A movement for change www.integratedcarefoundation.org @IFICinfo

The use of remote care in

improving the support to

community dwelling older people

Dr Nick Goodwin, CEO paper to Quality Care for the Elderly, Kowloon Shangri-La Hotel, Kowloon, 25 June 2016

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Understanding the role of new

technologies

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Effective ICT is the Key to System Cohesiveness

– The Glue and the Grease

Source: Valentijn et al (2013) Understanding integrated care: a comprehensive conceptual framework based on the

Integrative functions of primary care, IJIC, vol13. Jan-Mar

A movement for change

A Range of ICT Tools

Ambient assisted living (AAL) – a bundle of technologies used to enhance the quality of life for older people living in the home environment (www.aal-europe.eu)

Assistive (adaptive) technology – any system or device that allows individuals to perform tasks that they would otherwise be unable to perform (e.g. accessible keyboards; speech recognition software; text telephones)

Decision-support systems – computer-based information systems that support care professionals and providers make effective planning and treatment decisions, for example for predicting at-risk patients and/or making care treatment decisions across care pathways

Electronic health records – systematic collections of the health records of patients and populations that can be shared across different health and social care settings

Gerontechnology – techniques and products, based on knowledge of the ageing process, that attempt to match technological applications to health, housing, mobility, communication, leisure and work

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A Range of ICT Tools

Telecare – a service that uses a combination of alarms, sensors and other equipment to help people live independently (usually at home) by monitoring activity and connecting people to care services in times of need (e.g. falls sensors and pendant alarms).

Telehealth - the remote exchange of physiological data between a patient and medical or nursing staff to assist in diagnosis, monitoring and supported self-care (e.g. home units or mobile phone applications to measure and monitor blood pressure and other vital signs for clinical review at a remote location).

Telemedicine – the remote delivery of health care treatment services through the use of alerts, images, audio, video or other type of data used to make a clinical diagnosis and facilitate treatment.

Smart home technology – a collective term for home-based IT services that increase safety and help support independent living (e.g. falls monitors, automatic lighting, and environmental control systems).

Source: Goodwin and Alonso, 2014

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Telecare Telehealth eHealth, mHealth,

pHealth, telemedicine

Community Alarm

Remote monitoring tools

capture physiological

measurements and relay

them to a central location

for review, in order to

allow better clinical

decision making and

personalised support

Examples might include

the measurement of Peak

Expiratory Flow Rate and

Oxygen saturation for

people with chronic lung

disease, or the tracking of

changes in body weight

as a marker of the state of

a person’s heart failure.

Remote monitoring tools

to support the social

needs and safety of

people who require non-

medical support in order

to be able to function

safely within their own

home environment.

Examples might include

sensors which can

automatically indicate

whether a person has

fallen or has been

immobile for a prolonged

period.

Video clinical consultations

between health care

professionals and

individuals avoid the need

for travel to a general

practice or hospital.

Examples include

supporting a diabetic with

erratic glucose levels by

providing specialist nurse

and medical support so that

the patient can solve

emerging problems without

delay and without attending

a hospital clinic. Routine

surveillance appointments

for people with LTCs can

also be carried out using

this approach.

Warden alert, alarm

buttons and pendants

worn by individuals to call

for assistance in event of

an accident or

exacerbation of a pre-

existing condition.

Identified social service

staff can access the home

by remotely opening

doors in an emergency.

These systems are

normally installed and

used by local authorities

and social services in

extra care housing or to

support people living

independently in their

own homes.

Defining the Terms

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Where’s the evidence??

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The Evidence Base: Summary

Systematic reviews of the evidence-base show, or suggest

the potential for, positive benefits in terms of care

management to older people with chronic illnesses

– better clinical outcomes;

– client independence;

– reduced GP visits, A&E visits, hospitalisations and

institutional care placements;

– reduced lengths of stay

e.g. see Barlow et al (2007) A systematic review of the evidence base of the benefits of home telecare for frail elderly

people and those with long-term conditions, J Tel & Tel, 13(4) 172-179; and

Dellifrane & Dansky (2008) Home-based telehealth: a review and meta-analysis, J Tel & Tel,

14(2) 62-66

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The Evidence Base: Summary

• However, there are problems with the evidence – for

example:

– diverse range of technologies used;

– client and patient group differences;

– context of care systems;

– variable depth – usually very small numbers;

– variable quality

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The Evidence Base: Summary

“ Of the large number of studies conducted,

approximately half suggest clinical benefits and

the other half find no effect “

“ There is a lack of evidence to conclude that

telecare and telehealth innovations are cost-

effective “

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A growing field of enquiry

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SMARTCARE

Joining up ICT and service processes for

quality integrated care in Europe

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The SmartCare Approach

There are 22 Regions participating in

SmartCare in one of two groups:

• 9 regions deploying integrated health and

social eCare services

• 13 committed regions participate to learn

from experience of the deployment

regions and go through a programme of

service planning and scenario-based

piloting

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The SmartCare Solution Harnessing ICTs for the benefit of older persons people and those

with chronic diseases

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Integrated Long-Term Home Care

Support

Personalised multi-provider

service package

Entry point

(2):

Referral by

social care

provider Temporary

admission to

institution

(e.g.

hospital, care

home)

Monitoring /

review /

reassessment

of care

recipient’s

needs

Exit point:

Disenrollmen

t from

SmartCare

service (ICP-

LTCare)

Entry point

(1):

Referral by

health care

provider

Assessment

of care

recipient’s

needs for

long term

home care

Enrolment to

SmartCare

service (ICP-

LTCare)

Initial

integrated

care plan

Coordination

of integrated

care delivery

/ revision of

initial

integrated

care plan On-site /

home

provision of

formal social

care

Remote

provision of

health &

social care

(telehealth,

telecare)

Shared

documentatio

n of home

care provided

On-site /

home

provision of

formal health

care

On-site /

home

provision of

informal care

Entering into service Receiving continuous personalised care Leaving service

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Key Care Pathway implementation Services/Activities

and associated ICT applications

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Case Example: Region of Southern Denmark • 1 of 5 administrative Regional Authorities in Denmark

• Inhabitants: 1.2 Million

• Main responsibility:

– Health provision

– Regional development

• Municipalities (social care): 22

• GP’s: 800

• 4 hospital units – 1 university hospital

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Homecare

systems

- EPR

Electronical

patient record -

EPR

Medical system

Data

collection

Platform

The patient’s

individual plan

Information about own

conditiom

Entering data and

measurements

Questionnaire

Social care Hospital Medical practice

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• CareWell supports the integration of care in six European regions

• Aims to improve support for frail elderly patients through multidisciplinary programmes facilitated by ICTs

• Specific focus on elderly people with complex health and social care needs and a high risk of hospital or care home admission

• ICT enabled health and social care services coordination, monitoring, patient self-management, and informal care giver involvement

Elderly people with

complex health and

social care needs

Multi-

disciplinary

teams

ICT enabled

health and social

care services

coordination,

monitoring,

patient self-

management

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Basque Country: Before and After

1. Integration into the EHR of data from the hospital pharmacy

2. Integration of systems to provide EHR in a single system for both care sectors (primary and secondary care)

3. Integration of the clinical information from the CareWell chronic programmes in EHR

4. Messaging between patients (PHR) and clinicians (EHR)

5. Improve the Business Intelligence (BI) to provide new functionalities for patient stratification

6. Development of an educational web platform for patients

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Veteran’s Health Administration

VISN 23, Minneapolis

IFIC International Study Tour to the VHA

19-23 September 2016

Key digital modalities:

• Home telehealth

• Clinical Video Telehealth

(CVT)

• Store & Forward Telehealth

• myHealtheVet

• Mobile health

• eConsultations

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The challenge of adoption of new

technologies

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I can now reveal the answer to the business

case behind the mainstreaming of new

technologies!!

Thanks to James Barlow, Imperial College London

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Telehealth: The ‘chasm’ between early

adoption and mainstreaming

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Adoption Spread Mainstreaming

time

uptake

Enthusiasts

Grants

Pump

priming

Champions

Leadership Project mgt

Awareness

Evaluation

Evidence

Business case

Source: Barlow, Hendy,

Chrysanthaki 2010

The Technology Adoption Curve

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Key barriers

• A lack of robust evidence for the cost-effectiveness of

new technologies – e.g. telehealth/telecare

• The current high cost of deploying some of the

technology ‘at scale’

• Risk aversion within the context of a cold financial

climate

• Professionals and organisations adjusting to new ways

of working

• The lack of a consumer market

• The lack of interoperability and minimum standards for

the technology.

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Key Drivers (required):

• Leaders, champions and entrepreneurs to empower and

persuade

• Clarity of organisational goals

– proactive involvement of providers and users

• Strong commissioners who can decommission some

services and embrace new strategies

• Interoperability of technology – future-proofing

• Vision for service redesign and service delivery – not just

about the technology or product

• Evaluation and audit – i.e. proof!

– A business case that understands the costs and

benefits across the whole system

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Some Lessons for Adoption

• Fundamental service redesign

– Integrated care in the home environment

– Change management – key leaders and willing followers

• Re-shape professional development and training

• Industry re-think

– Risk-sharing

– Sell services not technology

– Meet service needs

• Patients and Carers

– Engaged as key stakeholders

– Technology simple to use and increases human contact

– Safe, secure, empowered

• Functionality

– Interoperability

– Shared care records, predictive risk, targeting

• Governance

– Integrated governance and aligned incentives

– Quality standards

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Conclusions

Evidence on integrated care suggests there is benefit to a “high touch /low tech” approach - technology is but a tool

Yet, new technologies have the potential to support improvements quality of life for users, improve care outcomes and to reduce unnecessary hospital admissions and care home institutionalisations

Considerable interest and policy momentum behind their adoption and diffusion across Europe and beyond

The technology is ready

More evidence is required to convince of the full potential of these innovations

Key challenge is on system redesign, cultural change, leadership, workforce, data management and service developments rather than the technology per se - its about mainstreaming the idea from the outset of the integrated care strategy

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Contact Information

Registered Address

Prof Ritzema Boslaaan 5, Utrecht, 3571CL, Netherlands

Administrative Office:

7200 The Quorum, Oxford Business Park North Garsington Road

Oxford, OX4 2JZ, United Kingdom

Nick Goodwin: nickgoodwin@integratedcarefoundation.org

Foundation website: www.integratedcarefoundation.org

Journal Website: www.ijic.org

E-mail address info@integratedcarefoundation.org

Telephone number: +44 (0) 1865487229

Twitter: @IFICinfo and @goodwin_nick

Vimeo: www.vimeo/integratedcare