Case Study

Winner 2019 – Communicating Effectively and Measuring, Reporting and Acting Categories

Digital technology is now a normal part of daily life and its use within healthcare is increasing.

As home enterally tube fed (HETF) patients require regular monitoring and support at home, there is a potential for the use of digital solutions. Therefore a mobile app for communication between HETF patients/carers and Nutricia Homeward Nurses was developed (The Nutricia Homeward App). The aim was to improve and simplify communication, reduce travel time, prevent hospital admissions and outpatient appointments.

The App was designed to be easy to use, available on a variety of mobile devices, secure and GDPR compliant.

An evaluation was undertaken in the first 3 months of launching the App (March – May 2019), and every month thereafter with outcome measures including: number of calls, time taken for each call, patients age and reason for the call. Patients and carers rated their experience via an inbuilt rating system (0-5-star rating), and the nurses travel time saved was estimated.

Uptake was strong and experience ratings excellent, the next steps are to widen the scope of the App as well as developing the functionality to enable HCPs to use the App to communicate with their HETF patients.

In 2018, nearly 171,000 nursing interventions were carried out across the UK by Nutricia Homeward Nurses, the majority of these were conducted in patients’ homes.

Analysis showed that in the same year over a third of nurse time was spent driving to and from patient homes responding to urgent requests, providing regular tube feeding reviews and providing additional training. This amount of driving has a negative impact on the environment and employee wellbeing and means the speed of responding to patients requests or questions is delayed. If a nurse is driving, they can’t respond to patients’ questions on the phone and if a patient has an urgent need for a face-to-face consultation there is a delay before the nurse can see that patient due to travel time. With these factors in mind a question was raised, “could a proportion of the Nutricia Homeward Nurse visits be conducted virtually by a video call if we had the correct technology in place?”

An audit was undertaken to understand the amount of time Nutricia Homeward Nurses spent driving to and from appointments and a trial using “WhatsApp” was undertaken by 2 nurses for 2 months to assess patients and carer feedback on whether a video call was an acceptable form of communication and for which types of interventions.

The results showed that the average round trip to see a patient took 60 minutes, although much longer in rural areas and the trial using “WhatsApp” showed that patients and carers found a video call a quick and acceptable method of communicating with their Nutricia Homeward Nurse.

A review of different options was undertaken, and a business case produced. A key element in choosing to develop a unique Nutricia Homeward App was to have a secure sign in and authentication process and the ability to only initiate calls one way (from nurses to patients) in order to minimise any confusion and improve the patients experience.

In the first 3 months of use 459 calls were conducted using the Nutricia Homeward App (approx. 145/month), with a mean call time of 17 minutes. This has now increased to approximately 400 calls per month with 2,431 calls conducted between July and December 2019.

Initial thoughts were that younger patients or parents of children would be more open to having a video call however the ages of patients using the app vary: 18% under 19 years, 51% between 19-65 years, and 31% over 65 years of age, therefore we can surmise that video calls are an acceptable form of communication across a wide age range of patients within the UK.

The most common reason for using the app was for trouble shooting or emergency advice (86%).

Patients and carers rated their app experience as excellent with 88% recording a 4- or 5-star experience (84%: 5-stars, 4%: 4-stars)

Although difficult to quantify, total nurse travel time saved has been approx. 188 hours per month

Although the facts above give quantifiable data, the qualitative data collected is just as impactful. Examples of the powerful, individual patient stories, demonstrating the positive impact of how using the App has improved two-way communication, are shared below:

Example 1: On Tuesday 23rd April 2019, the first working day after the Easter break, a Nutricia Homeward Nurse received a call at 8.50am from a 40-year-old head and neck cancer patient. This lady was known to the nurse and was worried about her gastrostomy site as it was red and sore. From the information given over the phone it sounded like the stoma site was infected. The patient had downloaded the Nutricia Homeward App during the nurse’s previous visit, so the nurse phoned the patient back using the App. As it is a video call, the Nurse could view the patient’s stoma site using the App, and it was clear it wasn’t an infection but a granuloma and therefore the right course of action was recommended. The time taken from initial call to diagnosis and recommendation of the correct treatment was just 20 minutes. Without the Nutricia Homeward App, the earliest the Nutricia Homeward Nurse would have been able to see this patient was the following day and her treatment and recovery would have been delayed.

Example 2: A patient in her early 80’s living alone in rural Sussex, gastrostomy fed and non-verbal. Usual communication with her Nutricia Homeward Nurse is through email however this can often result in long delays in the conversation. During a routine tube replacement visit the Nutricia Nurse supported download of the App and conducted a test call. Later that week a video call was conducted using the App as the patient had a query about her stoma site, the issue was resolved immediately. Without the Nutricia Homeward App this lady would have had to wait until the email was picked up several hours later. Feedback from the Nutricia Homeward Nurse is “The joy this brought to this lady was simply amazing to see, she had the biggest smile on her face and found getting an immediate response to her question fantastic.”

The Nutricia Homeward App has not only given this patient another form of communication, and one where she can get answers to questions promptly, but also the ability to see another human being in a life that can sometimes be very lonely.

Example 3: The Nutricia Homeward App was used in an outpatient’s clinic in East Sussex by the Nutricia Homeward Nurse and the home enteral feeding Dietitian to communicate with a patient in her early 20’s. This patient is at University and using the App in this way for her regular tube feeding review prevented an hour’s round trip to hospital, waiting time in the clinic and car parking charges. Everyone involved agreed that this was a perfect method of communication and they will use the App at alternate appointments, meaning that this patient only needs to attend an outpatient appointment twice a year, rather than four times a year.

There has been interest in the Nutricia Homeward App from other countries that provide similar Homecare services and Nutricia Australia is due to launch their version in early 2020.

We have highlighted the success of the App to healthcare professionals through the NNNG (National Nurses Nutrition Group) and BAPEN (British Association of Parental and Enteral Nutrition) through articles, abstracts and presentations to encourage healthcare professionals to consider digital solutions to communicate with patients. There is also potential for other healthcare providers to develop a similar App for Homecare, now that we have shown how effective it can be.

This initiative has benefits for patients, nurses and the environment; it has taken a simple concept which is widely used in daily life -video calls and implemented this as standard practice in a healthcare environment. The results are that home enterally fed patients can now access information and support, faster than ever before, in a convenient and acceptable way. The benefits for patients can’t be underestimated, being able to access support and advice quickly, at a challenging time such as when you have first been discharged from hospital or when you have a problem with your feeding tube which prevents hydration and nutrition entering your body is important for so many home enterally fed patients. Furthermore, increasing the use of digital technology within healthcare forms a key part of the recent NHS Long Term Plan dedicated to moving towards digitally enabled care across the NHS in the next 10 years, and this App has shown that this is possible, with benefits for patients, carers, healthcare professionals and the environment.

It was important to test the concept with end users, both patients and nurses, before launch to get feedback on what was needed as well as not needed. Testing of the actual App prior to launch on both apple and android phones was important and in hindsight we should have done more of this. We discovered that there are some very old handsets in use which have never had a software upgrade therefore trying to download a new App onto these phones without upgrading the software first was a challenge.

A dedicated person to provide training, answer questions and arrange password resets was needed in the first few months of launch.

A lot of time was spent prior to launch making sure GDPR regulations were met and DPIA (Data Protection Impact Assessments) were completed.

Conducting a certain number of App calls was included as a 2019 objective for all Nutricia Homeward Nurses which has encouraged extensive use and speedy adoption.

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