At a recent webinar for our live event series, HTN Now, we were joined by Rachel Woodington, digital care hub manager at Airedale NHS Foundation Trust, and Ruben de Neef, customer success lead at Luscii, to discuss the virtual COPD service launched at the trust including benefits, challenges and key learnings.
Rachel kicked off the session with an introduction to her role and some background about the digital care hub, explaining how she has been an advanced nurse practitioner for the last six years and a nurse for nearly 20. She joined Airedale two years ago as digital care hub manager to set up the COPD service.
“The digital care hub was started in 2011, but prior to that we’d implemented a prison service to stop prisoners having to come out for their outpatients appointments,” said Rachel. “It was helping increase capacity within the prison service, reduce costs, and increase the capacity of prisoners that were able to attend appointments, because they’re unable to attend if there aren’t prison guards to take them.”
A couple of years after the hub launched, Rachel described how digital technologies such as cameras and laptops were placed into care homes to help support patients with clinical consultations.
“We do that across the whole of England and Wales – we’ve got 750 care homes,” she shared. “That allows us to do one-to-one consultations, prescribe for them if required, or refer them onto an appropriate service, reducing hospital admissions and unnecessary pressure on primary care.”
In 2014, Goldline was introduced, an initiative for patients on the gold standards framework in the last year of life.
“We have 3000 patients across our local area on this caseload, and we support them with everything and anything that they need, referring them onto the district nurses or doctors if they need to be seen, and just being there for patients who are at the worst time of their lives,” said Rachel.
Moving onto the development of the COPD service, Rachel explained that from the time that she joined the hub, an umbrella called MyCare 24 was introduced, with a number of services beneath it. Starting with a Parkinson’s caseload, the service grew with COVID virtual wards during the pandemic, which linked into the rapid scaling of the COPD service.
“We were given some funds by NHS England to pilot the COPD service. There are just short of 14,000 patients in Bradford District and Craven that have COPD, and there were 8,366 patients at the time of starting this service that had moderate, severe, or very severe COPD. There were an awful lot of ambulance conveyances, and we were inundated at both hospitals with respiratory problems which were mainly COPD. In parts of our region, average life expectancy for a male with COPD drops by 20 years, due to deprivation and lifestyle factors; so there was something to be done about bridging that gap and focusing on we could create care for all equally, improve the quality of health, and reduce the risk factors on local services.”
Implementing Luscii
Rachel shared more around the implementation of Luscii, how this worked within the COPD service and some of the benefits being seen to date.
“We are not a virtual ward; we are a service at scale,” she said. “We started the pilot with 50, and we now have 7,000 patients sent to us by GP practices. We decided to join forces with Luscii, who we’d used during COVID – we really liked everything about the service, it’s wonderful for patients because it’s very patient friendly and helps them to see their own trajectory of care.”
The main focus was reducing hospital admissions, she continued; but the team was aware that there is “not always a massive amount of information on COPD for patients when they are first diagnosed”. She pointed out that patients are often picked up once they have had one or two acute admissions, which could have been reduced at the time if the patient had received the right education about lifestyle, medication management and to use an inhaler properly.
“Those things are really important with this cohort of patients, and we didn’t feel that having them on for a short period of time and then sending them off again was really going to have the educational effect that we wanted on them,” Rachel said. “We wanted them to feel like they did have 24/7 support. Unlike some virtual wards, we are a 24/7 service; so if they wake up in the middle of the night and they don’t feel well, they can call us and have somebody there on the end of the phone, rather than calling in a paramedic or leaving it until the morning and having deteriorating symptoms, and then ending up in hospital.”
In terms of benefits at scale, Rachel noted that when the service was set up it was estimated to cost £73 per patient, per year, based on a caseload of 6,000 patients. “We wanted to reduce unscheduled activity by 30 percent, which was around a £1.15 million cost benefit,” she shared.
“In terms of challenges, setting up any virtual ward is a challenge; it’s a very different way of thinking across the board. People fear that they might to lose their jobs, they fear that they won’t have control. A lot of people feel like care within their own home is still quite a risky place to be.
“I think we found those things a challenge, but not as much of a challenge as other things like the onboarding of patients – that was possibly our biggest challenge. I don’t think we fully expected the GPs to take it up as much as they did; when you’ve got 6,000 patients who all want onboarding very quickly, and you’ve got a limited amount of onboarders because of the way the funding was given, that can become a challenge.”
One of the ways in which the team overcame that challenge was to “join forces again with Luscii,” Rachel said, “and join forces with the company that was already within the trust called DrDoctor. They send out outpatient letters, which is brilliant and reduced our non-attendances. Luscii helped us set up a link that went through DrDoctor, so that patients could onboard themselves onto the Luscii platform, which massively reduced the length of time we spent on onboarding.
“Staffing is obviously an issue; we had challenges within the hub, especially since this started when we were still going through COVID. I think when we look back, we probably needed to look at the staffing model a little bit differently. I think if you were going to set this up at scale, I’d encourage people to really look into the staffing side – because it’s definitely a challenge with that amount of patients.”
Funding is also an issue, Rachel added, as is digital exclusion. “Within our local area, there’s an awful lot of deprivation, and that can mean patients that don’t have mobile phones that are able to put the app on, data challenges, some of the population not wanting to use a digital app or not knowing how.”
However, she noted that COVID “definitely helped change things with digital – I think it definitely allowed people to be more open to using apps.”
Service impact
Moving on to discuss the service impact, Rachel shared that the trust is working with Health Innovation Manchester under NHS England to perform a review.
“We average around 1,000 clinical calls a month, and 1,000 Luscii alerts – they can be red or amber alerts and they’re based on the NEWS2 scoring,” she shared. “If a patient is an amber alert, they will get a message to say that we’ve seen the alert and we’re aware, and if you need us to give us a call. If it’s a red alert, they’ll get message as well to say we’ll call you back within five minutes.
“Our response time is absolutely outstanding, patients feel secure and supported, and that’s making a big difference to their quality of life.”
Across the whole cohort since the started, there have been around 20,000 clinical calls. “We’ve got a 1.1 percent ambulance conveyance rate; for 6,000 patients and 1,000 clinical calls a month, that’s very low,” she continued.
Non-elective admissions have been reduced by 50 percent; A&E attendances by 21 percent; and there is a 7.83 percent referral rate to the GPs. 98.9 percent of patients remain within their own home.
The service links in with SystmOne, which Rachel said helps the team have “a full view of patients’ care. That really helps, because when they come in to us, we’re not asking lots of questions about past medical history; we can see all current medication, and we can start supporting them.”
A main aim of the service was to reduce the use of medication. If patients are not using current medications like inhalers properly, this can be seen on SystmOne. “We can refer them into places like pulmonary rehab and the hospice where they do better breathing groups, and refer them to exercise classes, smoking cessation classes, anything to try and improve their quality of life,” she said.
“If we pick up a patient who might be struggling at home, we can refer into services that might provide food parcels, blankets, heaters, change the light bulbs, help with the boilers. We really do link-in with community services; we look at these patients in a holistic viewpoint as well. Patients receive person-centred care.”
She added: “Although our service is digitally enabled, we realise that our patients may not be. As such, we do have a paper diary for patients which means they can follow their own trajectory of care and can call us 24/7 even if they don’t have Luscii.”
Key learnings and next steps
On key learnings and takeaways from the project to date, Rachel offered some of her insights, saying: “It’s important to keep patients active. They will use us a lot at the time of an exacerbation, they’ll use us quite a lot the first few months; then generally they’ll drop off a little bit. It’s been really important to keep those patients engaged, to make sure that they’re still managing their medications OK, that they’re getting the correct education and are looking after themselves, especially over the winter months.
“We will send messages out to make sure that they’re keeping up to date with vaccinations, that they’re keeping well. It’s really important to keep that engagement going – because we don’t want to be just used within a crisis, we want them to use us all the time. ”
In addition, Rachel said, it’s important to share why we’re digitally safe and engaging people to trust in digital.
“I think our results speak for themselves, and I think people are slowly starting to learn that and understand that we can look after these patients without seeing them face-to-face, and keep them well in their own home,” she said. “It’s important not to underestimate the time it takes to digitally engage patients. You’ve got to build that rapport, build that understanding, educate them on how to use the app, how to use a pulse oximeter, and how they can manage that level of care at home.”
Finally, Rachel presented the service’s next steps, and plans for the future.
“We’re currently going through business finance and systems to have this forever, which would be my hope,” she said. “It’s been a very long process; finances are very short and there are lots of services to fund, so despite having outstanding results, we still have to fight for our place within the business cases.
“We want to sustain all that meaningful engagement, so we’re doing a lot of engagement with our patients – follow-ups, three-monthly messages to remind them we’re here, what’s going on. The plan is to go back through all the patients that didn’t want the app at the time, and see if anything’s changed, if we can support them with that onboarding now.”
Another goal is to work with companies to get free digital support; Rachel shared that local supermarkets have supplied some mobile phones to patients which allows them to access the app. “It’s about making sure that we’re fully reaching our whole cohort, avoiding those recurrent admissions,” she said.
“We definitely want to work more closely with Luscii – we’ve got some video calling going on now, so we are sorting out some iPads as well as additional languages on the app, and doing some more data driven activity as well.”
Ultimately, the trust aims to expand the service to offer a service at scale for heart failure, dependent upon commissioner support.
The supplier perspective
After Rachel’s presentation, Luscii’s Ruben shared with us his insight from a supplier perspective.
“Luscii was born in 2018, in the Netherlands, and we made our way into the UK in 2019,” he shared. “Our mission is to create space for care, which comes down to saving time, doing things more efficiently, or using Luscii as a filter for flagging those patients who need the attention most, instead of having to monitor them one-by-one.
“What is striking in Airedale is that Luscii is being used to amplify the capacity to look after patients by using it as a filter. But that is only going to help you so far if you have a small team, because in the end, capacity will still have its limits. By setting up a hub that is not there just for Luscii, but also for multiple services, there is the capacity to look after way more patients. You can go all the way up to 6,000 patients, and still be able to manage that with a relatively small team. I think that’s the beauty of setting it up the way Rachel and her team have done at Airedale.”
On how the service could be expanded across an IBS, Ruben said: “If you want to expand throughout the region, setting up infrastructure like a hub is one of those things to do. That makes the way you care for patients applicable not just for one department, one hospital, one trust; but for the whole of the region, from a technical point of view with infrastructure and such.
“I think the other one is building on each other’s work, working together between trusts within the ICS, learning from each other. At Luscii we also facilitate people to share what they have done, and let other people apply it to their local context by configuring it without having to build it all from scratch. So if there’s already experience within the ICS with digital hubs, virtual wards, remote monitoring, it makes it easier if you just connect to each other and join those dots.”
Continuing on to discuss how the service could be expanded to other areas, Ruben commented that it may be difficult for organisations to foresee themselves running a service like this because of the scale, “but you start small and you dream big. That means that any of the experiences that you have with maybe 50 patients will help you discover what you need in order to do it at scale. Protocols are important, and if you have the right protocols in place that tell your staff what to do in certain situations or in decision-making, it makes it much easier to do these things from a centralised perspective.”
Ruben also talked about critical enablers for working at scale, sharing: “It’s important to have the mindset that will allow you to try something new, learn from it, and then try it at a bigger scale. This system has been used in over 350 care hubs in the Netherlands and the UK, and the patient safety element is covered through the design of the system. The thing that you need to get used to is the fact that you have a virtual team member that is monitoring your patients. Building trust in the technology, and in that it can actually make your life easier, I think that can be a difficult thing to learn.”
We’d like to thank Rachel and Ruben for sharing their work and experience with us.
