The BMJ has just published an open access paper entitled “Effect of telephone health coaching (Birmingham OwnHealth) on hospital use and associated costs: cohort study with matched controls” (BMJ2013;347:f4585, Steventon et Al). It reaches the rather depressing headline conclusion that telephone coaching did not reduce unplanned hospitalisations and if anything increased them.
This looks to fly in the face of the apparently less academically rigorous recent claims by the Leicester City CCG and Totally Health, that they reduced hospitalisations significantly, saving some £353,000 over a 30 week period with a cohort of between 47 & 50 patients that we reported recently.
However reading on, perhaps a key passage, in the conclusion, is : “Based on a systematic review and subsequent studies, including the present study, standard telephone health coaching seems unlikely to lead to reductions in hospital use, without the addition of other elements such as telemonitoring, shared decision making for preference sensitive conditions, or predictive modelling.” (So perhaps Totally Health should have mentioned Spirit Healthcare in their press release as without the telehealth service, possibly the huge saving would not have been achievable?)
The next two sentences in the BMJ paper’s conclusion make interesting reading too: “More care coordination might also be needed. Unless health coachers have established relationships with other clinical staff, new interventions could prove to be additions to existing patterns of service use, rather than create efficiencies.”
I’m probably reading far to much into this than I should. However one interpretation of this conclusion is that if you take a new technology-based service, plonk it down into an existing complex health community, without any attempt at integration with existing services or without recognising any new services that might be needed to support it, then it won’t deliver much, if any, benefit. Or put simply: technology is not a simple intervention. Now where have I seen that conclusion before?
Hat tip to Mike Clark for alerting me to this paper.
PS if you’re a bit rusty on the difference between a cohort study and an RCT, Wikipedia has a concise explanation.
I have to agree Charles, the introduction of any technologies can not be just an add on to existing service provision. When I gave my presentation at the Kings Fund Congress last month, I mentioned to the audience that the delivery of our virtual visiting systems must be part of service redesign. When services have asked me if they can use the systems to make live video calls to patients of service users, I ask them what they are going to do differently, if they just want it as an enhancement of the service then they don’t get it. Working this way just increases the cost of the service provision and doesn’t change the way it is delivered. Example of where it can work are where we reduce the level and number of dom care visits to people as part of a withdraw of our reablement service. By providing virtual visits as opposed to physical vists when no personal care is required, we can be more efficient, saving time and money but also be at hand to speak and see them when necessary. At the end of the rebalement process, we will decide if keeping the virtual visiting systems in the home will further enable independent living, we can also allow them access to other council of health services virtually, keeping them out of higher cost services across health and social care.
Just an example but it does go to show that the provision and adoption of technologies must be linked to greater integration and overall service redesign of services across health, housing and social care as opposed to health just doing telehealth and social care and housing doing telecare where there are no linkages.
I was a bit surprised at the reported outcome form the Birmingham Own Health project, as I had thought the outcome in terms of patient benefit was positive. Be that as it may:
1. We need to learn the lessons from the Birmingham Own Health project in which the use of Primary and Secondary resources increased for those patients participating.
2. It is not possible to make savings in Primary and Secondary resources, within the lifetime of a project, from patients who do not already use those resources. So, it the goal is to save money now, there must be a current cost.
3. Demonstrating savings from a program designed to address the potential long term needs of patients who are not yet using existing resources is highly unlikely to be possible from a short term study. There are going to be so very many variables and the time period to success will be long. We should focus on solving existing, known opportunities.
4. Measuring the project outcomes two years into a project is not acceptable. There has to be a methodology whereby measurements are made routinely and as they occur in real time. Otherwise there is no mechanism for continuous improvement in the processes and we carry on performing unproductive tasks, unchecked. Without regular feedback, the rate of introducing improvement is massively slowed for everyone.
5. The clinicians remotely managing the patient care need to be qualified to do exactly that, so they can safely and with confidence treat the patient to achieve the outcome of better care and less impact on traditional Primary and Secondary care resources. There is no point to the service if the clinician managing the patient feels compelled to refer the patient back to the traditional care pathways of hospital, GP and patient visits.
You make some valid points about the importance of integration, Charles. Of course, ‘technology is not a simple intervention’ and should not be implemented as an ‘add on’ to the existing health service, as Alasdair points out. Electronic healthcare and telehealth offer tremendous potential to transform services. But on their own they will achieve little – they must be joined together.
Health coaching provides a human mechanism to sit at the centre and evaluate all available, linked data, and identify areas where technology can help reduce costs and improve care pathways. Holistic systems that combine shared decision-making, telehealth and health coaching are therefore critical to the effective management of long-term conditions.
Tomorrow’s healthcare model must optimise technology, harness the power of information and share it across the health and social care system in ways that join up care, facilitate shared decision making, connect organisations and empower patients, as a simple and natural extension of existing processes, as has been evidenced at NHS Leicester City CCG.
If you’d like to learn more about the Leicester programme or Totally Health’s approach to health coaching, Charles then I’d be happy to speak further with you?
Wendy Lawrence,
CEO, Totally Health
http://www.totallyhealth.com