Helping patients manage multiple conditions in one place

Current pressures on the NHS and growing waiting lists are well publicised, but what is often not spoken about is that currently one in four people have two or more long term health conditions, a number predicted to double by 2035.

In Torbay alone, the number of people with two or more conditions equates to 50,000 people. The only way our integrated care organisation can manage this is to shift from reactive to proactive care, by putting the knowledge in the hands of patients to better manage their own health at home.

The rise in digital technology, accelerated over the past year, has meant that there are many digital tools available to patients. However, there is one key challenge.

At a patient participatory co-design event we hosted, funded by the South West AHSN and The Health Foundation Q Exchange, people told us that it was all very well having apps to support them in managing their health, but if they lived with several different conditions, having several different apps that didn’t ‘talk to each other’ was actually a burden, not a help.

This emphasised the need for us to create better unified care to help connect conditions and reduce the burden on patients.

Effective industry collaboration

In 2018 we started working with our partner organisation Health and Care Innovations LLP (HCI) on a multiple long term condition management app (CONNECTPlus) that we piloted in Rheumatology and MS (Neurology) to help patients better manage their conditions at home.

Early evaluation showed a reduction in Rheumatology related appointments of up to 50% and seven hours of weekly nursing time released from our education programme for patients being prescribed new medications. In addition, within six months we also saw diminished waiting times for our MS clinics.

We also received incredible feedback from both users of the app and our clinicians.

“I believe this app is a tool for empowerment. It is actually something that encourages you to be resilient, it gives you the tools to work with the information, and notice some progress for yourself and think yea, I can do this, I can cope.”

– MS Patient/App user

“It has enabled the patient to actually have some guided information that is guaranteed valid by your consultant, so it’s amazing.” – MS Patient/App user

“If you look at the app you can get all the information you need, you don’t need anything else” – Rheumatology Patient/App user

“I think patients feel support at home, which may seem odd, from an app, from a device in their pocket or in their bag. They feel like they have support with them at home, they feel that we are more easily accessible, their questions are answered but I think that they just feel more confident that they have something at home with them.” Rheumatology Specialist Nurse

“For the nurses we think the app is fantastic. It enables patients to go back and look at all the frequently asked questions, for the admin staff it cuts down the telephone calls to the department. It just empowers the patient to have all this information. Patients don’t want to keep asking, they don’t want to keep phoning. It just gives them that information and gives them the power to conquer their disease.” Rheumatology Specialist Nurse

App acceleration

2021 brings an accelerated approach to our development of CONNECTPlus. The aim this year is to add 15 additional conditions across multiple pathways including Cardiology, Hip and Knee pathways, Ophthalmology, Gastroenterology, Respiratory and Diabetes. This will be complimented with additional interactive symptom trackers and reporting, integration with smart watches, appointment diaries and medication management features.

More conditions within the app will not only bring benefits to patients and how they manage their comorbidities in a holistic manner, but will help us as a Trust manage the increasing demands on our services by better informing patients and clinicians, enabling patient initiated follow-up and ultimately reducing more unnecessary face to face clinical contacts.

In the Hip pathway alone our aim is to reduce post-procedure appointments by 80% and achieve savings of £216,000 each year. This puts us right on track for meeting the challenge of reducing our face-to-face appointments by 30% to meet NHS England’s Long Term Plan expectations.

Written by Adel Jones, Director of Partnerships and Transformation at Torbay and South Devon NHS Foundation Trust.


Join our audience of healthcare industry professionals

Join our audience of healthcare industry professionals