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A Whole System Approach to Developing Telecare StrategyPaul 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.
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
A whole system perspective 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 Discharge planning Delays in planning Delays in execution Alternative sites for discharge Admission diagnosis Inpatient diagnosis Delays in diagnosis Chronic disease Alternative access for diagnosis Delays in therapy Alternative settings for therapy (especially rehab) ‘Revolving door’ Avoidable e.g. chronic disease management Alternative sites for readmission © Balance of Care Group
The Balance of Care model high dependency medium dependency Older People low dependency © Balance of Care Group
The Balance of Care model long term care bed high dependency NHS community nurse physiotherapist medium dependency Older People respite care day care centre Local Authority care assistant low dependency telecare equipment Voluntary & independent sector care home © Balance of Care Group
The Balance of Care model long term care bed high dependency NHS option1 community nurse physiotherapist medium dependency Older People option 2 respite care day care centre Local Authority option 3 care assistant low dependency telecare equipment Voluntary & independent sector care home © Balance of Care Group
Balances to be struck Care Professionals Non-Clinical Managers Social Services Health Services High Dependency Low Dependency
Category 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. Category descriptions
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
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
Cycle of evaluation and strategy generation Strategy knowledge Operation practice Re-envisioning reviewing learning Evaluation
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