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31 Long Term Conditions Case Studies

In 2010 NHS Innovations was commissioned by NHS South West to audit and collate examples of best practice in management of Long Term Conditions from around the region.  These examples were then compiled into case studies and they are presented below for information in order to assist with the adoption and diffusion of innovations that deliver clear benefit for patients and health services.  

University Hospital Bristol NHS Foundation Trust 1

 
Synopsis

Direct Access system for patients with regular outpatient reviews
Patient led service. Through a direct access system (DAS), regular rheumatologist - initiated reviews were replaced by patient initiated reviews, accessed through a telephone helpline run by the rheumatology nurse specialists. DAS ensures timely care during episodes of urgent need, such as a flare-up of the disease, and reduces the number of routine but unnecessary reviews

Long Term Condition

Rheumatoid Arthritis

Meets National Priority Area
Fast Track Service

Benefits to Patient
Patients request fewer appointment found direct access more acceptable and needed a third less medical outpatient appointments

Benefits to Staff
Need fewer appointments so able to see more patients

Cost Savings/Efficiencies
Reduction in unnecessary hospital outpatient reviews

Outcomes Measured
Two year randomised controlled trial extended to six years. Outcome measures included clinical pain, disease activity, early morning stiffness, inflammatory indices, disability grab strength, range of movement and bone erosion. Psychological status, anxiety, depression, helplessness, satisfaction and confidence in the system. Number of visits to hospital physician and GP for advice

Sustainability
Project initiated six years ago and continues to run

Transferable
Suitable for use with patients with any LTC that requires regular booked reviews,
Winner of the service delivery long term condition award sponsored by the Multiple Sclerosis Society

Project Status
Ongoing

For more information e-mail info@nisw.co.uk
 

 

University Hospitals Bristol NHS Foundation Trust 2

 
Synopsis

Respiratory HOT Clinic
Set up as an admission avoidance service with the aim to support GPs with patients with chronic lung disease. Intended to be beneficial to the hospital for admission avoidance. The patients receive timely assessments by specialists and the PCT. Rapid access to specialist advice and services

Long Term Condition
Respiratory patients

Meets National Priority Area
Admission avoidance. Reducing LOS

Benefits to Patient
Confidence in the service. Quick access to specialist advice. Admission avoidance.

Benefits to Staff
Job satisfaction

Cost Savings/Efficiencies
From May 2009 to May 2010 the percentage of admission avoidance ranged from - 4% - 100%. Patients seen in one day in one place. All tests completed in one visit.

Outcomes Measured
Data collected monthly to inform number attended and numbers admitted on the day or within 1 week or within 1 month. Patient satisfaction. Improved communication between primary and secondary care.

Sustainability
Efficient and effective service

Transferable
Potential for other Trusts to use the same approach.

Project Status
Ongoing. Current service.

For more information e-mail info@nisw.co.uk
 
 

University Hospital Bristol NHS Foundation Trust 3

 
Synopsis

Facilitating discharge from admission wards and HOT clinics

A joint collaboration between BRI and Bristol Community Physiotherapy services for respiratory patients

Long Term Condition
Chronic Lung Disease

Meets National Priority Area
Admission avoidance

Benefits to Patient
High quality care in the home from a specialist MD team. Reduced risk of hospital acquired infection. Continuity of care

Benefits to Staff
Integrated care, close working with Primary Care and community teams to provide long term management of patients

Cost Savings/Efficiencies
Savings of £283,736 in the first year. £121,748 in the second year. In 2009 saved 197,748 from admission avoidance. Discharge target 48 hours. Hospital save inpatient beds. 571 patients were supported at home by the team. Their LOS would have been 2-5 days. The average LOS for COPD is 8 days in Bristol. Efficiencies: Quick access to specialist consultant's opinion. Reduction in further admissions and re-admissions Shorter LOS. Reduction in risk of hospital acquired infection

Outcomes Measured
Year 1 - 118 patients discharged within 4 hours
Year 2 - 206 (increase off 58%)
Patient satisfaction - 50% return- majority think the service is excellent. Monitor re-admission rate of patients discharged within 48 hours arte =23% 2009/2010. Patient satisfaction survey every 2 months. Monitor patients who have a facilitated discharge

Sustainability
In 2009/10 UHB had 500 patients admitted with COPD and 26% with asthma. Due to the number of smokers in the city and deprived areas the prevalence of COPD is high. So the need for the service will continue to reduce the number admitted to hospital as the culture of the city means the disease will remain prevalent

Transferable
No data

Project Status
On-going and plan to restructure COPD care to produce a path-way across the city to improve care from diagnosis through the disease to end of life care

For more information e-mail info@nisw.co.uk
 
 

University Hospital Bristol NHS Foundation Trust 4

 
Synopsis

Early supported discharge for stroke patients
Providing intensive rehabilitation in the home outreaching from the acute unit. Also accept referrals from the TIA clinic

Long Term Condition
Stroke

Meets National Priority Area
No delayed discharges

Benefits to Patient
Reduced LOS from an average of 24.2 days - 30.5 days

Benefits to Staff
Team approach to care

Cost Savings/Efficiencies
ESD funded by the closure of 10stroke beds on the Stroke Rehabilitation Units at Bristol General Hospital and outreach for the Acute Trusts. No additional infrastructure to the team since 2005.

Outcomes Measured
Patient satisfaction survey. All patients 74% highly satisfied and 18% satisfied with the Outcomes used- Goal attainment scale. Therapy Outcome Measures. Motor Assessment Scale for fore limbs. BERG (Balance).

Sustainability
Needs pump priming to develop the team

Transferable
Other Trusts using this approach

Project Status
Pilot implemented June 2008. Permanent service June 2009

For more information e-mail info@nisw.co.uk
 
 
 

Royal National Hospital for Rheumatic Diseases NHS Trust 1

 
Synopsis

Falls and fractures

The RNHRD has been developing a Falls and Fracture Liaison Service at the Royal United Hospital (RUH) Bath. This is a partnership between the RNHRD, RUH, BANES PCT and Wiltshire PCT.

These organisations are working together to identify and treat patients with osteoporosis, and to help people who experience frequent falls. The aim is to reduce both the number of people who fall, and proportion of falls which result in a fracture, thereby reducing the number of hospital admissions due to falls

Long Term Condition

Falls & fractures Osteoporosis

Meets National Priority Area

Avoidance of admission

Benefits to Patient
Reduced number of falls and fractures

Benefits to Staff

Working in partnership with staff from the RNHRD, RUH, BANES PCT and Wiltshire PCT

Cost Savings/Efficiencies
No data

Outcomes Measured

This service was recognised by the South West falls, bone health and fractures review (Sept 2009) as an example of good practice

Sustainability

Service has been running successfully since 2009

Transferable
An effective model of care that is transferable to other Trusts

Project Status
Ongoing

For more information e-mail info@nisw.co.uk
 
 
 

Royal National Hospital for Rheumatic Diseases NHS Trust 2

 
Synopsis

Using alternative media to support adults with Chronic Fatigue Syndrome (CFS)


Long Term Condition

Chronic fatigue syndrome

Meets National Priority Area
Avoidance of admissions

Benefits to Patient
Improved access to therapy led services for people who are unable to attend face to face appointments

Benefits to Staff

Able to provide an alternative service through email, telephone and texting

Cost Savings/Efficiencies
Face to face contacts were reduced where appropriate providing an annual cost saving of approx. £34,000

Outcomes Measured

A service evaluation showed that patient satisfaction with this alternative service was very high. An example of one users comment on the service was: 'Practical as it's not possible for all patients to come to appointments'. Very effective way to keep in touch. Flexible. I had help on my way back to work - telephone support was very good for a tricky situation'

Sustainability
This has been cited by NHS Evidence - Quality and Productivity as an example of good practice

Transferable

Simple to apply to other Trusts

Project Status
Ongoing

For more information e-mail info@nisw.co.uk
 

Royal National Hospital for Rheumatic Diseases NHS Trust 3

 
Synopsis

Mindfulness and Acceptance based therapies

This unit is the national leader in this area and the service model is fully in line with the CMO's recommendations, being a good example of a level 3 service, in his terms.
This is the first time that these techniques have been acknowledged and cited in policy, and the first time internationally that they have been cited by such a senior government agency, despite much research in the pain field being carried out in the USA

Long Term Condition

Chronic pain

Meets National Priority Area
Avoidance of admissions

Benefits to Patient
Support with effective chronic pain control

Benefits to Staff

Acknowledged as a leader in the field of acceptance based strategies and mindfulness research

Cost Savings/Efficiencies
No data

Outcomes Measured

Bath Centre for Pain Services (BCPS) has produced much research over the last 10-15 years in the area of Pain and more recently has been internationally acknowledged as the leader in the field of acceptance based strategies and mindfulness research

Sustainability
The BCPS's research is influencing policy agenda at the highest level, demonstrated by the fact that this year these techniques were recognised for the first time by the Chief Medical Officer, Sir Liam Donaldson, in his annual report 2008 (published March 2009).

Transferable

The treatment methods designed at the RNHRD are being increasingly used nationally by clinicians in specialty care centres - including currently London, Glasgow, Harrogate, Surrey, Leeds, Liverpool and Birmingham, among others.

Project Status
Ongoing

For more information e-mail info@nisw.co.uk
 
 
 

Royal National Hospital for Rheumatic Diseases NHS Trust 4

 
Synopsis

Mindfulness and Acceptance based therapies

This unit is the national leader in this area and the service model is fully in line with the CMO's recommendations, being a good example of a level 3 service, in his terms.
This is the first time that these techniques have been acknowledged and cited in policy, and the first time internationally that they have been cited by such a senior government agency, despite much research in the pain field being carried out in the USA

Long Term Condition

Chronic pain

Meets National Priority Area
Avoidance of admissions

Benefits to Patient
Support with effective chronic pain control

Benefits to Staff

Acknowledged as a leader in the field of acceptance based strategies and mindfulness research

Cost Savings/Efficiencies
No data

Outcomes Measured

Bath Centre for Pain Services (BCPS) has produced much research over the last 10-15 years in the area of Pain and more recently has been internationally acknowledged as the leader in the field of acceptance based strategies and mindfulness research

Sustainability
The BCPS's research is influencing policy agenda at the highest level, demonstrated by the fact that this year these techniques were recognised for the first time by the Chief Medical Officer, Sir Liam Donaldson, in his annual report 2008 (published March 2009).

Transferable

The treatment methods designed at the RNHRD are being increasingly used nationally by clinicians in specialty care centres - including currently London, Glasgow, Harrogate, Surrey, Leeds, Liverpool and Birmingham, among others.

Project Status
Ongoing

For more information e-mail info@nisw.co.uk
 

 
 

Royal National Hospital for Rheumatic Diseases NHS Trust 5

 
Synopsis

Lupus & Scleroderma Educational Programme

The education programme is provided separately for Lupus patients and Scleroderma patients as three education/ information sessions of half a day each and is repeated annually

Long Term Condition

Lupus & Scleroderma

Meets National Priority Area
Avoidance of admissions

Benefits to Patient
Self management of the disease. Empowered through education

Benefits to Staff

Effective experienced team

Cost Savings/Efficiencies
No data on cost savings provided

Outcomes Measured

Research was carried out to establish the content of a Lupus and Scleroderma Patient Education programme using qualitative methods. A pilot was designed and later evaluated which resulted in further development of the programme to meet patients and healthcare professional needs and resources

Sustainability
The RNHRD education programme is cited in the ARMA Standards of Care as an example of good practice.

Transferable

Suitable for other Trusts with specialist Lupus and scleroderma teams

Project Status
Ongoing

For more information e-mail info@nisw.co.uk
 

 

NHS Dorset PCT 1

 
Synopsis

SMILE

Self Management in Local Environment (SMILE) team service, Christchurch was set up to support the most vulnerable medically, socially and psychologically. To reduce unscheduled episodes of care, admission to secondary care, and ensures timely discharge from hospital

Long Term Condition

All Long Term Conditions

Meets National Priority Area
Avoidance of admissions. Reduced Length of stay. Reduced discharge delay

Benefits to Patient
Improved quality of life. Improved social and psychological aspects of health. More able to support self care and improved support for carers

Benefits to Staff
Optimised medical management of all LTC

Cost Savings/Efficiencies
No data to date

Outcomes Measured
Reduced unscheduled episodes of care. Reduced admissions to hospital. Timely discharge from hospital. Of 114 people 60% felt that the quality of their life had improved and friends/carers reported feeling reassured by the availability and interventions of the team

Sustainability
Without detailed cost savings and efficiency data difficult to say if the service is sustainable

Transferable
Service could be duplicated in other Trusts

Project Status
On-going service

For more information e-mail info@nisw.co.uk
 
 
 

NHS Dorset PCT 2

 
Synopsis

Anticipatory Care Planning Project

Improves the communication of a patient's key clinical information and care preference to all clinicians likely to be involved in the patient's care.
5 GP practices Bridport Medical Centre, Cornwall Road Surgery Dorchester, Broadmayne Surgery, Cerne Abbas and Milton Abbas. Each surgery with the community teams develops a vulnerable patients list that are eligible for a virtual ward, against specific outcomes. Each patient is assigned a key worker and categories such as red, amber, green dependent on the level of input needed. This list is regularly updated. Red is patient at high risk of hospital admission and is admitted to the virtual ward. This is highlighted on a board in the practice and actively managed by a combined practice and community team. M/D meetings weekly/monthly with informal discussion in between

Long Term Condition
All Long Term Conditions

Meets National Priority Area
Avoidance of admissions

Benefits to Patient
Increased independence. Increased patient satisfaction. Given choices and part of the decision making.

Benefits to Staff
Improved interaction between GPs and community teams. The internal practice team felt that the pilot improved input given by the wider community teams

Cost Savings/Efficiencies
Significant reduction and associated cost savings between in terms of non elective admissions. April 2008 data showed19 out of 20 admissions to hospital prevented
Cost - over the year for West Dorset locality around 7,730 community bed days saved and 5486 acute bed days saved. Financial saving over 2 years saw a gross saving of £528,640

Outcomes Measured
Patient experience questionnaire

Sustainability
Well planned and implemented pilot with positive results showing sustainability

Transferable
Service reconfiguration rather than the introduction of additional services or resources

Project Status
Pilot - ongoing

For more information e-mail info@nisw.co.uk
 
 
 

NHS Dorset PCT 3

 
Synopsis

Weymouth & Portland Community Ophthalmology
Community service model with particular benefit to patients with glaucoma

Long Term Condition

Ophthalmology

Meets National Priority Area
Avoidance of admissions

Benefits to Patient
Care closer to home. A service that meets the needs of this specific population. Access to specialist clinician. Access to associated services. Improved patient experience. Patient centred care. Patient in control of their condition.

Benefits to Staff
Increased capacity to meet future increase in demand for this service Reduced referrals to HES releasing time and resources with HES. Ability to achieve 18 week targets. Coordination of services. Enhanced skills. Better partnership working. Compliment secondary care service and reduces the workload.

Cost Savings/Efficiencies
In 2008-09 there were 14,014 new referrals and 27,358 follow up appointments to Outpatient clinics in acute hospitals commissioned by NHS Dorset. Analysis of local data suggest that 44% of new referrals and 58% of follow up appointments might be appropriate for the Community Service

Outcomes Measured
Expected outcomes include: Reduction in secondary care appointments. Improved patient experience. Timely referral

Sustainability
Service not yet operational

Transferable
Service not yet operational

Project Status
Service not yet operational

For more information e-mail info@nisw.co.uk
 
 
 
 

NHS Cornwall & Isles of Scilly PCT 1

 
Synopsis

The Newquay dementia pathway

A model of primary care based dementia community service which enabled a GP-led Memory service to be set up. This introduced a primary care based dementia liaison practitioner role provide specialist in-reach into care homes and community hospitals; run a country wide 'Worried about your memory?' public information and awareness campaign; and introduce a standardised dementia health check for all people diagnosed with dementia

Long Term Condition

Dementia

Meets National Priority Area
Avoidable admissions

Benefits to Patient
Patients supported to stay at home. Early cognitive stimulation prescribed
Memory Care and meetings in groups for cognitive stimulation therapy

Benefits to Staff
Part of an effective MD team. Patient stays on the case load until the end of life-continuity of care

Cost Savings/Efficiencies
No cost data. Efficiencies in working as a patient focused team

Outcomes Measured
Outcomes within the integrated care pathway have been measured using the Quality Outcome Framework. Significant event audit monthly. DoH audit tool used - result positive feedback

Sustainability
Service has been running for 2 years. 2 of the 16 locality based DoH integrated care pilot sites in dementia care and mental health

Transferable
Suitable for other Trusts and GPs

Project Status
Current - ongoing

For more information e-mail info@nisw.co.uk
 
 
 

NHS Cornwall & Isles of Scilly PCT 2

 
Synopsis

Personalised Care Planning
PCP offers an approach to the care of people with long term conditions/ complex needs that will help us to drive a shift from the organisation of services around professional groups to patient centred holistic care

Long Term Condition
All Long Term Conditions

Meets National Priority Area
Avoidance of admissions

Benefits to Patient
Improved quality of care
Complex needs identified

Benefits to Staff
Breaks down professional boundaries and organisational barriers and eliminates duplication of work and errors

Cost Savings/Efficiencies
No data

Outcomes Measured
Outcomes specified in provider contracts and measured. a step-change to the quality of care and health outcomes for this group of service users

Sustainability
Approach to care is still in service

Transferable

Potential to be used in other Trusts

Project Status
Ongoing

For more information e-mail info@nisw.co.uk
 
 
 

NHS Cornwall & Isles of Scilly PCT 3

 
Synopsis

Patients at Risk of Readmission (PARR)

Long Term Condition

All Long Term Conditions

Meets National Priority Area
Avoidance of Admissions

Benefits to Patient
Better understanding and management of their LTC. Supported to stay in their own home

Benefits to Staff
Coordinates care with proactive management of their patients

Cost Savings/Efficiencies
No data. Retrospective evaluation by the Nuffield Trust over the last five years included rates of admission against a control group

Outcomes Measured

No data. Awaiting results of the Nuffield Trust review

Sustainability
Potentially, but awaiting results of the Nuffield Trust review

Transferable
Potentially transferable

Project Status
Ongoing

For more information e-mail info@nisw.co.uk
 
 
 

NHS Cornwall & Isles of Scilly PCT 4

 
Synopsis

Combined Predictive Model

The next generation tool for risk prediction is the Combined Predictive Model. This combines information from primary care information systems and hospital activity, including A&E attendances and outpatient appointments as well as emergency admissions. This model will also enable the impact of interventions to be more accurately evaluated in terms of improvement in use of resources and benefits gained. This will support the longer term planning of the commissioning PCT and local partners

Long Term Condition

All Long Term Conditions

Meets National Priority Area

Avoidance of admissions

Benefits to Patient
Their needs identified and plans put in place to meet their needs and prevent unnecessary admissions. Targets patients who benefit most from preventative interventions

Benefits to Staff

This approach enables risk stratification of the whole population of each practice and provides a range of information that can be used to identify which patients will benefit most from preventative intervention

Cost Savings/Efficiencies

No data. Trial of the Combined Predictive Model - a local hands-on investigation into what it can provide. The initial model has now been built and the first output expected in 2010

Outcomes Measured
No data. The evaluation of the first data download will be critical to understanding how the Combined Model can be used and what benefits it can help us to achieve. This will inform the substantive implementation during 2010

Sustainability
Awaiting substantive implementation during 2010

Transferable
Awaiting evaluation

Project Status
Ongoing

For more information e-mail info@nisw.co.uk
 
 
 

NHS Cornwall & Isles of Scilly PCT 5

 
Synopsis

Long Term Conditions Portal
There are a great number of information sources but some require time-consuming searching and may not be accessible for some users. Identified as a gap in the service provision to support self care. Research from the Institute of National Statistics has shown that internet usage for those over the age of 65 is increasing and when applied to those with a LTC it shows that it is likely to be over 50% within the next 2-3 years.
The NHS Choices information on long term conditions and facility to develop personalised Information Prescriptions offers an excellent new resource to help clinical staff and those with long term conditions and their families to better understand their condition and what can help them to feel better. This as an essential part of the development of the Personalised Care Plan.
The PCT optimised the use of this facility by joining it with a local Long Term Conditions Portal and are working with the NHS Choices team with a view to syndication

Long Term Condition

All Long Term Conditions

Meets National Priority Area
Admission avoidance

Benefits to Patient
The focus of the portal is to provide a single point of contact for support and information. It will unite the existing information available through NHS Choices, Map of Medicine and Information Prescriptions with local community based information on self-care support, acting as a virtual campus of service and support. It will be web based but also have with the facility to provide the information in written and other forms for those who do not access the internet

Benefits to Staff
Easily accessible information for patients

Cost Savings/Efficiencies
No data not evaluated to date

Outcomes Measured
No data not evaluated to date

Sustainability
No data not evaluated to date

Transferable
No data not evaluated to date

Project Status
Ongoing

For more information e-mail info@nisw.co.uk
 
 
 

NHS Cornwall & Isles of Scilly PCT 6

 
Synopsis

RENEW
The Director of Public Health is leading this piece of work, which is being developed in partnership with the local authority. Working with Cornwall Sports Partnership to develop a new website search tool to ensure people to find local physical activity groups in their area.

Long Term Condition

All Long Term Conditions

Meets National Priority Area
Avoidance of admission

Benefits to Patient
Empowered to improve their own health. Increased mobility. Improved fitness

Benefits to Staff
Supporting patients to stay at home and keep fit

Cost Savings/Efficiencies
No data to date. Expect this as part of the evaluation

Outcomes Measured
Formally evaluating these programmes part of the response to the DoH 'Let's Get Moving' guidance. Application made for RENEW to be evaluated through Oxford Brookes University part of the DoH sponsored research into the beneficial effects of low impact physical activity for people with LTC.

Sustainability
Established self-sustaining community groups who continue to meet and actively recruit and engage local people. One group is now doing in-reach work in local schools and colleges educating young people about the risks of smoking.

Transferable
Potentially transferable to other Trusts

Project Status
On-going

For more information e-mail info@nisw.co.uk
 
 
 

NHS Cornwall & Isles of Scilly PCT 7

 
Synopsis

Diabetic Retinopathy Screening

Self contained mobile eye screening unit. Integrated team delivering a co-ordinated programme to fast track patients. This test uses specialist ophthalmic cameras to recall images of the retina. It operates in 70 locations throughout Cornwall seeing over 23,000 patients every year and refers over 599 for treatment in 3 District General Hospitals. Integrated team delivers coordinated programmes of activity through the ophthalmology and diabetes integrated team

Long Term Condition

Diabetes

Meets National Priority Area
Fast track service

Benefits to Patient

A weekly fast track laser clinic for ophthalmology. Seen by a specialist MD team
Patients book directly from the screening into an appropriate diagnostic test prior to referral to a Consultant

Benefits to Staff
A new state of the art argon laser treating retinopathy

Cost Savings/Efficiencies
Reduced consultant appointments. Pascal Argin laser is less painful and takes 5 minutes instead of 20 minutes so reduces theatre time and costs
Reduction in referral rates for sight threatening retinopathy by nearly 100%

Outcomes Measured
Improved clinical outcomes. Improved patient uptake of service by 80%.

Sustainability
Service able to support the number of patients with diabetes. This is predicted to rise by over 50% in the next 5 years

Transferable
Very valuable approach in rural areas

Project Status
Commenced 2008. Ongoing

For more information e-mail info@nisw.co.uk
 
 
 

NHS Cornwall & Isles of Scilly PCT 8

 
Synopsis

Telecare

Through technology empowers patients, users and carers to have more responsibility and control over their own care while giving them the personal and professional support they need. Support through Case Coordinators. Supports early discharge into a safe environment at home.
Telecare is used to safeguard a person where they live, for example bed pressure sensors and wrist alarms. This is the first of a two-year trial running is Cornwall, Kent and Newham, in which 44 local GP practices are involved, with 2,200 patients recruited. The Cornwall WSD team is currently very busy visiting patients in their homes to install the equipment, supported by the patient support team.

Long Term Condition

Dementia - Risk of falling

Meets National Priority Area
Avoidance of admissions

Benefits to Patient
Carers feel better supported. Clients feel more secure and confident in their homes

Benefits to Staff
Care staff fined the equipment easy to use

Cost Savings/Efficiencies
No data to date. Being evaluated on behalf of the DoH by five universities led by the University of Manchester

Outcomes Measured
Early observations from patients and clinicians are that patients of all ages take to the equipment.

Sustainability
A Business Case is being prepared to roll-out the programme more widely following the trial.

Transferable
The national WSD conference will be hosted by Cornwall in November

Project Status
Ongoing

For more information e-mail info@nisw.co.uk
 
 
 

NHS Cornwall & Isles of Scilly PCT 9

 
Synopsis

Telehealth

The Whole System Demonstrator Programme is a DoH trial of the use of preventative technology to support people with heart disease, diabetes and COPD. Telehealth is the use of biometric readings to monitor a person's health over a period of time This is the first of a two-year trial running is Cornwall, Kent and Newham, in which 44 local GP practices are involved, with 2,200 patients recruited. The Cornwall WSD team is currently very busy visiting patients in their homes to install the equipment, supported by the telehealth nursing team and patient support team

Long Term Condition

Heart disease, diabetes and COPD

Meets National Priority Area
Avoidance of admissions

Benefits to Patient
Carers feel better supported. Clients feel more secure and confident in their homes. Visual readings seem to have a positive impact on the person's health status and self management

Benefits to Staff
Care staff find the equipment easy to use. Nurses and Community Matrons can use telehealth information to prioritise workload, identifying and acting on changes and trends in biometric results. Early to prevent exacerbations

Cost Savings/Efficiencies
No data to date. Being evaluated on behalf of the DoH by five universities led by the University of Manchester

Outcomes Measured
No data to date. Early observations from patients and clinicians are that patients of all ages really take to the equipment. Patients have a better understanding of their condition and own parameters

Sustainability
A Business Case is being prepared to roll-out the programme more widely following the trial

Transferable
The national WSD conference will be hosted by Cornwall in November

Project Status
On-going

For more information e-mail info@nisw.co.uk
 
 
 

Royal Devon & Exeter NHS Foundation Trust

 
Synopsis

DEAG : The Royal Devon and Exeter's Disability Equality Action Sub Group

Established to look at the processes for admission, discharge and effective care of patient's with a range of disabilities. Group meets monthly and is steered by user representatives who work with frontline Matrons and managers. Group ensures that any service development is directed and led by the needs of the patient rather than influenced by service provider's perceived needs. Includes a robust assessment process to identify the individual's specific requirements at the point of admission. Flagging system with visual signs to alert patient's specific requirements

Long Term Condition

All Long Term Conditions

Meets National Priority Area
Fast track service

Benefits to Patient
It has made the hospital more accessible. Increased the overall hospital experience for patients, family members and carers

Benefits to Staff

Staff spend less time on attempting to modify systems in their local area. Improved information access regarding patient specific requirements

Cost Savings/Efficiencies

No data

Outcomes Measured

Patient satisfaction through comments and positive results

Sustainability

Providing the funding continues

Transferable
To any Trust providing there is funding to sustain the work

Project Status

Ongoing

For more information e-mail info@nisw.co.uk
 
 
 

Royal Cornwall Hospitals NHS Trust

 
Synopsis

Improving the provision of cardiac rehabilitation
Cardiac rehabilitation in Cornwall provides exercise and educational programmes across Cornwall and is available to people who have had heart surgery or suffered a heart attack. The service is available in hospital, at home and as an outreach service. It is provided by a team of cardiac nurses, exercise technicians, physiotherapists and an assistant clinical psychologist. The team is supported by pharmacists, dieticians, occupational therapists, heart failure and practice nurses

Long Term Condition

Cardiac

Meets National Priority Areas
Cardiac rehab

Benefits to Patient
Choice of rehab. At home or as an outpatient at the hospital. Self management

Benefits to Staff

Working as part of an integrated acute and community team

Cost Savings/Efficiencies

No data published

Outcomes Measured

Cornwall heart attack rehabilitation management study. 12 months audit of 106 patients

Sustainability
Service meets National Service Framework Goals

Transferable

Simple methodology- well researched

Project Status

Service developed in 1999 and still running

For further information email info@nisw.co.uk
 
 
 

Royal Bournemouth & Christchurch Hospitals NHS Foundation Trust

 
Synopsis

Diabetes Type 1 Educational Programme

Type I diabetes educational programme and treatment programme which allows patients to eat and drink whatever and whenever they like. Patients attend a once a week group outpatient education session for 4 weeks. Diasnet is used to illustrate how insulin doses affect blood sugar levels

Long Term Condition
Diabetes Type I

Meets National Priority Areas
Avoidance of admissions

Benefits to Patient

Patient able to control blood sugar levels. Greater flexibility. In-depth knowledge of diet and blood sugar. Patient controls diabetes

Benefits to Staff

Patients empowered to manage their diabetes effectively

Cost Savings/Efficiencies

No data

Outcomes Measured

Dr David Cavan research study: Cavan DA, Ploughman S, Hylesen OK. Use of internet to optimize self management of Type I diabetes: preliminary experience with Daisnet. Journal Telemedicine Telecare 2003:9(SI)50-52

Sustainability

Introduced in 2000 and continues to be delivered

Transferable
Potential to be replicated by other Trusts

Project Status

Ongoing

For further information email info@nisw.co.uk
 
 
 

North Bristol NHS Trust

 
Synopsis

Hospital Outpatient Treatments (HOT) clinics
An admission avoidance clinic for adult respiratory patients. It is recognised that a large number of patients with respiratory disease are admitted to hospital, where early specialist intervention may have resulted in the patient being managed at home. A daily respiratory "hot" clinic was therefore established. GP's may refer patients who they believe to be threatening admission up to 12 midday each day and they will be seen on the same day by a respiratory consultant

Long Term Condition

Respiratory disease

Meets National Priority Areas
Admission Avoidance

Benefits to Patient

A large number of patients are reviewed by the correct specialist team in a timely manner. A larger number of patients managed in their own homes, with the assistance of resp. specialist nurses

Benefits to Staff

Has allowed senior medical staff to focus their attention on some of the most acutely unwell respiratory patients and to use available resources to maximum efficiency to prevent un-necessary admissions to hard pressed medical beds

Cost Savings/Efficiencies
Completed a three year audit of activity. During the period 2007-2009, 1,381 patients were seen in the hot clinic. Case notes of a random sample of 750 were reviewed. Mean age was 63 years. 28% of patients were seen on the day of referral and 50% the following day. Most frequent diagnosis was COPD exacerbation (26%), asthma (9%), pleural effusion (8%) and pneumonia (7%). 17% of patients were admitted directly and a further 2% within one week of being seen and a further 5% within one month. 76% of patients were managed wholly within the com-munity. Respiratory specialists judged the referral as appropriate in 92% of cases. This provides a cost saving to the primary care trust. Patients admitted for less than 48 hours attract a tariff of £846 and those admitted over 48 hours generally attract a tariff of approx. £2,200. The tariff for a hot clinic attendance is £346. The service is consistently rated highly by patients

Outcomes Measured

If patients attending the hot clinic were appropriate at the rate indicated by the consultants in the clinic, then the total number of admissions avoided over three years equate to a total saving of over £600,000 to the local healthcare economy. This saving was achieved whilst providing a high standard of care which was highly rated by service users and which provided high quality care closer to the patient's home.

Sustainability

To ensure availability of consultant cover job plans were rewritten to ring fence 0.5 PAs daily to ensure medical staff had available time to provide adequate cover for the hot clinic. It would not be possible to conduct a clinic such as this on an ad hoc basis, due to the variable level of demand

Transferable

If patients attending the hot clinic were appropriate at the rate indicated by the consultants in the clinic, then the total number of admissions avoided over three years equate to a total saving of over £600,000 to the local healthcare economy. This saving was achieved whilst providing a high standard of care which was highly rated by service users and which provided high quality care closer to the patient's home

Project Status
Ongoing

For further information email info@nisw.co.uk
 
 
 

Great Western Hospitals NHS Foundation Trust 1

 
Synopsis

Shared primary and secondary care electronic patient record for End of Life Care in the first instance

A cross-cutting project that will have an impact on the management of several long-term conditions, use of Hospital and Community services, and also with transition from long-term condition to End of Life Care. The project addresses the issue of how best to manage long-term conditions with the provision of a clinical record that can be accessed by primary and secondary care leading to good communication with up-to-date clinical information and guidance on best practice

Long Term Condition
All LTC End of Life Care

Meets National Priority Areas

Reduction in emergency admissions

Benefits to Patient

Evidence-based audit of best practice, as well as enabling patient involvement

Benefits to Staff

Facilitates better Clinician/Patient relationship, and partnership for health care provision

Cost Savings/Efficiencies

Measure-able impacts are being derived to enable this to be assessed for each condition

Outcomes Measured
None to date but plan to evaluate

Sustainability

The project is to be developed with Clinicians to enable decision support as well as a shared record with agreed access for staff and a web page for patients, plus a reporting function

Transferable

Yes, once model process and design is structured

Project status
Ongoing

For more information e-mail info@nisw.co.uk
 
 
 

Great Western Hospitals NHS Foundation Trust 2

 
Synopsis

Think Glucose
NHSI Pathway for patients with diabetes is being implemented at the Trust

Long Term Condition

Diabetes

Meets National Priority Areas

Avoidance of Admissions

Benefits to Patient

Improves information and reduces incidents

Benefits to Staff

Clear clinical Pathway to follow

Cost Savings/Efficiencies

None identified. Redesign of service with no additional cost

Outcomes Measured

None to date but plan to evaluate

Sustainability

Evidence from the Institute

Transferable

There is an NHSI toolkit available

Project status

Project in early stages

For more information e-mail info@nisw.co.uk
 
 
 

Gloucestershire Hospitals NHS Foundation Trust 1

 
Synopsis

Exercise DVD

Long Term Condition
Cardiac event

Meets National Priority Areas
Cardiac rehab.

Benefits to Patient
Helps patients maintain exercise routine

Benefits to Staff

Supports the rehab. Programme and helps improve survival and morbidity rates

Cost Savings/Efficiencies
None identified to date.

Outcomes Measured
Patient questionnaire to be collated 2010.

Sustainability

Required no additional finance used existing resources to set up the service

Transferable

DVD available in the UK and abroad

Project Status
Launched January 2010
Project in progress

For further information email info@nisw.co.uk
 
 
 

Gloucestershire Hospitals NHS Foundation Trust 2

 
Synopsis

Fast Track Service for Multiple Sclerosis patients

A locally responsive service for people with multiple sclerosis (MS). Accelerated access to care for people with Multiple Sclerosis, through the development of a specialist practitioner role - a Neurological Nurse Consultant

Long Term Condition
Multiple Sclerosis

Meets National Priority Areas

Fast track service
Admission avoidance

Benefits to Patient

Fast track access to nurse led LP and IV methyl-prednisolone service

Benefits to Staff
Nurse Consultant delivering a skilled service. Nurse led telephone help line

Cost Savings/Efficiencies

Modest savings. No data collected

Outcomes Measured

Audit of first 6 months of the service in 2007

Sustainability

Award winning service in 2004 and 2005

Transferable

Transferable with the appointment of a Nurse Consultant

Project Status

Service fully established

For more information e-mail info@nisw.co.uk
 
 
 

Gloucestershire Hospitals NHS Foundation Trust 3

 
Synopsis

UTOPIA
The purpose of UTOPIA is to deliver a step-change in the quality, safety and efficiency of the Trust's Unscheduled Care Pathway, including those with long-term conditions
The key elements of UTOPIA are;
  • 7-day extended hours on-site Consultant presence in ED and Acute Care
  • 7-day on- site Consultant Radiologists
  • 7-day Pharmacy presence in Unscheduled Care
  • Single point of access - all unscheduled care patients to access the Trust via ED
  • Expanded Acute Care Units to manage acutely ill medical and surgical patients
  • Unscheduled Care Referral Centre (UCRC) to ensure GP referral patients are directed to the right place, first time - ED, direct to ward, outpatient clinic, community hospital
  • 24/7 Acute Care Response Team - to improve the identification and management of deteriorating patients on wards. Shared care (GOAM & Trauma) fracture NOF pathway

Long Term Condition
All LTC

Meets National Priority Areas
Demonstrates efficiencies

Benefits to Patient
Still in phase one but outline plans indicate benefits to patients including rapid access to specialist care 7 days a week

Benefits to Staff

Part of a team that responds rapidly to unscheduled care

Cost Savings/Efficiencies

Still in phase one but planned

Outcomes Measured

Still in phase one but outcomes set

Sustainability
Still in phase one

Transferable
Still in phase one

Project Status

Still in phase one but potentially and excellent model

For more information e-mail info@nisw.co.uk

Download GH NHSFT Case Study 3 Pdf

Devon Partnership NHS Care Trust 

 
Synopsis

Tea and Talk
A proactive preventative approach that focuses on promoting mental well being through a workshop programmes. Increase self awareness and awareness of others, improves understanding of how to reduce or prevent problems by altering behaviour

Long Term Condition
Mental Health

Meets National Priority Areas
Avoidance of admissions

Benefits to Patient

Preventative approach that focuses on promoting mental well being

Benefits to Staff
Able to support clients in the community and be proactive in their care to prevent avoidable admissions

Cost Savings/Efficiencies
No data

Outcomes Measured

None to date

Sustainability
The service continues to be well used by the clients

Transferable
There are other similar services across the South West Region

Project Status

Current service provision

For more information e-mail info@nisw.co.uk