Mainstreaming telehealth and telecare: similarities, differences and lessons from the WSD trial
This article is based on a presentation made at the WSDAN event, Birmingham, 12 March 2009.
The telehealth and telecare implementation process has a recruitment target of up to 6,000 people (making up both the intervention and control groups) in the three WSD pilot sites. GP practices are at the heart of the trial, and more than 200 practices are now actively involved. Sign-up has moved on more quickly through working with practice-based commissioning (PBC) clusters.
It has been inevitable that a number of challenging issues have arisen in the process, for example, linked to organisational readiness, data sharing, project management and system design.
Of course, some of these challenges arise specifically from the requirements of a randomised control trial. For instance, in the trial the process from first early discussions with a new GP practice through to installations of equipment in homes has taken an average of 80 days. In a mainstream service, telecare could be installed before a patient arrives home from hospital.
The importance of stakeholder sign-up
For a mainstream service, a ‘unit’ of activity where the technology is being focused might vary (eg, by geographical area, locality, GP practice or PBC cluster), but an important message from the trial is the need for sign-up from all stakeholders (practitioners, clinicians, managers) in the area to be covered.
Personalised care planning - explaining technological capability
It is important that people are visited, have their individual needs assessed and are given an explanation of what the technology is capable of. Information on the services to be provided can, together with the care plan, be shared with the necessary agencies before the technology is installed; this enables appropriate training and calibration. It should be stressed that every installation should be personalised – whether that be through the range of telecare sensors fitted, the type of response triggered, or type of vital signs that need to be measured and the frequency with which readings need to be made.
The importance of achieving ‘organisational readiness’ should not be underestimated. In the WSD pilots, for example, it has taken time to set up the arrangements for shared funding across local health and social care organisations as well as to amend agreements as new service areas have been brought into the programme. It is clear from this process that all involved need to be aware of their roles, responsibilities and contributions – especially in a changing organisational landscape (eg, staff turnover). Articulation of service aims, programme objectives, recruitment targets, communications, and workforce involvement needs to be constantly reviewed to ensure that governance and operational arrangements remain effective and fit for purpose. Within the trial, we have produced a wide range of briefing and training material that may help to ensure consistent messaging for mainstream service provision.
The trial has been governed by ethical requirements and we have been unable to promote the trial more widely as the number of eligible people who might benefit is tightly controlled. We have not wanted to set up public expectations that cannot be met. or to say that the interventions will definitely provide benefit, as that is for the trial to determine. In a mainstream service, however, it is possible to promote the technology actively to people who could benefit, and recruitment should be easier – as long as there is an established business case with identifiable benefits.
For some parts of the trial, it has been necessary to bring in additional resources – for example, to support practices in identifying and writing to potential joiners and in gathering and cross-checking data from different sources. Data searching and checking has been a resource-intensive element of the trial. This has included going to practices, looking at records, then matching them with the community records, hospital data, emergency and urgent care data, and with social care records using NHS numbers as the common key. For local mainstream services, these additional costs may not be necessary.
Eligibility and recruitment
Defining the criteria by which people can be enrolled onto a mainstream service needs to be specific, for example, by going beyond providing equipment to people over a certain age. Individual sign-up can focus on people who provide initially positive responses to using the technologies. In many cases it will be possible to introduce an ‘opt-out’ clause for participants while the ethics of the trial only allow for an ‘opt-in’ model.
For the trial, we have gained a better understanding of why people may not want to be supported by technology (for example: ‘too ill’, ‘do not wish to be reminded of current condition’, ‘unable to follow a daily routine of data collection’, ‘family objections’). We have also been recording the drop-out rates in each site to see if there are patterns in certain demographic groups. This information will be important for wider roll-out.
The trial’s tightly defined eligibility criteria does reduce the potential pool size of service users. For long-term conditions, the eligibility query checks whether someone has COPD, CHF or diabetes of a certain severity. There is a subsequent requirement that they have made some use of unplanned care over the last year. This second aspect reduces the numbers of eligible people to approximately one-fifth of the people with the condition.
In addition, as previously reported, sites have been surprised that very few people meet our telecare and telehealth eligibility criteria.
To build up the potential recruitment pool and to handle delays in entering new referrals onto systems, the WSD sites are supplementing the data searches of GP systems by actively engaging with specialist services such as falls and memory clinics to look at the data they hold. Sites are also retrospectively using the combined predictive model to compare risk scores with outcomes. This should provide information on whether there is a correlation between high risk and benefit and hence enable better targeting in future.
A learning point for all organisations looking to provide services at scale is the extent to which potential beneficiaries with long-term conditions are very active, mobile and at work. This means that services such as informative consent visits, technical support, assessments and installation have to be provided out of hours.
As the numbers in the trial increase over time, so do the number of follow-up interviews; there are 3-month and 12-month interviews with people on the trial. We also have to allow for people refusing the follow-up interviews and hence reducing our sample size. With a mainstream service, it will be important to carry out intermittent reviews to ensure that people are benefiting and their needs are being met.
Many elements of the trial are common to mainstream service arrangements so the learning from the trial will be relevant to a wider group of organisations using these technologies. WSDAN has shared much of the documentation and supporting materials from the three demonstrators with its 12 member sites. Over time, WSDAN will produce reports and guidance that will help support mainstream activities.
Tim Ellis is WSD Programme Manager, Department of Health