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


OlderPeople

highdependency

lowdependency

mediumdependency

The Balance of Care model


OlderPeople

highdependency

lowdependency

mediumdependency

long termcare bed

community nurse

Voluntary &independent sector

NHS

LocalAuthority

care home

physiotherapist

care assistant

day care centre

respite care


telecare equipment


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


telecare equipment


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



GPSIs)





Data interface

Data input & access


Web-basedaccess

tool

Clin

ica

lsy

ste

ms

(HIC

SS

)

Blood Pressure Cuff

Pulse Oximeter

Peak Flow Meter

Weighing Scales

Glucometer



GPSIs)





Data interface

Data input & access


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



GPSIs)





Data interface

Data input & access


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



GPSIs)





Data interface

Data input & access


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



GPSIs)





Data interface

Data input & access


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%

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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

A Whole System Approach to Developing Telecare Strategy Paul Forte The Balance of Care Group .

Documents

patient care

hours of home care

intensive home care

social care strategy

social care professionals

social care service

long term care needsnumbers

continuing social care