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Management of the complex patient at home to improve the quality of life and reduce dependency on care services


Management of the complex patient at home to improve the quality of life and reduce dependency on care services

There is an increasing body of evidence supporting the benefits of managing patients complex care requirements in the community. Many patients have multifaceted needs not suited to periodic assessment and reactive intervention management. Not all complexities are readily identifiable through conventional means.


As a result, inappropriate care services may develop, or patients increasingly use emergency services.

This case study shows that effective care management can improve the quality of life of patients, family and caregivers and reduce the the burden on resources.

The Patient

This subject is a 64-year man diagnosed with COPD, Hypertension, Hyperlipidaemia, Diabetes Mellitus, IBS and iron deficiency anaemia. He had a history of poly-pharmacy use and experienced frequent sleep disturbance. He suffered from severe anxiety and depression accompanied by an extreme ‘needle’ phobia.

Before enrolment to the Telehealth programme, was previously assigned to alert management systems within the community and secondary care settings targeted to reduce hospital admissions. During the previous 12 months he had been admitted to hospital 17 times, was calling NHS Direct daily and Out of Hours Services every weekend as well as making frequent calls to his general practice surgery.

Other operational factors

Changes to local secondary care services resulted in journeys to the county accident and emergency unit, some twenty miles distant involving up to six ambulance journeys from
the initial call-out to the final discharge of the patient to his home.

Home monitoring

The patient was enrolled, and the home monitor configured to enable the patient to record information in the morning and late evening and selective information at any time. Following the instruction on the use of the home monitor, the patient self-monitored twice daily, achieving 100% compliance across the monitored period. He was made aware that it was not a replacement for emergency service.

The morning session presented a picture of health status after a period of rest, whilst the evening session identified the impacts of daily activity. The patient used the ‘anytime function’ if feeling unwell or anxious about his health status.

During the period of monitoring the patient was sent supportive messages from the surgery directly to the monitor in the patients home. The patient kept up-to-date with changes and results using the messaging service.

A standard set of questions and measurements were created and used to define a baseline over 14 days. A range of typical responses was recorded and used to establish the patients normalised health status.

Telehealth Results

  • During the 6-month monitored period his usage of home oxygen was reduced from 24 to 14 hours per day with a corresponding improvement in clinical signs.
  • The patient was found to have extreme side effects from theophylline which caused Aortic spasm and reduced his cardiac efficiency by as much as 70%.
  • Following the withdrawal of this medication, the aortic spasm ceased and his cardiac efficiency improved
  • Over four weeks, significant swings in systolic pressure from a low of 74 mm Hg to a high of 210 mm Hg occurred. Investigation of the adrenal gland indicated a raised Vanillylmandelic Acid (VMA)  by 27%.


Each of the issues, previously not identified, were managed and daily recording of ECG and symptoms enabled daily assessment of the patient. Anxiety and depression declined in intensity across the monitored period. Panic attacks diminished, then ceased and his clinical condition stabilised and was much improved.

In the six months following commencement on the programme, hospital admissions reduced to zero (0), and there was no contact with NHS Direct, Out of Hours Services and no calls made to emergency services.

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