Integrating Telemedicine into mental Health Care learning from a Care Homes Vanguard Rachel Binks Nurse Consultant Digital & Acute Care Airedale NHS Foundation Trust Chris North Care Home Liaison Team Bradford District Care Trust
Digital Health Telecare Telecoaching Telemonitoring Teleconsultation
A system designed by default Some people seem to do quite well without waiting for healthcare support
right care today Teleconsultation Prison health care Care at home Nursing & residential care Supporting end of life patients 24/7 clinical hub improving patient experience changing patient flow reducing costs Electronic shared record connecting primary & secondary care now connecting whole health & social care economy tomorrow
right time care anywhere
right place - replicable model 475 Nursing/Residential Care Homes + 50 in implementation Supporting > 14,000 residents
Aims of the service Provide, safe, effective high standards of care To support residents to stay at home Support residents/nurses/ carers in the planning and delivery of care Escalate to community teams out of hours
Other services delivered from the digital care hub Gold Line GP Triage Intermediate Care Hub Acute Care Team Single Point of Access Complex Care Team Registered practitioners Shared record Visual contact
Video insight into our telemedicine and Gold Line Service http://www.health.org.uk/gold-line http://www.airedale-trust.nhs.uk/services/telemedicine/
Data from End of Life Care Profiles PHE and district wide reporting (CSU) National data England 2013 AWC 2013 Bradford District 2013 Bradford City 2013 GSF/Gold Line Year 2013/14 All deaths in hospital All deaths at home All deaths in care homes All deaths in hospice 48.3 36.0 45.9 50.4 14% 22.4 20.1 24.5 23.1 41% 21.6 33.2 19.0 19.7 22% 5.5% 8.8 8.3 4.6 23%
Call sheet
Reporting Nursing Homes Residential Homes Day Current Last % YTD Day Current Last % YTD Month Month Variance Month Month Variance Monday 128 85 51% 213 Monday 194 153 27% 347 Tuesday 117 74 58% 191 Tuesday 174 121 44% 295 Wednesday 83 83 0 166 Wednesday 152 121 26% 273 Thursday 76 79 4% 155 Thursday 128 104 23% 232 Friday 88 108 19% 196 Friday 145 160 9% 305 Saturday 106 107 1% 213 Saturday 153 174 12% 327 Sunday 110 76 45% 186 Sunday 197 108 82% 305 Time Current Last % YTD Time Current Last % YTD Month Month Variance Month Month Variance Morning 295 255 16% 550 Morning 456 379 20% 835 Afternoon 413 357 16% 770 Afternoon 687 562 22% 1,249 Hours Current Last % YTD Hours Current Last % YTD Month Month Variance Month Month Variance In Hours 344 329 5% 673 In Hours 466 419 11% 885 Out Of Hours 364 283 29% 647 Out Of Hours 677 522 30% 1,199 Total 708 612 1143 941
Reason for call Nursing Homes Residential Home Purpose Current Last % Variance YTD Current Last % Variance YTD Advance Plan/DNAR 0 0 0 0 0 0 0 0 Agitation/Confusion 0 0 0 0 0 0 0 0 Anxiety 1 4 75% 5 8 11 27% 19 Bowel concerns 0 0 0 0 1 0 100% 1 Breathing difficulties 18 14 29% 32 31 17 82% 48 Catheter concern 12 10 20% 22 26 22 18% 48 Cerebral event 1 0 100% 1 0 0 0 0 Chest infection 75 65 15% 140 68 46 48% 114 Chest pain 2 0 100% 2 7 9 22% 16 Death 0 0 0 0 0 0 0 0 Dehydration 12 6 100% 18 24 7 243% 31 Emotional distress 7 4 75% 11 6 8 25% 14 EOL Symptoms 0 0 0 0 0 0 0 0 Eye Infection (eye) 8 9 11% 17 21 7 200% 28 Falls 49 31 58% 80 119 91 31% 210 General Deterioration 0 0 0 0 0 0 0 0 Head Injury 0 0 0 0 0 0 0 0 Medication issue 0 0 0 0 1 0 100% 1 Nausea 4 1 300% 5 6 5 20% 11 Other 239 197 21% 436 398 251 59% 649 Pain Management 39 24 63% 63 68 50 36% 118 Seizure 5 5 0 10 10 3 233% 13 Skin complaints 86 25 244% 111 106 86 23% 192 UTI (suspected) 68 41 66% 109 109 76 43% 185 Vomiting 13 10 30% 23 18 10 80% 28 Wound care 11 5 120% 16 17 30 43% 47
Outcome of calls Nursing Homes Referral Residential Homes Current Last Current Last % Variance YTD Month Month Month Month % Variance YTD collaborative care team 0 1 100% 1 0 3 100% 3 community matron 2 3 33% 5 4 12 67% 16 district nurse 12 5 140% 17 60 72 17% 132 palliative care service 0 1 100% 1 0 0 0 0 palliative care physician 0 0 0 0 0 1 100% 1 Referral to social services 0 1 100% 1 0 0 0 0 Referral to GP 224 204 10% 428 258 223 16% 481 GP out of hours service 170 115 48% 285 209 152 38% 361 Intention (would have) Current Month Last Month % Variance YTD Current Month Last Month % Variance YTD called their GP 509 342 49% 851 721 509 42% 1,230 attended A&E or called an ambulance 56 38 47% 94 85 68 25% 153 contacted community nursing 8 9 11% 17 69 58 19% 127 Not have contacted an alternative healthcare provider 20 6 233% 26 32 18 78% 50 Not applicable 57 56 2% 113 137 76 80% 213 Outcome Current Month Last Month % Variance YTD Current Month Last Month % Variance YTD Patient remained in place of residence 618 527 17% 1,145 1,018 779 31% 1,797 Ambulance request for patient 83 65 28% 148 123 110 12% 233 Hospital notified of death 7 2 250% 9 9 9 0 18
What would you have done? 350 300 250 Called an ambulance 200 Contacted a GP 150 Contacted a community nurse 100 Done nothing 50 Question not asked (follow up etc) 0 W/C 07/12/2015 W/C 14/12/2015 W/C 21/12/2015 W/C 28/12/2015 W/C 04/01/2016 W/C 11/01/2016 W/C 18/01/2016 W/C 25/01/2016 W/C 01/02/2016 W/C 08/02/2016 W/C 15/02/2016 W/C 22/02/2016 W/C 29/02/2016 W/C 07/03/2016 W/C 14/03/2016
Actual GP referrals 80% 70% Referred to OOH GP % 60% 50% 40% Referred to In Hours GP % 30% 20% 10% 0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Referred GP (both In & Out of Hours ) %
Reason for Hub on-referral to GP Random 30 cases audit for GP Triage Homes in September 53% for GP Visit 20% Medication review 20% Prescription 2% Advanced Care Planning 5% other
Impact NW CCG - Care Homes Innovation Programme (CHIP)
Impact 2 NW CCG - CHIP
GP triage Clinical assessment by Hub nurse Onward refer if required to HCP for home visit Request prescription GP surgery informed by NHS secure mail
GP feedback "Of all the changes in the 15 years I have been working this is the greatest change which has reduced workload I can remember. I don't mind the extra "late" duty doc visit as this is more than made up in the drop in other visits. A big thank you to all involved."
Innovation potential The innovation that telemedicine promises is not just doing the same thing remotely that used to be done face to face, but awakening us to the many things that we thought required face to face contact, but actually do not. David D Asch MD, MBA, Perelman School of Medicine, University of Pennsylvania
Mental Health First Response Link to the Mental Health Trust Advise for physical health issues Advice for mental health issues Access to experts Visual contact for both teams Potential Outcomes Reduced attendance to ED Reduced admissions Clinical Support and Advise for both teams to enable immediate robust assessment and care
Care Home Liaison Project Team can access hub Team can access each other Access to First Response hub Access to Digital Care Hub Remote consultation and appointments Potential Outcomes Reduced travel Immediate response Reduction in crisis calls
BDCFT Care Home Liaison Virtual Clinics (1) 5000+ people in the district with dementia (PWD) Expected to rise to 6000 by 2020. About 4000 with a diagnosis, 1000 without diagnosis 1000 new cases expected each year 2/3 rds of PWD living at home 80% of care home residents are PWD c. 1600 care home residents are PWD 25% of hospital beds occupied by PWD
BDCFT Care Home Liaison Virtual Clinics (2) Older People s Community Mental Health Services Over 65 popn = 92500, 4 x Community Mental Health Teams: AIREWHARFE / CRAVEN / BRADFORD (CITY & NORTH) / BRADFORD (SOUTH & WEST) Domiciliary Support (lots of travel for clinical staff) Out-Patient Clinics (lots of travel for patients & families) Memory Clinics (as above) Acute Hospital Liaison ( captive audience) Care Home Liaison (lots of travel for clinical staff)
BDCFT Care Home Liaison Virtual Clinics (3) Craven OP CMHT / Care Home Liaison (CHL) Based at Skipton General Hospital Over 65 popn = 14500 16 Care Homes, spread over 450 square miles Referral-led model 0.5 x wte Band 6 Care Home Liaison Nurse (RMN) c.100 referrals per annum to CHL 150 face-to-face contacts per annum c. 350 referrals and 950 contacts per annum in Bradford (South & West), popn = 24500 Delivery of Dementia & Delirium training CQUIN to 8 care homes across the district in 2015-16
BDCFT Care Home Liaison Virtual Clinics (4) Telehealth Craven CHL Pilot (Dec 2016 Mar 2017) Weekly virtual clinic with 5 most remote care homes Ingleton, Settle, Thornton-in-Craven, Grassington Test out concept of virtual mental health support Attempted / successful telehealth contacts Failed telehealth contacts & reason: Technical problem No response at care home Other (state) No of care home residents consulted about Total time of consultation
BDCFT Care Home Liaison Virtual Clinics (5) Telehealth Craven CHL Pilot Monitor / evaluate impact and outcomes : PATIENT OUTCOMES LIAISON ACTIVITY Advice only Change of care plan Visit by CHL arranged Mental Health Act Assessment Admission to MH facility A&E attendance Admission to hospital Referral to other health or social care professional GP / Practice Nurse District Nurses Community Matron / ANPs Community MH Team Complex Care Team Social Services Telemedicine Hub Other (state)
Remote training and clinical support Support for care home staff using the VTR Support for DNs and community teams do they need to attend? Overview and clinical support of care home staff developing enhanced roles Remote outpatient clinics
Questions Technology Enabled Health the art of the possible