This case study describes how the team in Cambridge working on the Health Foundation’s Co-creating Health programme has developed a feasibility study to trial a web-based self management package with nurse coach support for housebound patients with COPD.
The team in Cambridge working on the Health Foundation’s Co-creating Health programme won Regional Innovation Funding to conduct a feasibility study to trial a web-based self management package with nurse coach support for housebound patients with COPD.
The system provides the patient with an overall health risk assessment, personal Prevention Schedule according to NICE guidelines, their physician- defined care plan, action programmes to tackle risks, a full Personal Health Record, NHS Choices content rendered within their personal portal, trackers, safe messaging and telephonic and messaging support from the patient’s care team. For the care team, a clinical back-end enables population health management, workflow management, passing messages between care team members, managing telephonic support for the patient, co-ordination with community care etc.
COPD patients who are mainly housebound are supported by a nurse coach to use The Prevention Plan and those who do not already have internet access at home are provided with the necessary equipment (tablet or laptop) and internet connection. The nurse coach will identify and then work with patients to coach them in the use of the Prevention Plan and provide self management support for personal health planning.
The trial was in its early stages at the time of writing, but still includes learning from the process so far.