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

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.

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Developing a business case for telecare Its 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 whats 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 AdmissionDiagnosisTreatmentDischargeRe-admission Social details alone, carers, residence Risk factors: age, drugs, co- morbidities, psychiatric/ dementia, falls Preventative care Disease management Managed 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

Older People high dependency low dependency medium dependency The Balance of Care model © Balance of Care Group

Older People high dependency low dependency medium dependency long term care bed community nurse Voluntary & independent sector NHS Local Authority care home physiotherapist care assistant day care centre respite care The Balance of Care model telecare equipment © Balance of Care Group

Older People high dependency low dependency medium dependency long term care bed community nurse Voluntary & independent sector NHS Local Authority 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 ProfessionalsNon-Clinical Managers Social ServicesHealth Services High DependencyLow Dependency

Defining the telecare population

Category descriptions Category LabelIntended Population BaseData Source for Telecare Valley Care home residents - not EMHPermanent care home residents over 65 supported by council (excluding Elderly Mental Health) England residents at / 150 Care home residents - EMHPermanent care home residents over 65 supported by council (Elderly Mental Health) England residents at / 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 / 150. Other long term care needsNumbers 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 / 150 Other low intensity needsNumbers over 65 receiving home care (< 5 hours per week) Other England low intensity home care (<5hrs per week) at / 150 Unsupported at home >65Total 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

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

Evaluation

Cycle of evaluation and strategy generation Strategy knowledge Operation practice 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 agents 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