This Bevan Exemplar project introduced digital companions to support older people lacking confidence in using digital health services.

Background

Digital exclusion is a significant public health challenge. As the digital transformation of health services continues, there is a risk that those who could benefit most from the digital health revolution are those that are left behind.

Lack of interest, motivation and trust are the main reasons why people don’t go online. Many have concerns around privacy and security. The best way to conquer these fears is through one-to-one support from someone they personally know and trust.

Aims

• This Bevan Exemplar project identified older people lacking digital confidence and skills, and recruited a friend or relative to be their Digital Companion.
• Companions were given guidance to help them support their friend/relative. Over a period of several months, they helped them gain confidence using digital health services.

Challenges

• Companions were initially concerned they would be asked to deal with personal or financial details by the people they were assisting, and might encounter security risks and online threats.
• Companions needed reassurance that their role was only to provide a first positive experience of the internet to others, and build slowly from that point.
• Building the confidence to engage digitally is one of many issues Companions faced with the individuals they supported.
• Learning difficulties, access and mobility limitations were also contributing factors which need factoring in with personal development.

Outcomes

• Hywel Dda HB region – 15 Companions trained and now delivering their role; 40 more booked in for training.
• Aneurin Bevan HB region – 34 Companions trained and now delivering their role; 20 more booked in for training.
• The project harnessed digital technology and created opportunities for people to become more active in their own care, confidently interacting with services and information online. With help from their Digital Companion, people were able to make informed choices about their own treatment, care and support.
• The project was underpinned by the principles of prudent healthcare – enabling co-production, reaching those with the greatest needs, encouraging self-care and reducing the digital divide.

“Being a Digital Companion is very rewarding. To see someone’s face light up as they watch their favourite singer performing songs on the tablet was lovely. She had never even touched a digital device before so it helped give her confidence as well as pleasure.”

Digital Inclusion in Health and Care in Wales

“As a Digital Companion, I feel that being able to offer support through the medium of Welsh to my friends or family is essential if I want them to trust me.”

Hazel Thomas Development and Promotion Officer for Merched y Wawr, Ceredigion and Pembrokeshire Division

Next steps

Digital Companions has now been incorporated into the Welsh Government programme, Digital Communities Wales: Digital Confidence, Health and Well-being for roll out across all Health Boards in Wales.

“The Bevan Exemplar scheme provided an opportunity to deliver digital inclusion support in an alternative way. This is social prescribing which could be hugely beneficial to many patients.”

Marc Davies, Wales Co-operative Centre

This Bevan Exemplar project introduced a decision tool to support care home staff to identify if a person can be safely assisted up following a fall, minimising their time spent on the floor.

Background

A high volume of 999 calls relating to falls are received by the Welsh Ambulance Services NHS Trust every year. In 2017/18 over 62,000 calls were to people that have fallen, many of these calls were to an older adult in a care home.

A ‘long lie’ can result when a person spends an hour or more on the floor, complications include pressure ulcers, dehydration, hypothermia and rhabdomyolysis; a breakdown in skeletal muscle that can lead to kidney failure.

Aims

To empower care home staff to make a safe judgement call as to whether a resident can be assisted up following a fall, either eliminating the need for an ambulance or minimising the time a resident spends on the floor whilst awaiting an ambulance.

Four care homes were selected to test the use of I FELL DOWN using a Plan Do Study Act (PDSA) approach. Approval was gained from the Local Authority Commissioning Officer, Safeguarding Team and Health and Safety Team. Care home staff were given guidance on how to use I FELL DOWN by a health care professional, supplied with a Mangar Camel Lifting Cushion and given training in its use.

At the start of the PDSA, the study was concentrated on one home. For all residents that were lifted following a fall, if following assessment using I FELL DOWN they were deemed by the care staff to not need an ambulance, or deemed suitable for a referral to an alternate health care provider such as a GP or District Nurse, the Trust Project Lead was contacted to attend the home and review the decision making.

All referrals, non-referrals and 999 calls during phase one were considered appropriate with no adverse incidents. The remaining three homes were then introduced.

Challenges

Other assessment tools such as ISTUMBLE, supported by ambulance services and used by care homes, are useful in identifying a non-injury faller. For a faller with an injury or illness, other assessment tools advise leaving a person on the floor to await a 999 response, a hospital admission following a fall may then result due to complications of long lie. I FELL DOWN allows for the injured or ill faller to be moved where appropriate, eliminating long lie whilst awaiting a 999 response.

Outcomes

Data was analysed for the four care homes involved in the PDSA, outcomes during the 9 month PDSA were compared to outcomes for the same date period the previous year.

• 186 residents were assessed using I FELL DOWN over a 9 month period.
• 18 residents had an ambulance requested for them following assessment using I FELL DOWN, down from 131 ambulance requests in the same date period the previous year.
• 11 of the 18 residents that had an ambulance requested for them were lifted from the floor whilst awaiting ambulance arrival to prevent long lie.
• Ambulance hours involved in attending a falls call for the 4 homes reduced from 132 hours the previous year to 36 hours during the PDSA.

This Bevan Exemplar project introduced virtual reality technology to deliver mandatory training for the nursing workforce at Velindre Cancer Centre.

Background

The training and education requirements for the nursing workforce are increasing significantly, but the ability to release nurses to undertake this training has decreased within Velindre Cancer Centre. This has significantly impacted attendance and compliance on mandatory and statutory training. In order to provide safe, effective care to patients within the cancer centre, the project team were tasked with exploring solutions to the problem, using ‘Clinical Fire Safety Level 2’ as the pilot course.

The concept of ‘just for me, just in time’ in education allows the nursing workforce to access the training at a time which suits them. This immediately called in to question the effectiveness of the traditional classroom taught sessions on set days of the month.

Following a search of the literature and scoping exercises, it was decided that the team would use immersive virtual reality technology via mobile virtual headsets to deliver ‘Clinical Fire Safety Level 2’ to determine if this concept would increase training compliance.

Aims

• Provide wider opportunities for staff to complete the mandatory ‘Clinical Fire Safety Level 2’.
• Comply with the NHS Wales Core Skills Training Framework, the recognised minimum standard for statutory and mandatory training and maintain competence of the clinical staff involved in the event of a fire.
• Improve retention and quality of knowledge so that in the event of a fire and subsequent evacuation the correct procedure is followed correctly maintaining the safety of patients.
• Allow the fire safety manager to focus resource on providing more bespoke training when required.
• To deliver cost savings for the trust.

Challenges

Owing to the nature and infancy of the use of virtual reality in education and training of staff within NHS Wales, the main challenge has been navigating the complicated procurement and processing system. This has proven costly in terms of time and being able to work with the industry partner of our choice despite months of research and meetings with various tech companies to choose the ‘best fit’.

The time take to overcome this has led to a delay in the project from August 2019 to January 2020. The team have persevered and, working alongside procurement, have been able to justify working with the industry partner of choice and the content is now in production.

Outcomes

Despite the delay to the pilot, the team have been able to predict outcomes based on research, industry case studies and pre-collection data at the cancer centre. These have been identified as:

• Compliance rates to increase.
• Retention of knowledge predicted to increase significantly based on a case study by the industry partner and current evidence available.
• Overall cost savings.
• Generation of income by the adoption and spread of the content to other health boards and trusts in Wales.

Next steps

• Pilot fire safety level 2 amongst a cohort of 62 nurses over a 4 week period.
• If successful begin scaling out to other areas.
• Begin process of adopt and spread.
• The possibilities are endless!

“I am a Bevan Exemplar and the opportunities this has given myself professionally and the growth, confidence and personal ability has been incredible. I suspect we would not be where we are now on the VR project without this programme.”

Hannah Russon

This Bevan Exemplar project introduced a telephone support service for health board staff.

Background

Staff with common health conditions (such as muscle/joint pain, stress, anxiety and depression) previously waited between six and eight weeks for an initial appointment with the staff wellbeing service. Feedback suggested that staff health was declining during these waiting times, increasing the potential to become a sickness absentee or leading to longer sickness absence if on sick leave.

Project Aim

To develop a prudent, early intervention telephone-based support service to enable staff to speak to the relevant professional within a minimum of seven working days. This initial wellbeing assessment would take 20 minutes, and the Advisor would discuss the employee’s needs and provide advice, signposting to other services or arrange appropriate support from the team.

Key Outcomes

• 95% of employees referring themselves for health & wellbeing support are offered an initial wellbeing assessment within five working days.
• 20% of those referrals require no further support, therefore releasing resources for the remaining 80% who do require further support.
• Staff who previously had to wait 6-8 weeks are now able to receive this within a week.
• 67% of staff who were absent from work at referral had returned to work at discharge.
• 72% of staff reported that the service had a positive impact on their work status.
• 59% of 1,321 staff accessing the service in the first year were ‘presentees’ – seeking support to remain in work and therefore sickness absence and associated variable costs may have been higher without the Wellbeing Service.

“The main benefits were having someone who was supportive and in regular contact with me. I have now returned to work successfully and have learnt many coping strategies that will help me to stay well and look after myself.”

Staff member

“The programmes and support offered have really helped staff to remain in work whilst managing some very challenging personal situations. The wellbeing service remains our first port of call whenever discussing personal or workplace challenges, with which the team feel they would benefit from extra help.”

Line Manager

Challenges

• Managing staff expectations during the transition to a telephone wellbeing assessment, as staff were used to a face-to-face service.
• The Wellbeing Advisors adapting to a different way of working and undertaking telephone based assessments, including shorter screening/advice calls and signposting staff to other relevant services when appropriate.
• Challenges were overcome by the Advisor using their skill and expertise to explain the benefits to the employee and the shorter timescales to receive appropriate support. The new service was described and communicated to staff using bulletins on the Intranet and e-mail networks.

Next steps

To continue developing the service, measuring outcomes and disseminating the learning to potential adopters.

“Being a Bevan Exemplar has been both a valuable and supportive experience, providing excellent networking opportunities. It has been inspiring to learn about other initiatives and provided a platform to promote our work.”

Project Team

Background

Clinical information requirements are integral to the development of digital solutions across NHS Wales and may be used as part of the patient electronic health record (EHR). However, there is no standard to how this activity is conducted, nor a clear ability to reuse data definitions for a variety of different clinical areas.

Translating health and social care concepts into the digital domain, and maintaining the clinical voice requires tools that are accessible by both technical and clinical partners. The resulting models must be clear to all potential users.

Clinical care data is complex and constantly evolving. openEHR is a technology used across the world to support digital records. The ability to create and reuse clinical models known as archetypes is part of national programmes worldwide. It uses the Clinical Knowledge Manager (CKM) tool.

Aims

This project sought to establish if the underlying principles of openEHR could support the work of the Wales Cardiac Network (WCN) in defining a digital model of the acute coronary syndrome (ACS).

Clinical care is an expensive resource and it is vital that time is spent effectively in the development of software and applications. openEHR supports the virtual curation of clinical models, providing a governance wrapper around how they are developed and subsequently requiring clinical sign off. The potential to support clinical staff to carry out this work without invoking resources to hold physical workshops and arrange transportation could provide an additional level of agility during the development of digital systems.

The ability to work in a way that fits the patterns of clinicians across the Health Service was an important attribute.

Reusing models developed by others and subsequently sharing those produced by the project demonstrates a means to reduce variation in this process whilst sharing the burden of governance.

Challenges

• Engaging with an interested clinical group.
• The project was seen by some to produce working software although there was no scope (or budget) to do The WCN saw the development and agreement of data definitions as a specific issue that has affected them historically. They became an effective stakeholder to support the project aims.
• Securing clinical time to hold an initial training workshop proved difficult. The nature of clinical modelling is complex although the openEHR tooling alleviates some of the more technical aspects, training is still required to support understanding of the techniques and processes involved.

Outcomes

Curation of the ACS pathway lead to the development of two new archetypes for Crusade Bleeding Risk and GRACE ACS Risk scores. Most of the model development comprised of archetypes already available, or those needing minor modification. However, the proportion of reusability was significant. The nature of the ACS pathway involves perspectives from different stakeholders, and describes key processes such as referral, clinical history, risk assessment and investigations.

It therefore represents a complex clinical model that required decomposition into key components. Curating a model in this way made it more digestible with the stakeholder modelling team, leading to the creation of two “templates” for ACS Referral and ACS Pathway Outcome.

To support learning, the training workshop employed a “handholding” approach, using concepts that were well understood by cardiologists and working with pre-developed models. As the modelling progressed, the aim then became to tail off support as understanding of the process became embedded. New archetypes were reviewed with the group using the internet based digital tools over a two-week timeframe.

The resulting models have been published on the UK CKM, with new models submitted to the international CKM for consideration by the wider community.

Next steps

Following the successful development of the ACS pathway models, a governance review will be conducted by the WCN. This will be analysed before the curation of the remaining three pathways that are a deliverable of the Cardiac Informatics roadmap.

The publication of ACS models will facilitate further work to assess the efficacy of openEHR tooling for NHS Wales clinicians. The nature of publication on the CKM will invite collaboration with other openEHR communities across the world.

These templates represent readily deployable clinical data structures for use within any openEHR compatible system, supported by electronic forms for rapid application development.

“I’m grateful for the development of my Bevan peer network that has forged links with new friends and colleagues – it’s been very valuable to me!” 

John Meredith

This Bevan Exemplar project introduced a model to involve patients, carers and staff in role redesign.

Background

In healthcare, role re-design usually takes a top-down approach. Traditionally, the people who receive or give care and are therefore best placed to know what is needed, are not involved in designing work and addressing the challenges.

When working with the “Transforming Mental Health” Programme, an opportunity presented to work on an innovative model of role design.

This would enable a workforce model to draw in perspectives from carers and service users in health, social care and third sector agencies, building on the coproduced service model evolving through transformational pilot projects to support change and transformation.

The opportunity to engage in a dialogue on the “optimum care giver” with the identification of role, responsibility and competence requirements to generate positive experiences for carers, service users, health & social care professionals:

• confidence to deliver appropriate care (or self-care).
• confidence in those delivering care.
• clarity on role in management of care and where skills best placed.
• clarity on role in self-management and where skills best placed.
• greater job satisfaction and from using expertise.

Aims

To create a model for redesigning roles in health and social care in coproduction with service users and carers.

To create an active and engaged process for role design to reshape the workforce to changing population needs, based on the principles of prudent healthcare.

The aim of the project was to create a simple framework in workforce design, to improve:

• Healthcare outcomes.
• Patient experience.
• Staff experience.
• Collaboration across health and care settings: professionals and carers.
• Resource effectiveness and efficiency.

With the long-term intention that the methodology become a fluid and embedded practice to:

• Enable advance assessment of efficiency and effectiveness of changing roles and align to health outcomes.
• Enable approach to quantify and qualify impact of role design and enable consistent evaluation of role design outcomes.
• Enable a framework for integration and possible cross organisational or sectoral accreditation of roles and learning provision.

Challenges

Challenges included:

• Service change in an iterative framework
• Coproduction as an operating model.
• Internal project management landscapes shifting.
• Engagement in a “dialogic” model of role design.
• Underpinning contractual frameworks for employment.
• Workforce challenges – capacity to engage; and impact upon.
• A longer period of time to establish engagement would have been helpful, however, context as noted above had a significant This project may have been overambitious.

Outcomes

3 new role outlines were created; Navigator, Healthcare Assistant and Nurse in Community Mental Health Centre.

Outcomes to date include:

• an outline model of new roles in a community mental health centres.
• an outline model of a role design model based on coproduction, wellbeing and prudence.
• knowledge on how to tackle the challenges of engagement.
• knowledge on how to address the challenges of a contractual nature.

Next steps

• Find a home within organisational structures or even wider regional spaces.
• Utilise the core group and individuals who see value and build on this energy.
• Encourage the mantra of do only what you can do and embed in practices that are small and practical.
• Keep picking up on the signals and cues within groups and build on conversations
• Track progress, however small and identify the shifts in engagement and practice.

This Bevan Exemplar project introduced a peer-led education programme for people living with low-level continence problems.

Background

The Continence Service identified long delays for routine referrals to a Specialist Continence Advisor.

The waiting time was up to two years, leading to the problem becoming more severe and having more of an impact on a person’s health and wellbeing, potentially for the rest of their life.

Aims

• To develop a programme in partnership with patients, NHS educators and Continence Nurse Specialists (CNS) to support early intervention and prevent long-term complications and unplanned admissions
• To be able to deliver the programme in safe, comfortable environments in the community and to be more about health and wellbeing rather than a clinical appointment.
• To be a peer-led patient education programme available for anyone living with low level continence issues, offering practical ways to manage continence issues on a day-to-day basis.

Outcomes

The team established a task and finish group, gathered relevant information and evidence and developed a manual for tutors to deliver from, along with documentation for those attending the course, including invitation letters and resource packs.

Staff and tutors were trained to deliver the programme, and piloted the session in partnership with the Continence CNS.

The programme has proven to be cost effective as group sessions can see 20 people in 2.5 hours, and not just people with continence problems.

Staff from nursing and care homes can attend and take their learning back to their place of work.

The programme demonstrated a reduction in Referral to Treatment Time. Running the programme frees up CNS time to see those with the greatest need.

Next steps

The programme has the potential to be delivered in a variety of ways:

• In areas with Education Programmes for Patients: in the local community for people living with continence issues g. small group sessions in community halls.
• Added to the end of other programmes delivered locally such as the Pain Management Programme in the community.
• Targeted at Residential Nursing Homes/Supported Living/Day Service Centres or alternatives where a large group of people would be likely to be living with continence issues.
• As an integral part of the Continence care pathway in Health Boards, by identifying all routine referrals and offering the education in partnership with a continence clinical nurse specialist. Before offering a high end clinical appointment and/or prescribe a medication without basic behaviours being addressed to establish the true level of continence issues in the patient.
• Work in partnership with a GP cluster to deliver a programme as a joint venture.

This Bevan Exemplar project, in partnership with Alpha Laboratories, implemented a new laboratory-based technology to guide referral for colorectal cancer in symptomatic adult patients in primary care.

Background

Quantitative faecal immunochemical testing (FIT) has been declared “fit for purpose” by the NICE guidance DG30 for guiding referral for colorectal cancer in symptomatic adult patients in Primary Care.

Aims

The aim of this project was to implement the FIT test in our laboratory to identify patients in primary care who are unlikely to have significant colorectal disease and would not benefit from colonoscopy referral, potentially saving resources and minimising waiting times. We also wanted to create a pathway for primary care with our gastroenterology colleagues and support patient user documentation for the FIT test.

Challenges

• Local demand and capacity concerns from gastroenterology.
• The need to standardise documentation for all-Wales use.
• Agreement of standardised measurable outcomes for use across Wales, and how to obtain this data reliably.

Outcomes

The HM-JACKarc analyser was implemented and interfaced with the all-Wales laboratory software through to Welsh Clinical Portal and Primary care systems.

The service is provided out of Prince Charles Hospital and has full UKAS accreditation (ISO 15189).

Comprehensive documentation has been produced for use across Wales which includes patient feedback. CTMUHB are currently running pilot FIT samples for Aneurin Bevan University Health Board GP patients and for a research study (CRaFT) based in Swansea.

Next steps

A local pilot will begin soon in Cwm Taf Morgannwg University Health Board and data can be gathered to look at the impact FIT has on earlier detection of bowel cancer and measure the effect on unnecessary colonoscopy procedures.

This Bevan Exemplar project utilised a specialist prescribing pharmacist to initiate bone protection treatment following identification of osteoporotic vertebral fractures.

Background

Osteoporosis is a condition where your bones lose strength, making you more likely to fracture a bone. These fragility fractures can have a huge impact on a patient, their independence, their family, social care systems and the NHS.

Treating patients who have been diagnosed with an osteoporotic fracture helps to reduce the incidence of future fractures and their associated complications:

• More fractures
• Chronic pain
• Loss of independence
• Impaired physical function
• Deformity
• Immobility
• Low self esteem
• Depression

Patients diagnosed with osteoporotic vertebral fractures within the Trauma Directorate at Cardiff & Vale UHB do not routinely receive information about their condition, nor are they offered treatment to lower their future fracture risk. This is in contrast to the robust assessments performed for all patients admitted with osteoporotic hip fractures.

Aims

• Ensure all osteoporotic vertebral fracture patients admitted to the Trauma Directorate receive a bone health assessment.
• Educate patients about their diagnosis of osteoporosis.
• Initiate treatment at the point of diagnosis.
• Improve access to timely, comprehensive treatment.
• Perform meaningful interventions that positively impact health.
• Empower patients by involving them in the decision making process and development of treatment plans.
• Assess patients during their hospital admission to reduce the need for additional outpatient and GP appointments.
• Enhance patient engagement, experience and outcomes.

Challenges

• Balancing existing roles with providing additional services.
• Establishing logistics and ensuring clinic capacity for any referred patients.
• Generating engagement with other linked specialties.
• Gaining IT support to ensure electronic treatment plans are accessible to other healthcare professionals.
• Gaining support from Finance partners to fund the service.

Outcomes

• All vertebral fracture patients received dietary and lifestyle advice and were signposted to additional information sources.
• Improved patient experience through co-production.
• No additional medical support was required.
• No additional appointments were necessary.
• Reduction in harm through improved access to treatment.
• Effective use of resources and skilled personnel.
• Financial savings through prevention of future fractures, in-patient admissions and follow up appointments.

Next Steps

• IT support needs to be maximised for clear communication.
• Work collaboratively with Radiology to ensure clinical guidelines are followed for effective identification of fractures.
• Demonstrate that the costs of a Pharmacist Independent Prescriber and subsequent treatments can be offset by the potential cost savings of preventing a future fragility fracture-related hospital admission.

This Bevan Exemplar project aimed to assess and meet the medicines management needs of every patient discharged to a GP practice.

Background

It is recognised that not enough support is given to patients to manage their medicines after discharge from hospital. Most at risk are the frail elderly who may not be able to access the usual community pharmacy resources.

The intervention

All recently discharged patients (105) were assessed over 4 months in one GP practice.

Patients were assessed as needing one of the following interventions:

• Home visit by pharmacist or pharmacy technician (14, 13%).
• Referral to the Community Pharmacy Discharge Medicines Review (DMR) service (58, 55%).
• No additional medicines management support (33, 32%).

Criteria for assessment included age, number of admissions in past 6 months, duration of admission, co-morbidities, number of medicines and number of medicines changes at discharge.

Challenges

Only 39% of DMR referrals were acted upon by the community pharmacy. Reasons included patient not contactable, patient declined, time constraints, no internal communication of referral, IT issues.

Outcomes

For very little time investment (1-2 hours of a pharmacy technician band 5) per week, it was possible to assess all discharges. A small proportion of patients, those with the greatest need, were visited at home where their understanding and adherence to their medicines regimen could be assessed and adapted as necessary. Every patient visited at home had input from the pharmacy team.

Home Visit – Stan’s Story:

• 83 year old gentleman discharged after admission for anaemia due to bleed (NSAID stopped prior to admission) and chest infection.
• Partially sighted, lives with wife.
• Concerned about whether his inhaler works when he is breathless. Inhaler difficult to use.
• Inhaler device changed to suit patient preference.
• Previous inhalers taken away (stockpiled as not used).
• Advice given to not use NSAIDs in future.
• Citalopram dose reduced after discussion with Stan, his wife and the GP (dose higher than recommended for age).

Discharge Medicines Review (DMR) In Action: Kenneth’s Story

Discharged after a Total Knee Replacement on strong opioids and apixaban.

Part 1: Explanation to patient that apixaban short course and strong opioids only in first few weeks after operation.

Part 2: Follow up with patient regarding pain control. Strong opioids now stopped.

Next steps

Reliance on referrals from hospital staff to the DMR service may not be the way forward. The DMR service does not tend to help those most in need of support post discharge. This small project has shown that there is potential for assessment, and delivery, of patients’ medicines management needs within primary care – where they are known best.

Working within Primary Care Clusters, this assessment could be streamlined in the future.