COPD coaching pilot saves £353,000 in 26 weeks


Leicester City Clinical Commissioning Group awards new 12-month contract to Totally Health to expand health coaching programme

Leicester City Clinical Commissioning Group (CCG) has awarded Totally Health a new 12-month contract that expands on its existing health coaching pilot programme supporting a number of patients with Chronic Obstructive Pulmonary Disease (COPD).

The current integrated health coaching and telehealth service, provided to a 50-person cohort of patients, has saved Leicester City Clinical Commissioning Group (CCG) more than £353,000 in its first 26 weeks.

Based on this success, Leicester City CCG has chosen to upscale and expand the current service clinical model from the current 50 COPD patients into a redesigned long-term conditions service model with health coaching for 150 existing COPD patients and 250 newly-diagnosed COPD patients.

The programme, which has been developed and delivered through a partnership between the CCG, Leicestershire Partnership NHS Trust, and Totally Health, averted 87 hospital admissions for patients registered with the service during the first 26-week period of the original pilot. The admission rate for this 50-person cohort of patients has fallen from an average 3.29 unscheduled admissions to 1.24. This evidence shows that the service has already delivered considerable cost-savings and, crucially, significantly improved the patient experience.

The Totally Health programme combines shared decisionmaking, the new COPD patient decision aid, health coaching and telehealth monitoring – underpinned by a system that links local GP and secondary care databases. Prior to its launch, Leicester City CCG used risk stratification to identify the COPD patients at greatest risk of repeated hospital admissions that it considered would benefit from monitoring and advice from qualified care providers. It is also planning to use similar risk stratification tools to expand the service, as well as introducing newly-diagnosed patients to health coaching as they are identified as most likely to benefit from the mentoring approach health coaching presents.

Totally Health provides a two-way health coaching service that supports individual patients across their total care pathway. Totally’s experienced health coaches are registered nurses, who help patients manage their condition by providing mentoring and support via phone calls alongside telehealth monitoring.

The initial programme launched in December to provide the CCG with immediate support during the winter months when, traditionally, unplanned and often avoidable hospital admissions increase due to exacerbations caused by poor preparation for severe cold weather. Health coaches work with patients and carers to ensure people suffering from long-term conditions are adequately prepared, are fully compliant with their treatment regimen and, when exacerbations occur, use their rescue medication in a timely and appropriate manner. In the process, the service helps to minimise exacerbations and reduce expensive, unnecessary unplanned hospital admissions.

An admission is qualified as ‘averted’ based on a measure of the respiratory specialist nurse and/or the health coach providing an intervention to support the individual patient to manage their condition, to the extent that without this clinical support the patient would have been admitted. If the patient is not admitted for a period 14 days, after the 14th day the intervention is classified as a saved hospital admission.

The integrated programme has so far proved to be a great success for Leicester City CCG. Beyond the substantial reduction in avoidable admissions, the service has also led to a demonstrable improvement in patient experience and patient satisfaction. During the first quarter of the 12-month programme, each patient had an individual ‘symptom response plan’ developed and was supported to increase their confidence to ensure the plan was put into action when appropriate. 54% of patients subsequently activated their plan in response to an exacerbation of their condition. In addition, each patient was contacted and supported to ensure they were optimally prepared for severe weather during the winter months. As a result of the service, almost a third of patients -30% -are already reporting an improvement in their well-being.

CCG programme manager, Emma-Jane Roberts, said: “We wanted to be able to give our patients access to qualified, specialist advice services so that we can shift the balance and focus from a model that responds to illness, to one which promotes health and wellbeing. The health coaching service provides the continuity for these patients to ensure that they maintain the improved self-management of their condition.”

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Dr Durairaj, GP and lead for COPD for the Leicester City Clinical Commissioning Group, added: “Our patients get the support of managing their own condition at home. We know patients are happier and recover quicker when their care is managed at home. We are really pleased that the scheme is working and the project has enabled patients to avoid a hospital stay.”