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NHS Test Bed: ‘Smart with your Heart’ Reducing Readmission Rate for Heart Failure Patients at the Royal Stoke University Hospital: A Telehealth Coordinators Perspective

posted 16 Oct 2020, 02:49 by Hollie O'Connell


Kylie Dentith 
Technology Enabled Care Senior Support Assistant - Simple Share Healthcare 


16 October 2020 


Following a successful pilot demonstrating a significant reduction in readmissions for patients admitted with heart failure, Florence was chosen to be part of the NHS Test Beds Programme at Royal Stoke University Hospital called ‘Smart with your Heart” in October 2018.  Florence, along with two other digital technologies were combined and have now been scaled up, with the aim of further reducing the readmission of patients with chronic long-term heart failure through community-based clinical interventions and remote support, to better self-manage their condition post-discharge.

The “Smart with your Heart” project also aimed to improve patient’s health literacy and their capability to safely ‘self-care’, using bespoke patient-education materials and referrals to appropriate third-sector services.  The project has now come to an end and is in the evaluation phase to produce a final report for wider sharing.

Dr Duwarakan Satchithananda, Consultant Cardiologist and Clinical Lead for the project, commented 

Patients felt supported by the combinatorial nature of the project – not just with the combination of digital products, but with the combination of the digital products and a human face to help patients get to the appropriate team that could help them” 

In the pathway designed by Dr Duwarakan Satchithananda, patients were prompted by Flo to reply every 2 days as to whether they felt better, worse or the same compared to their previous response, in order to identify any early deterioration in their condition and facilitate early intervention.  The patient was then guided by Flo to check how their symptoms matched against the heart failure symptom checker that they were provided with and reply with Red, Amber or Green accordingly.  Along with interactions around symptoms, Flo also provided patients with tips and information about managing their condition, as well as links to the other digital technologies. 

In the prevention of readmission, it was clinically relevant for the team to review any patients who were experiencing worsening symptoms and to be able to intervene quickly.  Flo notified the Telehealth Coordinators, and the team would then review any patients clinically indicated and intervene with a phone call to the patient to ask some further questions, and advise what appropriate course of action the patient was required to take.  As part of the Smart with your Heart project the team also developed a patient tracker to record patient details, crucial dates, call notes and patient ID’s for each of the technologies used as part of the pathway.  The responses from patient phone calls including the main points of the discussion could then be noted and added to the patient tracker, which the Telehealth Coordinators had access to should this be required to support the team based approach.



Nicola Antrobus was one of the Telehealth Coordinators for the Smart with your Heart Test Bed Project
and has kindly shared her perspective of how her role supported the project.  Nicola worked directly with patients and focused on their engagement with the new pathway; if a patient met the criteria, Nicola would advise how the project would support them and the expected benefits associated with the likelihood of reducing the potential need for readmission. 

The SHINE Clinic was a key resource for the project, acting as an Ambulatory Heart Failure Clinic offering heart failure treatment such as intravenous diuretics on an out-patient basis, meaning that patients requiring treatment can have this delivered to them as an outpatient without the need to stay in hospital.  As one of the Telehealth Coordinators, Nicola visited the SHINE Clinic on a daily basis to talk to patients about the Smart with your Heart project, and ensured that patients knew they could approach her for more information, advice or to have a general chat about everyday life.

Nicola found that patients were more engaged in the project after receiving the face to face visits where she explained what was involved and how Flo could support them.  Nicola felt that the first introduction was important in building the relationship with the patient, and told them her name and job title, how she was a part of the Smart with your Heart project and that the patient had been referred by one of the consultants or the heart failure nurse.  If needed, Nicola also helped patients to opt in to receive messages from Flo, would provide them with information around useful websites and talk through the symptom checker to ensure the patient understood what to do.  Nicola and the team would always be willing to call or visit the patient again to offer further support.

Due to the high level of interaction required with the patient for this project, Nicola explained that having effective communication skills within her role was crucial.  As well as explaining the project in a clear and informative way, Nicola also needed to be sensitive and understanding of each patient's situation, and due to the personal information required to take part in the project, it was essential that Nicola built trust with the patient and their family so that they felt comfortable and reassured that their information was going to be used in an appropriate and secure way.

Not only was communication key while introducing patients to the project, it was also important to Nicola that she helped patients feel at ease and to grow their trust in her.  Throughout the pathway, if a patient responded to their daily prompt saying they felt worse, the Telehealth Coordinators would call the patient and it was extremely important that the patient was open and honest about why they were feeling worse, as this would then help to guide the Coordinators on what the most clinically appropriate advice or action was for the patient based on the pathway.  As these calls could often be sensitive and concerning for the patient, it was imperative that Nicola was understanding and communicated effectively.
This level of adaptable communication enabled patients to fully utilise and benefit from the pathway by reducing any barriers that could have been present when encouraging patients to take part in the project, and when developing working relationships with others involved.

Nicola explained that the role was not without its challenges, one of which was the introduction of new ways of working within the heart failure patient cohort and engaging clinicians in wanting to introduce digital technologies to their patients as part of their post-discharge care.  Subsequently, it was important that the Telehealth Coordinators worked closely with the wider clinical team, supporting them to take an active role in the project and providing a reference point.  The Telehealth Coordinators would always try to work with the clinicians as much as possible and would attend the weekly heart failure meetings to provide more information and initial feedback on the project, as well as guide clinicians as to what was required from them to help the uptake of the project.  One of the main issues was that it took quite a bit of time to get approval for clinical governance, which was raised at many meetings.  If there had been any resistance from the wider team this could have proved difficult to recruit patients to the project, however, everyone involved was supportive and worked cooperatively to overcome any issues and make this project successful.  The Telehealth Coordinators also linked in with the Heart Failure Nurses’ monthly meetings which were across the Trust and with the Community Heart Failure Nurses.  This helped to build up working relationships with those outside of the Trust and keep them informed about the project.

Nicola felt that the role exceeded her expectations as she enjoyed the variety of responsibilities each day brought, and she also really enjoyed the interactions with the patients, Community Heart Failure Nurses and the team.  Nicola found Flo very easy to use for herself and was simple and easy to understand for the patients too.  Whilst being a part of the project Nicola learnt that patients didn’t really know what signs that they were looking for around a deterioration in their condition, by using Flo and being prompted to look at the symptoms on the symptom checker, the patients became more educated and clearer on what to look out for and why it was important in helping to prevent any health deterioration.  Nicola also thought it was great to see patients who had a fear of a mobile phone become more confident and comfortable in using technology and in some instances start to use it more to contact family members.

When asked what advice Nicola would give to others she replied 

Don’t be put off by any resistance in the departments you are dealing with, learn and understand as much as you can and grow the relationships with your patients and colleagues and support each other