Technology Enabled Care in Care Homes

ICIC16, Barcelona May 2016

Dr Jenny Hall
Rural Health and Wellbeing
University of the Highlands and Islands
Inverness, Scotland

Technology Enabled Care in Care Homes

The Team
Dr Fiona McGibbon, Consultant Older Adult Psychiatry, NHS Highland
Cathy Dorrian, Service Development Manager, Scottish Centre for Telehealth
and Telecare (SCTT)

Richard OKeeffe, Lead nurse for Dementia, NHS Highland

Wilma Allan, Manager, Abbeyfield House
Dr Sara Bradley, Research Fellow, Rural Health and Wellbeing, UHI
Dr Jenny Hall, Research Fellow, Rural Health and Wellbeing, UHI
Steve Westbrook, Economic Intelligence Unit, UHI

Technology Enabled Care in Care Homes

Context
NHS Highland
over 32,500 km2
population of 320,000
Two partnerships:
Highland Health & Social Care Service (2012)
Argyll & Bute Health and Social Care
Partnership (2016)

59 Care home for older adults

NHS Highland (17)
Private organisations
Voluntary sector

Technology Enabled Care in Care Homes

Background
SCTT began discussion
on use of technology
enabled care with the
mental health team at
NHS Highland (2010)
Particularly looking at
video consultation units
for remote and rural area
to link up with specialised
services

Mental health team

review of outreach
services, including care
homes
6 monthly consultant
visits, with little additional
direct support being
provided
Challenge of geography
and resourcing up to 5
hours round trip

Technology Enabled Care in Care Homes

Context

New Craigs

Mackintosh Centre

Invernevis House

Clava Ward

Abbeyfield House

Technology Enabled Care in Care Homes

Implementation Timeline
Abbeyfield
House
June 2011

Mackintosh Centre

Invernevis House

February 2012

February 2012

N3 network connections
installed
Network points installed

N/A

May 2013

June 2013

August 2011

June2013

June 2013

Nurse at Clava Ward

secured
Site visit by clinical team

August 2011

August 2011

August 2011

September 2011

November 2013

November 2013

System installed and

tested
Service Protocol
Finalised
Staff training & walk
through
First live clinics

October 2011

July 2013

July 2013

November 2011

November 2011

November 2011

November 2011

November 2013

November 2013

December 2011

November 2013

June 2014

Initial discussions with

care home managers

Technology Enabled Care in Care Homes

Technology
ITEM
Video Conference Unit
Software
Screen

DESCRIPTION
TANDBERG Edge 95 HD Base
Natural Presenter Package (NPP)
26 LCD screen (LE26C450E1WXXU 26 LCD TV)

Remote camera control

Pan-tilt-zoom
functionality

Units are on wheeled

carts, which can easily
be moved about the care
home and used in any
room with appropriate
data ports

The nurse leading the

clinic has full control over
the distant sites camera.

Technology Enabled Care in Care Homes

Service Description

Clinic frequency and timing

(one clinic per month just
with staff)
Face-to-face visits by clinical
team

Abbeyfield
House
Twice weekly,
Afternoon

Mackintosh
Centre
Weekly, Afternoon

Invernevis
House
Weekly,
Afternoon

Biannual

Biannual

Biannual

Overseen by consultant
Clinical guidelines used included
Abbey pain scale, BPSD guidelines, Prescribing Update for Old
Age Psychiatrists

Technology Enabled Care in Care Homes

Aims of the new service model

Improve access to psychiatric care services

Reduce unnecessary hospital admissions
Reduce antipsychotic use for people with dementia
Improve the management of behavioural and psychiatric
symptoms of dementia
Improve the management of functional psychiatric illness

Technology Enabled Care in Care Homes

Referral for VC clinics

Reason for referral

Referral route

Most due to stress and

distress in dementia
Depression
Behavioural disturbances
secondary to another
condition
Routine review
Assessment following a
suicide attempt.

Most already on case

load
Care home staff
GP
General adult psychiatric
community mental health
team

Technology Enabled Care in Care Homes

Evaluation Realist approach steps

Realist approach to evaluation

Technology Enabled Care in Care Homes

Evaluation Stakeholder Groups

The steering group and service provider:

NHS Highland (New Craigs Hospital)
Dr Fiona McGibbon, Consultant Older Adult Psychiatry
Richard OKeefe, Lead Psychiatric Nurse

Scottish Centre for Telehealth and Telecare - Cathy Dorrian

Care home managers and staff

Care home residents/family members
Occasional care home users (day care and lunch clubs)
Other users
GPs, social workers, hospital consultants, pharmacists, community
nurses

VC psychiatric clinics in care homes

HYPOTHESIS OF CHANGE

Abbeyfield
Ballachulish
Nov 2011

Rural
context

Mackintosh
July
Mallaig
2014
2013

Residents/patients

Care Home Staff

( +lunch club/day-care)

More involvement
in clinics possible

Expertise
and
experience
of lead
nurse

Because
clinic is in
the care
home

Staff training and

confidence

Staff feel
empowered
and valued

Staff morale?
Staff retention?

Staff
travel

Staff
consultations

Eg
Check
lists

Staff more likely to

take action

Increased access to
the service

Nurse led from New Craigs

Invernevis
Fort William
June 2014

Buy in

GP input

Care home
organisations
/managers

Integrated Service
Care home/secondary
care

More
frequent

Because
Disruption to routine i
its in
Travel i
the care
Accompanied by known staff home
Distress/stress i

Prescriptions i
Admissions i
Care plan reviews h

Attitudes

Steering Group

Makes
consultations more
readily available

Lead nurse
importance

More
frequent
review

Staff Knowledge exchange

VCs Emergency responses i
Prescription review h
Care/management plan
review h
More
frequent
review

Better QoL outcomes

No travel
for HCPs

Broadens lead nurse

experience
Patient numbers
Use of VC

Ability to train others

to deliver VC clinics

Demand
Retain
Expertise
Experience

Economic Impact?

Care
homes

Wider
community
use

Resources
Time to train?
Staff to train?

Technology Enabled Care in Care Homes

Evaluation Interviews
Staff

Residents

Relatives

3 care home managers

2 care home 6
8 social care
1 sheltered
1 nursing
housing
Staff
Residents
2 clerical 3 care home managers
2 care home
2 day care/sheltered
8 social care
1 sheltered housing
housing 1 nursing
2 clerical
1 other
2 day care/sheltered housing

Relatives
6

Additional
Users
GP
Community
nurse
Additional users
Hospital
GP
consultant
Community
nurse
Hospital
consultant
Social
worker
Social worker
Pharmacist
Pharmacist

1 other

Care Home

Number of Interviewees

Abbeyfield

16

Mackintosh Centre

Invernevis House

Evidencing User Experiences

Impact on residents and family members

Quicker assessment, treatment, review and regular monitoring.

More responsive to need.
Not waiting for appointments.
Greater specialist input.
More effective behaviour management.
Can be observed by specialist when displaying particular
behaviours - improved targeting of medication.
Avoiding travel
Developing relationship with lead nurse via regular access and
opportunity to talk
Opportunity for family members to speak with specialist

Evidencing User Experiences

Impacts on Care Home staff
Access to specialist knowledge, experience and advice.
Opportunity to discuss residents, raise concerns and report
observations.
More actively involved in care.
Greater knowledge and understanding increases confidence and
skills.
Support and expertise from lead nurse increases ability to manage
difficult behaviours.
Feeling more valued in their role.
Reduced travel

Evidencing User Experiences

Lead Nurse Perspective
Patient Engagement
Impacts on staff
Key Impact on residents
Protocol Development
Delirium Protocol Developed
Behavioural Management Plans

Technology Enabled Care in Care Homes

Clinical Impacts and Outcomes
Thirty nine patients were seen by VC clinic
All patients were seen sooner than would otherwise have been the
case, with more frequent reviews if needed.
Six cases were identified where it was believed that hospital
admission was prevented.
Sooner and more frequent follow-up following discharge was
possible when hospital admission was not prevented
Eleven patients were treated with antipsychotics for specific target
symptoms. Regular and frequent review allowed for shorter duration
of treatment. Night sedation was stopped in 2 cases.

Technology Enabled Care in Care Homes

Success Factors - Implementation/Service Delivery
Early discussion with care home managers and staff.
Organisation and provision of staff training.
Development of a Service Liaison Protocol detailing all the key
contacts.
Visits of clinical team (consultant and nurse(s)) prior to clinics
starting to meet with both staff and residents.
Technical support visit to allow staff to meet and know who will be
on the other end of the phone if they have problems.
Several ports to allow the equipment to be moved around

Technology Enabled Care in Care Homes

Factors in a successful clinic

Staff catch-up.
Support for resident.
Time.
Planning and organisation.
Presence of a relative.
Repetition.
Advance warning of delay.
Specialist nurses approach.

Technology Enabled Care in Care Homes

Failure Factors
Implementation/Service Delivery
Service continuity.
Primary-secondary care communication.
Clinic Delivery
Delays.
Hearing impairment.
Visual confusion.
Overall Service
Breaks in service delivery because only one nurse was available to
deliver the VC clinics.

Technology Enabled Care in Care Homes

Key Factors in Overall Success

Post clinic reviews, including review of level of engagement

Increased staff knowledge and awareness
Increased staff confidence
Frequency of clinics
Accessibility of lead (link) nurse and clinics
Greater opportunity for communication with relatives.
Particularly important when involved with decisions on
medication and moving into full time residential care.
Increasing knowledge and awareness in relatives, and
residents/clients when there is still the capacity

Technology Enabled Care in Care Homes

Aims vs Objectives
Improve access to psychiatric care services
Residents can be seen weekly if necessary
Hospital Admissions
Care homes more able to cope with complex cases and challenging
behaviour and less likely to admit patient to hospital
Reduce antipsychotic use
More frequent review and adjustment
Behavioural plans only
Improve the management of behavioural and psychiatric
symptoms of dementia
Staff knowledge and confidence
Behaviours can be observed

Technology Enabled Care in Care Homes

Cost Benefit Analysis
Costs of the Clinics
(per home year)

Hospital Admissions saved

(per home year)

Specialist nurse and other

medical staff

20,000 Hospital Cost

150,000
(est)
(292 per bed per day): 6
people x 1 year (assumed
average stay) @ 100,000 4
Equipment costs (purchase cost 4,000. Ambulance Cost
2,500
averaged over 6 years,
(assumes 4 people return): 10
maintenance, operation)
trips x 1,000 4
Care home staff training
1,000 Friends and Relatives Visits: 900
(est).
6 x 20 visits x 30 4
Care Home Room Paid For &
Not Used: 6 x 800 per week
x 3 weeks average 4
Total

25,000

3,600

157,000

Technology Enabled Care in Care Homes

Other Benefits
Other Benefits (not quantified), include:
Improved quality of life for the 39 people (total cost 100,000 over 4
home years = 2,500 per person).
Other uses of the VC equipment.
Home care staff with improved understanding of dementia.
Improved quality of life for the friends and relatives of the 39 people.

Technology Enabled Care in Care Homes

Conclusions
The VC clinics are valued by all participants
The clinics have successfully addressed the intended aims of the
service
The clinics have supported the development of more consistent care
Staff have become more aware of signs and symptoms which might
indicate a deteriorating condition and on the whole feel confident
and empowered to take the appropriate action to avoid escalation

We believe that the key mechanism by which the clinic impacts have
been realized is through increased knowledge and awareness of staff
brought about by both the frequency and regularity of the clinics

Technology Enabled Care in Care Homes

Other Service Developments

Virtual Hospice Highland Hospice MDT clinics

Polypharmacy review Clinics
Wound Management/tissue viability
Community weight management classes
Community links to CPNs
Local GPs meetings/training
Care Home Managers
Beginning to look at delivering diabetes clinics to care
homes using the same specialist nurse led clinic model

Thank you for listening!

Jenny.hall@uhi.ac.uk