IBM Health and Social Programs Summit: Person-centered Team-based Care: Adventures Through Space and Time

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Opening General Session: Improving Outcomes, Changing Lives with

Smarter Care and Social Programs

1. Welcome

John Hearne, IBM General Manager Smarter Care & Social Programs

2. IBM commitment & investment in health & social programs

Steve Mills, IBM Senior Vice President, Group Executive, Software & Systems Group

3. Health and Social Programs as a Cornerstone of Economic Vitality

Dan Pelino, IBM General Manager, Public Sector

Outcomes: the imperative for change in H&SP service delivery

The Honorable Patrick Kennedy, Former US Representative (no presentation, video replay only)

Re-opening the session after break – and introduction of Judge Leifman by Farhana Alarakhiya, IBM Director, Smarter Care

The Realities and Impact of Mental Health Care Approaches

The Honorable Judge Steven Leifman, 11th Circuit District Court, Miami Dade County (no presentation, video replay only)

4. Innovations in access and engagement: Mobile strategies and solutions for health and social programs

Nicole Gardner, IBM Global Industry Leader, Government Healthcare and Social Services

5. Person-centered Team-based Care: Adventures Through Space and Time

Ronan Rooney, IBM Research, Director of Care Programs

Q&A moderated by Farhana Alarakhiya, IBM Director, Smarter Care

© 2014 IBM Corporation

Ronan Rooney

Director, Programs of Care,

IBM Research

#ibmhsps14

Person-centered, Team-based Care Adventures in Time and Space

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Really?

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The Challenge: Improve the lives of our vulnerable populations while

lowering the unsustainable growth in cost to care for them

Slide 10, http://www.hfma.org/anihandouts/xtbce9adrpp1/A03.pdfSource: Commercial Sample – MarketScan

Commercial claims data; Medicare Sample – Medicare 5% sample.

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... If data is considered oxygen for

super-utilizer programs, the care

management team and its

interventions are considered the

“secret sauce” … ... Invest heavily in

“boots on the ground”

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The Need for a New Approach

Australian Social Work Volume 22, Issue 4, December, 1969

“Lack of coordination in the social welfare field has commonly presented communities with major problems… …ineffectual use of already available resources, or, in services for maltreated children, further injury or even death to the child.”

Care

Network

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Key Objectives – Improve The Efficacy Of Care

How do the planned

interventions improve

the quality of care

and care goals?

What are the estimated and actual costs

for different planning and delivery options?

How appropriate is the

execution of the plan for

the citizen, their family

and the care team? Experience

Cost

Effectiveness

Efficacy of Care

Planning Delivery

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Reimaging - Person-centered, Team-based Care

Chris

! Wheelchair

! Sandra cannot take day off

7:00 9:00 12:30 14:00 18:00 21:00

Dressing

Meals

Get up/Go to bed

Medication

S-Dressing up

S-Breakfast

S-Getting up

S-Medication T-Medication M-Medication T-Medication

M-Lunch

S-Medication

S-Dinner

Responsibility Sandra Teresa Mary Teresa Sandra + Chris

WE

EK

DA

YS

Fo

rese

en

Urg

en

tE

me

rge

nc

yA

no

ma

ly

1.2 Doctor’sappointment

10:30, 5KM away

1.1 Sandra on vacation, Chris on Business trip

Teresa needs support,Sandra and Chris need updates that are non-intrusive for Teresa

3. The night before, Sandra

falls ill is unreacheable.

Chris on Business trip.

4. Teresa fallsand gets injured

2. Teresa deviates from typical route

Teresa needs support from the Safety Net to get assistance in going to the doctor

Teresa goes to the weekly seniors’ club meeting

Using GPS sensor, detect deviation

from typical route

Subtle Notification for Teresa

Sandra

Teresa Panics

Teresa Dismisses

message

Teresa Changes

Course

Teresa Late

Notify

Chris

MDT

Teresa could be in trouble. Early intervention either through relatives or through safety net

MDT

MDT MDT

MDT MDTThe family is in need of help. The primary caretaker has fallen ill, a new person will need to be found on short notice to get through the day

FALL!

Sandra Teresa Mary Chris MDT Alfred

Sandra

Once the fall is detected, a neighbour (with a key) is notified to go over. He waits for the emergency services. Family is notified.

MDT

Alfred

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Holistic

Adaptive

Multi-disciplinary Understanding, adapting and

responding to the Citizen,

environment, the context, the

situation and the team

Enabling the multidisciplinary

team to be more effective and

efficient across the Planning

and Delivery phases

Inclusive understanding of the

client, their social network, and

their engagement with the care

network

Person-centered Design Principles

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Planning Optimization

Social

Context

Inherent complexity across

needs, services, providers

and the connections between

them

BioPsychoSocial

Reference

Model Biological

Social Psychological

Vulnerability Index Safety Network

Find temporary foster

care placement and

child care options for

Sandra’s two children

that are near her

employer, her mom’s

house and with easy

access to their two

schools

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Planning Optimization

Social

Context

Inherent complexity across

needs, services, providers

and the connections between

them

BioPsychoSocial

Reference

Model Biological

Social Psychological

Vulnerability Index Safety Network

Find temporary foster

care placement and

child care options for

Sandra’s two children

that are near her

employer, her mom’s

house and with easy

access to their two

schools

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Planning Optimization

Social

Context

Inherent complexity across

needs, services, providers

and the connections between

them

BioPsychoSocial

Reference

Model Biological

Social Psychological

Vulnerability Index Safety Network

Find temporary foster

care placement and

child care options for

Sandra’s two children

that are near her

employer, her mom’s

house and with easy

access to their two

schools

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Delivery Optimization – Micro-Planning - Adventures in Time and Space

Social

Context Time Care Team

Inherent complexity

across needs, services,

providers and the

connections between

them

Location Transportation Safety Network

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Delivery Optimization – Micro-Planning - Adventures in Time and Space

Social

Context Time Care Team

Inherent complexity

across needs, services,

providers and the

connections between

them

Location Transportation Safety Network

Find the closest

care worker to

Teresa that has free

time from 11 to 12.

Which family

member is available

to come and chat with

Teresa at the

hospital?

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Delivery Optimization – Micro-Planning - Adventures in Time and Space

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Delivery Optimization – Micro-Planning - Adventures in Time and Space

• No food ahead of 10:30 appointment

• Check in with secretary on arrival

Hospital Information:

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Key Benefits

Improved Care

Experience

Optimized Care

Planning

More Time with Clients

Location, Temporal,

Transportation and Care

Network analytics evaluate

service delivery options to

enable Care Teams to develop

efficacious care plans

Real-time analytics deliver

prioritized, accurate and situation-

aware information to Care Teams so

that they can spend more time with

their clients and make better

informed decisions

A suite of IBM MobileFirst apps

deliver a transformative and

person-centered user

experience for the Client, the

Family and the Care Team

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Business Process Model

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IDENTIFY

ASSESS

RESPOND

MANAGE

MEASURE

End of Day 1

General Session