Enhancing COPD self-management and pulmonary rehabilitation through the co-design and deployment of the CONNECTPlus app in Torbay and South Devon.
Project overview, including who was involved in the project
Working in partnership with Health and Care Innovations (HCI) the Torbay and South Devon NHS Foundation Trust (TSDFT) respiratory team have co-designed and deployed resources on the multi-condition CONNECTPlus app to support COPD self-management and pulmonary rehabilitation (PR). The app utilises a "For, From, About" model:- Information FOR Patients: 24/7 access to tailored support and information that patients and their carers can revisit at any time.
- Pulmonary Rehabilitation: Educational resources, on-demand videos and structured self-directed education sessions replicating existing face-to-face programme.
- COPD Management: Self-management resources covering inhaler technique, management of exacerbations, lifestyle changes, exercise and mental health support.
Information FROM Patients: Interactive features capture data from patients including:
- Pulmonary Rehabilitation: Daily activity check-ins, completion of programme modules, BORG scale scores and pre/post exercise symptom levels.
- COPD Management: Symptom trackers for breathlessness, coughing, sputum, energy levels, and BORG Scale scores.
Information ABOUT Patients: Dashboards provide clinicians with access to real-time data enabling monitoring of:
- Pulmonary Rehabilitation: Health status and completion of pulmonary rehabilitation programme modules.
- COPD Management: Care plan compliance and identification of signs of deterioration enabling early proactive intervention
CONNECTPlus is available for all COPD patients across Torbay and South Devon. Engagement with primary care and community nurses in the co-design of content and functionality ensured it can support care wherever it is being provided, thus enabling the adoption of neighbour health models as well as supporting secondary care delivery. A partnership with Optum (now owners of EMIS Health) will enable direct connection of COPD patients on the primary care record to CONNECTPlus.
Who was involved in this work/project?
Torbay and South Devon NHS Foundation Trust (TSDFT) Respiratory Service
Health and Care Innovations (HCI) Ltd
Project outcomes/impact
The implementation of CONNECTPlus has shown significant positive impacts including- release of staff time through ability to offer completely digital or hybrid rehabilitation programmes
- ability to deliver programmes at reduced cost and despite staff shortages
- avoidance of need to contact health professionals e.g. access to FAQ’s/advice/guidance
- delivery of care truly personalised to patients’ current health status and needs
- prevention of crisis and proactive early intervention avoiding unplanned contact with health system
- increased accessibility for patients to self-management advice and guidance and consistency of information provided
For pulmonary rehabilitation specifically
- over 400 patients signposted, 120 patients joined the digital pathway directly, reduced drop-out rates, patients spend 1 hour per session (45% higher than standard app engagement), and 83% of users would recommend CONNECTPlus.
- patient-reported outcomes show improved mobility and reduced reliance on in-person sessions.
- data insights enable service planning and population health management
- export of data enables local and national audit reporting
- ability of a local system to demonstrate alignment to core strategic objectives of delivering neighbourhood health, care closer to home, prevention rather than treatment and shift from analogue to digital.
If you were to run the project again, what would you do differently?
- Engage with senior operation leads to enable integration of the service transformation into Trust strategic transformation programmes from outset- Identify evaluation metrics and data collection resources required and embed into project plan from outset
- Engage with business intelligence / performance and finance teams to enable health economics assessment of new pathway
- Develop multi-lingual versions of the videos and app content in order to address health inequalities
- Leverage commissioning leads to promote to primary care
- Develop a solely digital pulmonary rehabilitation pathway which patients can access directly via self-referral
Advice you would have for others undertaking the same type of project.
- Co-design CONNECTPlus content and functionality with patients and the multi-disciplinary team across secondary and community based care- Reflecting local pathways and information in the app gives patients confidence that it is an integral part of the service that is supporting them and therefore promotes engagement and retention
- Provide FAQ’s alongside information on when and how to get additional support as this reduces overall number of unplanned contacts
- Utilise communications team to promote CONNECTPlus to patients and staff, share benefits and celebrate successes eg onboarding of first cohort of patients
- Identify CONNECTPlus champions / super-users within the clinical team who can engage with colleagues to support embedding and scaling of the new pathway