Digital first approach enables self-management and reduces admissions amongst older heart failure patients
"The use of digital technology when caring for our heart failure patients has proven essential when developing remote monitoring pathways and revolutionised the way we care for this complex cohort of patients including the vulnerable and the elderly.”
Angela Murphy, Heart Failure Nurse Manager at Chelsea and Westminster NHS Foundation Trust
Introduction
The Problem
Heart failure is a common chronic condition which places a significant burden on NHS resources, utilising an estimated 2% of all inpatient bed days according to a 2018 study by the National Institute for Clinical Excellence (NICE). Patients diagnosed with heart failure often attend multiple appointments with deterioration frequently leading to unplanned appointments / admissions.
The HF team at Chelsea & Westminster (C&W) wanted to test the theory that a previously underserved community of heart failure patients could benefit from using digital resources incorporated into their care, supporting two pilot projects:
HFpEF@Home: Heart Failure with Preserved Ejection Fraction presents in an often elderly, frail group of patients which have significant unmet care needs. Monitoring changes in their symptoms and physiological parameters can enable earlier intervention, providing them with timely guidance to self-manage at home. C&W wanted to use PKB to support and monitor patients post diagnosis or discharge from hospital.
Admission Avoidance project/rapid uptitration of guideline directed therapy: Heart Failure with Reduced Ejection Fraction (HFrEF) affects millions of patients worldwide, with around 8,000 in North West London alone. Traditional approaches to Guideline-Directed Medical therapy (GDMT) optimisation in patients with HFrEF often leads to delayed initiation and titration and early discontinuation of therapy. Research has shown effective medical optimisation improves survival, quality of life, reduces the risk of hospitalisations, and heart failure re-admission rates. As part of a multidisciplinary team, C&W aimed to implement an admission avoidance/Early Supported Discharge (ESD) virtual pharmacist-led clinic to initiate and rapidly uptitrate GDMT following a diagnosis of HFrEF to improve just-in time decision support.
The Solution
Since 2019 C&W Heart Failure teams have pioneered the use of PKB (PKB is known as Care Information Exchange in North West London) to support heart patients post discharge and diagnosis with education and self-management techniques. Patients learn to self-monitor and record blood pressure, heart rate and weight measurements alongside their symptoms. Through using PKB’s tools, such as care plans, they build the understanding to recognise changes and identify when to seek assistance. Functionality usage has deepened over the four years, most recently focusing on serving the HFpEF and HFrEF patient cohorts.
Clinical usage
Heart Failure Care Plan
Care plans have evolved from reviews, and are now not only informative about the patient’s condition but with videos embedded to show how to take measurements and manage their health at home. A traffic light instruction was introduced so every patient knows the course of action if their symptoms become abnormal.
Patient education
The library functionality now includes videos made by the team to support those with lesser technical ability to navigate their care plan from the comfort of their own home. Alongside this the team developed a plan with local authority partners to connect with patients who struggle with digital. This includes the creation of an educational video made available in the resource library on PKB’s platform and ‘how to’ films on the Trust’s website to support the remote monitoring and Virtual Ward programmes, using digital champions and volunteers to support patient training. This initiative has been enabled by funds secured from the healthcare charity, The Burdett Nursing Trust.
Outcomes/Impact
Patients have embraced CIE/PKB with almost 60% of registered heart failure patients being over 65. Care plan usage has increased with around eight plans created a week. Patient entered symptoms and measurements have grown by 200% in the last year. Secure messaging is replacing calls to the office, with usage across the Trust up 7% since launching the pilot projects. As well as being convenient for patients and clinicians, this ensures everything is structured properly and recorded in one place:
- Rapid optimisation of appropriate evidence medications. The StrongHFstudy identified new guidelines with proven better prognostic outcomes. Using PKB’s digital tools has meant that the Heart Failure service has been one of the few international heart failure services that has been able to translate this research into clinical practice.
- Reduction in readmissions. C&W has recorded 48% lower readmission rates on the HF virtual ward using digital tools compared to inpatient admissions for the same diagnosis. Alongside, there has been an overall reduction in face-to-face clinic reviews required, with associated impact reduction on travel costs and time for patients as well as the environment.
- Safe implementation of Virtual Wards. A core Trust wide initiative, PKB is used by patients to input vital data, communicate with teams as well as follow care plans. In research when asked if patients felt that being on a virtual ward was better than being in hospital, 84% of respondents indicated yes and 93% said they felt very safe.
- Bed and financial efficiencies. To date the trust has recruited 295 patients to the Heart Failure Virtual Ward indicating a saving of 600 beds and an estimated saving of £75,000 over a one year period. With the Trust’s investment in resources, education and use of digital tools, it is close to recruiting 60 patients a month demonstrating substantial potential future efficiencies while improving the patient experience.
- Patient access to specialist teams and support. The use of care plans with symptom guidance together with digital messaging functions has supported timely patient access to specialist clinicians.
Remote monitoring of our HFpEF and our Admission Avoidance patients has resulted in a notable fall in patient calls into the offices, and patients have commented on how well supported they feel by the team.
Patients have particularly appreciated evidence-based medications via messaging with comments including: ‘A great service, I’m fine now and I’m planning to go on holiday next year and; ‘Very pleased with the service and to everyone who made me well'
Learnings and developments
The project has been presented at healthcare conferences and local and regional events. A poster was designed to explain and visualise the shared learnings of the project and how it supports the broader Virtual Ward initiative (example in supporting evidence) and will be presented at the Royal Pharmaceutical Society.
The remote monitoring tools and functionality of CIE, provided by PKB, are being used broadly across the wider London region, and indeed across the country where PKB contracts now cover around 30% of the UK population. As of today, across the CIE Network 589,662 patients have a PKB record.
Dr Sadia Khan, Clinical Lead, Cardiology at Chelsea and Westminster Hospital explains
‘My specialist nursing colleagues have really pioneered the use of digital tools in a health condition where many thought digital was not an option. We can already see an improvement in experience for staff and patients and better care delivery. We can see that further developing these resources and pathways will enable greater access to specialist care at the times when people really need it’
