need. Accurate patient data is required for organisations to identify those who are most likely to benefit. Organisations will need to consider different monitoring models and decide which model, or combinations of models, is right for them. Will readings be monitored by community matrons, GPs, dedicated call centres, other frontline professionals, or a mix of these? Interoperability and integration of systems will need to be achieved if the full potential of integrated working is to be realised. Organisations need to establish legal frameworks that allow information sharing and governance to be established. There have been some negative patient views which indicate that some people may be reluctant to adopt the technology. For example I am not sick enough to need this or I don t want to be reminded that I m ill. 2010 KPMG LLP, a UK limited liability partnership, is a subsidiary of KPMG urope LLP and a member firm of the KPMG

Switch On! The Case for Telehealth 9 xpanding the opportunity To date, telehealth use has tended to be focussed on long-term use by patients with established disease COPD, heart failure or diabetes. But there is further potential for short-term use for newly diagnosed patients, those undergoing changes to medication or after discharge from hospital. And whilst there is widespread use of telecare for the frail elderly, there remain opportunities which have yet to be fully realised such as for use with people with dementia, mental health needs, or children and adults with disabilities. In establishing funding, we could look to the trend of personal investment in healthcare a potential model for the future could be one where a level of government spend can be topped-up by consumers. Some high street chemists already sell a range of personal health devices, for example blood glucose monitors and blood pressure monitors, some supplemented with online information. Whilst telehealth has shown improved quality and cost savings when deployed alone, it can become a far more powerful tool when linked to existing systems. Information should be shared or integrated with patient care records, enabling care managers to record details and access data, which should improve real-time monitoring and decision-making. Data from telehealth systems should be used with workforce scheduling tools to help professionals organise their patient workloads more effectively. It should be linked with handheld devices such as a BlackBerry or smartphone, giving greater, quicker access to detailed, accurate, up-to-date patient data for professionals. Telehealth has the potential to save the NHS many billions of pounds, while also improving quality of life and the management of health for millions of patients. It can only achieve such a goal as part of a wider, fundamental change in health and social care with greater focus on primary, preventative and integrated care. There also needs to be greater integration of patient data and utilisation of modern technology to enable remote working. Those prepared to embrace this approach can benefit from a truly patient-focused service that empowers professionals and makes better use of resources. The danger is that, in a period of austerity, it may not be seen to offer enough of a quick win. Health professionals should however realise that the rising costs of reactive care are unsustainable, and that telehealth offers a highly effective way to manage patients in the community at lower cost. As the Web 2.0 generation mature they are likely to be more demanding, seeking out doctors who facilitate access to technology for their families. As living with a long-term condition becomes the norm the use of technology will be essential to negotiate a way through the system in an informed, responsive way rather than the passive paternalism of today. Telehealth and telecare offer autonomy and self determination to patients and the best physicians will foster that opportunity. Hilary Thomas, Professor of Oncology and KPMG Health Team 2010 KPMG LLP, a UK limited liability partnership, is a subsidiary of KPMG urope LLP and a member firm of the KPMG

10 Switch On! The Case for Telehealth vidence of the effectiveness of telehealth The table below highlights some of the successes of telehealth, although the cost savings are typically theoretical, based upon reductions in the number of admissions or interventions, which would be replaced by less costly activity. Study Trial population Findings Benefits demonstrated Quality of life Cost Interventions Department of Veterans Affairs, Office of Care Coordination Services, Washington 5 17,025 patients 25% reduction in numbers of bed days of care 19% reduction in numbers of hospital admissions Mean satisfaction score rating of 86% after enrolment into the program Gartner: ehealth for a Healthier urope 6 meta data review of 60 clinical studies across 11 ehealth technologies 83% reduction in the 90 day readmission rate for congestive heart failure 25% reduction in average number of bed-days for admissions for chronic conditions 25% reduction in prescribed medication costs 19% reduction in hospital admissions for chronic conditions 55% reduction in hospital admissions for congestive heart failure A randomized trial of home telemonitoring in a typical elderly heart failure population in North West London: results of the Home HF study Owais Dar et al 7 randomised controlled trial of 182 elderly patients with heart failure Similar outcome to usual specialist care, but reduced clinic and emergency room visits and unplanned heart failure re-hospitalisations at little additional cost Although there was no change in overall health-related quality-of-life as measured through the Q5D, quality-of-life measured through the disease specific Minnesota living with heart failure questionnaire improved slightly NHS Direct & NHS South ast ssex At home, not alone COPD Telehealth Project 8 80 COPD patients Approx. 25wte of CM time released for every 53 patients equating to a saving of 12,465.60 per annum 12% reduction in number of CMs visits to patients Patients reported that they liked the service, were less anxious, and felt supported 72% reduction in 999 calls 56% reduction in GP visits 75% reduction in A& visits equating to a total saving of 13,092 per annum for 53 patients 83% reduction in hospital admissions equating to a saving per annum of 847,000 Sheffield NHS Primary Care Trust: Telehealth Case Study 9 30 high risk COPD patients 50% reduction in COPD hospital admissions saving the PCT 30,000 to 40,000 80% reduction in home visits to COPD patients Orchard Medical Centre, Bristol: Telehealth in a GP Setting Case Study 10 18 CHF patients with severe or advanced form of illness 46% reduction in hospital admissions 67% reduction in A& attendances 16% reduction in visits to GP surgery All patients reported increased reassurance and improved quality of life 2010 KPMG LLP, a UK limited liability partnership, is a subsidiary of KPMG urope LLP and a member firm of the KPMG

Switch On! The Case for Telehealth 11 Sources 1 http://www.dh.gov.uk/en/healthcare/longtermconditions/tenthingsyouneedtoknow/index.htm 2 valuation of the Telecare Development Programme Final Report. January 2009 Crown copyright 2009 3 Assistive Technology (AT) London Borough of Havering Case Study DH document 4 http://www.tunstall.co.uk/news-and-vents/latest-news/cornwall-mainstreams-telehealth-solutions-following-successful-department-of-health-pilot 5 Care Coordination/Home Telehealth: The Systematic Implementation of Health Informatics, Home Telehealth, and Disease Management to Support the Care of Veteran Patients with Chronic Conditions http://www.liebertonline.com/doi/pdfplus/10.1089/tmj.2008.0021 6 Gartner: ehealth for a Healthier urope (se2009.eu) http://www.se2009.eu/polopoly_fs/1.8227!menu/standard/file/ehealth%20for%20a%20healthier%20urope.pdf 7 Owais Dar eta al. A randomized trial of home telemonitoring in a typical elderly heart failure population in North West London: results of the Home-HF study. uropean Journal of Heart Failure (2009) 11, 319 325 8 NHS Direct & NHS South ast ssex At home, not alone COPD Telehealth Project Final valuation http://www.telecareaware.com/images/pdfs/nhsd-essex -final-eval-telehealth-26feb10.pdf 9 Sheffield NHS Primary Care Trust Telehealth Case Study http://www.tunstall.co.uk/assets/literature/managing_longterm_conditions sheffield_pct.pdf 10 Orchard Medical Centre, Bristol: Telehealth in a GP Setting Case Study http://www.tunstall.co.uk/assets/literature/case%20studies/managing_chf orchard_medical_centre.pdf 2010 KPMG LLP, a UK limited liability partnership, is a subsidiary of KPMG urope LLP and a member firm of the KPMG

kpmg.co.uk Switch On! The Case for Telehealth 12 Contact Mark Britnell Head of Health for the UK & urope +44 (0) 20 7694 2014 mark.britnell@kpmg.co.uk Helen Isaac Associate Director +44 (0) 20 7311 1582 helen.isaac@kpmg.co.uk Roberta Carter Partner, Health Advisory +44 (0) 20 7311 4190 roberta.carter@kpmg.co.uk Frank Harburn Associate Director +44 (0) 20 7311 6395 frank.harburn@kpmg.co.uk The information contained herein is of a general nature and is not intended to address the circumstances of any particular individual or entity. Although we endeavour to provide accurate and timely information, there can be no guarantee that such information is accurate as of the date it is received or that it will continue to be accurate in the future. No one should act on such information without appropriate professional advice after a thorough examination of the particular situation. KPMG LLP does not control and is not responsible for any of these sites or their content. KPMG LLP is obligated to protect its reputation and trademarks, and reserves the right to request removal of any link to our Web site. 2010 KPMG LLP, a UK limited liability partnership, is a subsidiary of KPMG urope LLP and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative, a Swiss entity. All rights reserved. KPMG and the KPMG logo are registered trademarks of KPMG International Cooperative, a Swiss entity. Publication name: Switch On! The Case for Telehealth Publication number: RRD-200343 Publication date: June 2010 2010 KPMG LLP, a UK limited liability partnership, is a subsidiary of KPMG urope LLP and a member firm of the KPMG