Please note that these case studies have been anonymised to protect the identity of those who have lived these experiences.
Confidence around the clock: how technology-enabled remote monitoring is empowering patients and transforming lives in Yorkshire and beyond.
Thousands of people living with Chronic Obstructive Pulmonary Disease (COPD) across Bradford District and Craven are managing their condition from the comfort of their own home, with life-changing assurance and support from a nurse-led digital service. Based at Airedale NHS Foundation Trust, within the Digital Care Hub, the MyCare24 COPD service is supporting an increasing number of people through technology-enabled remote monitoring, with patients, families, clinicians and health and care staff reporting positive and in some cases life-changing results.
In the space of 12 months, an initial pilot that started with 50 people living with COPD has received more than 6,000 referrals and is supporting a caseload of 2,450 across a dozen primary care networks, spanning a range of cultural and socio-economic backgrounds in both rural and urban communities.
Rachel Woodington, MyCare24 COPD digital Implementation manager and advanced nurse practitioner, said: “Many of our patients are between the age of 70 and 80 and since the service launched, we’ve seen more than half submitting their readings to the hub digitally rather than by phone call.
“As primary and secondary care referrals increase, we’re working with a specialist company to ensure the service is digitally inclusive for every person who wants to use it in Bradford District and Craven, regardless of age or background.”
With a total headcount of 57, the hub team offer several services including MyCare24, which has nine dedicated staff, and includes experienced nurses working to support people alongside call handlers and operational and clinical service leads.
Day and night, the team support people living with COPD alongside an increasing number of people with other health and care needs including other respiratory conditions and Parkinson’s.
The team was able to rapidly scale the COPD service, which onboards patients following clinical referral, due to strong existing infrastructure that provides a range of services.
These include Immedicare, which provides video enabled clinical consultation to more than 600 care homes across England; Goldline, which supports people nearing the end of their life across Bradford District and Craven, and a ‘72 hours’ service that supports people to reduce their time in A&E and safely return home.
Marie Buchan, head of the Digital Health Hub, said: “This gave us a really strong foundation from which to build and scale very quickly and meant we have been able to safely manage the increase in patients.”
Marie added that developing the business case for the COPD service, alongside an original funding bid, paved the way to both fully embed the service and carry out a strong, timely evaluation over a full three-year period, supporting sustainability and future recommissioning.
Robust governance processes are key; with performance, standard operating procedures and training all audited regularly.
Rachel Binks, nurse consultant and service clinical lead said: “Our priority is supporting our patients with safe care and developing our staff to ensure best practice.
“Staff training is hugely important, and we also offer educational support to empower patients within their own homes.”
The impact of the service and how it can best support patients is reviewed monthly by a multidisciplinary team of clinicians, consultant nurse, advanced clinical practitioner, and respiratory clinical specialists working across primary and secondary care.
Together the team use the app data to review their caseload each month.
This includes looking at the decile (10 per cent) of cases that have alerted the most, in order to provide further tailored support.
The impact of this work means four in five of such cases don’t remain in the same decile (with the highest alerts) in subsequent months. Of those cases that do remain, this is predominantly due to specialist reasons such as awaiting a lung transplant.
Alongside a team culture where specialists work side by side to support one another, the successful development of the service has been driven by a holistic, collaborative approach around referrals across primary, secondary and community care.
This includes working closely with hospital and district nursing teams to tailor support for each patient and epitomises the ‘Act as One ethos’ driving the work of the Bradford District and Craven Health and Care Partnership.
Marie said: “Setting something up from scratch is not always an easy journey and it needs people to be creative, tenacious, and brave. We’re lucky that we have a strong clinical team that’s been central to this work and play an active role.”
The team is working to encourage understanding, use and promotion of technology-enabled remote monitoring and to reduce inequalities by working closely with nursing, clinical and patient communities.”
Tools and technology
Patients use oximeters, funded by NHS England, to submit regular vital sign readings to the hub team using the Luscii app on their phone or tablet. Alternatively, they can phone the hub with their readings for a team member to input.
The team is quickly alerted if a patient’s readings are not ‘normal’ for them and may warrant further intervention, such as additional monitoring or triage to a community, primary or acute service.
Rachel Woodington said: “We can pick an alert up within minutes, give that patient a call and check to see how we can help and support them.
“The service is accessible and empowering for patients, care givers and families. Just by knowing they can put oxygen readings into the app at 3am and if there is a clinical concern someone will call them is really reassuring.
“It helps promote self-care, and I think this is a key reason why we are seeing a reduction in hospital admissions and bed days.
“It is helping to reduce hospital admissions, GP appointments and improving quality of life, keeping people happy and healthy at home.”
The data submitted by the patients also provides an additional layer of insight during clinical reviews, helping nurses and clinicians identify patterns leading up to an acute episode at home or an admission to hospital and to put tailored, preventative support in place.
The hub also has video consultation capability and a well-established end of life (Goldline) phone service for additional or follow-up support, with a major element of its success stemming from the service being staffed around-the-clock, seven days a week.
Benefits and impact
Early data suggests a positive impact in reducing acute hospital-based activity for those referred to the service. Looking at six months pre and post referral for the 232 patients referred to the service in December 2021:
- A&E attendances reduced by 10.7 per cent, from 121 to 108.
- Emergency admissions reduced by 28.8 per cent, from 80 to 57.
- COPD related hospital days reduced by 63.4 per cent, from 142 to 52.
Patient: “I feel listened to and very reassured that the service is there when I need it as I have difficulty breathing and can panic when I can’t contact my doctor. I have been calling the ambulance but don’t feel I need to with this new service.”
Family member: “This app gives us peace of mind if anything is of concern. I feel reassured that my dad will get the attention he needs quickly.”
Respiratory clinical specialist nurse: “At a time when our hospital workload is increasing it is reassuring to know that our patients have some contact post discharge and that any concerns will be redirected back to us.
“When patients become unwell on a Friday, it is great that MyCare24 are there to chase a plan that I have put in place, obtaining a rescue pack for example, and then contacting the patient over the weekend to check on progress.
“It is reassuring and means that I don’t have to worry over the weekend.”
GP: “This service is fantastic and has taken some of the pressure off us in practice regarding these patients, as we know they are there even when we are closed.”
Talking head videos