Intouch has developed a new service called “Staywell” focused on self care education for patients with long-term conditions. As well as empowering patients and improving their confidence and quality of life, Staywell is designed to reduce their complications and exacerbations. It is therefore a key element in unscheduled care strategies, the avoidance of hospital admissions and the shift of care out of the acute setting and into the community.

The Staywell range currently covers COPD, Angina, Diabetes and Medication Compliance. This will shortly extend to Atrial Fibrillation, Stroke Prevention, Heart Attack, Heart Failure and Hypertension.

A special version of the service, Staywell 75, is designed to identify early stage, emerging health risks in older patients which are likely to result in hospitalisation if not managed in good time.

The service is very straightforward and has four main elements.

1.Patient knowledge gap “audit”
A non-intimidating, easy-to-complete questionnaire asks patients how much they know about certain key aspects of their condition and its management. Questions range from eg “Do you know how to self-monitor (measure) your diabetes?” to “Are you aware of local support services for people with diabetes?” The survey also helps detect behaviour gaps (eg not eating the right things). In the case of Staywell 75, the questionnaire focuses on health risk situations, eg where the elderly patient has had a fall recently.

2.Patient check-up gaps
Part of the survey checks whether patients have had all the check ups which they should have as part of their care plan, eg had their insulin injection sites checked..

3.Filling the gaps
Staywell provides immediate information to plug the gaps in the patient’s knowledge, including how to go about getting the check ups they need and how to access all the local facilities that are available to them. In Staywell 75 the focus is on advice as well as information to help the elderly and their carers manage developing health risks.

Patients can participate in their survey and obtain answers both in “pen-and-ink” format and electronically via the internet and touchscreens. There will soon be a phone version, and attention is being paid to the needs of hard to reach groups, including people whose first language is not English.

4. Valuable Reports
The system produces valuable data to help practice nurses and GPs to conduct more effective consultations with patients and to identify those patients at most risk.

Additional data allows PCT managers to identify most prevalent knowledge gaps and risks across their whole health community so that patient education and advice can be more effectively planned.