The Challenge

St Helens Council and Bridgewater Community Healthcare NHS Trust have been using telecare and telehealth to support people with long-term health and care needs for some time, including the services as part of packages of care to help to increase independence and safeguard service users. In June 2013 the Adult Social Care and Health team, in partnership with Environmental Protection Careline services, commenced a year long pilot project to assess the benefi ts of including telehealth as part of its Reablement Service.

The Reablement Service aims to:

• Help people to remain at home and be independent as possible
• Prevent unnecessary admission to hospital
• Help people recover faster from illness
• Support discharge from hospital
• Prevent unnecessary admission to long-term care homes

What We Did

The initiative has been developed by a multi-disciplinary team including staff from St Helens Careline, nurses from Bridgewater Community Healthcare NHS Trust and the Reablement Service. The Reablement Service offers support in the community and at a 5 bed facility located with

Brookfield Residential Home to help people return home after a stay in hospital and regain their independence. The service is delivered by social care and clinical staff, including experienced Social Workers, Occupational Therapists, Nurses, Physiotherapists, Technical Instructors, Community Psychiatric Nurses, Assistant Practitioners and Intermediate Care Support Workers.

Referrals are received from the Integrated Hospital Assessment Team (ICAT), based at Whiston Hospital and include adults who need guidance on managing long-term conditions such as diabetes or Chronic Obstructive Pulmonary Disease (COPD).

The reablement unit at Brookfield has a myclinic multi-user telehealth system, which is used to record the vital signs of patients daily. These readings can include blood pressure, weight, temperature and blood oxygen levels depending upon the condition being monitored. Results are transmitted to St Helens Careline for triage, and verified readings outside the parameters set for the individual patient will raise an alert prompting Careline staff to take appropriate action. Community matrons can also log into the system remotely at any time, helping to inform the ongoing care plan and highlighting any cause for concern at an early stage.

Patients generally use the Reablement Service for a 6-8-week period, which often combines a stay at Brookfield with follow-on support in the community. Patients with long-term conditions may then be offered the use of one of five mymedic telehealth systems to monitor their signs and symptoms at home.