A National Service Model for Home and Mobile Health Monitoring

A National Service Model for Home and Mobile Health Monitoring RELEASE 1.1 May 2017

Document Control Title A National Service Model for Home and Mobile Health Monitoring Version Number 1.1 Document Type Guidance Author/Owner Scottish Centre For Telehealth & Telecare Publication Date 5th May 2017 Changes Revisions to descriptions of Long Term Condition prevalence Acknowledgements This work was commissioned by the Scottish Government though the Technology Enabled Care Programme. It has been produced and published by the Scottish Centre for Telehealth and Telecare in collaboration with local partnerships and Health Board colleagues involved in the Scottish Government's Technology Enabled Care Programme (TEC). Scottish Long Term Conditions Data was provided by NHS National Services Scotland Information Services Division. Copyright Notice The Scottish Government Unless otherwise stated, the Scottish Government retains the copyright to this and related works and hereby grants an Open Government License to freely share and reuse this work on a non-commercial basis under the terms of the Non-Commercial Government License for public sector information http://www.nationalarchives.gov.uk/doc/non-commercial-government-licence/noncommercial-government-licence.htm When you use this information under the Open Government Licence, you should include the following attribution: "A National Service Model for Home and Mobile Health Monitoring, Scottish Centre for Telehealth and Telecare, November 2016, licensed under the Open Government Licence http://www.nationalarchives.gov.uk/doc/non-commercial-government-licence/non-commercialgovernment-licence.htm." 2

Overview This document is the first part in a suite of guidance intended to inform Health and Social Care services in Scotland about Home and Mobile Health Monitoring (HMHM). It will support the redesign of services using technology to provide better outcomes for citizens while achieving productivity and efficiency gains. When complete, the suite of guidance will be accessed as modules and published on the Scottish Centre for Telehealth and Telecare website (www.sctt.org.uk) where they will be routinely updated to reflect ongoing developments and learning. The diagram below illustrates this document's role and the additional complementary guidance in the development plan. A National Service Model (Autumn 2016) Introduction The Case The Framework Enabling Scale What HMHM is What it does The problem How HMHM helps Concept Principles Maturity Model Success factors Organisation Strategic fit How others use it Core pathway Pathway components Shared services Return on Investment Technology Procurement Guidance (Spring 2017) Introduction A changing approach How to use this advice Reference Model Generic system System components Technical Requirements Generic statements Performance considerations Routes to Market Procurement approaches Sources of help and guidance Implementation Guide to the National Service Model (Summer 2017) Introduction Preparations Implementation Evaluation Why a framework How to use this guide Self-assessment Business case Communication for change Planning Start-up Scale-up Improvement Growth Contribution to outcomes Economic impacts Tools & Templates Tools & Templates 3

Contents Foreword... 5 1. An Introduction to Home and Mobile Health Monitoring... 6 1.1 Definition... 6 1.2 How it works... 6 1.3 Strategic context for HMHM... 8 2. The Case for Adoption in Scotland... 10 2.1 Projected prevalence of patients with Long Term Conditions... 10 2.2 How Home and Mobile Health Monitoring helps... 11 2.3 Examples of how HMHM is used to manage demand... 13 2.4 Positive evidence about HMHM... 14 2.5 Evidence from large scale pilots and mainstreaming... 16 2.6 The United4Health Programme in Scotland... 17 2.7 What this means for home and mobile health monitoring in Scotland... 18 3. National Service Model Framework... 19 3.1 Purpose... 19 3.2 The Framework Components... 19 3.3 The Conceptual Model... 19 3.4 Service Model Principles... 23 3.5 Core Service Pathways... 23 4.Enabling the Delivery of Home & Mobile Health Monitoring Services at Scale... 28 4.1 An Ilustrative Maturity Model for Home and Mobile Health Monitoring... 28 4.2 Critical Success Factors... 29 4.3 Optimising Organisational Models... 30 4.4 Shared / Coordinated Services... 32 4.5 Return on Investment... 33 4.6 Common requirements and standards for technology solutions... 36 4.7 Procurement... 38 4.8 Workforce Development... 38 5. Developing and Refining The National Service Model... 40 ANNEX A CASE STUDIES... 41 ANNEX B Strategic Success Factors... 42 ANNEX C Success Factors for Implementation... 43 ANNEX D - Implementation Guide - Outline... 45 4

Foreword This document is aimed predominantly at strategic planning colleagues in Health and Social Care Partnerships and Territorial Health Boards; Clinicians and Managers with responsibility for delivering Long Term Conditions services and colleagues with responsibility for service improvement and re-design. As a direct result of the Scottish Government's Technology Enabled Care Programme (TEC), Home and Mobile Health Monitoring (HMHM) has seen significant growth in Scotland, both in the number of organisations using these solutions and in the numbers of citizens benefiting from those services. The introduction of simple and lower cost technologies has led to much higher levels of senior management and clinical engagement, as colleagues have looked afresh at this service option to help improve local productivity. In turn, this has led to significant interest and ambition to utilise the technology outside of the traditional long-term condition specialties, most notably in Primary Care and Outpatient services. Experience from this suggests that there is significant potential for HMHM to help manage the growing demand for health and care services and to support the development of effective and efficient integrated care for the citizens of Scotland. As Home and Mobile Health Monitoring services in Scotland begin to move into the early stages of scaling-up, this Release 1.0 Model forms a starting point for a managed evolutionary development process. It establishes a national direction of travel to support wider participation from health and care organisations across Scotland and forms the basis for future updates, which will methodically capture and apply shared learning from this rapidly evolving area of service development. 5

1. An Introduction to Home and Mobile Health Monitoring Home and mobile health monitoring (HMHM) is an application of technology that supports better personal outcomes and experiences for citizens while helping services to target the use of clinical resources. 1.1 Definition "Home and mobile health monitoring (remote monitoring) describes those activities that enable patients outside of healthcare settings to acquire, record and relay clinically relevant information about their current condition to an electronic storage system where it can be used to inform or guide selfmanagement decisions by the patient and / or to support diagnosis, treatment and care decisions by professionals." 1.2 How it works HMHM supports citizens to better manage their own health by helping them to learn about their own condition, the changes in health that they experience and establishes links between these changes and their personal choices about adherence to treatments and lifestyle. With this information and knowledge, citizens acquire a greater confidence in making decisions and taking responsibility for managing their health and lifestyle choices on a daily basis. In practice, citizens are selectively provided with the tools and knowledge that they need to gather clinically significant information about their health and to record that information in a remote database where it can be accessed by appropriate professionals. This involves providing citizens with; access to digital services, medical and other devices, basic training and guidance to enable the proper use of these tools; a personalised course of activity (care plan) that leads to the routine collection of clinically significant data during their episode of care. The data can then be used in a variety of ways: By citizens to: By Health Care Professionals to: Gain meaningful information and education about their condition and the Aid in the clinical diagnosis of conditions Provide supplementary support 6

impact of treatment and lifestyle choices Gain greater confidence and capacity to manage their own health and wellbeing on a daily basis Better inform their care givers about their care needs. information for ongoing patient treatment and condition management decisions Provide early warning of deteriorations in a patient's condition and to inform subsequent decisions about early intervention Triage patient cohorts to the most appropriate support. The advantages of using HMHM over existing practice are: For citizens: For Health Care Professionals : For services: Less time spent waiting for and attending appointments in healthcare facilities Greater independence Better access to services Staying healthier for longer. Better availability of data to assist in diagnosis and for assessing the progress of treatments Greater patient adherence to treatments leading to better outcomes When targeted appropriately, fewer individual patient contacts thus freeing up time to care for others Enhanced capacity to deliver services More effective services Better use of resources Better received services. Reduced patient transportation costs (particularly in remote and rural settings) Enabling a greater proportion of individual clinician's work to be carried out towards the top of their licence. There are many benefits to deploying HMHM solutions in clinical pathways. However, it is not a universal solution. The limitations on using HMHM are: Citizens need to be capable of and comfortable with using the technologies. They must be prepared to take responsibility for their self-monitoring and, ideally, be open to the idea of self-management. Not all care pathways are a good match for HMHM. For operational benefits to be realised, the use of HMHM needs to have a focused clinical purpose that can be achieved in a way that utilises the technology to save time, effort or expense. 7

1.3 Strategic context for HMHM Strategic drivers for HMHM The Scottish Government 2020 Vision sets out a high level description of the direction to be taken in response to the challenges presented by a changing demography and economic environment. Specifically, it calls for integrated health and care services that focus on prevention, anticipation and supported self-management. More recently, the Scottish Government published "A National Clinical Strategy for Scotland 2016" 1. This describes a change in the main focus of the NHS in Scotland from hospitals to primary and community care and explains that this is necessary to meet the increasing demand on services and to ensure best value is achieved from available resources. It acknowledges that: "Much of the effort of achieving this change will come from giving people the confidence and knowledge to manage their own conditions and retain their independence." Specific areas of focus include: Enabling supported patient self-management Addressing the demand generated by long-term conditions Providing more optimal treatments and eliminating waste Reducing avoidable hospital admissions and ensuring timely delay-free discharge Using technology to improve access to services and decision making. The potential of HMHM is widely recognised in healthcare policy in Europe (WHO, 2011) and the UK. Given the growing functionality of Telehealth 2, in particular its facilitation of the extension of health and long term care provision outside of hospital settings and in individual homes, it is an essential component for enabling the future integration of care information systems. 1 Scottish Government A National Clinical Strategy for Scotland 2016 http://www.gov.scot/publications/2016/02/8699 2 Telehealth is the broad category of remote healthcare activities of which HMHM is a sub-category. 8

"Wide scale adoption of Telehealth will be essential for sustaining the future of health and care delivery systems. The power and reach of these technologies can improve access, overcome geographical distance and shortages of Health Care Professionals while providing a more versatile and personalised approach to healthcare "(Deloitte, 2015) 3. Changing demand Scotland has an ageing population and faces an associated increase in demand on health and care services. This demand will need to be met in an environment where the workforce faces the same demographic challenges and where financial resources are likely to remain constrained. Based on current mainstream working practices, this will inevitably result in increased pressure on services to deliver more with the same or fewer resources. Strategic planning and commissioning will need to include options that: a) Increase the capacity to deliver effective services with the same or fewer resources b) Reduce or manage the demand for services and c) Reduce consumption of healthcare resources during episodes of care. Changing citizen expectations Citizens' expectations of health and care service increasingly reflect their experiences as consumers of commercial services in other areas of their life. The consumer experience outside of health and care settings features 'on-demand' services accessed via technology and often tailored to the consumer. Citizens will look increasingly to their health and care services to offer a similar approach to service delivery and there is evidence of this expectation already 4. Deployed appropriately and at scale, HMHM can enable health systems to cope better with the growing demands of an ageing population, increasing chronic disease and changing consumer expectations. 3 Connected Health: How Digital Technology is transforming Health & Social Care, April 2015, Deloitte 4 Digital NHS Healthcheck: The Citizens' View, August 2015, YouGov/Trustmarque 9

2. The Case for Adoption in Scotland 2.1 Projected prevalence of patients with Long Term Conditions The number of patients in Scotland with long term conditions is growing fast and this trend is predicted to continue for at least the next 15 years. From a baseline of 2013 there is a projected increase in Diabetes patients of 28% by the end of 2018, 63% by the end of 2023 and 109% by the end of 2028. From a baseline of 2014 there is a projected increase in: Hypertension patients of 26% by the end of 2019, 55% by the end of 2024 and 89% by the end of 2029. COPD patients of 18% by the end of 2019, 38% by the end of 2024 and 61% by the end of 2029. Heart Failure patients of 8% by the end of 2019, 20% by the end of 2024 and 34% by the end of 2029 An increase of 54,447 patients over 15 years An increase of 21,027 patients over 15 years An increase of 262,194 patients over 15 years An increase of 277,959 patients over 15 years Figure 2 Projected prevalence of long term conditions (Source: ISD - Public Health & Intelligence SBU, Nov 2016) 10

Overall, there is a projected increase of circa 620,000 5 people with these four long term conditions over a 15 year period. Growth in demand is taking place in an environment where there is limited scope to increase the size of workforce to address this. Working practices must therefore change or Scottish citizens will have to wait significantly longer to receive treatment. In turn, this may result in citizens needing more resource intensive care. Home and mobile health monitoring (HMHM) can help to alleviate some of the pressure by supporting ways of working that reduce pressure on the workforce while improving citizen outcomes and experience. 2.2 How Home and Mobile Health Monitoring helps Traditional models of care have professionals as active providers of care solutions and citizens as largely passive recipients of those solutions. Research 6 has shown that where patients are more active or activated in the management of their health and their healthcare they achieve better outcomes and consume less healthcare resources. HMHM is a mechanism by which citizens are supported to take an active role in managing their health and their care. When embedded appropriately in suitable pathways, HMHM can: Increase capacity by reducing clinicians participation in data gathering and processing activities and by pre-qualifying and triaging healthcare contacts Reduce demand for care by supporting citizens to self-manage aspects of their care to stay healthier for longer periods of time Optimise consumption of other healthcare resources during episodes of care by helping to manage healthcare consumables. It is through these impacts that HMHM has an important contribution to make towards local delivery of the National Health and Wellbeing outcomes. Contribution to national outcomes Outcome 1: People are able to look after and improve their own health and wellbeing and live in good health for longer Through Supporting citizens to self-manage Supporting better adherence to treatments 5 Projecting Long Term Conditions A bespoke analysis, ISD Public Health & Intelligence SBU 6 Supporting People to manage their Health : An Introduction to patient Activation, The Kings Fund, 2014 11

Outcome 2: People, including those with disabilities or long term conditions, or who are frail, are able to live, as far as reasonably practicable, independently and at home or in a homely setting in their community Outcome 3: People who use health and social care services have positive experiences of those services, and have their dignity respected Outcome 4: Health and social care services are centred on helping to maintain or improve the quality of life of people who use those services Outcome 5: Health and social care services contribute to reducing health inequalities Through Supporting citizens to self-manage Supporting better adherence to treatments Enabling early intervention when a patient's condition deteriorates Through Reducing the need for citizens to wait for, travel to and attend consultations in healthcare settings Providing a more responsive service Citizens having more meaningful interactions with clinicians based on information. Through Reducing the need for citizens to wait for, travel to and attend consultations in healthcare settings Enabling early intervention when a citizen's condition deteriorates Through Improving access to timely support particularly for those living in remote and rural locations. Outcome 8: People who work in health and social care services feel engaged with the work they do and are supported to continuously improve the information, support, care and treatment they provide Outcome 9: Resources are used effectively and efficiently in the provision of health and social care services Through Better information about citizens and their conditions Through Reduced need for routine face-toface healthcare contacts Increased working to 'top of license' Increased avoided admissions Increased early discharges Reduced citizen transport 12

2.3 Examples of how HMHM is used to manage demand Preventing avoidable hospital admissions through early intervention Time and costs can be saved when hospital admissions are avoided. One of the ways in which admissions by citizens with Long Term Conditions can be avoided is by intervening before the citizen's condition deteriorates to a point where an admission becomes necessary. The information that citizens provide via HMHM is used to build up a picture of their condition. The system compares the data sent with a personalised set of rules. When a citizen's response falls out with these preconfigured parameters, or if certain patterns emerge, the system generates an 'Alert'. Alerts are prompts that a citizen needs attention and serve as an 'early warning' system. It is this process that prompts contact for further clinical support before their condition worsens. Enabling prioritised, targeted and focussed home visits When citizens who are living independently receive routine nursing support for the management of their condition they will receive periodic home visits as part of routine follow up and assessment. A proportion of these visits will be primarily focussed on assessing the citizen and their health needs. By enabling these citizens to self monitor and to relay this information back to nursing staff, some additional time to care can be released and decisions can be made to ensure that scarce nursing capacity can be focussed on helping those with the greatest need first. Reducing the need for GP practice appointments to deliver routine monitoring Where citizens need routine measurement of vital signs and other symptoms as part of a diagnosis protocol or as part of routine care there is usually a need for a series of primary care practice appointments. Sometimes other forms of contact such as telephone and letter are additionally required to facilitate this process. Often the process can take a period of several weeks or months to conclude. In some cases HMHM can be used to significantly reduce the number of appointments / attendances required to collect the data and shorten the time period in which sufficient data are collected to inform clinical decisions. This saves clinical time and allows for earlier treatment interventions. Triaging work to the most appropriate staff Where HMHM services use a system of alerts, these typically can be categorised as being either administrative in nature or clinical. Clinical alerts can be further categorised to make distinctions between routine and critical alerts. Through this system, care contacts may be triaged to Healthcare Workers, Nurses and Consultants as appropriate. 13

Supporting adherence to treatments Better adherence to prescribed treatments leads to citizens staying healthier for longer periods. In addition to helping citizens to make the link between their health and their choices, HMHM also supports the adherence to treatments by providing a sense of accountability (the monitoring service is more present for citizens than their clinicians) and by repetition. These attributes help to establish positive personal routines and to engrain positive habits. Reducing the need for outpatient appointments Early work in this area is exploring whether SMS text based services can reduce the need for routine follow-up Consultant appointments for post operative patients or to pre-qualify, appropriately route and triage referrals. Note: At scale, it is anticipated that reducing the need for routine healthcare appointments may also have a positive effect on waste by reducing the incidence of citizens failing to attend appointments (DNA's). Supporting early hospital discharge HMHM also has a role to play in facilitating early discharge, by providing confidence that ongoing monitoring will be provided for a period. Typically this would be as a component of a wider care package. Long term control in chronic conditions In the longer term, HMHM has the potential to make significant long-term system scale impact on the nation's health and on service capacity by reaching and supporting large numbers of citizens to gain and maintain better control of chronic conditions from an early stage. 2.4 Positive evidence about HMHM There is a growing and compelling body of UK and international research that evaluates the clinical and cost effectiveness of HMHM. The following review of this evidence deliberately seeks to draw out and examine those areas where HMHM is shown to work and to use this to inform an effective service model. There are a number of systematic reviews that evaluate the effectiveness of services where home monitoring is a component of care for patients with specific chronic 14

conditions. Good examples include studies carried out at University of Salford 7 and University of York 8. Overall, the published clinical evidence is stronger for some conditions than for others, but the trends are largely positive suggesting that HMHM is clinically effective in terms of contributing to; Reducing citizen mortality and hospital admissions 9 for chronic heart failure Reducing blood pressure in citizens with Hypertension 10, Improving glycaemia control (Reduced HbA1C) in citizens with Diabetes 11 HMHM has also been found to have a positive impact on compliance, education, behaviour change and better citizen self-management and on reducing the burden on the individual and services 7. The latter is particularly the case where interventions are mobile, computer or internet based because these are simple to use and familiar to citizen groups 12. A number of systematic reviews have commented on the quality of evaluations, particularly in making connections about the clinical and cost effectiveness benefits of HMHM 13. For example, whilst acknowledging the limitations of this particular study, the results from a randomised control trial undertaken by the Department of Health in England in their Large Scale Whole System Demonstrator (WSD) programme identified the following clinical benefits 14 15% reduction in A&E attendances 20% reduction in emergency hospital admissions 14% reduction in hospital bed days 8% reduction in tariff costs 45% reduction in mortality rates 7 University of Salford, Salford, 2013 ; Telehealth: The effects on clinical outcomes, cost effectiveness and the patient experience 8 York Centre for Reviews and dissemination, National Institute of Health Research, June 2013 www.york.ac.uk/media/crd/telehealth.pdf 9 Inglis SC, Clark RA, Dierckx R, Prieto-Merino D, Cleland JGF. Structured telephone support or non-invasive telemonitoring for patients with heart failure. Cochrane Database of Systematic Reviews 2015, Issue 10. Art. No.: CD007228. DOI: 10.1002/14651858.CD007228.pub3 10 Omboni S, Gazzola T, Carabelli G, Parati G. Clinical usefulness and cost effectiveness of home blood pressure telemonitoring: meta-analysis of randomized controlled studies. J Hypertens. 2013;31(3):455-67 and McKinstry B, Hanley J, Wild S, Pagliari C, Paterson M, Lewis S, Sheikh A.Telemonitoring based service redesign for the management of uncontrolled hypertension: multicentre randomised controlled trial. BMJ 346, f3030 11 Marcolino MS, Maia JX, Alkmim MB, Boersma E, Ribeiro AL. Telemedicine application in the care of diabetes patients: systematic review and meta-analysis. PLoS One. 2013;8(11):e79246. And Wild, SH, Hanley J, Lewis SC, McKnight, JA, McCloughan LB, Padfield P et al (2016) Supported Telemonitoring and Glycaemic Control in People with Type 2 Diabetes: The Telescot Diabetes Pragmatic Multicenter Randomized Controlled Trial. PLos Med 13(07): e1002098. doi:10.1371/journal.pmed.1002098 12 Vassilev I et al Assessing the implementability of telehealth interventions for self-management support: a realist review. https://www.ncbi.nlm.nih.gov/pubmed/25906822 13 University of Salford, Salford, 2013 ; Telehealth: The effects on clinical outcomes, cost effectiveness and the patient experience 14 Department of Health, Whole System Demonstrator ProgrammeHeadline Findings December 2011 15

In terms of cost effectiveness the results were less positive. However, researchers increasingly accept that there were a number of contributing factors including: Poor alignment to any self-care management programme or regime The use of expensive technology The methodology (randomised controlled trial) that imposed constraints on patient selection criteria The absence of any redesign of the service pathways These factors led in many cases to the HMHM interventions in this study to becoming "one size fits all" additions to routine care. A number of significant changes have taken place since the Whole System Demonstrator study; Technology costs are now significantly lower. Today the technologies in use are more agile, user friendly and mobile enabled. There has been a move towards a more simple approach to HMHM utilising lower cost solutions (e.g. mobile technology). This has reduced the need for expenditure on hardware, software development activities and it promotes a "bring your own device" approach. The service delivery model is changing. HMHM is being used to take work out of pathways rather than adding work. This is improving costs and productivity. In addition to the evidence discussed here rapid reviews carried out by Healthcare Improvement Scotland have confirmed the difficulty in providing firm recommendations based on existing randomised control trials alone 15. 2.5 Evidence from large scale pilots and mainstreaming There is wide variability across the UK and Europe when it comes to the maturity of HMHM enabled pathways and their deployment into mainstream health and care services. Since 2012, home and mobile health monitoring solutions have been increasingly deployed at larger scale and in several regions and countries these are now mainstreamed into routine services (e.g. Denmark, Basque region in Spain, USA and Canada). 15 Healthcare Improvement Scotland: Home health monitoring devices compared with usual care for patients with hypertension; evidence note 59 Home health monitoring compared with usual care for patients with moderate to severe chronic obstructive pulmonary disease: evidence note 60, 16

These regions offer a range of HMHM services for people with chronic health conditions such as COPD, Heart Failure, Hypertension and Diabetes. Two examples of these services are outlined in case studies provided at Annex A. Although there are pockets of deployment excellence, Scotland and the wider UK lag behind many other European and International countries in this respect. To help address this Scotland took part in a European deployment initiative called United4Health. It focussed on stimulating adoption, scaling-up and assimilation of evaluated interventions into mainstream pathways. 2.6 The United4Health Programme in Scotland United4Health (U4H) was a three year European Programme that concluded in January 2016. It provided valuable learning about at-scale implementation of simple, digital health monitoring solutions that are designed to support people living with long term conditions. U4H is one of the largest deployment observational studies undertaken both in Scotland and across Europe. The programme reached a combined population of around 10,000 citizens across 14 regions in Europe, of which approx 5,900 were from Scotland. The programme demonstrated that real life scaling-up of digital health monitoring is achievable and can deliver clinical and cost effectiveness when it is deployed as part of routine care. Key outcomes and findings from the programme are: - Evidence of improved clinical outcomes indicating reductions in unplanned admissions for COPD, Diabetes and Heart Failure. Evidence of cost per patient reductions for HMHM interventions. High levels of patient satisfaction with HMHM deployed across all three conditions. Simple, low cost solutions are increasingly available and proven to be as effective as high end solutions. Participating regions, particularly Scotland and Wales have been able to demonstrate cost reductions per patient due largely to the at-scale use of low cost solutions. From an organisational prospective, evidence suggested that practitioners are targeting remote monitoring more effectively and report it is easier to use than perceived. The integration of home and mobile health monitoring solutions into routine care pathways is a critical success factor for mainstreaming solutions. The learning from U4H has directly informed the development of this National Service Model. 17

2.7 What this means for home and mobile health monitoring in Scotland Firm conclusions that can be drawn from the evidence are that HMHM has the ability to be beneficial for citizens and that it can be a cost-effective means of delivering these benefits. However, cost-effectiveness depends greatly on how the HMHM activity is implemented. This includes choices about the technology used and the design of services. The evidence also suggests that there are pre-requisites to the successful implementation of services at scale. These include organisational and operational factors and that the standardisation of approaches is needed to generate more robust cost-benefit comparisons and ultimately, sustainable services at scale. 18

3. National Service Model Framework 3.1 Purpose This National Service Model for Home and Mobile Health Monitoring (HMHM) in Scotland is a tool to support service design and development. The framework; consolidates learning from early adopters and service pioneers in Scotland and applicable learning from other parts of the world, especially Europe and North America; establishes a foundational service template designed to be scalable and efficient when applied in the context of services in Scotland; provides a starting point from which new experiences based on common principles can be used to drive improvement in this field of practice. 3.2 The Framework Components The framework is constructed from the following key components: A conceptual model which describes the environment in which HMHM services operate, the citizens that these interventions best serve and the ways in which citizens and pathways are supported A set of service principles to inform service and pathway design. These describe the purposes of interventions and underpin the attainment of cost and clinically effective interventions A core service pathway and components to inform a consistent approach to pathway development and implementation across Scotland. This will support equitable care and standards and the realisation of efficiencies. 3.3 The Conceptual Model Whilst the focus for HMHM has been and remains on supporting citizens who are living with long term conditions, HMHM can support citizens and services across a much broader spectrum of health and care needs. Recent work in Scotland has seen a significant positive change in the appeal of HMHM as a result of introducing technologies that are easier to work with and at a significantly lower cost. The flexibility of some of these new technologies have led to service developers being able to offer clinical and professional colleagues tailored solutions to meet their needs This has resulted in a broadening scope of application for HMHM to support citizens with a wider range of chronic and acute conditions. 19

To support this broader application, the conceptual model uses a tiered approach to delivering citizen and service support. This provides flexibility to meet the changing needs of citizens living with long-term conditions as well as supporting diagnosis, triage and review activities for a wider range of Primary Care and Outpatient pathways. It is anticipated that mainstream adoption of targeted HMHM will lead to positive impacts on health outcomes and capacity to care at a health system level. Home and Mobile Health Monitoring Scope of Application The objective is to reach the point where services in Scotland can efficiently and effectively support as wide a range of citizens as is practical across tiers 2, 3 and 4. Figure 3 HMHM Scope of application This conceptual model (illustrated above) describes the landscape in which Home and Mobile Health Monitoring interventions are applied. It illustrates the context in which these types of intervention can deliver the greatest value. Citizens are grouped into tiers according to the intensity of their healthcare needs. The tiers also reflect the relative citizen population, health resource utilisation and the per capita costs at each tier. Tier 1: Citizens self-managing and maintaining their good health and wellbeing generally outside of healthcare. Tiers 2 through to Tier 4 are the focus of remote health monitoring activities and describe escalating citizen healthcare needs and the ways in which those needs are met. 20

Tier 5 represents citizens with acute needs receiving healthcare outside of a community setting. They are largely or wholly dependent on NHS services. To date, HMHM is most effective when focussed on Tiers 2, 3 and 4. Citizens in Tier 2 are supported mainly in the community by Primary Care practices and other community based services. Outside of initial diagnoses, these citizens receive only very occasional or 'exceptional' involvement from hospital based specialists. Citizens in Tier 3 have an extended or enduring condition or health problem and are likely to have at least part of their care managed by specialists over the course of two or more visits in an ambulatory care setting. This includes citizens with single episode acute needs as well as citizens with periodic episodes of care related to one or more chronic conditions. Citizens in Tier 4 have complex and enduring specialist requirements and are typically supported by a team of multi-disciplinary professionals to preserve their health and wellbeing outside of a hospital setting. Home and Mobile Health Monitoring A Tiered Approach Figure 4 A 'Step-up' - 'Step-down' model (Source: SCTT) The needs of citizens change as they move up and down the tiers. HMHM services must adapt to these changing needs and support the changing strategies that are 21

employed to preserve and improve the health and wellbeing of individuals at each level. Tier 2 Implementations Tier 3 Implementations Tier 4 Implementations Supporting Primary and community care pathways Diagnoses and assessment of conditions Assessment of treatments Stabilise / establish / reestablish condition control Health and wellbeing coaching to inform and enable self-management Preventative interventions to promote behaviour change in lifestyle, diet, self care. Promote anticipatory care newly diagnosed LTC Examples: Diagnosis of hypertension using remote monitoring of readings (reduced GP appointments) Faster assessment of initial treatment / titration of BP medications (reduced GP appointments) Re-establish selfmanagement after an episode of poor control. Supporting specialist and community care pathways Triage to outpatients Pre-consultation data gathering Assessment of treatments Timely interventions to exacerbations / crisis/ deterioration in stable condition Support to re-stabilise / reestablish condition control Treatment compliance and adherence to medication Examples: Supporting heart failure patients to monitor symptom changes and to self-manage Supporting difficult to reach patients with T1 Diabetes to regain control of Hb1AC (avoidable admissions) Supporting patients with respiratory illness to selfmanage exacerbations (avoidable admissions) Medication titration for patients with Chronic Heart Failure Self management of weight to support control of a chronic condition Support and triage wound care in the community. Supporting later stage & complex long term conditions pathways in the community To support coordinated case management and anticipatory care To support early interventions for citizens with resource intensive needs Early discharge (with appropriate care package) Examples: Supporting Chronic Disease Management in patients with a later-stage single condition e.g. COPD (early intervention). Support multi-discipline care of citizens with complex and multi comorbidities (anticipatory care and early intervention) Symptoms management for end of life care. 22

3.4 Service Principles The following principles inform the design of Home and Mobile Health Monitoring (HMHM) services and pathways. They underpin delivery of cost and clinically effective interventions. These principles have been deliberately generalised to ensure that they are relevant to a range of health conditions, types of intervention and across health and care settings. HMHM services should be delivered in partnership with citizens, clinicians and where applicable with other professionals, organisations and carers. Strong collaboration across all participants in HMHM enabled pathways optimises the impact and benefit of the intervention. Citizen Identification & Assessment Potential service users are identified using pre-determined criteria that reflect service objectives. 'Case finding' criteria should include clinical appropriateness and use risk stratification information where available and applicable. Willing participants and self-identifying candidates are assessed for propensity and capacity to benefit from the intervention. Assessment informs each new episode of service. Duration of Deployment Citizens receive episodes of HMHM support only for a period of time appropriate to the purpose of the intervention and their ongoing clinical needs. (Typical periods range from a few weeks to 3, 6 and 9 months programmes). HMHM provided by the public sector is not intended to be a lifetime service. The use of remote monitoring is routinely reviewed with the citizen by their Health Care Professional at appropriate intervals. By exception, long term monitoring can be considered for higher risk citizens with complex needs as part of the individual's anticipatory care planning arrangements. Tiered Service Delivery Where practical, appropriate HMHM services are available to local service users at each of the target Tiers. (Tiers 2, 3 and 4 as shown in Figure 4). Services are flexible enough to support the changing needs of users as their pathway transitions up and down service tiers. Service users are discharged back to their referrer or to appropriate onward support when their episode of monitoring is concluded. 23

Person Centred Care The provision or continuation of HMHM services is considered within the context of the individual's wider care circumstances. Service episodes are commenced with an explicit understanding by users of how the intervention will help them and if appropriate, their care givers. Users' needs are assessed with input from the user/carer and appropriate service adaptations are made prior to each episode of service commencement. Users/carers are actively encouraged to fully engage and provide feedback on their service experience in support of service improvement. Technology Users can access HMHM services via the technologies that best suit their individual competencies and preferences. Where provided by health and care services, equipment and peripherals are simple, low cost, easy to use, portable and wherever practical, wireless. Technology choices support the delivery of optimal service pathways. Supplier solution architecture is interoperable with health and care systems and complies with defined international standards. Solutions make provision for HMHM users who wish to utilise their own devices and / or peripherals. Solutions facilitate the optimal use of clinical time by processing raw data, presenting information in clinical user specified and preferred formats and by facilitating remote access to this information by users authorised to do so. Data Management Where appropriate, data processing arrangements for the delivery of local services meet the appropriate local data governance controls. Data management arrangements fall within local, national and where applicable international standards. Integration of HMHM and Telecare TEC Pathways Opportunities to improve user experience and to achieve time, effort and cost economies through closer working with Telecare services are explored when they arise and are acted upon where practical. Opportunities to develop joint HMHM and Telecare assessment processes are explored and new working practices are adopted where practical. 24

3.5 Core Service Pathways Generic Care Pathway The following diagram describes a generic care pathway for all home and mobile health monitoring services in Scotland. It describes a minimal number of steps to deliver a fully functioning monitoring service. Crucially, this design invites the use of technology to support existing pathways rather than to create additional levels of intervention. A Generic Pathway for HMHM Figure 5 The 'Core' Pathway (Source: Scottish Centre for Telehealth& Telecare) In this Core Pathway the term 'Usual Care' is used to describe the full spectrum of citizen care practices in which clinicians have the opportunity to individualise care. The process for this pathway flows as follows: 1. Patient is reviewed as part of usual care and assessed for HMHM. 2. Where the patient matches pre-agreed criteria and there is individual capacity to engage, a referral is made. 3. Service is initiated. 4. Monitoring commences, alerts are triggered and early interventions made as appropriate. 25

5. The patient is reviewed and next steps are decided: a. Continue as-is b. Step up intensity c. Step down intensity d. Step off HMHM and return to appropriate Usual Care This core pathway process serves as a foundation for more specific care pathway redesign. Core Pathway Components To be of practical use to service designers a more detailed examination of the core components is required. The following diagram describes the core pathway process in terms of 3 phases Initiation, Delivery and Review, and Close. In each phase it identifies the service components from four perspectives: Clinical, Patient, Operational and Technology. Figure 6 The 'Core' Pathway Components (Source: Scottish Centre for Telehealth & Telecare) Together the core pathway and components serve as a service design / redesign template. Their purpose is to support a nationally consistent approach to developing HMHM enabled pathways. As per current practice, appropriate clinical guidance is referenced locally by supervising clinicians according to their specific requirements from individual 26

pathways. There is scope to develop condition specific model pathways and work to investigate the practicality of these has been initiated. Similarly, patient information is developed and provided locally to reflect local arrangements. Further details about the technology layer are being developed as an integral part of Procurement Guidance (for release Spring 2017). A generic template for Standard Operational Procedure documentation can be found in this publication's accompanying "Implementation Guide" (for release Summer 2017). Service planners will also wish to consider local Support and Maintenance Requirements for HMHM enabled pathways. 27

4. Enabling the Delivery of Home & Mobile Health Monitoring Services at Scale 4.1 An Illustrative Maturity Model for Home and Mobile Health Monitoring Figure 7 An Illustrative Maturity Model The maturity model illustrated above describes the characteristics of current HMHM services (Start-Up) and extrapolates these into two further stages of maturity, 'Growth' and 'Scale-Out. It describes in simple terms the characteristics of scale with the current context of services and assumes a future state where services are pooled, at minimum, across localities, perhaps across Health Board and Integration Authority boundaries and potentially, at some later stage, nationally. The relative maturity of a service is determined by referring to a range of indicators of scale. These are defined as follows: 28

Number of Tiers served: refers to the tiers described in the Conceptual Model (see Figure 4), specifically the applicable tiers (Tier 2, Tier 3 and Tier 4). Specialties: refers to the number of distinct specialist disciplines that are using HMHM enabled pathways within the service. Pathways: refers to the total number of active pathways within a service, regardless of speciality, that utilise HMHM. Channels: refers to the number of different media channels through which citizens communicate their data. Examples include Tablet (POD), SMS Text, Website, Digital TV, Automated Voice (IVR), and Push Notification. Location: refers to the geographical range of the service. Patients: refers to the number of current active citizens using the service at a given point in time. At present all HMHM activities in Scotland are classified as Stage 1 with some beginning to show Stage 2 characteristics. There is still much to be learned about scaling-up in practice before services will be ready to transition to Stage 3. Routes to the 'Scale-Out' stage may be liable to change quickly and significantly as the Health and Social Care landscape adapts to meet the demands of integrated working. It is intended that potential routes to 'Scale Out' will be explored in later versions of this document and within the context of integrated health and care services. 4.2 Critical Success Factors In response to increasing international adoption of HMHM services a body of work is developing to identify the factors that determine the successful deployment of services at scale. An example of this was published by a European project called Momentum in 2014. The project set out to identify answers to the question, "What is needed to deploy Telehealth at scale?", and identified 18 critical success factors for the transition from pilots to at-scale services. These factors were organised into 4 themes and serve as a check-list for planners to reference in assessing their own organisation's readiness to deploy home and mobile health monitoring services. The themes identified are as follows: Critical success factors for; a deployment strategy managing organisational change 29

Critical success factors from; a legal, regulatory and security perspective an ICT perspective A full list of the critical success factors along with a self-assessment questionnaire can be found in ANNEX B Additional research in this area carried out in Scotland during 2015 focussed specifically on Home Health Monitoring. It set out to answer the question, "What are the critical success factors of service models that have been used to implement home-health monitoring for people with long-term conditions at scale across Scotland, the UK and developed countries? " This work has identified 37 specific factors that service managers should consider in their planning. These have characterised as either Risk Factors or Mitigating Factors and have been organised into 5 themes: Resources Activities Reach Outcomes Overarching Factors A full list of the 37 factors can be found in ANNEX C and the full report entitled "Home health monitoring: critical success factors for implementation" on the website of the Scottish Centre for Telehealth and Telecare www.sctt.org.uk Service developers should assess and monitor their organisation's readiness to scale up HMHM as part of their preparatory work to initiate services and consider the home health monitoring specific factors in the design of local services. 4.3 Optimising Organisational Models Current HMHM practice in Scotland typically involves services arranged around two functional components, a service development and coordination function and clinical supervision and response function. In many cases the configuration of these organisational arrangements are evolving as service managers learn through experience about the optimal arrangements for their particular service and circumstances. Service development and coordination Service development and coordination is, in all cases, centralised as a function within local service arrangements. 30

The roles fulfilled by this function are focussed on establishing and managing enabling processes. These include: Awareness raising, education and advisory services Establishing and coordinating tests of change and managing the transition of new approaches into routine practice Support to redesign and refine pathways including HMHM enhancements Technical support to establish and refine protocols within software systems and to set up / revise standard operating procedures Procurement and management of supplier contracts Support with the management of equipment and peripherals 1 st line technical support for citizens and clinicians Performance measurement and reporting Ongoing service development and improvement Clinical supervision and response Clinical supervision and response activities can be either centralised in a 'clinical hub' operation or wholly devolved to discrete clinical teams. The roles fulfilled by this function are focussed on two areas: Protocols and individual care plans Results and Alerts management. The specifying, approving and adjusting of protocols along with the establishment of citizens' initial individual care plans are in all cases devolved to local clinical teams and to individual clinicians. This is where the clinical governance arrangements for HMHM are established and maintained. The maintenance of citizens' initial individual care plans over the course of an HMHM episode, in the majority of cases, is also devolved but this may be a shared activity between centralised and devolved teams. The management of alerts involves responding to system generated messages that highlight the need for an action or decision in relation to individual citizens. These alert messages can be categorised as being either administrative in nature or clinical. Clinical alerts can be further categorised to make distinctions between routine and critical alerts. Through this system care contacts may be triaged to Healthcare Workers, Nurses, General Practitioners and Consultants as appropriate. These categorisations enable the efficient triage and processing of alerts and it is these activities that are the most readily centralised component of the Clinical Supervision and response function. In practice, this centralisation can be carried out through either a physical or virtual 'hub' arrangement, or a combination of both. However, scale and local working 31

practices will determine decisions about the practicality and desirability for this component either to be performed centrally or to be devolved to local clinical teams. As larger scale services develop, the operational arrangements for clinical supervision will play a significant role and need to be routinely revisited in order to ensure optimal configuration. 4.4 Shared / Coordinated Services For higher volume HMHM services to be delivered effectively and efficiently at scale some aspects of service operations and administration will require to be pooled. While there is still opportunity to gain insights about which elements of service are best suited to pooling, there are a number of candidate activities that planners will wish to consider. Shareable service elements Alerts and triage Risk mitigation and resilience Systems integration (manual) Integration with OOH services Continuity of care Alerts and triage As discussed earlier in this document, HMHM of citizens with chronic conditions generate alert notifications of differing types and at different volumes and frequencies. Alerts are stratified as administrative and clinical alerts and clinical alerts can be further sub-divided by priority. When services reach a certain scale it becomes more efficient for a small number of appropriately qualified people to manage the volume as part of a streamlined process than for a large dispersed number of qualified people to manage the volume as a part of their duties. In this way supervising clinicians need only become involved in the small proportion of alerts that require their attention. As individual service volumes grow, the argument for the pooling of local 'alert review' activities becomes stronger. As the number of localities offering similar services grows, the argument for regional or even national pooling of 'alert review' activities grows. Risk mitigation and resilience 32

The alert system requires that someone is able to receive and act upon the most 'critical' class of alerts. This means that for any alert based activity to be 'safe' there is a need for more than one person to be involved in reviewing alerts. While HMHM services are not intended, nor offered as an alternative to emergency care, there is the potential for increased risk that human error will lead to incidence of important or critical alerts being missed. For example, two people in one locality being on leave at the same time or unavailability of staff due to other emergencies such as flu epidemics etc. Individual local services are also less likely to have appropriate disaster recovery arrangements in place. As local services grow into the high-hundreds of citizens the risk increases. There is a cost to increasing the resilience of services that again would likely be met more efficiently through a shared service model. Temporary systems integration The poor interoperability of HMHM systems with existing NHS systems acts as a barrier to adoption. It may be practical in the short-term to use a pooled service as an integrator clinicians deal with one system only, the integrator service, instead of having to manage multiple interfaces for a range of different suppliers' monitoring solutions. Integration with OOH HMHM collects a wealth of diagnostic information in-hours that could be utilised to improve the effectiveness and efficiency of Out Of Hours services. At present, this information is not available to OOH services. There is an argument that co-locating HMHM support services and OOH services would make it easier for OOH patients to benefit fully from their existing monitoring activity. Further consideration Planners may also wish to consider other co-location opportunities. For example, it may make sense for pooled remote health monitoring services to be co-located with other call centre based citizen health and care services, ideally as part of integrated health and care pathways. 4.5 Return on Investment Fully realised, the return on investment from scaled-up and optimised HMHM services are anticipated to be; a healthier population an enhanced capacity to cope with growing demand for services. HMHM also has the potential to serve as an enabling factor in the refocusing of NHS Scotland from hospitals to primary and community care by helping to release 33

capacity in primary and community settings. This would be achieved through supporting citizens to do more to manage their own conditions. The challenge is to reach the point where those returns can be achieved reliably and cost effectively. HMHM enabled services in Scotland need to expand to a degree where system level impacts become tangible and service delivery costs become optimised. This expansion needs to take place both in the numbers of citizens benefiting from HMHM and in the range of pathways that offer HMHM. In the short-term, this means finding and encouraging good 'candidate' services for scale-up, testing their viability and encouraging wider adoption of those pathways that show the most promise. In this way, meaningful returns can be achieved through the service development phase and sufficient evidence can be gathered to support further investment. It is intended that this approach will lead initially to wider-spread local utilisation, followed by the pooling of resources into regional services and if beneficial, consolidation into national services. This aggregating of activities and benefits will produce system level impacts. The Scottish Government TEC Programme and SCTT are currently supporting a number of local partners to grow and learn from a range of initiatives at various stages of development and across the National Service Model tiers. Through these activities and by observing similar activities outside of Scotland, candidate scale-up services are emerging. The criteria for identifying good 'candidate' services vary depending on the specific clinical aims of individual interventions. However, common criteria are; demonstrable time-saving advantages in the short-term (reduced contacts and travel); demand prevention (better access to timely care, adherence to treatments and long-term condition control) in the mid-to-long term. These benefits must be delivered without detriments to citizen health outcomes, at a lower operational cost-to-serve than traditional pathways and ideally, demonstrate tangible cost reductions. Emerging candidate services The following table shows some examples of emerging services and models that show promise as scalable propositions. 34

Tier 2 Service Hypertension Diagnosis and Titration From work carried out through TEC we know 16 that using HMHM to diagnose Hypertension and to titrate medication can save around 4 primary care appointments per patient. If all new cases of Hypertension in Scotland were diagnosed in this way, some 140,000 17 primary care appointments would be saved equivalent to a complement of 32 FTE practice staff 18 comprising 10 GP's and 22 Practice Nurses 19 and at an annual cost of 420,000 20 There are around 1.3m primary care Hypertension appointments per year in Scotland for around 570,000 patients 21. This suggests that there are further opportunities to save appointments where patients need blood pressure monitoring additional to their annual review. Tier 3 Service U4H Telehealth Model for Diabetes in Scotland This model of HMHM supports improved self-management in citizens with either Type 1 Diabetes or Insulin dependent Type 2 Diabetes. It has demonstrated 22 significant cost savings in Scotland of 230 for 33 invested. Savings were derived predominantly from reduced Acute admissions as well as through fewer Primary, Outpatient and Emergency Department contacts. Tier 4 Service Long Term Conditions Hub NHS Liverpool CCG run a mixed condition Supported Self Care hub model and have evidenced a 22-32% reduction in emergency admissions and secondary care costs for citizens with a high risk of re-admissions (>25%). The suggested savings per patient are significant based on NHS England tariff costs of admissions. Further work is required to determine how well this would translate in NHS Scotland settings. Earlier stage candidate services that are being explored by TEC funded partners include Wound Care pathways (potential 50% cost and time savings) and Oral Nutritional Supplementation follow-up and monitoring services (potential 3 saving per 1 invested) both of which have the potential to deliver significant regional and national benefits if the results are proven robust and scalable. 16 NHS Lanarkshire - Rapid Improvement Study: Hypertension Monitoring in General Practice 17 ISD Hypertension Data Explorer - 35,000 new cases (2014) x 4 appointments = 140,000 appointments 18 Average 19 appointments per day x 230 days per year 19 Based on a 1:2 ratio of GP to PN appointments (PTI October 2013) 20 SMS Text message costs based 0.08 x 6 per day x 21 days plus 19% overhead = 12 per patient 21 PTI October 2013 Hypertension (2012/13) 22 U4H Deliverable D6.7 Final Trial Evaluation Diabetes Version 1.3 united4health.eu 35

Evaluating candidate services TEC work to evaluate this National Service Model will support the identification and verification of 'candidate' services. Running from winter 2016 to summer 2018 the programme of evaluation will focus, in the main, on Long Term Conditions pathways and will provide a consistent framework and methodology for evaluating HMHM pathways in terms of their contribution to National Health and Care Outcomes and economic impact. Guidance on evaluation and return on investment can be found in this publication's accompanying "Implementation Guide" (for release Summer 2017). 4.6 Common requirements and standards for technology solutions Technology solutions underpin the delivery of HMHM services. The scaling-up of services requires solutions that meet the changing needs associated with robust, secure, user-centric, at-scale data collection and information processing. Rigid, stand-alone, condition-specific products and services have a diminishing significance in a service model designed to serve a wide spectrum of citizen needs in high volumes, via multiple channels and with specified experiences for each user. Cost-effective at-scale services will increasingly require solutions that: allow the re-use of existing assets avoid bespoke extensions to standard products fit into the existing technology landscape are open systems that support the free flow of information use international standards (to allow procurement in the wider EU market). Reference model The diagram shown on the next page maps the elements of a system that can be procured as part of an HMHM solution. The following is a conceptual overview to show an outline of system components, at what locations they will be found and how they are connected. A given service may not need to have all of these. 36

Figure 7 A Technology Reference Model Defining technology requirements for at-scale services The diagram that follows is based on the internationally recognised Continua model. It uses the Continua language where it applies. It also reflects market intelligence gathered in the United4Health project about the typical elements that can be found in current vendor offerings. Service planners will wish to note that this model identifies the building blocks for further technical specification work being carried out at a national level. Monitoring and triage Business layer - offers products and services to external customers, which are realized in the organisation by business processes performed by business actors. Asset management System support Training On site logistics Service user interface Service admin user interface Clinical user interface System admin user interface Care Plans Management Information Application layer - supports the business layer with application services which are realised by (software) applications. Observation capture Protocols Alerts Configuration Gateway application Server API NHS Integration point Observations database User database Educational content NHS Health Records system Service provider core system Technology layer - infrastructure services (e.g., processing, storage, and communication services) needed to run applications Personal device Application hosting device WAN communication Wide Area Network device SWAN communication Health Record Network device 37

Figure 8 Technology Architecture 4.7 Procurement The market for Home and Mobile Health monitoring (HMHM) products and services has evolved, in the first instance, to serve pilot programmes and initiatives. This has led to service development being based on implementing a particular technology or solution that happened to be available at the time. To achieve sustainable, cost efficient services at scale there is a need for ready access to technology solutions that instead support the efficient delivery of redesigned services and pathways. These service designs are built around meeting patient and clinician needs and have specified the ways in which technology can best support implementation. A national service model presents an opportunity to develop common procurement advice by identifying common functionality and specifying common requirements. It also provides an opportunity to inform the market about emerging demand for solutions that use open standards, can support a variety of citizen needs in a variety of circumstances and using a range of access channels that best suit the citizen. At present there is no specific national procurement framework for Home and Mobile Health monitoring. However, equipment and services can be acquired through other national framework arrangements and through local procurement routes. Service planners will wish to note that Procurement Guidance is in development. This will be released as a companion document to A National Service Model for Home and Mobile Health Monitoring in the Spring 2017. 4.8 Workforce Development Education and training of the workforce is a key component in the successful scale up of HMHM. There is a need to support the current and future workforce to use these technologies and transition to revised working practices and roles. While technology is an important feature of providing HMHM, the impact is achieved through the implementation of redesigned pathways, which reflect updated models of care. Consideration will be given at a national level about how best to educate and support staff in the implementation of HMHM enabled pathways and to supporting the transition to revised ways of working. 38

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5. Developing and Refining the National Service Model This first release of A National Service Model for Home and Mobile Health Monitoring is intended as a starting point for the encouragement, development and support of service redesign and expansion rather than a definitive guide. There is still a lot of innovation in this arena and new opportunities for HMHM to be utilised to the benefit of citizens, clinicians and services alike are being uncovered. This guidance needs to reflect the rate of discovery and new learning and as such will remain a 'living' document for the foreseeable future. Through continued work with TEC Programme Partners and in particular the Home and Mobile Health Monitoring Action Group, further content is planned and will be developed as a part of what is now a growing Community of Practice in Scotland. In particular SCTT with support from the Home and Mobile Health Monitoring Action Group is developing evaluation arrangements that will support better understanding of the cost benefits of HMHM in Scotland along with the contribution that these services make to the local delivery of the National Health and Social Care Outcomes. Learning from these activities and routine operational experiences will be recognised in future iterations of this document. Two companion documents to this National Service Model are in development; Procurement Guidance: This is being developed in response to demand from health and care partners and is being designed for use by local services in the first instance. It will also inform national procurement activity in due course. It is anticipated that this document will become available in Spring 2017. An Implementation Guide: This will package and share the learning about the operational aspects of HMHM service start-up and implementation. It is anticipated that this will become available in Summer 2017. A proposed outline is provided at ANNEX D. To provide comments on this document please contact: Michelle Brogan Service Development Manager Scottish Centre for Telehealth and Telecare Michelle.Brogan@nhs24.scot.nhs.uk 40

ANNEX A CASE STUDIES US Department of Veteran Affairs In the US, the Department of Veteran Affairs has been using Telehealth including remote Health monitoring for a number of years. As an organisation VA has had considerable success in supporting patients with Long Term Conditions through care at a distance and promotion of self-management and is considered as a global leader in this field. The VA has grown its Telehealth and remote patient monitoring from an initial programme of 2,000 in 2003 to over 150,000 in 2012. It provides services to people between the ages of 50-90 years of age with specific disease programmes addressing diabetes (48%); Hypertension (40%); Congestive Heart Failure (25%) and COPD (12%). Two thirds of these patients have a single condition whilst the remainder have two or more conditions. Extensive studies show the VA consistently provides better care than other US health providers at a lower cost. Published reports demonstrate that Telehealth at scale cut annual healthcare expenses between 2009 and 2012. Costs for veterans treated via Telehealth decreased by 4% one year after beginning the use of such services. In fiscal year 2013 alone, it is reported VA-specific Telehealth applications delivered care from 151 VA medical centres and more than 705 community-based outpatient clinics. Of the 608,900 veterans who were treated via Telehealth, 45% lived in rural areas. In total, nearly 1.8 million episodes of care used Telehealth services. The number of veterans receiving Telehealth is increasing by about 22% each year. In addition, Home Telehealth services reduced bed days of care by 25% Home Telehealth services reduced hospital admissions by 20% The annual cost to deploy these programs is 1,128, per person compared to over 9,100 for traditional home based care. NHS Liverpool Clinical Commissioning Group, Innovate UK Since 2015, NHS Liverpool Clinical Commissioning Group (CCG) through the UK DALLAS programme have progressed a large scale project enabling the scaling up and adoption of Home Health Monitoring and Supported Self Care to over 1808 people living with long term conditions (LTC s) including diabetes, heart failure and COPD. This large scale study sought to improve patient independence and emotional wellbeing using innovative tele-monitoring equipment alongside the support of a clinical Hub and structured programme of case management, monitoring, education and coaching for a population living with varying levels of long term conditions. The results highlighted clear benefits among study participants, with reductions in admissions and secondary care costs ranging from 22% to 32% for patients with above average risk of admission scores. Furthermore, patients reported outcomes suggested that 90% felt more in control of their condition, gained confidence and or felt they had a better ability to cope. References: http://www.commonwealthfund.org/~/media/files/publications/case%20study/2013/jan/1657_broderick_telehea lth_adoption_vha_case_study.pdf Evidence for supporting Self Care at Scale: A population Approach to evaluating technology enabling support for Long Terms Conditions, March 2016, NHS Clinical Commissioning Group. 41

ANNEX B Strategic Success Factors Momentum Critical success factors 1 Critical success factors for a deployment strategy Ensure that there is cultural readiness for the telemedicine service. Ensure leadership through a champion. Come to a consensus on the advantages of telemedicine in meeting compelling need(s). Pull together the resources needed for deployment. 2 Critical success factors for managing organisational change Address the needs of the primary client(s). Involve healthcare professionals and decision-makers. Prepare and implement a business plan. Prepare and implement a change management plan. Put the citizen at the centre of the service. 3 Critical success factors from a legal, regulatory and security perspective Assess the conditions under which the service is legal. Identify and apply relevant legal and security guidelines. Involve legal and security experts. Ensure that telemedicine doers and users are privacy aware. 4 Critical success factors from an ICT perspective Ensure that the appropriate information technology infrastructure and ehealth infrastructure are available. Ensure that the technology is user-friendly. Put in place the technology and processes needed to monitor the service. Establish and maintain good procurement processes. Guarantee the technology has the potential for scale-up. 42

ANNEX C Success Factors for Implementation Critical Success Factors for Implementation of Home Health Monitoring (asterisk indicates a factor reported in Scottish research) potential risk factors factors to consider when planning for resources *connectivity or reliability problems could deter users *patients may have problems using the technology *technology does not link up with existing patient record potential mitigating factors *the technology is used as part of a routine the technology reminds patients to take measurements *the technology is easy to use the technology provides timely feedback or receipt after patient transmits data the technology is able to be personalised to patients potential risk factors factors to consider when planning for activities patients may not be confident to self-manage or adjust medication *patients may feel anxious about an aspect of home health monitoring such as having more responsibility or using the technology competently *patients perceived professionals retain primary responsibility for their home health monitoring potential mitigating factors patient learning and support needs relevant to home health monitoring are identified and addressed on an ongoing basis *patients are adequately trained in self-management *professionals are competent in supporting self-management a sufficiently skilled practitioner reviews data and provides feedback *a joint self-management plan is developed between patient and health care professional outlining their new responsibilities potential risk factors factors to consider when planning for reach *the patient-clinician relationship or interaction changes home health monitoring is not suitable for all patients 43

*there may be concerns that patients will see themselves as sick or patients may become more dependent *professionals have concerns about increased workload as a result *professionals have concerns that patients will become more dependent on them *professionals may be concerned that patients will not self-manage *changes required for patients to self-manage and patients and professionals to assume their new roles and responsibilities are complex potential mitigating factors *professionals felt leadership was important to developing services *potential patients are carefully selected *patients feel reassured as they perceive that their health is being closely monitored potential risk factors factors to consider when planning for outcomes patients may not implement advice as suggested *patients may mistakenly believe their data is being monitored continuously lack of appreciation of the complexity of telemonitoring potential mitigating factors patients take and interpret their own measurements *patients gain increased knowledge of their condition patients are less anxious when they take their own blood pressure and so avoid inaccurate readings *patients have a trusted relationship with the health professional who is providing advice *patients make decisions about their care and when to contact professionals based on the data they collect potential risk factors overarching factors not easily attributed to results chain *self-management impacts on existing systems of care potential mitigating factors *important to plan the project with stakeholders and undertake ongoing evaluation with staff and patients *telemonitoring is integrated in to an established clinical context 44

ANNEX D - Implementation Guide - Outline Introduction Purpose Advance Preparations and Organisational Readiness Organisational readiness assessment (Momentum Project) The business case o Outcomes o Cost modelling o Return on Investment o Supporting documentation Cost modelling tools Business case template Example RoI statements Communication for change (education) A guide to service redesign for HMHM Planning and preparation o Critical Success Factors o Setting objectives o Stakeholder engagement o Pathway redesign o Workforce development o Supporting documentation Model Pathways Model SOP Workforce development resources Start-up and review Scaling-up your initial service Operational evaluation, learning and improvement Extending service provision Service Evaluation and improvement Sources of further support. 45

2016 The Scottish Government 46