The Frimley Health and Care Integrated Care System (ICS) has rolled out a proactive approach to remote monitoring that is helping to reduce hospital admissions.

The ICS, which covers East Berkshire, Surrey Heath, Farnham and North East Hampshire, has rolled out the solution to 4,000 patients with high-risk conditions such as diabetes, heart failure and chronic obstructive pulmonary disease, as well as 800 care home residents.

The approach is part of Frimley’s digital transformation programme, Connected Care, and was run in two phases. The first stage saw it implemented within care homes in March 2022, with the patients with complex needs following in December 2022.

Since implementation, Frimley Health and Care has seen hospital admissions reduced by 40% for high-need patients and 34% for care home residents. While A&E attendance has dropped by 31% for high-need patients and 40% for care home residents. In addition, GP contact was reduced by 19% for the high-need patients and 20% for care home residents, while both groups reduced the volume of medications prescribed by 11%.

Anna Fishta, associate director shared care records and remote monitoring at Frimley ICS, said: “Results like these, such as the reduction in hospital admissions and A&E visits, are encouraging, and why we are all so passionate about the project.

“Remote monitoring is part of our overarching commitment to working differently, more effectively and efficiently. Patients are automatically identified and contacted for the remote monitoring service when needed, using our population health solution, which is faster than the traditional referral process. Because of that, care teams are able to help their patients at the earliest possible opportunity.”

Patients are identified using Graphnet Health’s population health solution, CareCentric. This uses data-driven insights to help providers identify those who are most in need of additional support.

Once accepted onto the programme patients are provided with remote monitoring technology by Docobo, including the DOC@HOME app. This app allows users to communicate with healthcare professionals quickly and easily, as well as submit health readings and other vital information.

Shared care record integration

Additionally, the DOC@HOME remote monitoring solution integrates with Frimley’s shared care record – which is powered by Graphnet. This enables health and care teams to access patient information from acute trusts, primary and community providers, clinical monitoring hubs and out-of-hours GP services. Should a patient present in an urgent care situation, staff have all the information needed to ensure they receive appropriate and timely care.

Fishta added: “Feedback has been positive so far, with patients feeling more in control of their own health and better supported.”

She continued: “On the clinical side, we’ve had doctors telling us that the approach is preventing their high-risk patients from falling into crisis. Those testimonials are what it is all about. The technology is a means to an end, it’s the people and helping them live better quality, more independent lives that is at the heart of what we’re doing.”

There are now more than 5,000 patients onboarded onto the remote monitoring programme, with plans to roll out the approach to the remainder of the Frimley ICS region over the next six months.

The first ratings awarded to every integrated care system for the ‘digital maturity’ of its NHS providers placed Frimley Health and Care very highly.