How the combination of population health and remote monitoring has become the cornerstone of Liverpool’s hospital transformation

Telehealth initiatives in Liverpool date back to 2012, with the deployment of a remote monitoring platform provided by Docobo and supported by a clinical hub of remote-working nurses, healthcare assistants and administrative staff. Over time, the service has expanded to cover Cheshire and Merseyside and to support over 25 clinical pathways with comprehensive remote monitoring, with around 2,000 patients on board for long-term conditions. A paper published by the team in 2019 in the BMJ  showed that using a rudimentary population health approach to onboarding patients for remote monitoring demonstrated  a 22.7% to 25% reduction in emergency admissions for patients. 

The start of the Covid pandemic proved to be a ‘gamechanger’ for the Telehealth Team, which saw the service cater for many more patients, and in particular, to roll out remote monitoring for silent hypoxia. Whereas the national model for silent hypoxia was paper based, the Liverpool team were able to pivot their Telehealth platform towards providing oximetry at home, which was monitored through the Docobo platform.

The team was able to rapidly deploy the solution and took referrals from multiple sources. A&E particularly used this pathway if they had a patient on the cusp of admitting to hospital or not – knowing these patients were going to be monitored at home meant that they could send more patients home from that first attendance rather than admit them as a ‘just in case’ process. 

Successful work with Docobo paved way for collaboration with Graphnet 

When national guidance came out around Covid drug treatments for those in the most vulnerable populations, the team started to use the Graphnet population health platform, making the most of its ability to give the team a view of the shared care record and population health.   The team worked to produce a dashboard which would present all the patients who were in the most vulnerable groups and was also able to demonstrate which patients were and were not suitable for particular types of treatment. This meant that the clinical decision was still very much down to the clinician, but it saved time trawling through patient records and presented the information simply and in an easy-to-use way. 

Ongoing remote monitoring and population health plans 

With less of a focus on Covid, the team are now going to go back to focus on long-term condition monitoring and adapting the successful population health and remote monitoring approach across Cheshire and Merseyside. 

Dr Rosie Kaur, CCIO for Mersey Care NHS Foundation Trust and clinical lead for Telehealth says: ‘Although Mersey Care has an excellent Telehealth platform, the initial approach only included an element of data in it and there was no uniform or consistent process to the onboarding of those patients, as it was labour-intensive.  Since Covid, the team is going back to use population health and looking at how they can have more systematic approach to identifying those people who need remote monitoring. We want to target the people, give them visibility, early identification and any prevention we can put in. 

We know that using Graphnet we can apply filters using the John Hopkins tool and that presents to us around 17,000 patients that meet the criteria that would have a probability of emergency admissions. We are aiming - through the use of the tool - to target 9,000 of those patients.  We’ve had agreement in Liverpool for us to be able to use this proactively and we're going to scale up the number of patients we put on LTC monitoring. 

The team are very keen to reduce unwarranted variation and use scalability by using the Graphnet population health tools and Docobo Remote Monitoring to target those patients who really need it.’  

The Graphnet and Docobo CIPHA (Combined Intelligence for Population Health Action) approach - which joins up population health and remote monitoring - enables users to identify cohorts of patients who require proactive support and breaks down barriers between healthcare organisations with its seamless case management. This means that the entire care team has access to pertinent information while facilitating online interaction between patients and clinicians and implementing remote monitoring technology for continuous care in the comfort of patients’ homes.

How does the new approach work? 

The Graphnet population health tools incorporate risk stratification from Johns Hopkins and has a case finding tool that enables people to identify patient cohorts. Once these are identified, Docobo Remote Monitoring can be deployed, which uses a RAG rated alert system, monitored by the clinical Hub and an escalation into whichever team is overseeing that pathway. 

Rosie says: ‘The team can now provide targeted interventions that are digitally supported. The Graphnet element means we have the population data we need and that means we are having better patient outcomes, with more patients being able to be treated within the time frame.’ 

Futures

The Telehealth Team also support Virtual Wards in heart failure and has done some work around ADHD in clinical harm. The team also has pathways going in pre-elective care, enabling prehabilitation and identification of early deterioration of people on the waiting list. The team is working with colleagues at Liverpool Heart and Chest Hospital on a pathway around people waiting for cardiac surgery which has had really good results so far. 

Rosie says: ‘We want to start using our population health AI tools to look at those people at risk of admission due to comorbidities and targeting those people at risk of deterioration while on waiting lists or at patient appointments or even between patient appointments. This will mean we can opitimise their care while they are in surgery. We are looking at those patients who are at risk of admission while waiting for their surgery so that's a pre-elective care and also look at optimising their care while they're in in surgery. We’re starting to get really meaningful information around how we can optimise patients, so they are in the best possible condition when they when they're ready for surgery.’ 

‘We want to use a combination of population health and remote monitoring to predict and prevent and treat. We are also starting to look at more work in care homes. We also want to start expanding our work around supporting around clinical harm reviews and also post-operative early supportive discharge.’ 
Excellent patient feedback and workforce benefits from population health and remote monitoring 
Rosie explains: ‘Patients have said to us that they absolutely feel that the remote monitoring makes them feel visible to clinicians between hospital appointments; visibility while they are not attending Primary Care and visibility while they are waiting for surgery. This visibility can lead to improvements in patient safety through the early identification of deterioration.’

Colleagues are also experiencing benefits of this joined up approach. For example, says Rosie: ‘The approach helps our workforce work effectively so they can prioritise the patients who need to see them. The initial findings from the cardiac surgery pathway shows about 6% of patients were escalated due to the remote monitoring picking up deteriorations in physical activity   and there were patients who potentially could have been admitted as an urgent admission. This means that you are bringing people in earlier as elective care, which is much more efficient than if they were brought in as urgent care.’ 
Remote monitoring patients are more knowledgeable about managing their condition which means they are more likely to intervene at an earlier stage and you're less likely to get to the point where the patient presents in primary care. 

When incorporating Telehealth into community heart failure nursing pathways for supporting patients, the team has found that they have potentially reduced the need for colleagues to visit so often. Rather than going out twice a day they can gather the data from remote monitoring and only need to visit once a day, which ultimately is reducing unwarranted variation particularly around long-term condition monitoring.’ 
Rosie concludes: ‘The combination of population health targeting of higher risk groups and our Telehealth and remote monitoring platform enabling them to be visible to clinicians, will optimise their care as we are ultimately empowering those patients. This is key in for out of hospital transformation.’ 

Peter Almond, Telehealth Head of Service says: ‘The platform's goal has always been to aid patients in managing long-term conditions by enabling early intervention and reducing the need for medical interventions. The combination of population health and remote monitoring together has become the cornerstone of our hospital transformation as we go forward to meet the challenges that we face.