Implementation Lessons from the Jeroen Bosch Hospital
This case study focuses on the vision of digital care within the Jeroen Bosch Hospital and explains how two departments have established home monitoring in daily practice.
- By embedding innovation into the departments, a culture of trust has been created and successful pilots are scaled up quickly.
- 80% of notifications are handled through central triage and Luscii’s smart algorithm. This gives caregivers more time for patients who need more support.
- Patients value this form of digital care (over 4* rating on a scale of 5).
Introduction
The Jeroen Bosch Hospital (JBH) aims to achieve the highest health and wellbeing rating in the Netherlands for the region by 2025. Healthcare does not always have to take place in the hospital, in fact, bringing care closer to home and giving patients more control are important themes. With Luscii, a hospital-wide approach has been chosen to allow as many departments as possible to use home monitoring. Patients with COPD, hypertension, heart failure, complications during pregnancy, and other conditions, have been able to use home monitoring for some time. More recently, the cardiac rehabilitation and the Covid at Home programs were launched in collaboration with regional GPs.
As innovation manager, Rina Arkesteijn is closely involved with many innovation projects throughout the hospital. “We really work together as partners on the continued development of programs that meet the needs of each department. Innovation must take place in collaboration with healthcare professionals. That is why the i-team (i stands for innovation & implementation) is not a separate department. Otherwise, as an innovation department, you are responsible for the success of innovation and, instead, the change must come from the employees themselves. As an innovation team, you must be able to learn from your projects, and allow space for creativity and experimentation”.
The JBH Board of Directors strongly believe in innovative projects, which is reflected in the available budget and the way innovation is embedded into the organisational structure. The i-team falls directly under the Board of Directors. One of the board members is chair of the innovation committee. Within the i-team, members are seconded for a number of hours to a specific project, under the support of their own department. “There must always be a driving force behind the project, if no one gets excited about it, it gets left behind. This allows you to keep the innovation within the department, while also creating shared responsibility and nurturing trust”. The hours and costs of the innovation are funded by the i-team’s budget. If the result is successful, i.e., everyone involved (patients and employees) is satisfied, the innovation is embedded into the department in daily practice.
“Trust is also very important when collaborating with innovative external partners; that you work together towards a higher goal. The focus should lie with the process and not the end product. Often, you don’t know in advance how a project will turn out, which makes it more of a surprise, as you shape it together as you go along. We prefer to work with a few suppliers hospital-wide rather than a different party for each department. Numerous different apps and systems are not conducive to a satisfying patient experience. As an innovation manager, you keep this overview”. In every innovative project, patients are involved from the start to find out as early as possible whether the innovation really meets their needs and whether it will actually be used in practice. And patients very much like to be involved, they really enjoy it when they are asked to be a part of such a project.
“Doctor, take a look at my app, I can keep track of it all in here, and if I press this, they give me a call” Patient (83 years old)
Creating a soft landing by involving the ICT department at an early stage
“As an i-team, we have a close relationship with the hospital’s MICT department. However, a gap existed between successful pilots and subsequent implementation. So, the decision was made to assign the implementation to the i-team following a pilot. Once the implementation is complete, we hand it over to the MICT management team. By involving them in innovative pilots at an early stage, we create a soft landing. As the management of ehealth and cloud solutions requires different skills from the management team than traditional functional management”.
Early inclusion and use of the monitoring centre
Joke van Driel, nursing specialist at the heart failure clinic, has been involved from the very beginning, since Luscii began working with the JBH back in 2018. As part of her research into telemonitoring for her training, she supervised and analysed the very first group of 25 patients with heart failure. The group has now grown to more than 100 patients. This required adjustments to the organisation of care.
Home monitoring significantly contributes to the quality of care
“A patient diagnosed with heart failure is referred via the cardiologist. We make a distinction between two patient groups: chronic and acute. We arrange an in-depth introductory appointment with every patient at the hospital, during which we explain both the condition and the treatment (medication and lifestyle guidelines), and home monitoring. This appointment is also important for explaining the ‘why’ of home monitoring. This helps patients understand why they should increase their medication, for example. In principle, all patients can participate; our oldest patient is 91 years old.
Patients will then take their own measurements for two to three weeks, followed by a telephone consultation to assess whether the medication can be increased. As the patients have already taken measurements (heart rate, weight, blood pressure) for weeks, which I have access to, I can increase the medication much more precisely than if they come to the clinic and provide one measurement there and then. In chronic patients, you can see the weight increase and can intervene earlier to prevent admission due to decompensation. This makes a significant impact on the quality of care and the quality of life. Patients need to visit the hospital less often, too. The next time would be for their ultrasound, which occurs three months after their medication has been adjusted to its optimum dosage.
Patients discharged from the ward can also participate; the doctor decides which patients are eligible. Selected patients are enrolled on the ward and the use of the app is explained and the materials (scales and blood pressure monitors) are provided. When the patient visits the clinic for the first time, after two weeks, there are already two weeks’ worth of measurements to fall back on and you can adjust the treatment directly.
“… They were lovely people there at the JBH, but still, I prefer my wife”
Monitoring centre single-handedly deals with 80% of alerts
Due to the growth in the number of patients, it is impossible as a nursing specialist to be able to do everything yourself. A monitoring centre is a godsend in cementing the success of home monitoring. During the first Corona wave, the hospital’s monitoring centre was set up at speed, manned full-time by two interns. They ensure that every patient registered for home monitoring receives an explanation of the app and the necessary materials to take measurements at home. They visit the ward to ensure that patients can get started independently with home monitoring or contact patients who are enrolled through the outpatient clinic by telephone. In addition, the monitoring centre plays a crucial role in handling alerts. Simple alerts, such as a single high blood pressure reading, are handled according to protocol, and the nursing specialist is only consulted in the case of a complex alert. This consultation takes place for half an hour every working day, as standard. The monitoring centre is an essential filter, which means that a nursing specialist is only needed for complex cases.
In practice, it appears that the monitoring centre can process 80% of alerts without consulting a nursing specialist. As a result, mutual trust is very important; for the nursing specialist to let go and for the interns to gain the confidence to make decisions. Naturally, they have received a thorough explanation of the conditions and protocols, so that they can carry out a short telephone inquiry with the patient. The interns work hospital-wide, so also with COPD, asthma, pregnancy hypertension and the COVID-19 home program. We are already seeing many benefits from organising capacity in a different way. Soon, simple alerts will also be handled by Luscii’s smart algorithm, which will result in even more effective monitoring”.
Act quickly and dare to experiment
As a physiotherapist, Ruud Reijmers is involved in the multidisciplinary care of cardiac rehabilitation. Patients attend the hospital for group training and are coached to achieve clear goals. Corona made it much more difficult to support patients during their recovery, as group training was no longer allowed.
Fast-tracked thanks to Corona
“For years, we had the idea of offering people more than physical rehabilitation in the hospital. Every patient is different, and you want to be able to adapt the training program to the specific needs and preferences of your patients. Some patients are very independent and want to be able to do more training at home. Thanks to Corona, this idea gained momentum. We were no longer allowed to receive patients for rehabilitation at the hospital and had to rely on telephone support. That worked reasonably well, but that lack of ‘visibility’ left questions about what exactly the patient does at home in terms of training. That’s when we sat down with Luscii to see what was possible within the app.
We have made agreements within the cardiac rehabilitation team as to which patients are suitable to participate in this form of remote care. We are now starting with the non-STEMI group that show no fear of exercise, are digitally skilled and are happy to take part. We then expand inclusion slowly, for example, to patients with an acute coronary syndrome, who will then receive a more extensive and intensive program. The cardiac rehabilitation nurse plays an important role in selecting and informing patients. If patients are suitable, the monitoring centre takes over the explanation and handles the logistics.
Home rehabilitation customised for every patient
A rehabilitation program that normally takes three to six weeks with hospital visits twice a week has been converted into a hybrid program. We schedule patients in for 6 weeks of supervision, with the aim of independent training, at home, after 3 weeks. Patients visit the hospital several times in the first few weeks for physical training. The physiotherapists supervise this training and, at the same time, familiarise the patient with the program via the app. During this period, patients are encouraged to think about how they can get enough exercise at home and what kind of exercise suits their body and lifestyle. Someone who likes to swim, for example, can use that activity as part of the training. After a period of up to 3 weeks, the patient then continues his or her activities at home, using the Luscii app. As an example: after swimming, the patient fills in an intensity score and simply measures their heart rhythm using their smartphone’s camera. This allows the progress of the recovery to be monitored remotely.
The patient is coached for three months via the app, during which there are at least two telephone appointments. Based on the app scores, the physiotherapist can provide specific guidance and coaching. We also advise patients to provide as much information as possible with their scores, for example, “I was cycling into the wind”, so that we can ensure truly customised guidance. And if someone has worked in the garden for an hour, that also counts as exertion. Based on the measurements and feedback from the patients, it may be necessary to have more frequent contact, which is an important role for the multidisciplinary team. The psychologist, for example, also has access to the measurements and can contact the patient via the app.
Get started, even if your program isn’t perfect yet
We developed this program in a short time, with Corona really acting as an accelerator. Thanks to the enthusiasm of the multidisciplinary team, we were able to act quickly, while matters such as patient safety were also critically examined. The program is not yet completely watertight, but we want to learn as we go. We want to get people on board now and continue to evaluate throughout the process. Patient satisfaction regarding the program will also be investigated. We already expect to be able to support about 10% of the 650 patients we see annually at our cardiac rehabilitation clinic. In time, we also want to broaden the inclusion criteria to allow even more patients to participate.
My expectation is that patients will be enthusiastic, that it really brings added value. Of course, even in general society, people are already busy measuring their health status, just think of apps, such as Strava, and smartwatches and wearables (FitBit). As healthcare providers, you want to be part of this movement. In international studies, too, you see the measurement of values via devices in healthcare occurring more often. This simply is the future!”.
*All patients who use a Luscii program in the JBH enter a rating score within the app.
