15th November 2016
Patients with heart conditions in Buckinghamshire are being put on an innovative new care programme which integrates services across primary, secondary and community settings and directly engages the patients in their wellbeing, care and rehabilitation.
The care programme is led by Janssen Healthcare Innovation, part of the Johnson&Johnson group, in collaboration with Buckinghamshire Healthcare NHS Trust, Chiltern and Aylesbury Vale CCGs and Graphnet.
Called Care4Today®, it combines a cross-community shared care record, mobile clinical workstations, a patient portal and telehealth devices for remote monitoring. The solution is based on Graphnet’s CareCentric shared record software and the myCareCentric patient portal.
The aim of the project is to improve the treatment of patients with heart failure by making better use of existing clinical data and by monitoring patients in their own homes. Anticipated benefits to the NHS include reduced acute admissions, readmissions and length of stay.
“This is a radical and exciting project which is using information-sharing and innovative IT as the base platform for transforming services for people living with long term conditions”, said Brian Waters, chief executive of Graphnet. “It combines patient engagement with different ways of working among GPs and community nurses, and in a way which will ultimately help patients better look after themselves.”
Dr Piers Clifford, consultant cardiologist and clinical lead for cardiology at Buckinghamshire NHS Trust, commented: “Devising new models of care are crucial to a changed NHS and this is an important initiative for us.”
Heart failure is the most common reason for hospital admission in the UK, and accounts for around 2% of NHS spending, with most of that cost spent on treatment in secondary care. High readmission rates are in part attributed to preventable factors such as lack of patient knowledge about the condition, poor compliance with treatment, failure to recognise early symptoms of deterioration and seek advice and poor social support.
Around 20 participating GP practices in the Aylesbury Vale and Chiltern CCGs are currently signing up to 175 patients onto the research programme. The programme will measure a series of clinical, service, staff and patient outcomes over the course of the next 12 months against a control group of another 175 patients following existing care pathways.
Each patient will use connected devices to monitor blood pressure, heart rate and answer symptomatic questions on a daily basis. Professionals will be able to monitor results from mobile devices and as single sign on from GP systems and intervene promptly at signs of deterioration.
The myCareCentric patient portal will also allow individuals to track their progress against personal targets, share goals and success with family and friends and learn more about their condition. Active engagement in rehabilitation programmes is a key factor in heart failure recovery.
Prompts can be set up to remind patients, carers and GPs of key events such as medication reviews and appointments. Clinicians can also set up alerts, such as for unscheduled admissions.
“Janssen Healthcare Innovation is really interested in exploring how digital health can be used to improve patient outcomes”, said Jack Turner, health solution lead at the company. “Working with Graphnet has allowed us to develop a digital health solution that has the potential to not only improve patient outcomes, but also support integrated working across the care pathway.”
The Buckinghamshire project is part of Graphnet’s commitment to build on the potential of shared record solutions to deliver the ambition of the NHS Five Year Forward View and the transformation of services.
In September, Poole Hospital NHS Foundation Trust announced it was using myCareCentric Epilepsy - a solution which combines the latest in wearable technologies, shared care records, machine learning and data analysis tools – to improve the quality of life and care for people living with epilepsy.