Managing complex and frail patients in East Kent using remote monitoring and a central monitoring hub

A remote monitoring service for frail and complex patients living at home is showing positive results for patients and clinicians.

East Kent Health and Care Partnership (EKHCP) is piloting the population health and remote monitoring service with partners including Kent and Medway Integrated Care Board (ICB), Kent Community Health NHS Foundation Trust (KCHFT) and East Kent Primary Care Networks (PCNs), working with Docobo Remote Monitoring, Graphnet and East Berkshire Primary Care (EBPC).

EKHCP has been working with Graphnet and Docobo Remote Monitoring for some time on different digital health projects and this pilot is a collaboration between their population health and remote monitoring solution, 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. It contains automated, regular data feeds from acute hospital trusts, community services providers, mental health providers, GP practices and local authority social care.

How did the project start?

The team at EKHCP started by 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.

There are five GP practices involved in the project. Patients who have been 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 are contacted join the scheme.

The details of those patients who have consented are then passed to Docobo who register them on the system.  The patients are then contacted by East Berkshire Primary Care (EBPC), who provide the remote monitoring clinical hub, to discuss their equipment needs and agree their monitoring regime.

Any equipment that is required is dispatched by Docobo within one working day. Although user guides are sent with the equipment, EBPC are also on hand to provide support to patients on set up.

How does the remote monitoring work?

Once patients have been registered and received the equipment, they send in their daily observations which are monitored by the hub at EBPC. Patients also fill in questionnaires and submit observations. Any alerts are picked up by the clinical hub. EBPC provides first line support, escalating support needs for patients to Docobo when necessary.

The Docobo Remote Monitoring technology platform – which is used in care homes, in primary care settings and in patients’ homes – enables patients to be monitored by clinicians in the comfort of their own homes.

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 to have worked together across the system to implement this pilot. Outcomes of the pilot so far are encouraging and we look forward to gathering more data for our evaluation. Patient feedback is good with patients reporting they feel more in control of their own health while being fully supported by clinicians.’

Service evaluation

The service is being evaluated using Graphnet dashboards in the KMCR Population Health platform. These dashboards will compare patients in the service with a matched group of similar patients using metrics such as: emergency attendance, emergency admission, GP contacts, volume of medications prescribed and acute length of stay. There will also be qualitative analysis in the form of patient surveys and healthcare professional surveys.

Futures

The team at East Kent Health and Care Partnership will be evaluating and sharing the results of this innovative remote monitoring and population health project service as data is collected and analysed.

Sarah concludes: ‘We are very excited about the potential for this initiative to improve the management of complex and frail patients in East Kent, bringing benefits for both patients and clinicians.’

“We are really proud to have worked together across the system to implement this pilot. Outcomes of the pilot so far are encouraging, and we look forward to gathering more data for our evaluation. Patient feedback is good with patients reporting they feel more in control of their own health while being fully supported by clinicians." Sarah Phillips Chief Medical Officer at Kent Community Health and Senior Lead for the remote monitoring pilot and Chair of the project Programme Board.