Patient-Initiated Follow-Ups
Geared up to mobilise NHS organisations for Phase 3 of the COVID19 Recovery Plan from NHS England.
Patients Know Best (PKB) is a patient-facing digital platform, used since 2008 to support clinical teams manage care delivery and empower patients to take control of their health. PKB is also proven model for Patient-Initiated Follow-Up (PIFU) as referenced (pp 11-14) in NHS England’s latest guidance. This model supports Phase 3 of the COVID19 Recovery Plan by helping to create capacity and change the delivery of NHS services to prepare for winter pressures, and a potential second wave while reducing the inequalities in service provision forced by the pandemic.
Mobilise Patients & Services
The PKB digital platform facilitates data exchange through a secure personal health record. This record can be accessed by patients and professionals anywhere, and at anytime. It is also the only platform that can combine patient-generated data and display this alongside provider data (i.e. from hospitals, EPRs or PAS) in real-time. To support a variety of clinical workflows and empower patients to self-manage their health, NHS providers determine the datasets to be securely shared. This has been proven to create capacity and improve outcomes. The platform can be used to:
- Mobilise patients to monitor symptoms (with guidance) to understand when it’s appropriate to initiate appointments and travel/ not travel for appointments.
- Combine data to create tailored care plans for each speciality or pathway, personal to each patient for self-management.
- Communicate remotely with messaging and exchange information of medical importance to be securely viewed, stored and archived along with the contextual narrative.
Tools for managing Patient-Initiated Follow-Ups
- Administrative and clinical data from networks of NHS provider organisations.
- Patient-generated data collected manually and via apps, wearables and devices.
- Dynamic patient care plans, combining all data with RAG status, clear actions and additional resources i.e. videos, PDFs or external sources and links.
- Patient and professional team-based messaging to flag changes in symptoms and quickly offer additional preventative support for remote consultation and assessment, with the ability to exchange images, videos and files.
- Clinical workflow tools allowing services to assign actions to individual staff members i.e. remote consultation or scheduling of appointments.
How to manage elective care
For patients that have been waiting for elective care, NHS organisations can:
- Share or request information for pre-appointment assessments using questionnaires.
- Support aftercare by providing shared care plans and guidance information with patients and wider multidisciplinary teams i.e. discharge notes, symptom tracker, journal and signposting to further help and support.
- Assess the need for follow-up care using messaging to exchange videos, documents or images in real-time. These messages can be assigned, actioned and archived to manage communication.
- Monitor patients remotely using wearable devices (i.e. glucometers, defibrillators or vital signs monitors), giving clinical teams the ability to intervene before problems escalate.
Organisations successfully using PIFU models
Inflammatory Bowel Disease Service
Bedfordshire Hospitals NHS FT (formerly Luton and Dunstable)
Bedfordshire Hospitals NHS FT (formerly Luton and Dunstable)
Features used:
- Care plans with RAG rated symptom tracking to monitor conditions.
- Messaging with the team to initiate professional support and review.
- Messaging with patients to share information of medical importance to be securely viewed, stored and archived along with the contextual narrative.
Outcomes:
- ⅓ of patients moved to a PKB remote pathway where patients initiate the follow-up.
- Released 1,100 appointment slots from a patient group of ~600.
- Empowered patients with self-management, remote monitoring capabilities and virtual consultations.
“Not only does it save patients having to come into hospital but also allows us to see when patients flare up, so we can see them within 48 hours rather than generate clinic appointments.”
Inflammatory Bowel Disease Service
Surrey and Sussex Healthcare NHS Trust
Surrey and Sussex Healthcare NHS Trust
Features used:
- Care plans to more effectively manage aftercare and health needs.
- Messaging to keep communication lines open with patients.
- Symptom tracking to enable faster, more preventative care.
- Access to test results empowering patients to make changes when needed.
Outcomes:
- Increased outpatient capacity for patients that need face-to-face intervention.
- Offered oversight of patients who were able to self-manage and self-monitor their condition.
- Improvements in patient care by optimising medications – the local AHSN forecast this as a health economy saving of £4 million from this single cohort.
- Published by the Secretary of State for Health and Care, Matt Hancock, in ‘The Future of Healthcare’, 2018.
Dermatology Service
Swansea Bay University Health Board
Swansea Bay University Health Board
Features used:
- Sharing test results with patients for more effective monitoring of skin conditions.
- Appointments and collection of medications at a time and place to patients.
- Messaging to follow up with patients about medication reviews remotely rather than offer face-to-face appointments every 12 weeks.
Outcomes:
- Patients that were previously seen on average 4 times a year, now have 1 annual appointment.
- Eliminated unnecessary outpatient appointments and reduced the ‘follow up not booked’ list of patients to zero (*reported pre-COVID19).
- Patients empowered to manage their medication needs, review remotely and message their health team with questions only when needed.
- Patients are empowered and educated on their condition and able to understand the importance of blood monitoring for their chronic skin disease.
Urology Service
Swansea Bay University Health Board
Swansea Bay University Health Board
Features used:
- Sharing test results to initiate a virtual clinical review and patient self-management of PSA results.
- Messaging to share outcomes of the review remotely.
Outcomes:
- Moved from PSA blood test reviews every 3, 6 or 12 months with outcomes shared with patients in 4-6 weeks, to results automatically shared in the PKB record within 7 days.
- Saving significant administrative time with data collected ahead of virtual appointments.
“..after being in hospital having treatment for cancer and then being discharged, there was the anxiety of being at home with no contact. With this system you can easily contact people and if you have any queries you just ask.”
HIV Service
University Hospitals Plymouth NHS Trust
University Hospitals Plymouth NHS Trust
Features used:
- Sharing test results with patients for more effective monitoring of conditions.
- Secure messaging with patients and professionals, facilitating the secure sharing of images.
Outcomes:
- Improved monitoring of health conditions.
- Preventative measures can be taken by clinical teams before symptoms escalate.
- Empowering patients to take control and self-manage their condition with remote support.
The hospital has been using PKB for many years starting with the HIV Service. The trust has expanded on the success of this team for other services to help manage workflow during COVID19.
Sexual Health Service
University Hospitals Plymouth NHS Trust
University Hospitals Plymouth NHS Trust
Features used:
- Sharing test results with patients for more effective monitoring of conditions.
- Secure messaging with patients and professionals sharing images with confidence.
- Questionnaires for collecting data remotely to support effective triage.
Outcomes:
- Over 900 new patients treated remotely between April and August 2020 – this number continues to rise by approx. 40 – 50 patients a week.
- Preventative measures can be taken before symptoms escalate.
- Patients can communicate remotely and report issues which may have otherwise been unreported in person – approx. 150 messages exchanged per week.
- 60% of patients in the SHiP satisfaction survey stated that they are happy to share images securely with their clinical team using the PKB digital platform.
- 99% of patients (including those using PKB) that had a telephone consultation, reported being satisfied with the consultation.
With walk-in clinics not operating during COVID19, the team adapted the workflow to enable patients to be safely diagnosed and to open communication lines with clinicians.
HIV Service
Manchester University NHS Foundation Trust, formerly The Pennine Acute Hospitals NHS Trust
Manchester University NHS Foundation Trust, formerly The Pennine Acute Hospitals NHS Trust
Features used:
- Secure messaging with patients and professionals sharing images with confidence.
Outcomes:
- Appointments moved from every 6 months, to once a year (50% reduction) with patients still able initiate appointments in between if needed.
- Preventative measures can be taken by clinical teams before symptoms escalate.
- Patients empowered to take control and self-manage their condition with remote support available as and when needed.
“Why should we force someone to take time off work and come in when it’s 99.9% certain they’ll be fine. And if they’re not fine, then why wait for the six-month check-up – come and see me now.”
