A Whole System Approach to Developing Telecare Strategy Paul Forte The Balance of Care Group .
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Transcript of A Whole System Approach to Developing Telecare Strategy Paul Forte The Balance of Care Group .
A Whole System Approach to Developing Telecare
Strategy
Paul ForteThe Balance of Care Groupwww.balanceofcare.com
Telecare and telemedicine
• Telecare:Continuous, automatic and remote monitoring of real time emergencies and lifestyle changes over time in order to manage the risks associated with independent living.
• Telemedicine:The use of medical information exchanged via electronic communications for the health and education of the patient or healthcare provider and for the purpose of improving patient care. It includes consultative, diagnostic, and treatment services.
Communities of Living
Communities of Care
Communities of Communities of Professionals/Practice
Work
Family life
Leisure
Sport
SchoolsLearning
Parent craft
Community societies
Religious life
Utilities
Environment
Healthy living
Local government
Community legal frqmework
Local transport
Primary care
Social care
Chronic disease
management
Community care
Emergency care
Care homes
Sheltered housing
Voluntary
organisationsSocial work teams
Primary care teamsHospital
teamsCare home teams
Managers
Disease Management teams
Rehab teams
Relationships between the Communities of Living, Care , Professionalsand Practice
Pubs/bars
Local shops
© Balance of Care Group
Developing a businesscase for telecare
• It’s more than installing alarms and having a call centre:– what kind of service are you planning to
provide for people at home?– who should it be provided for? – how does it connect with wider health
and social care strategy?• …and how do you prevent schemes from
becoming ‘yet another pilot’?
Local telecare developments
• How does what’s currently underway locally fit with existing service provision?
• Expansion of telecare – what will the local implications be for: – service reconfiguration?– information flows and exchange?
• Evaluation of telecare projects
New technology + Old system =
Expensive old system
Pre admission
Pre admission Admission Diagnosis Treatment Discharge Re-admission
Social details
alone, carers, residence
Risk factors:
age, drugs, co-morbidities,
psychiatric/
dementia, falls
Preventative care
Disease managementManaged populations
Source of referral
Time
Waiting time
Route
Decision maker
Reason for admission
Alternatives to acute admission setting
Admission diagnosis
Inpatient diagnosis
Delays in diagnosis
Chronic disease
Alternative access for diagnosis
Delays in therapy
Alternative settings for therapy (especially rehab)
Discharge planning
Delays in planning
Delays in execution
Alternative sites for discharge
‘Revolving door’
Avoidable e.g. chronic disease management
Alternative sites for readmission
A whole system perspective
© Balance of Care Group
OlderPeople
highdependency
lowdependency
mediumdependency
The Balance of Care model
© Balance of Care Group
OlderPeople
highdependency
lowdependency
mediumdependency
long termcare bed
community nurse
Voluntary &independent sector
NHS
LocalAuthority
care home
physiotherapist
care assistant
day care centre
respite care
The Balance of Care model
telecare equipment
© Balance of Care Group
OlderPeople
highdependency
lowdependency
mediumdependency
long termcare bed
community nurse
Voluntary &independent sector
NHS
LocalAuthority
care home
physiotherapist
care assistant
day care centre
respite care
option1
option 2
option 3
The Balance of Care model
telecare equipment
© Balance of Care Group
Balances to be struck
Care Professionals Non-Clinical Managers
Social Services Health Services
High Dependency Low Dependency
P6 Unsupported at home (aged over 65)
P1 Care Home Residents(not EMH)
P2 Care Home Residents(EMH)
P3 Frailty CaseManagement
(Severe)
P4 Other long term careneeds
(Moderate)
P5 Other low intensityneeds(Minor)
Defining the telecare population
Category descriptionsCategory Label Intended Population Base Data Source for Telecare Valley
Care home residents - not EMH Permanent care home residents over 65 supported by council (excluding Elderly Mental Health)
England residents at 31-03-2004 / 150
Care home residents - EMH Permanent care home residents over 65 supported by council (Elderly Mental Health)
England residents at 31-03-2004 / 150.
Case management - frail older people
Numbers over 65 receiving intensive home care (> 10 hours per week). These are assumed to be the people who would be included in case management schemes for frail older people.
Based on England number receiving intensive home care (over 10 hours) at 31-03-2004 / 150.
Other long term care needs Numbers over 65 receiving home care (5- 10 hours per week). These are assumed to be the people who require continuing social care support, but do not have chronic healthcare needs appropriate for case management.
Based on England number receiving 5-10 hours of home care at 31-03-2004 / 150
Other low intensity needs Numbers over 65 receiving home care (< 5 hours per week)
Other England low intensity home care (<5hrs per week) at 31-03-2004 / 150
Unsupported at home >65 Total resident population 65 years and over, not receiving a social care service
England 2001 Census, resident population over 65, divided by 150, and net of estimated values for P1 to P5 inclusive.
Building the business case: the way ahead…
• Organisational issues: – partnership working? innovative
connections? workforce / skills development?
• Information issues: – Access/ sharing data? Information
exchange? common definitions/ criteria?
• …while bearing in mind…– need to harness the drive of health and
social care professionals, clients and carers
Evaluating complexity
• How do we evaluate a complex adaptive system which is:– always changing?– subject to constantly shifting goal posts?
• Evaluation on a multi-dimensional framework– variation over time– variation between similar system
The ‘Balanced Scorecard’ approach
• Evaluation on several dimensions such as: care/ clinical outcomes patient/ client satisfaction systems process outcome cost/ cost effectiveness
• All within the same time frame
• Using a wide range of agreed quantitative and qualitative measures and tools
Key issues
• Identifying communities and networks of care• Role of telecare as a network ‘enabler’ • Integration and sharing of information• Configuration of service response and delivery• Evaluation
Clin
ica
lsy
ste
ms
(HIC
SS
)
Blood Pressure Cuff
Pulse Oximeter
Peak Flow Meter
Weighing Scales
Glucometer
Video/ patientinterface
Specialist Staff(Spec Nurses, Consultants
GPSIs)
Case Managers(Comm matrons, social workers)
Other Key Staff(GPs, Community Geriatrician.
Therapists, District Nurse)
Possible Information Flows to link Telemedicine Applicationsto Management of Long Term Conditions
Data interface
Data input & access
Direct communication
Clin
ica
lsy
ste
ms
(HIC
SS
)
Blood Pressure Cuff
Pulse Oximeter
Peak Flow Meter
Weighing Scales
Glucometer
Video/ patientinterface
Specialist Staff(Spec Nurses, Consultants
GPSIs)
Case Managers(Comm matrons, social workers)
Other Key Staff(GPs, Community Geriatrician.
Therapists, District Nurse)
Possible Information Flows to link Telemedicine Applicationsto Management of Long Term Conditions
Data interface
Data input & access
Direct communication
Web-basedaccess
tool
Clin
ica
lsy
ste
ms
(HIC
SS
)
Blood Pressure Cuff
Pulse Oximeter
Peak Flow Meter
Weighing Scales
Glucometer
Video/ patientinterface
Specialist Staff(Spec Nurses, Consultants
GPSIs)
Case Managers(Comm matrons, social workers)
Other Key Staff(GPs, Community Geriatrician.
Therapists, District Nurse)
Possible Information Flows to link Telemedicine Applicationsto Management of Long Term Conditions
Data interface
Data input & access
Direct communication
Web-basedaccess
tool
Clin
ica
lsy
ste
ms
(HIC
SS
)
Ca
resy
ste
ms
(PA
RIS
)
Blood Pressure Cuff
Pulse Oximeter
Peak Flow Meter
Weighing Scales
Glucometer
Video/ patientinterface
Specialist Staff(Spec Nurses, Consultants
GPSIs)
Case Managers(Comm matrons, social workers)
Other Key Staff(GPs, Community Geriatrician.
Therapists, District Nurse)
Possible Information Flows to link Telemedicine Applicationsto Management of Long Term Conditions
Data interface
Data input & access
Direct communication
Web-basedaccess
tool
Clin
ica
lsy
ste
ms
(HIC
SS
)
Ca
resy
ste
ms
(PA
RIS
)
Blood Pressure Cuff
Pulse Oximeter
Peak Flow Meter
Weighing Scales
Glucometer
Video/ patientinterface
Specialist Staff(Spec Nurses, Consultants
GPSIs)
Case Managers(Comm matrons, social workers)
Other Key Staff(GPs, Community Geriatrician.
Therapists, District Nurse)
Possible Information Flows to link Telemedicine Applicationsto Management of Long Term Conditions
Data interface
Data input & access
Direct communication
Web-basedaccess
tool
Clin
ica
lsy
ste
ms
(HIC
SS
)
Ca
resy
ste
ms
(PA
RIS
)
Blood Pressure Cuff
Pulse Oximeter
Peak Flow Meter
Weighing Scales
Glucometer
Video/ patientinterface
Specialist Staff(Spec Nurses, Consultants
GPSIs)
Case Managers(Comm matrons, social workers)
Other Key Staff(GPs, Community Geriatrician.
Therapists, District Nurse)
Possible Information Flows to link Telemedicine Applicationsto Management of Long Term Conditions
Data interface
Data input & access
Direct communication
Web-basedaccess
tool
TelecareApplications
Telecare model
Policy assumptions
• Main focus on social care
• Restrict to ‘currently supported’ clients
• Investment in ‘response mode’ telecare only
• Model populated for average council - ‘Telecare Valley’
Of course, these assumptions can be varied to suit local applications
BALANCE OF CARE PLANNING MODELCurrent Location: Telecare Valley
Definitions and Data Results - tables
ModelResults - graphs
Scenarios
Client Categories
Service Details
Care Options
CLOSE
Service Costs
Service Units
Cost by Service
Summary
Cost by Client Category
Cost by Service Group
Scenario Menu
Locations
P2 - Care home residents - EMH No. of C lients: 218Unit Cost: £21,320 £19,583 £16,835 £ £ £ Totals
Allocation: 85% 10% 5% 100%Allocated C lients: 186 22 11 0 0 0 218
Code Service Description Current Extra care Home with Opt 4 Opt 5 Opt 6 CostS1 Community nurse £S2 P hysiotherapist £S3 Care Assistant 730 1095 £386,026S4 OT 12 12 £9,825S5 Geriatrician £S6 Rehab asst £S7 Care home EMH 52 £3,956,637S8 Care home (non-EMH) £S9 Acute bed £S10 Comm hospital bed £S11 Telecare 52 52 £25,545S12 CP N £S13 Night sitter 12 12 £19,650S14 Extra care housing 52 £170,300S15 Day care £
Total Cost: £3,956,637 £427,567 £183,780 £ £ £ £4,567,983Quality Score: 60% 80% 100% 64.0%
Menu ><
Evaluation
Cycle of evaluation and strategy generation
Strategy
knowledge
Operationpractice
Evaluation
learning
Re-envisioning reviewing
Complex adaptive systems
‘A complex adaptive system is a collection of
different agents with freedom to act in ways that are not always totally predictable, and whose actions are interconnected so that one agent’s actions changes the context for other agents – examples are the immune system, a colony of termites, the financial market… and just about any collection of human beings.’
Plsek 2001
Criteria to consider
• What will we measure?• How will we measure it?• How and to whom will it be reported?• What are the changes necessary and
how will they be implemented?• What have we learned?
Possible outcomes to be measured: 1
• Care outcomes: deaths and morbidity measures hospital admissions avoided/patients
kept at home improved clinical function better medicines management
• Customer satisfaction:
patient/ client satisfaction questionnaires
referrers satisfaction (timeliness, one call, etc)
Possible outcomes to be measured: 2
• Processes accessibility use and appropriateness of technology monitoring and availability of data base functioning of ‘expert teams’
• Cost total budgets banded costs per episode comparative costs of community
compared with hospital care
Steps in evaluation
• Build an ‘external evidence’ database• Agree a set of evaluation measures
with users• Use first small-scale trials of TM
equipment to prove whether these measures are sufficient and if data can be readily obtained
• Refine evaluation measures• Roll-out on a larger scale• Reporting cycles and timescales