Quick Overview
The East Kent Health and Care Partnership (EKHCP) is broadening its remote monitoring pilot program, initially aimed at patients with frailty and complex needs, to now include individuals suffering from chronic obstructive pulmonary disease (COPD).
Key Details
- The pilot commenced on April 29, 2024, in collaboration with various partners, including the Kent and Medway Integrated Care Board (ICB), Kent Community Health NHS Foundation Trust (KCHFT), East Kent Primary Care Networks (PCNs), Graphnet, and East Berkshire Primary Care (EBPC).
- This initiative will continue until March 31, 2025, integrating Graphnet’s population health solution with Docobo Remote Monitoring, which connects to the Kent and Medway Care Record (KMCR). This integration allows healthcare professionals to access a comprehensive view of patient care across multiple providers.
Patient Feedback and Outcomes
- Sarah Phillips, Chief Medical Officer at Kent Community Health and senior lead for the pilot, expressed pride in the positive outcomes and patient feedback received.
- Patients have reported decreased anxiety levels and a greater sense of control over their health, while still receiving support from clinicians.
Identification and Onboarding of Patients
- The pilot has utilized the Johns Hopkins ACG System’s segmentation model, Patient Need Groups (PNGs), to identify patients who could benefit from remote monitoring.
- A total of 7,000 patients were identified, with 1,500 selected for onboarding, ultimately narrowing down to a caseload of 500 complex or frail patients linked to two PCNs in East Kent: Folkestone, Hythe and Rural PCN, and Mid Kent PCN.
Remote Monitoring Process
- Patients receive tablets that connect to the remote monitoring clinical hub, allowing them to discuss their equipment needs and establish their monitoring regimen.
- The Docobo Remote Monitoring platform enables patients to be monitored from home by completing questionnaires and submitting observations to the EBPC hub.
Impact on Patient Care
- Patients have noted a reduction in anxiety and an increased sense of empowerment regarding their health management, supported by their healthcare providers.
Future Directions
- The EKHCP aims to continue refining and expanding its remote monitoring capabilities to enhance patient care and support for those with chronic conditions.