Synergy between SmartCare, BeyondSilos and CareWell

ICT-enabled integrated care projects

A Maturity Matrix for Integrated Care Workshop

European Summit on Active and Healthy Ageing

10th March 2015

Marco d’Angelatonio, MD HIMSA

The rationale behind the projects

A core group of partners have come together over time and have developed a common strategy to maximise the outcomes and impacts of EU funded projects. This has materialised in:

• Building and extending the evidence base on the impact of eHealth, eInclusion and AAL for elderly care and to support the independence of older people.

• Sharing the lessons learnt through the successes and failures in deploying ICT-based care services.

• Using the pioneers and early adopters to pull others into their slipstream.

3

The chronological sequence

2008

2009

2010

2011

2012

2013

2007

Year

Users

200 300 1.000 5.000 8.000 10.000

Complexity

Ambient Assisted Living

Integrated Care

Telehealth

Integrated Healthcare

RCT RCT

MAST

PRE-MAST

Projects’ timeline

Project 2013 2014 2015 2016 2017

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1

SmartCare

BeyondSilos

CareWell

Relative positioning of the three projects

CareWell Beyond Silos

Smartcare

HEALTH CARE SOCIAL CARE

Complementary Interconnected

HOME

Analysis of the three projects – set up SmartCare BeyondSilos CareWell

Type of integration and research

Horizontal and deployment Horizontal and deployment Vertical and deployment

Overall objective of the project

Implementation of two generic integrated health and social care pathways enabled by ICT

Implementation of two generic integrated health and social care pathways enabled by ICT

Implementation of a care coordination and patient empowerment pathway enabled by ICT

Target population and inclusion criteria

People requiring either short-term and/or long-term care and support from both health and social care service organisations

Older people living with at least two chronic conditions and social care needs according to the Barthel Index and IADL

Frail, ≥65, , ≥2 chronic conditions included in the Charlson Comorbidity Index and meet local /national /organisational frailty criteria

ICT Information shared for assessment, care plan, coordination, monitoring, EHR/ECR, TH & TC, online platform

Information shared for assessment, care plan, coordination, monitoring, EHR/ECR, TH & TC, online platform

Information shared to enable coordination of health care, monitoring and review, patient education, EHR, TH & TC, online platform

Analysis of the three projects – evaluation SmartCare BeyondSilos CareWell

Methodology MAST and ASSIST MAST and ASSIST MAST, ASSIST and predictive modelling

Intervention period Short-term pathway – up to 3m Long-term pathway – min 6m

Short-term pathway – up to 8w Long-term pathway – up to 8m

12m

Data collection – Mandatory and voluntary measures and metrics according to population cohort in deployment site

• Disease specific metrics • WHOBREF, Barthel, QoL for

carers • Psychological – GDS & HADS • eCCIS questions on service

utility and costs • User empowerment – PAM

• Disease specific metrics • CCI, Barthel, IADL • Psychological – GDS & HADS • PIRU questions on user

experience & NHS LTC6 • eCCIS questions on service

utility and costs

• Disease specific metrics • CCI, Barthel • Psychological – GDS & HADS • PIRU questionnaire on user

experience & NHS LTC6 • eCCIS questions on service

utility including carer & costs

Data storage Single central database

Comparator group Parallel groups – 8 sites Historical comparison – 1 site

Parallel group – 6 sites 6 month of comparison collection (usual care) followed by 8 month of new care – 1 site

Parallel group – 5 sites Historical comparison 12 month of comparison collection (usual care) followed by 12 month of new care – All 6 sites

Similarities in collected data Birth

Gender

Material status

Weight

Height

Status/severity of primary condition

Tobacco

Alcohol consumption

Comorbidity

Total contacts Hospital

Death

User perspective PIRU

Economic aspects

Organisational aspects

MAST domains

Health problem & characteristics of the application

Safety & Clinical effectiveness

Patient perspectives

Economic aspects

Organisational aspects

Socio-cultural, ehtical & legal aspects

SmartCare pathways

SmartCare pathways

BeyondSilos pathways Integrated Long-Term Home Care Support

BeyondSilos pathways Integrated Home Support after Hospital Discharge

CareWell pathways

Patient identification (at home or healthcare centre):· Assessment· Therapeutic plan· Follow up

Primary Care

Yes No

Additional resources needed?

· Specific empowerment programmes

· Social resources· Ehealth centre· Telemonitoring

Primary CareFollow-up:· Therapeutic plan· Patient training· Assessments· Tests

GP

Primary care nurse

Unstable patient?

Yes

No

Primary Care

GP /Primary Care

nurse

· Clinical assessment· Therapeutic plan

Telecare Centre

Emergency

ehealth Centre

Home care?

Yes No

Stable patient out of hospital care Unstable patient out of hospital care

Stable patient?

Yes No

Scheduled admission

Emergency Day hospital

Secondary Care

· Assessment· Clinincal interventions· Therapeutic plan

In hospital care Hospital discharge preparation

Cardiologist Pulmonogist

Other specialist

Discharge report (electronic)

· Coordination with Primary Care

· Follow-up planning

Integrated social assessment

· Social assessment

· Home hospitalization· Sub-acute hospital

admission

Yes

No

Stable patient, additional resources needed?

Reference internist

Hospital nurse

· Home hospitalization· Reference internist

(interconsultation)· ehealth Centre

Social resources

Social Care

Hospital Social worker

Secondary CareReference internist

Secondary Care

Hospital nurseSecondary Care

Reference internist

Social Care Secondary Care

* Entering into service

Tools exchanged among projects Standard terminology about Integrated Care and related issues (contribution

from CareWell c/o IFIC).

Combining dissemination activities and in particular final conferences of BS and CW.

Care pathway concept and sharing of expertise in service design and gap identification and representation.

Representation of pathways adjusted to specific needs of projects

Predictive modelling

Change management coaching (Multidisciplinary Pathway Team)

Challenges • With SmartCare, BeyondSilos and CareWell, we have started a long

journey but a lot remains to be done:

there are more regions out there which would follow and deploy integrated care services with an adequate incentive

current general pathways should evolve towards individual personalised pathways

• It is a pity that Horizon 2020 seems to have forgotten about deployment projects

this is going inevitably to widen the technology adoption gap.

THANKS FOR YOUR ATTENTION