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Thousands of patients enrolled on to Frimley Health & Care remote monitoring service, reducing hospital admissions by up to 40%

26 September 2023

The Frimley Health and Care Integrated Care System (ICS), which covers East Berkshire, Surrey Heath, Farnham and North East Hampshire, has rolled out a successful proactive approach to remote monitoring service using population health analytics to 4,000 complex need primary care patients (those with high-risk conditions such as diabetes, heart failure, and chronic obstructive pulmonary disease), and 800 care home residents.

As a result, local communities are seeing positive outcomes. Early evaluation signals indicate the initiative is:

  • Reducing hospital admissions by 40% for high need patients and 34% for care home residents.
  • Reducing A&E attendance by 31% for high need patients and 40% for care home residents.
  • Reducing GP contacts by 19% for high need patients and 20% for Care Homes
  • Reducing volume of medications prescribed by 11% for both high need patients and care home residents.

Patients are identified using Graphnet Health’s population health solution, CareCentric, which uses data-driven insights to help health and care providers identify those in most need of support. The impact of the project is also tracked using this tool. Patients are provided with remote monitoring technology by Docobo, including the DOC@HOME app, which can be accessed via tablets and phones. This enables patients to communicate with clinicians quickly and easily from the comfort of their own homes and submit health readings and other information that is relevant to their care.

The DOC@HOME remote monitoring solution also integrates with Frimley’s shared care record, powered by Graphnet, enabling health and care professionals to access patient information from acute trusts, primary and community providers, clinical monitoring hubs and out of hour GP services. This visibility allows providers to work far more efficiently, ensuring that patients receive appropriate care when they need it.

Anna Fishta, Associated Director Shared Care Records and Remote Monitoring at Frimley ICS, says:

“Results like these, such as the reduction in hospital admissions and A&E visits, are encouraging, and why we are all so passionate about the project. Remote monitoring is part of our overarching commitment to working differently, more effectively and efficiently. Patients are automatically identified and contacted for the remote monitoring service when needed, using our population health solution, which is faster than the traditional referral process. Because of that, care teams are able to help their patients at the earliest possible opportunity.

“Data from remote monitoring is also flowing into our shared care record, so if a patient does present in an urgent care situation, the staff know all of the key details and can provide better, faster care.”

“Feedback has been positive so far, with patients feeling more in control of their own health and better supported. Just the other week, a young stroke patient who was proactively onboarded onto remote monitoring was able to record that they’d had a fall and were experiencing dizziness. Within an hour, they’d received a response from our digital health team who were able to get their medications changed. On the clinical side, we’ve had doctors telling us that the approach is preventing their high-risk patients from falling into crisis. Those testimonials are what it is all about. The technology is a means to an end, it’s the people and helping them live better quality, more independent lives that is at the heart of what we’re doing.”

The two phases of the remote monitoring project were launched in March 2022 (for care homes) and December 2022 for patients with complex needs) by Frimley ICS, which is a partnership of NHS, health services, local authorities, and other organisations dedicated to improving health and care outcomes for local people. It is part of Connected Care, which is Frimley’s digital transformation program.

So far, 45 GP practices and 23 care homes have signed up for the remote monitoring project. The aim is to continue rolling out the approach amongst the remainder of the Frimley ICS region over the coming six months. Since the remote monitoring programme was launched, more than 5000 patients in total have been onboarded.

For more information on Connected Care, visit