Setting the scene – the evolution of virtual wards and remote monitoring

We started with an overview from Docobo MD, Adrian Flowerday. While the theme was ‘Virtual Wards – What Next,’ we were also very much looking at how to keep people healthy and stop people from being admitted to hospital in the first place. Remote monitoring is all about caring for people in the comfort of their own homes and Adrian gave some background about how – although Docobo has been providing remote monitoring since 2001, the pandemic saw the uptake of more remote monitoring schemes and opened up to the concept of virtual wards. 

Adrian also explained that there are more efficient means of getting people onto remote monitoring – in the form of targeted cohorting using population health solutions. Often patients have been referred to remote monitoring by a GP or acute ward, and this has worked, but it can be a struggle to scale up virtual wards. Where our clients have successfully achieved this at scale, they have used population health to identify cohorts and then introduced more targeted remote monitoring.

This is good news for both patients and clinicians and reduces volume of people going into hospital and providing less costly admissions.

Anna Fishta shares Frimley successes.

Adrian introduced Anna Fishta, Associate Director of Shared Care Record & Remote Monitoring at Frimley ICS, which has been having great success with its remote monitoring and population health management programmes.

Anna talked about how they have used a proactive approach to remote monitoring, and how by working with Graphnet and Docobo, the Connected Care team have created ‘data driven, digitally enabled transformation.’

She described how by using Graphnet’s population health approach and the shared care record – and remote monitoring, the team were able to reduce hospital admissions and GP visits.

Anna went into more detail on the ability to segment patients using population health from Graphnet and then move patients onto remote monitoring. She talked about the different streams – with particular reference to the excellent results they had had from the remote monitoring for frail, vulnerable, multimorbid. She also talked about the Johns Hopkins ACG System, where Patient Needs Groups are used to segment and identify high risk patients These results have been quite extraordinary.

Anna talked through how remote monitoring is supporting Frimley’s highest risk residents, which includes questions on a daily, weekly, monthly, or anytime basis. Once completed, RAG rated responses are reviewed and dealt with by the nurse led clinical digital health team.

Frimley now has 60 GP practices already onboarded in the service, with 34 Care Homes on Remote Monitoring and with over 6,000 patients now being remotely monitored.

Results are as follows for High-Risk patients:

•        Reduced A&E attendance by 38.6%

•        Reduced admissions by 53.7%

•        Reduced GP contacts by 19.4%

•        Reduced volume of medications prescribed by 7.6%

•        Reduced total bed days by 45.6%

They have since branched out into other areas, including heart failure – to support patients and have had real success in F2F contact with patients. 

Anna said that by using population health to identify patients, they were then able to target those patients who would best benefit from remote monitoring.

“This enabled us to join everything up - with a flow back into the shared care record. By bringing all elements together we can evaluate, refine our approach, and do things better.”

Mersey Care on the benefits of joining up population health and remote monitoring.

Adrian Flowerday, MD of Docobo and David Grigsby from Graphnet then talked about the joined-up approach of using population health and remote monitoring and how the combined platform shows great results. These were demonstrated by Anna at Frimley and then with our next speaker, Peter Almond, Telehealth Head of Service at Mersey Care.

Peter Almond provided some background on the telehealth service at Mersey Care, explaining how –having worked in telehealth since 2014 – they were one of the first areas to create a Covid virtual ward during the pandemic. The telehealth hub now has close to 60 fulltime equivalent clinicians and runs services right across the ICS, providing remote monitoring for patients from a wide breadth of pathways – including long term conditions, cardiac surgery and beyond.

Mersey Care is currently supporting 4,000 patients on remote monitoring. While Peter agrees that virtual wards have been successful in capitalising on digital health and a move to deliver services remotely and this has started to help digital health become mainstream, “we still have a way to go”.

Peter then went on to talk about virtual wards and what has been achieved to date. Virtual wards were designed to help reduce pressure on hospital trusts and to get patients home earlier and free up beds. Tackling admission avoidance – and why people come to hospital in the first place is the real challenge.

Peter said we should first look at the delivery model - making sure that there is a real focus on admission avoidance. By picking the right patient for remote monitoring, you can maximise the value of virtual wards or remote monitoring. 

Peter said:

“Linking back to what Anna and David said - we need to ‘shift left’ - and stop people falling in river in first place – and have a much greater focus on proactive care. By thinking differently, it would mitigate pressures and challenges and help close the gaps in workforce.”

Peter’s vision is that a ‘shift left’ would see a reduction of hospital admissions and also in GP utilization, with patients becoming more proactive in their own self-care. Peter explained that in Mersey Care they are following Frimley’s approach to population health – adopting the approach of using population health to segment and cohort for targeted remote monitoring.

Peter then went on to expand on the clinical pathways they are using across Mersey Care – at least 30 of these – all using telehealth in a different way, while expanding a breadth of deployment. working on.

Thank you so much to both our speakers for their amazing contribution to the webinar, and for sharing their fantastic stories and outcomes.               

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