A Whole System Approach to
Developing Telecare Strategy
Paul Forte
The Balance of Care Group
www.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.
Relationships
between the
Communities
of Living,
Care ,
Professionals
and Practice
Communities of
Living
Communities of
Care
Local
government
Local
transport
Primary
care
Work
Family life
Social care
Local shops
Community
care
Community
legal frqmework
Voluntary
Environment
Social work
teams
organisations
Primary care
Hospital
teams
Utilities
teams
Care home
Sheltered
Rehab teams
teams
housing
Managers
Religious
Disease Management
teams
Leisure
management
life
Care
homes
Chronic disease
Pubs/bars
Healthy
living
Communities of
Professionals/Practice
Emergency care
Community
societies
Sport
Parent craft
Schools
Learning
© Balance of Care Group
Developing a business
case 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
Preadmission
Pre
admission
Social details
alone, carers,
residence
Admission
Source of
referral
Admission
diagnosis
Time
Risk factors:
Waiting time
age, drugs, comorbidities,
Route
psychiatric/
Decision
maker
dementia, falls
Reason for
admission
Preventative
care
Alternatives
to acute
admission
setting
Disease
management
Managed
populations
Diagnosis
Treatment
Discharge
Re-admission
Discharge
planning
‘Revolving
door’
Inpatient
diagnosis
Delays in
planning
Delays in
diagnosis
Delays in
execution
Avoidable
e.g. chronic
disease
management
Alternative
sites for
discharge
Alternative
sites for
readmission
Delays in
therapy
Chronic
disease
Alternative
access for
diagnosis
Alternative
settings for
therapy
(especially
rehab)
© Balance of Care Group
The Balance of Care model
high
dependency
Older
People
medium
dependency
low
dependency
© Balance of Care Group
The Balance of Care model
long term
care bed
high
dependency
NHS
community nurse
Older
People
medium
dependency
physiotherapist
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
option1
Older
People
medium
dependency
NHS
community nurse
physiotherapist
option 2
respite care
option 3
day care centre
Local
Authority
care assistant
low
dependency
telecare equipment
Voluntary &
independent sector
care home
© Balance of Care Group
Balances to be struck
Care Professionals
Social Services
High Dependency
Non-Clinical Managers
Health Services
Low Dependency
Defining the telecare population
P6 Unsupported at home
(aged over 65)
P1 Care Home Residents
(not EMH)
P3 Frailty Case
Management
(Severe)
P5 Other low intensity
needs
(Minor)
P2 Care Home Residents
(EMH)
P4 Other long term care
needs
(Moderate)
Category descriptions
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.
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
Pulse Oximeter
(HICSS)
Blood Pressure Cuff
Clinical
systems
Possible Information Flows to link Telemedicine Applications
to Management of Long Term Conditions
Specialist Staff
(Spec Nurses, Consultants
GPSIs)
Peak Flow Meter
Weighing Scales
Other Key Staff
(GPs, Community Geriatrician.
Therapists, District Nurse)
Glucometer
Video/ patient
interface
Case Managers
(Comm matrons, social workers)
Data interface
Data input & access
Direct communication
Pulse Oximeter
(HICSS)
Blood Pressure Cuff
Clinical
systems
Possible Information Flows to link Telemedicine Applications
to Management of Long Term Conditions
Specialist Staff
(Spec Nurses, Consultants
GPSIs)
Peak Flow Meter
Weighing Scales
Glucometer
Video/ patient
interface
Other Key Staff
(GPs, Community Geriatrician.
Therapists, District Nurse)
Webbased
access
tool
Case Managers
(Comm matrons, social workers)
Data interface
Data input & access
Direct communication
Pulse Oximeter
(HICSS)
Blood Pressure Cuff
Clinical
systems
Possible Information Flows to link Telemedicine Applications
to Management of Long Term Conditions
Specialist Staff
(Spec Nurses, Consultants
GPSIs)
Peak Flow Meter
Weighing Scales
Glucometer
Video/ patient
interface
Other Key Staff
(GPs, Community Geriatrician.
Therapists, District Nurse)
Webbased
access
tool
Case Managers
(Comm matrons, social workers)
Data interface
Data input & access
Direct communication
Pulse Oximeter
(HICSS)
Blood Pressure Cuff
Clinical
systems
Possible Information Flows to link Telemedicine Applications
to Management of Long Term Conditions
Specialist Staff
(Spec Nurses, Consultants
GPSIs)
Peak Flow Meter
Weighing Scales
Other Key Staff
(GPs, Community Geriatrician.
Therapists, District Nurse)
Webbased
access
tool
Glucometer
(PARIS)
Care
systems
Video/ patient
interface
Case Managers
(Comm matrons, social workers)
Data interface
Data input & access
Direct communication
Pulse Oximeter
(HICSS)
Blood Pressure Cuff
Clinical
systems
Possible Information Flows to link Telemedicine Applications
to Management of Long Term Conditions
Specialist Staff
(Spec Nurses, Consultants
GPSIs)
Peak Flow Meter
Weighing Scales
Other Key Staff
(GPs, Community Geriatrician.
Therapists, District Nurse)
Webbased
access
tool
Glucometer
(PARIS)
Care
systems
Video/ patient
interface
Case Managers
(Comm matrons, social workers)
Data interface
Data input & access
Direct communication
Pulse Oximeter
(HICSS)
Blood Pressure Cuff
Clinical
systems
Possible Information Flows to link Telemedicine Applications
to Management of Long Term Conditions
Specialist Staff
(Spec Nurses, Consultants
GPSIs)
Peak Flow Meter
Weighing Scales
Glucometer
(PARIS)
Care
systems
Video/ patient
interface
Telecare
Applications
Other Key Staff
(GPs, Community Geriatrician.
Therapists, District Nurse)
Webbased
access
tool
Case Managers
(Comm matrons, social workers)
Data interface
Data input & access
Direct communication
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 MODEL
Current Location: Telecare Valley
Definitions and Data
Results - tables
Client Categories
Summary
Service Details
Service Units
Locations
Service Costs
Model
Care Options
Results - graphs
Cost by Service
Scenarios
Cost by Service Group
Scenario Menu
Cost by Client Category
CLOSE
P 2 - C are ho me residents - EM H
Menu
Unit C o s t:
£21,320
£19,583
£16,835
A llo c a tio n:
85%
10%
5%
A llo c a te d C lie nts :
186
22
11
C o de Service D escriptio n
C urrent Extra care H o me with
S1
Community nurse
S2
Physiotherapist
S3
Care Assistant
730
1095
S4
OT
12
12
S5
Geriatrician
S6
Rehab asst
S7
Care home EM H
52
S8
Care home (non-EM H)
S9
Acute bed
S10 Comm hospital bed
S11 Telecare
52
52
S12 CPN
S13 Night sitter
12
12
S14 Extra care housing
52
S15 Day care
To ta l C o s t: £3,956,637
£427,567
£183,780
Qua lity S c o re :
60%
80%
100%
<
>
£
N o . o f C lients:
£
£
0
Opt 4
0
Opt 5
0
Opt 6
£
£
£
218
T o tals
100%
218
C o st
£
£
£386,026
£9,825
£
£
£3,956,637
£
£
£
£25,545
£
£19,650
£170,300
£
£4,567,983
64.0%
Evaluation
Cycle of evaluation and strategy
generation
Strategy
knowledge
Re-envisioning
practice
reviewing
learning
Evaluation
Operation
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