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Frimley Health and Care Integrated Care System uses remote monitoring in care homes


Frimley Health and Care Integrated Care System uses remote monitoring in care homes, enhancing outcomes for residents

Frimley Health and Care Integrated Care System uses remote monitoring in care homes to ensure care is provided to patients in the right place, at the right time, enhancing outcomes for residents.

Frimley Health and Care Integrated Care System (ICS) is offering a remote monitoring service to all care homes with impressive feedback:  demonstrating a reduction in waiting time for clinical access, reducing avoidable GP visits to the homes, gathering and providing vital information for clinical decision making, speeding up access to clinicians, upskilling staff and providing enhanced outcomes for residents.

This successful remote monitoring project forms part of the Connected Care programme in Frimley, where Docobo’s DOC@HOME® remote monitoring solution seamlessly integrates with Graphnet’s Shared Care Record, enabling health and care professionals to access patient information from acute trusts, primary and community providers, clinical monitoring hubs and ambulance providers.

The Connected Care team at Frimley ICS has made use of population health tools and remote monitoring since the start of the  Covid pandemic, and have since expanded into remote monitoring in care homes and a focus on monitoring those with long term conditions. or a combination of complex conditions

The team has worked with Docobo, Graphnet, Berkshire Primary Care and East Berkshire Primary Care Out of Hours (OOH) to implement Docobo’s remote monitoring solution where it is integrated into the shared care record.

Care home staff there can take residents’ readings – such as blood pressure and blood oxygen – and record symptoms and soft sign feedback via DOC@HOME, with the data being made available to a clinical monitoring hub – run by either Berkshire Primary Care or East Berkshire Primary Care Out of Hours (OOH). This has proved to reduce avoidable GP visits to the home, while enabling teams to monitor residents in their usual environment and reduce workload for primary care teams.

The problem

Frimley ICS’s Connected Care team wanted to roll out remote monitoring to its care homes across the region in order to enhance care for residents in the home.

What is remote monitoring in care homes?

  • If a resident shows signs of deterioration, a member of the care home’s staff can record vital signs and symptoms into a provided tablet device Care homes can carry out ‘resident of the day’ checks on residents to provide baseline measurements which can be vital to clinical decision making or baseline readings are recorded monthly with a ‘Resident of the Day’ system.
  • Information is transferred to the clinical monitoring hub
  • Care homes can track information on clinician website
  • Clinical hub responds to any requests or alerts within two hours and the alert is triaged.

The project has rolled out at care homes across Farnham with great feedback:

Susan Gurung is Support Manager at Ashton Manor Nursing Home in Farnham and says: It is a very smart system and supports day-to-day working. If you are an RGN working alone and have concerns about your resident, you can set an alert via Docobo tablet. It saves time calling the GP or Matron and you don’t have to wait on the telephone. EBPC are really helpful in reviewing alerts, providing clinical advice, and triaging. The training was good – particularly the ‘train the trainer’ session. I have also found Connected Care (Graphnet) very useful where we can access all the medical history, check changes in medications, and GP consultation dates – it’s saved a lot of time.’

David Brown, GP, Farnham PCN Clinical Director, Clinical Lead for Integration (Farnham Integrated Care Team), Clinical Lead – Population Health (NHS Frimley ICS), and Chair of Farnham Integrated Care Services (FICS) says: ‘The homes like remote monitoring – it encourages them to collect the data needed for the clinicians at the practice. It has also encouraged the homes to work on other technological advances. As a duty doctor, I always look at the data in Connected Care before I contact the home, as the baseline data is really good. For example, when a patient alerted with low temperature and low pulse rate, we looked at their data and found that this was normal for them. We were able to provide feedback on the service to the monitoring hub who act on that information.’

Juliana Haddaji is Registered Manager at Grace House in Farnham says: ‘Senior staff are really championing the ‘resident of the day’ approach and we are using this to do further training with the staff as it’s been really useful for baselines. All the seniors are very familiar with the system and really like it. We don’t have nursing staff onsite, as we are a residential home– so the Docobo system gives staff the confidence that – once triaged – EBPC will phone really quickly and give them advice or aid in escalating as necessary. Prior to remote monitoring, escalating NEWS scores was met with a lack of understanding from professionals in the field, Docobo has improved communication with professions as well as Safety and confidence for residents and staff , the system has proved to be a valuable addition to us as  a residential care home.

Once staff have used Docobo once, they’re happy. Not all staff tech confident, but once they have used it – they are happy to use it.  Remote monitoring has really improved things – and speeds things up. The telephone queue for the surgery is usually really long, so using remote monitoring speeds this up and saves time. At the weekends, calling 111 takes a person off the floor to wait on hold.

It’s given staff confidence – they know that if they have a query about a resident, the query is triaged and responded to. Patient safety has improved. The monitoring hub team are absolutely brilliant – calm and reassuring.’

May Edwards, Community Matron at Farnham PCN says: ‘The Docobo/Graphnet (DOC@HOME and Connected Care) portal is excellent! The system has streamlined the process for care homes to talk to a clinician directly for advice and support. The residential care home staff have found it invaluable to escalate care, as often they cannot get through to the GP surgery promptly.

I have found the patient info gathered and displayed on Graphnet / Docobo (Connected Care) portal is so useful as it gives me a snapshot summary of that patient, so that my decision making is optimised to arrange correct treatment. The clinical info displayed is super clear and user friendly.’

Mandy Gundry, Community Matron at Farnham PCN says: ‘We’ve only had positive feedback from the homes. It’s a very efficient use of staffing and gives peace of mind for the homes.’

Kailash Khanal, Registered Manager at Beech House in Binfield says: ‘The Docobo remote monitoring system is working really well for us. We are not having to contact our GP as much – but we are not bypassing them, simply using them when we really need to. Some of the team don’t have clinical backgrounds and so using the remote monitoring system to collect vital signs has really empowered them to use their skills and to build their confidence. It’s really reducing the time that used to be consumed by making phone calls to the surgery. We are really happy! We enter the vital signs into the iPad, and it’s all uploaded! It really supports our person-centred care planning and it’s so easy to use.’

Sophie Anderson, Remote Monitoring Service Manager, at EBPC says: ‘I feel we have a great interaction with all our care homes. Staff and I are supporting the care homes with various visits, to empower their staff with the importance of entering data onto Docobo for their residents and answering any queries the care homes may have about our service.’

Michelle O’Keefe, Operations Manager, at Berkshire Primary Care (BPC) says: ‘As a relatively new service to BPC, we were impressed with the ease of introducing DOC@HOME to our care homes, massively helped by the ongoing support and training provided by Docobo.

Over time we can measure the positive impact DOC@HOME has had on Care Home residents and staff, along with our GP surgeries – quicker response times, ability to detect early deterioration which in turn can prevent ambulance call outs / hospitalisations, freeing up the services of GPs when able to use alternative escalation pathways.’

Julie Chell, Nurse, at BPC says ‘Having spent time with care homes during their implementation of Docobo, it is positive to see how staff have embraced and engaged with the platform.  It is great to see once using it to its full potential the staff can clearly see the benefits of getting support for deteriorating residents in a timely manner’.

Anna Fishta, Associate Director Shared Care Records & Remote Monitoring, Frimley ICS ‘By working together with Care Homes we can leverage digital capability to spot signs of deterioration early, often before the naked eye could. We are already seeing some fantastic outcomes for our residents and Remote Monitoring is having a positive impact across the whole system.’



‘By working together with Care Homes we can leverage digital capability to spot signs of deterioration early, often before the naked eye could. We are already seeing some fantastic outcomes for our residents and Remote Monitoring is having a positive impact across the whole system.’"

Anna FishtaAssociate Director Shared Care Records & Remote Monitoring, Frimley ICS
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