East Kent extends remote monitoring pilot for complex and frail patients after positive feedback

East Kent Health and Care Partnership (EKHCP) is extending its remote monitoring pilot for patients living with frailty and complex needs living at home, after seeing positive results for patients and clinicians, as well as excellent feedback. Patients have reported a reduction in anxiety levels when using remote monitoring and have said they felt more in control of their own health while being fully supported by clinicians. The pilot will also extend its remit to include a cohort of patients living with COPD. 

EKHCP has been working on this pilot since May 2024 along with partners including Kent and Medway Integrated Care Board (ICB), Kent Community Health NHS Foundation Trust (KCHFT) and East Kent Primary Care Networks (PCNs) Graphnet and East Berkshire Primary Care (EBPC).

The pilot is a collaboration between Graphnet’s population health solution and Docobo Remote Monitoring from Graphnet, integrating into the Kent and Medway Care Record (KMCR).  The KMCR provides healthcare professionals with a joined-up view of someone’s care and treatment from multiple health providers. The pilot so far has been identifying patients that might benefit from remote monitoring, using the Johns Hopkins ACG® System’s segmentation model - Patient Need Groups (PNGs) - which is integrated into Graphnet’s solution. The resulting list of 7,000 patients were categorised into PNGs 10 and 11 – the most complex segments - and further filtered to identify 1,500 patients for onboarding to remote monitoring. EKHCP further refined the list to a caseload of 500 complex or frail patients linked to two PCNs in East Kent: Folkestone, Hythe and Rural PCN and Mid Kent PCN.

Five GP practices have been involved in the project. Patients were identified as being suitable for the scheme are contacted by their practice and asked if they would be interested in opting in. Around 50 per cent of patients who were contacted joined the scheme.

The patients are provided with tablets which connect to the remote monitoring clinical hub, to discuss their equipment needs and agree their monitoring regime.

The Docobo Remote Monitoring platform enables patients to be monitored by clinicians in the comfort of their own homes. Patients fill in questionnaires and submit observations to the hub at EBPC and any alerts are picked up by the clinical hub.

Feedback has been positive so far.

Sarah Phillips, Chief Medical Officer at Kent Community Health and Senior Lead for the remote monitoring pilot and Chair of the project Programme Board says:

We are really proud of the outcomes of this pilot and the amazing patient feedback we have received. Patients have reported a reduction in anxiety levels in using the system and have reported that they feel more in control of their own health while being fully supported by clinicians.

Patients have fed back as follows:  

I think the service is brilliant and I’ve told my GP this too. My wife has been in nursing for 45 years and if she thinks it is good then it is! My GP has also said it was good.

I really love the service. My GP told me it was good, and they will be rolling it out to more patients.

You guys are amazing! Thank you so much! I really appreciate it and I’m so grateful for you guys! We believe in giving good feedback when it’s due. Thank you once again, we express our gratitude!

I have had excellent support received from the Digital Health Team working in the Remote Monitoring Hub. I have found the equipment to be very easy and straight forward to use. On an occasion when there was a problem with oxygen readings, I received a call from my GP within half an hour of submitting the reading. I’m really pleased to have been invited to be part of the service – it has made a significant improvement to day-to-day life – I feel assured knowing I will get a check in call if required. The team were extremely helpful in the set up and use of equipment.

The service is being evaluated using Graphnet dashboards in the KMCR Population Health platform - supported by the University of Kent - and the team will share further information in due course.