The Beginner's Guide to SmartCare

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Leo Clark
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1 The SmartCare project is co-funded by the European Commission within the ICT Policy Support Programme of the Competitiveness and Innovation Framework Programme (CIP). Grant agreement no.:

2 List of partners

4 SmartCare in a nutshell Started in March 2013 and will end in March partner organisations from health, social, research and policy across 15 European countries SmartCare services will be piloted in 9 European regions within the project duration; further 13 regions participate to prepare for future service implementation Pursues a programme of systematic service process innovation complemented by adaptation of technology. Multi-staged work programme enables the views of a wide range of stakeholders being systematically taken into account: Older people with chronic conditions, family rs, diverse health and social occupations, service funding organisations. Evidence-based planning and mainstreaming of SmartCare services by relevant stakeholders will be enabled by a robust evaluation programme. Pilot A under ICT PSP Programme The project is partially funded under the ICT Policy Support Programme (ICT PSP), grant agreement number

5 WP Leaders Workpackage Lead organisation Duration WP1 Requirements and use case definition EMP M1-9 WP2 Service process model EMP M3-11 WP3 Integration Infrastructure Architecture and Service Specification IFIC M1-12 WP4 System implementation & test Vidavo M5-20 WP5 Pilot site preparation Aragon M5-22 WP6 & 7 Pilot operation FVG M15-36 WP8 Pilot Evaluation RSD M1-36 WP9 WP10 Exploitation support and dissemination EMP M1-36 Project management and performance monitoring FVG M1-36

6 Deliverable list Title Nature Dissemination Level Delivery Date D1.1 Requirements for pathways and Integration infrastructure R PU M8 = October 2013 D1.2 SmartCare Pilot-level Pathways and Integration Infrastructure R PU M13 = March 2014 D3.1 Deployment Level Service Specification Final Revised D PU M13 = March 2014 D4.2 SmartCare Field Test Report (V1) R PU M12 = February 2014 D8.1 Evaluation Framework R PU M7 = September 2013 D8.1 Addendum V1.0 - SmartCare evaluation update R PU M13 = March 2014 D10.1 Quality Plan R CO M8 = October 2013 D10.2 Ethics and Data Framework R PU M7 = September 2013 D10.2 SmartCare Ethics & Data Protection Framework (V2.0) R PU M13 = March 2014 D2.1 Smart Service Process Models O PU M12 = February 2014 D3.2 D4.1 D9.1 SmartCare Service Specification - initial draft SmartCare System Integration Architecture (V1) First report on dissemination and exploitation activities O PU M15 = May 2014 R PU M9 = November 2013 R PU M12 = February 2014 D10.3 Interim periodic progress report R CO M6 = August 2013 D10.4 Periodic progress report Year 1 R CO M12 = February 2014 D4.4 SmartCare System Integration Architecture V2 R PU M12 = February 2014 D4.5 SmartCare Field Test Report (V2) R PU M7 = September 2013 D10.5 Interim progress report Year 2 R CO M12 = February 2014 D4.3 Integrated ICT infrastructure (V1) O PU M15 = May 2014 D4.6 Integrated ICT infrastructure (V2) O PU M21 = November 2014 D5.1 SmartCare Operational deployment sites O PU M22 = December 2014 D6.1 SmartCare Common Specifications R PU M30 = August 2015

7 Title Nature Dissemination Level Delivery Date D6.2 Report on Operation of Deployment sites R PU M36 = February 2016 D8.2 First interim process evaluation report R PU M22 = December 2014 D8.3 Second interim process evaluation report R PU M28 = June 2015 D8.4 SmartCare deployment Outcomes R PU M36 = February 2016 Interim report on dissemination & D9.2 exploitation activities R PU M24 = February 2015 D9.3 Guidelines for deployment R PU M36 = February 2016 D9.4 Deployment plans for SmartCare Pathways & Integration Infrastructure R PU M36 = February 2016 D10.6 Project periodic progress report RP2 R CO M24 = February 2015 D10.7 Interim periodic progress report R CO M30 = August 2015 D10.8 Project final report incl. PR for RP3 & report on the distribution of the financial contribution R CO M36 = February 2016 Workplan Requirements Elicitation & Care Pathway Development Organisational & ICT-related pilot preparation Pilot operation & evaluation WP1 Requirements & use case definition WP3 Integration architecture & service specification WP6/7 Pilot operation WP2 Service process models WP4 System implementation & test WP5 Pilot site preparation WP8 Pilot evaluation WP9 Exploitation support & dissemination WP10 Consortium management and performance monitoring The project is partially funded under the ICT Policy Support Programme (ICT PSP), grant agreement number

8 The SmartCare Mission Improving co-ordination of delivery across established health and social services Developing and delivering integrated ICT-supported services for older persons who have complex needs to facilitate: Person-centred, co-ordinated for individuals and their rs Greater levels of self- and self-management A unified approach of the health and social system Effective and efficient communication between all parties Better use of resources, less duplication and more streamlined The project is partially funded under the ICT Policy Support Programme (ICT PSP), grant agreement number

Two generic pathways Integrated Long-Term Home Care Support Entering into service Receiving continuous personalised Leaving service Entry point (1): Referral by health provider Entry point (2):

9 Two generic pathways Integrated Long-Term Home Care Support Entering into service Receiving continuous personalised Leaving service Entry point (1): Referral by health provider Entry point (2): Referral by social provider Assessment of recipient s needs for long term home Enrolment to SmartCare service (ICP- LTCare) Initial integrated Coordination of integrated delivery / revision of initial integrated Personalised multi-provider service package On-site / home provision of informal On-site / home provision of formal social On-site / home provision of formal health Remote provision of health & social (telehealth, tele) Shared documentatio n of home provided Monitoring / review / reassessment of recipient s needs Temporary admission to institution (e.g. hospital, home) Exit point: Disenrollmen t from SmartCare service (ICP- LTCare)

10 Integrated Home Support after Hospital Discharge Entering into service Receiving continuous personalised Leaving service Entry point: Discharge from hospital impending Assessment of recipient s needs for home Enrolment to SmartCare service (ICP- Discharge) Initial integrated Coordination of integrated delivery / revision of initial integrated plan Personalised multi-provider service package On-site / home provision of informal On-site / home provision of formal social On-site / home provision of formal health Remote provision of health & social (telehealth, tele) Shared documentation of home provided Monitoring / review / reassessment of recipient s needs Readmission to hospital Exit point: Disenrollment from SmartCare discharge service Exit point: Transition into SmartCare longterm service Discharge from hospital

SmartCare Regions The 22 Regions participating in SmartCare are members of one of two different groups: 9 regions will deploy integrated health and social ecare services 13 committed regions

11 SmartCare Regions The 22 Regions participating in SmartCare are members of one of two different groups: 9 regions will deploy integrated health and social ecare services 13 committed regions participate to learn from experience of the deployment regions and go through a programme of service planning and scenario-based piloting Wave 1 regions Aragon Southern Denmark Scotland Friuli Venezia Giulia Wave 2 regions Tallinn Attiki Etelä-Kariala Noord-Brabant Kraljevo

12 Information collection and recording systems Integrated Long-Term Home Care Support Entering into service Receiving continuous personalised Leaving service Entry point (1): Referral information Health record paper/er, GP system Entry point (2): Referral information Social record - paper/er, GP system Joint assessment information Integrated H&SC record paper/er Enrolment and consent Integrated H&SC record paper/er, SmartCare database, GP system Initial integrated Integrated H&SC record paper/er, GP system Care coordination Integrated H&SC record paper/er Personalised multi-provider service package Informal Carers onsite services Caseload management & appointment systems, CR held record Social Care onsite services Caseload management & appointment systems, CR held record Health Care onsite services Caseload management & appointment systems, CR held record Remote provision of health & social and support Online platforms, telehealth & tele Integrated and shared documentation Integrated H&SC record paper/er, CR self Monitoring / review / reassessment info Integrated H&SC record paper/er Temp admission to institution info Integrated H&SC record paper/er, Hospital PAS, GP system Exit point: Discharge info Integrated H&SC record paper/er, SmartCare database, GP system Information collection and recording Systems

13 Information, communication and sharing mechanisms Integrated Long-Term Home Care Support Entering into service Receiving continuous personalised Leaving service Entry point (1): Referral information Health record Entry point (2): Referral information Social record Joint assessment information H&SC record, integrated record, system generated message Enrolment and consent H&SC record, integrated record, system generated message, paper fax Initial integrated Community H&SC record, , fax, phone Care coordination Community H&SC record, , system generated message, fax, phone, letter Personalised multi-provider service package Informal Carers Integrated record, , system generated message, fax, phone, shared paper diary Social Care Integrated record, , system generated message, fax, phone, shared paper diary Health Care Integrated record, , system generated message, fax, phone, shared paper diary Remote provision of health & social and support , telemonitoring system, web-based system, integrated record, phone Integrated and shared documentation , integrated record, system generated message, fax Monitoring/revie w / reassessment , integrated record, system generated message, SMS, fax, phone, letter Temp admission to institution info , integrated record, system generated message, fax, phone Exit point: Discharge info , integrated record, system generated message, fax, letter Information, communication and sharing mechanisms

14 ICT infrastructure Integrated Long-Term Home Care Support Entering into service Receiving continuous personalised Leaving service Referral information Community health LAN/WiFi,broadb and, paper filing, GP LAN Referral information Community social LAN/WiFi, broadband, paper filing, GP LAN Joint assessment information Community H&SC LANs/WiFi, broadband, paper filing system, GP LAN Enrolment and consent Community H&SC LAN/WiFi, Broadband, paper filing system, GP LAN Initial integrated Community H&SC record paper/er, GP system Care coordination Community H&SC LAN.WiFi, SPA, Call Centre, paper filing system, GP LAN Personalised multi-provider service package Informal Carers Health Care Community Community LAN/WiFi, LAN/WiFi, broadband, paper broadband, paper diary system, CR diary system, CR home broadband, home broadband, paper record paper record Social Care Community LAN/WiFi, broadband, paper diary system, CR home broadband, paper record Remote provision of health & social and support CR home broadband, paper record, SPA, Call Centre LAN/WiFi Integrated and shared documentation Community LAN/WiFi, broadband, paper filing system Monitoring / review / reassessment info Community LAN/WiFi, broadband, paper filing system Temp admission to institution info Community LAN/WiFi, GP LAN, Hospital LAN, paper filing system Discharge info Community H&SC LAN/WiFi, GP LAN, paper filing system, SmartCare database ICT Infrastructure

HCP #1: Hospital HCP #2: GP SCP #1: Community organisation SCP #2: Meals on wheels service provider TPC: Voluntary home help oragnisation I/FC : Relative 1 End Starting point of SmartCare

relatives to be informed? No No action According to jointly defined protocoll 1 Look up initial home HIS : Hopital Information sytem 2 Check available admission related info (e.g. in existing HIS, paper Yes Inform relative (I/FC) records) Inform GP, e.

Joint home stored in ICR 2 Yes According to jointly defined template / structure 1 Home plan stored in ICR ICR: Integrated Care Recordm No No action End Voluntary home help to be provided 1 Yes

15 HCP #1: Hospital HCP #2: GP SCP #1: Community organisation SCP #2: Meals on wheels service provider TPC: Voluntary home help oragnisation I/FC : Relative 1 End Starting point of SmartCare ICP-Discrage components: 1) Needs assessment, (2) Service enrolment, (3) Initial integrated home & (4) Discharge Hospital discharge impending Inform GP (HCP #2) Confirm receipt of service request Any relatives to be informed? No No action According to jointly defined protocoll 1 Look up initial home HIS : Hopital Information sytem 2 Check available admission related info (e.g. in existing HIS, paper Yes Inform relative (I/FC) records) Inform GP, e.g. message, report? Joint home stored in ICR 2 Yes According to jointly defined template / structure 1 Home plan stored in ICR ICR: Integrated Care Recordm No No action End Voluntary home help to be provided 1 Yes Inform voluntary home help service (TPC) Confirm receipt of service request Social received prior to admission? Yes Develop initial medical home Enrol client to SmartCare ICP- Discharge End No action End No Home plan stored in ICR Home plan stored in ICR Develop initial social home Meals on wheels to be provided? Yes Inform meals on wheels service (SCP #2) 1 Confirm receipt of service request 2 End 2 No Inform social provider (SCP Home plan stored in No No action ICR Home plan stored in ICR Endpoint of (potentially) existing pathways related to patient's hospital stay / discharge 2 2 Social required after discharge? 1 Yes Develop initial medical home Enrol client to SmartCare ICP- Discharge No Home plan stored in Patient No discharge #1) ICR 2 Patient discharge No No action Home plan stored in ICR 2 Develop initial social home plan Meals on wheels to be provided? 1 Yes Inform meals on wheels service (SCP #2) Confirm receipt of service request End Inform social provider (SCP #1) Home plan stored in ICR No No action Home plan stored in ICR End 2 End End 2 Voluntary home help to be provided 1 Yes Inform voluntary home help service (TCP) Confirm receipt of service request Home plan stored in ICR Patient discharge Yes Inform relative (TPC) Any relatives to be informed? 1 No No action Loo up initial home End Starting point of ICP-Discharge component: (5) Coordination of delivery / revision of initial home The Beginner's Guide to SmartCare From pathways to service process models How the process models were developed WP 1 WP2 Generic SmartCare pathways (ICP-LTCare, ICP- Dischage) Requirements for implementation within given regional context Transformation into formalised workflows within regional context Entering into service Receiving continuous personalised Leaving service Entry point (1): Referral by health provider Entry point (2): Referral by social provider Assessment of recipient s needs for long term home Enrolment to SmartCare service (ICP- LTCare) Initial integrated Coordination of integrated delivery / revision of initial integrated Personalised multi-provider service package On-site / On-site / home home provision of provision of formal health informal Remote On-site / home provision of provision of health & social formal social (telehealth, tele) Shared documentation of home provided Monitoring / review / reassessment of recipient s needs Temporary admission to institution (e.g. hospital, home) Exit point: Disenrollment from SmartCare service (ICP- LTCare)

16 Lessons learned (I) All generic pathway element addressed at each site in one way or another Transition points between ICP-LTCare & ICP-Discharge Some structural commonalities: Two staged needs assessment (validation of initial assessment by collaborating stake holders) Service integration involves (a) primary health actors, (b) public sector social services & (c) family rs in each case... albeit involvement of further stakeholders may vary (e.g. tertiary, Third Sector, private sector social ) Lessons learned (II) Some structural differences: Primary entry point into the integrated service varies: single access point for health & social services (4) primary (1) hospital (2) various (2) Initial needs assessment by primary heath with subsequent validation by other actors (4) or hospital (2), initial assessment by joint team in (3) Development on initial integrated : dedicated lead function (5) vs. distributed responsibility across actors (4) Permanent monitoring of delivery: Dedicated lead function for (7) vs. distributed responsibility across actors (2)

17 Lessons learned (III) Re service modelling process: Pay attention to framework conditions potentially acting as constraining factors for the operational implementation of a cross-organisational service model at an early stage Balance out diverging interests of individual stakeholders to be involved in joined-up service delivery in a sensible way As far as achievable under given circumstances, underpin the service modelling process by evidence

18 Evaluation PICO-criteria Population Users of health & social services Intervention SmartCare services Comparator Usual Outcomes Quality, timeliness, effectiveness, cost minimizing Evaluated through the MAST framework MAST adapted to SmartCare MAST domain Health Social Volunteers/relatives 1. Health problem and characteristics of application 1. Health problem and characteristics of application 1. Social problem and characteristics of application 1. Health and social problem and characteristics of application 2. Safety 2. Safety 2. Safety 2. Safety 3. Clinical effectiveness 4. Patient perspectives 3. Clinical effectiveness 4. Patient perspectives 3. Care effectiveness 3. Clinical and effectiveness 4. End-user perspectives 4. End-user perspectives 5. Economic aspects 5. Economic aspects 5. Economic aspects 5. Economic aspects 6. Organisational aspects 7. Socio-cultural, ethical and legal aspects 6. Organisational aspects 7. Socio-cultural, ethical and legal aspects 6. Organisational aspects 7. Socio-cultural, ethical and legal aspects 6. Organisational aspects 7. Socio-cultural, ethical and legal aspects The project is partially funded under the ICT Policy Support Programme (ICT PSP), grant agreement number

19 Study design Deployment sites Intervention Control SmartCare Meta-analysis Meta-regression If possible, individual patient data meta-analysis

20 Exploitation support Supporting service mainstreaming Cost-benefit analysis and business modeling will underpin the evaluation. Outcomes will provide the regions with the necessary evidence-base to mainstream the delivery of integrated services for other population cohorts within their deployment and elsewhere. Policy level Service level Individual / organisational level Upscaled, societal SER Should this become the way of doing things? Service SER, ROI and time to break even Under what conditions is the service viable? Service-related costs and benefits Under what conditions do we want to get involved? SER = Socio-economic return, ROI = Return on investment The project is partially funded under the ICT Policy Support Programme (ICT PSP), grant agreement number The assessment is done in three steps: In Step 1: Service Assessment Model Setup, the service change to be evaluated is analysed to identify key components such as the applicable governance & reimbursement model(s) and other relevant framework conditions, the stakeholders involved, and the envisaged impacts (in terms of costs and benefits) on each stakeholder. The latter includes identifying possible business models for a sustainable service operation for the organisational stakeholders involved. The resulting service-specific stakeholder and indicator set is entered into the software toolkit as a prerequisite for the following steps. In Step 2: Data Collection and Monetarisation, data on all identified indicators is collected and fed into the software toolkit. Data is usually collated from various sources including an evaluation of the pilot operation of the service under analysis, data logs of health and social IT systems, fact finding interviews with key informants in the pilot site (e.g. managerial staff, professionals, accountants) and other primary sources, all of which are planned to be used in the framework of SmartCare. Furthermore, data from secondary sources such as literature or datasets from other studies will be used where appropriate. The software toolkit comprises a graphical user interface where the data can be entered in different formats. For subsequent analysis, all input data needs to be monetarised, i.e. be available in currency values. This is straightforward for financial input data, i.e. data for which a market price exists, such as costs for hardware or software. Personnel resources or staff time are usually transformed using full labour costs, i.e. wages plus employer contributions. Intangible costs and benefits require more complex transformation approaches, such as calculation of time cost, use of suitable monetary proxies, or valuation approaches (i.e. a subject s perception of the relative or absolute value of a thing) such as willingness-to-pay. Step 3: Calculation of Performance Measures. On the basis of the input data, different performance measures or return indicators are calculated, as shown in the figure below. The performance measures are expressed as ratios of different kinds of costs and benefits. The main outcome measure is based upon the ratio of total costs to total benefits, i.e. including financial costs and benefits, resource costs and benefits, and intangible costs and benefits. This overall ratio is referred to as socio-economic return (SER). At the overall service level, it can be seen as reflecting the perspective of a higher-level decision maker (e.g. a national policy maker); the SER can support the assessment and evaluation of options and decisions for improved service delivery. Ratios of the

financial costs and benefits indicate cash flows and the affordability of the service, sometimes called the cash flow return on investment (CFROI).

21 financial costs and benefits indicate cash flows and the affordability of the service, sometimes called the cash flow return on investment (CFROI). Ratios using the totals of financial and resource costs and benefits are tangible and a measure of an economic ROI because they measure the potential net income for the service.

Joining up ICT and service processes for quality integrated care in Europe

Joining up ICT and service processes for quality integrated care in Europe Background National welfare & health systems and regional/local support practices are developing more and more specialisation