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21/50 - National Evaluation of NHS @home supporting document


Supporting document for 21/50 - National Evaluation of NHS @home
Closing date: 1pm, 03 August 2021

Below is a list of the various programmes within NHS @home which are likely to be within scope of the evaluation. 

Proactive Care @home

Restoring essential proactive care for people with long-term conditions (including cardiovascular disease, atrial fibrillation, hypertension, high cholesterol, type 2 diabetes, asthma and chronic obstructive pulmonary disease) who have been identified as being at higher risk and who would benefit from more targeted proactive care. Work is currently underway with 4 integrated care system (ICS) sites and there are plans to scale this significantly for every ICS in 2021/22.

Blood Pressure @home

This service provides blood pressure monitoring devices (200,000 are being distributed) to people with uncontrolled hypertension so they can take readings in their own home enabling self-monitoring and effective management of the condition. This work will be taken forward under the Proactive Care @home programme as one of the pathways for people with hypertension.

Pulmonary Rehab @home

This work will align closely with Proactive Care @home and aims to support the restoration and recovery of rehabilitation through an @home approach to increase the number of patients being referred, reduce variation and health inequalities, improve outcomes, and improve processes.

Virtual Wards

Virtual wards support safe and earlier discharge of patients from hospitals. People are given pulse oximeters and other devices / treatment and support to help manage their recovery at home. Discussions are underway regarding expansion of the Virtual Ward model to non-COVID patients.

Heart Care @home

Implementation of targeted and specialist support in five ICS to provide support to people with heart failure.  Working with a specialist clinician, patients supporting to better self-manage their condition. This includes managing medications, reducing salt intake, monitoring, and recording their weight and blood pressure daily as well as support to recognise when their condition deteriorates, and appropriate action is needed.