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

Transcription

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

2 Background National welfare & health systems and regional/local support practices are developing more and more specialisation and clear boundaries closed them to cooperation Today Today s reality is characterised by fragmentation and bureaucracy in current provision systems resulting in disjointed and patchy support services Tomorrow Leading to inefficiencies, duplication of resources, and potentially to reduced levels of quality of care Social care Healthcare Informal care

3 SmartCare in a nutshell Started in March 2013 and will end in February partner organisations from health care, social care, 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 carers, diverse health and social care 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

4 The SmartCare Mission Improving co-ordination of care delivery across established health and social services Developing and delivering integrated ICT-supported care services for older persons who have complex needs to facilitate: Person-centred, co-ordinated care for individuals and their carers Greater levels of self-care and self-management A unified approach of the health and social care system Effective and efficient communication between all parties Better use of resources, less duplication and more streamlined care

5 The SmartCare Solution Harnessing ICTs for the benefit of older persons people and those with chronic diseases

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

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

8 Key Care Pathway implementation Services/Activities and associated ICT applications

9 Information collection and recording Systems Entering into service Receiving continuous personalised care Leaving service Entry point (1): Referral information Health record paper/er, GP system Entry point (2): Referral information Social care 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 care plan 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 care and support Online platforms, telehealth & telecare Integrated and shared documentation Integrated H&SC record paper/er, CR self care plan 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

10 Information, communication and sharing mechanisms Entering into service Receiving continuous personalised care Leaving service Entry point (1): Referral information Health record Entry point (2): Referral information Social care 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 care plan 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 care 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

11 ICT infrastructure Entering into service Receiving continuous personalised care Leaving service Referral information Community health LAN/WiFi,broadb and, paper filing, GP LAN Referral information Community social care 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 care plan 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 Community LAN/WiFi, broadband, paper diary system, CR home broadband, paper record Social Care Community LAN/WiFi, broadband, paper diary system, CR home broadband, paper record Health Care Community LAN/WiFi, broadband, paper diary system, CR home broadband, paper record Remote provision of health & social care 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

12 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

13 SmartCare Regions The 26 regions participating in SmartCare are members of one of two different groups: 9 regions will deploy integrated health and social ecare services 17 committed regions participate to learn from experience of the deployment regions and go through a programme of service planning and scenario-based piloting

14 Aragón, Spain The region Aragón is a region located at the North-East of Spain with a population of 1.3 million The region comprises three provinces (Zaragoza, Huesca and Teruel) and 731 municipalities 50% of the population lives in the regional capital city, Zaragoza, while the remaining 50% is sparsely spread among the rest of the municipalities

15 Healthcare system 1 only health provider (SALUD) Public body Aragón, Spain Social and Healthcare Service provision Primary Care + Specialized services + Mental health One only ICT Infrastructure. Same network, common DBs, management APPs + Intranet giving access to all information to all health professionals in all the territory, Social care system Several providers (public & private) External funds (Public grants or membership + public grants) Each provider offers its own basket of services Users ask for services to any provider. Those can be granted if the user fulfils requirements. There might be duplicities of services Each provider has its own Information Systems Databases are independent No citizen s data shared among them

16 Aragón, Spain Existing IT infrastructure SALUD Common ICT infrastructure for Primary Care & Specialized Care Same network, common DBs SALUD IS: EHR Viewer (Primary Care + Specialized Care patient data) HIS: Scheduling & monitoring information apps Departmental apps (PCH, LIS, RIS, telemonitoring portal, Patient s surveys, e-prescription) Videoconferencing system unique EHR for Primary Care + Specialized Care Help desk SOCIAL care providers Social Services Recording IS Proximity Local App: Contact centre + agenda Citizens info databases Informal carers Proprietary systems/none/paper SALUD Departamentales AGENDA ESPECIALIZADA PCH (Urgencias) RIS BDU HIS (Admisión) PACS EMPI INTRANET OMI- AP Cartera de Servicios LIS Farmacia (Laboratorio) Social providers Motor Integración (Rhapsody) AGENDA PRIMARIA Informes (HP-Doctor) SALUD INFORMA GESTOR DE PACIENTES

17 Aragón, Spain SmartCare infrastructure Collaboration platform for the provision of Integrated Care - SmartCare platform Accessible by all care agents involved on the provision of care All agents share data (minimum data set) SALUD shares IT and clinical data Social providers share social data Integration with the already existing information systems Unique point of data on integrated care provided to citizens Sharing of clinical and social data Common basket of integrated-care services Collaboration platform to ease the collaboration among organizations & encourages participation of professionals Collaboration framework to define commonly the integrated care plan Schedule the activities for the provision of the services Documentation point CARE RECIPIENT HEALTH PROVIDER SOCIAL PROVIDER Common Framework INFORMAL CARER SALUD & IASS under the same Aragon Government Department. Alignment of policies and strategies Single unique identifier of users in the social and healthcare Aragon Systems. (BDU) Initial deployment so as to lead and define the change management in SALUD

18 Attikí, Greece The region Attica encompasses eight dirstricts Social care services are delivered through 193 community centres and five day care centres Home help programme Healthcare services are provided by a network of 199 public/private hospitals and primary care centres

19 SmartCare in Attica Implementation in Alimos, Agios Dimitrios and Palaio Faliro Joining-up service delivery to older people living with Type II diabetes and their caregivers Service users will receive personalised information and guidance on how to self-manage their condition through an Electronic Platform Community nurses, dieticians, social carers and diabetologists provide coordinated care

20 Attiki: Concept & Approach Updates patient data CR Record Community Nurse, Care Coordinator CR, FC Record Automatic monitoring data Patient Record Updates patient data Diabetologist ATTICA Pilot Porta; Updates data ( e.g. self measurement), uses messaging & video consultations Data reports, messaging, video consultations Care Recipients Patient Record Family carer Updates patient data Hospital nurse Patient record Dietician 1 client record Social Worker Updates patient data Updates client data

21 Etelä-Kariala, Finland The region In Finland self-governed municipalities have the main responsibilities for providing basic social and healthcare services South Karelia pursues a dedicated policy ensuring equal access to joined-up social and healthcare services South Karelia Social and Health Care District (Eksote) organises provision of primary and secondary healthcare, elderly care and social care under a single roof

22 SmartCare in Etelä-Kariala Enables better co-operation between social and healthcare professionals operating under the same organization (Eksote) Aim is the keep elderly people at home by providing them the wider range of services to home Support elderly daily living by developing more integrated home care supported by telecare Social care support using telecare Video phone connection GPS tracker Shared Care plan accessible online by service user, family carer and social care/healthcare professionals

23 Etelä-Kariala: Concept & approach

24 Marino Sterle Friuli Venezia Giulia, Italy The region Italian border region located in the heart of Europe The capital is Trieste. It has an area of 7,856 km² and about 1.2 million inhabitants Marino Sterle

25 Friuli Venezia Giulia Background Friuli Venezia Giulia Region has defined a model of integrated system of social and health care services: The promotion of home care and community-based care through the partnership between Municipalities and Local Health Authorities and the involvement of the Third Sector Innovative models for integrated care: multi-dimensional and cross-sectorial evaluation of needs, person-centered project, integrated care provision, continuity of care Innovative tools for local integrated health and social planning: Territorial Activities Program (PAT) and Local Plan for Social Policy (PdZ, Piano di Zona) Joint initiatives with research/innovation (ICT) and housing sectors

26 SmartCare in Friuli Venezia Giulia Integrated care models implementing the two pathways 200 patients to be recruited, locally randomized study design (100 in usual care control group, 100 in new ICT supported integrated care intervention group). Health care, social care, third sector, informal care enrolled Target population - Age >50 - At least one moderate-to-severe chronic condition (HF, diabetes mellitus, COPD). - End users with social needs (social isolation, insufficient or inadequate social, or family support, need for environmental monitoring). Identification of social frailty to be made as per one BADL missing item.

27 Friuli Venezia Giulia Monitoring system - Smart Care Service vs. Usual Care Usual care Initial evaluation data Mid term evaluation data Final evaluation data Enrollment Usual monitoring system Permanent monitorin system Outcomes Compared analysis Intervention Group

28 Kraljevo, Serbia The region Located 180 km south of capital Belgrade Inhabitants Average age is 42.3 years Over are 60+ From which had some form of social protection Healht Centre Kraljevo (PHC) has a separate organisational unit for Home care Center for Social Work is basic unit that provides social protection

29 Kraljevo, Serbia Background Challenge Currently no electronic communication between social and health providers in Kraljevo Information exchanged with paper documents using post service Poor IT infrastructure Our Goal To connect two institutions using new ICT technologies To create new services from both social and health domain Benefit for the end users and care professionals

30 SmartCare service in Kraljevo

31 Noord-Brabant, Netherlands The region Netherlands: Decentralized unitary state Bismarck care model Noord-Brabant: Verse Beeldwaren

32 Noord-Brabant, Netherlands Background Decentralised service delivery system. National government is responsible for health care and general insurance matters. Social services are provided by non-profit organisations, which are funded by the state, local authorities and social insurance. Recent health care sector reforms to introduce more competition and to shift decision power to regional and local governance levels. Regional strategy. Facilitating the integration of hitherto separated care chains by the development of an electronic platform enabling a reliable electronic exchange of care related data across a variety of stakeholders.

33 SmartCare in Noord-Brabant Cardiac rehabilitation: Multidisciplinary intervention for physical and psychosocial recovery after a cardiac event or intervention with proven beneficial effects on morbidity and mortality. All stakeholders will work together and exchange data: Need for: Cardiac patient Informal carers Health care professionals Social workers Increased cardiac rehabilitation program uptake More sustained effects on cardiovascular risk behaviour

34 Noord-Brabant, Netherlands Focus on cardiac telerehabilitation using a personalized patient-centred ICT platform enabling self-management and collaborative monitoring and coaching. Home-based exercise program comprising remote monitoring and coaching of physical activity behaviour, by using wearable sensors. Various treatment modules such as education, dietary interventions, weight reduction and smoking cessation. Improved impact on self-management skills and self-efficacy to induce more sustainable lifestyle changes. Tool to enable collaboration, highly-secured exchange of medical information, and sharing of treatment goals.

35 Scotland, United Kingdom Background NHS 24 has a national responsibility in Scotland as advisor, facilitator and promoter of technology enabled health, care & wellbeing for 5.2m population SmartCare s overarching pop 1.1m (20% of Scotland s population) Project involves : seven local authorities and three territorial Health Boards Range of voluntary, charitable & independent sector organisations Service users and carers

36 SmartCare in Scotland aims To improve the health, care and wellbeing of 10,000 people aged 50+ within Ayrshire and the Clyde Valley. It will do this through better co-ordination and an improved approach to falls prevention and management. It will fully utilise ICT services and applications that are vital in supporting integrated care

37 SmartCare in Scotland is SmartCare is a new online person centred service which aims to support people who are at risk of a fall or recovering from a fall. The service promotes enablement, self care, information sharing and care coordination. The service will benefit people managing a long term condition who want to remain independent in their own home It will also support their family, carers, Health and Social care sector and providers supporting them. Integration on

38 Scotland User stratification Hospital or care home Diary and PHF Diary and PHF Self Assessment Tool Intense support Rehabilitation and enablement Staying independent Increasing Frailty LiU Self Care Hub Community wellbeing 38

39 ICT-enablers in Scotland

40 The region 1 of 5 administrative Regional Authorities in Denmark Inhabitants: 1.2 Million Main responsibility: Health provision Regional development 22 Municipalities (social care) 800 GP s 4 hospital units 1 university hospital Driving force behind the establishment of MAST

41 Challenge The structure - Health and social care needs to collaborate to take into account continuous care The mentality -New cross-sectorial mindset was needed to focus on the care pathway and a citizen-centered approach We needed IT to support the patient-centered focus across sectors

42 We needed... Social care Hospital Medical practice Homecare systems - EPR Electronical patient record - EPR Medical system Data collection Platform Information about own conditiom Entering data and measurements Questionnaire The patient s individual plan

43 SmartCare SmartCare service in RSD Shared Care Platform Hospital Municipality GP EHR ESR EHR Existing Infrastructure + Electronic Messages (MedCom) + Collaboration guidelines (SAM:BO) + Shared Care Platform = SmartCare service in RSD

44 The region of Tallinn encompasses 8 districts Tallinn, Estonia Background Healthcare services tend to be delivered mainly by publicly owned hospitals under private regulation and private primary care units. Responsibility for social care rests with more than 200 municipalities throughout the country. Implementation of a nation-wide electronic health information system

45 SmartCare services in Tallinn Provides better joining-up of service delivery across all districts. Care coordinators at the municipal level are enabled to access the SmartCare integration infrastructure through a dedicated portal with the help of the national ID card used to access the national health information system. Health care professionals and family carers on consent will be granted access as well. A dedicated contact centre serves as a coordination hub vis-á-vis further service providers, including telemonitoring services and a social alarm service.

46 Tallinn Service Specification

47 Evaluation PICO-criteria Population Users of health & social care services Intervention SmartCare services Comparator Usual care Outcomes Quality, timeliness, effectiveness, cost minimizing Evaluated through the MAST framework

48 MAST adapted to SmartCare MAST domain Health care Social care 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 care 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

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

50 Outcomes, database MAST domain Health care Social care Volunteers/relatives 2. Safety Deaths, Technical safety 3. Clinical effectiveness Health and social care services effectiveness Number of contacts: Physical, mail, telephone 4. Patient perspectives End-user perspectives Empowerment 5. Economic aspects WP 9 6. Organisational aspects SmartCare questionnaire + process evaluation

51 Supporting service mainstreaming A dedicated strand of activitiy deals with business case modelling, underpinned by cost-benefit analysis. Outcomes will provide deployment region with the necessary evidence-base to mainstream the delivery of integrated care services. 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

52 Cost-benefit analysis Cost-benefit analysis is used to economically evaluate the services and prospectively model different scenarios for service upscaling.

53 User Advisory Board AGE Platform Europe European Patients Forum European Federation of Nurses Eurocarers AOK (insurers) International Federation for Integrated Care (IFIC)

54 Objectives of the UAB UAB: a group aiming to gather information and reflect on all users-related aspects Integrated care with users and not only for users Capacity to support exchange and sharing of practices among deployment sites from a user perspective EU-wide organisations: multiplier effect

55 One main UAB activity: Visits to SmartCare deployment sites Investigation of: Structures, means and resources available for the ICT solutions for integrated care Involvement of informal carers Management of the SmartCare process Quality of service

56 Committed Regions Board Regions being SmartCare partner already (13) New regions joining the CRB (7+)

57 Objectives Prepare regions for future deployment of integrated ecare service: Use experience from deployment sites to boost preparation Follow process design & implementation Stimulating political leadership in the regions Raise awareness and inform regions for the uptake of integrated care service across Europe

58 Consortium

59 Information & Contact For more information please visit www. pilotsmartcare.eu/ and follow us on Or contact us at

60 ADDITIONAL SLIDES

61 Formal side of SmartCare Funding programme: Competitiveness and Innovation Programme (CIP), ICT Policy Support (ICTPSP) subprogramme Funding instrument: Pilot type A (main beneficiaries are governmental bodies) Starting date: 1 st March 2013 Total investment: 16,000,000 EU Contribution: 8,000,000

62 Integrated Care supporting key functions through ICT Care co-ordination Information sharing Joint, integrated assessment and care planning Support for self care and self management

63 SmartCare deployment sites

64 Focus Target audience Dissemination channels Requirements & pathways Technology & Evaluation Economics & Europe Prevention, screening & early diagnosis Health literacy, patient empowerment, ethics and adherence Personal health management Prevention, early diagnosis of functional and cognitive decline New paradigm of ageing Innovation in service of the elderly people Horizontal issues Regulatory and standardisation conditions Effective funding Evidence base, reference examples, repository for age-friendly innovation Marketplace to facilitate cooperation among various stakeholders Care & Cure Guidelines for care, workforce (multimorbidity, polypharmacy, frailty and collaborative care) Multimorbidity and R&D Capacity building and replicability of successful integrated care systems Active ageing & independent living Assisted daily living for older people with cognitive impairment Flexible and interoperable ICT solutions for active and independent living Innovation improving social inclusion of older people Vision / Foundation Focus on holistic and multidisciplinary approach Development of dynamic and sustainable care systems of tomorrow Dissemination strategy Project Phase I: Integrated care pathways development Project Phase II: Organisational & ICT related pilot preparation Project Phase III: Experiences from pilots & transferability Approach, objectives Requirements Partner regions Useful integrated care pathways Useful integrated care pathways Fit-for purpose service specifications/design Preliminary expectations on benefits & economic validity Evidence on user acceptance Technical infrastructure & integrated service model SmartCare guidelines and specifications Benefits & economic viability, business models Dispersed audience: Interested expert circles Public at large EIP AHA Action Groups (B3) Early adopter regions Local/regional/national-level service providers & funders User organisations (older people, informal/voluntary carers) Relevant research / policy actors Relevant technology providers/ integrators Presentations Workshops Special events, supported by: IFIC Presence in the media in participating regions Project leaflet, brochure, newsletter Publications in / special issue of the Project website SmartCare: (tentative) Final SmartCare Marketplace Social media sites representations Conference Links to other projects, initiatives