Download - The Beginner's Guide to SmartCarepilotsmartcare.eu/.../documents/The_Beginner_s_Guide_to_SmartCa… · The Beginner's Guide to SmartCare The Beginner's Guide to SmartCare. The project

The SmartCare project is co-funded by the European Commission within the ICT Policy Support Programme

of the Competitiveness and Innovation Framework Programme (CIP) . Grant agreement no.: 325158

The Beginner's Guide to SmartCare


The Beginner's Guide to SmartCare.

List of partners



The project is partially funded under the ICT Policy Support

Programme (ICT PSP), grant agreement number 325158

SmartCare in a nutshell

• Started in March 2013 and will end in March 2016

• 42 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



WP Leaders

Workpackage

Lead organisation

Duration

WP1 Requirements and use case definition EMP M1-9

WP2 Service process model EMP M3-11

WP3 Integration Infrastructure Architecture and Service Specification

IFIC M1-12

WP4 System implementation & test Vidavo M5-20

WP5 Pilot site preparation Aragon M5-22

WP6 & 7 Pilot operation FVG M15-36

WP8 Pilot Evaluation RSD M1-36

WP9 Exploitation support and dissemination

EMP M1-36

WP10 Project management and performance monitoring

FVG M1-36



Deliverable list

Title Nature

Dissemination Level

Delivery Date

D1.1 Requirements for pathways and Integration infrastructure

R PU M8 = October 2013

D1.2 SmartCare Pilot-level Pathways and Integration Infrastructure

R PU M13 = March 2014

D3.1 Deployment Level Service Specification Final Revised

D PU M13 = March 2014

D4.2 SmartCare Field Test Report (V1) R PU M12 = February 2014

D8.1 Evaluation Framework R PU M7 = September 2013

D8.1 Addendum V1.0 - SmartCare evaluation update


D10.1 Quality Plan R CO M8 = October 2013

D10.2 Ethics and Data Framework R PU M7 = September 2013

D10.2 SmartCare Ethics & Data Protection Framework (V2.0)


D2.1 Smartcare Service Process Models O PU M12 = February 2014

D3.2 SmartCare Service Specification - initial draft

O PU M15 = May 2014

D4.1 SmartCare System Integration Architecture (V1)

R PU M9 = November 2013

D9.1 First report on dissemination and exploitation activities

R PU M12 = February 2014

D10.3 Interim periodic progress report R CO M6 = August 2013

D10.4 Periodic progress report Year 1 R CO M12 = February 2014

D4.4 SmartCare System Integration Architecture V2

R PU M12 = February 2014

D4.5 SmartCare Field Test Report (V2) R PU M7 = September 2013

D10.5 Interim progress report Year 2 R CO M12 = February 2014

D4.3 Integrated ICT infrastructure (V1) O PU M15 = May 2014

D4.6 Integrated ICT infrastructure (V2) O PU M21 = November 2014

D5.1 SmartCare Operational deployment sites O PU M22 = December 2014

D6.1 SmartCare Common Specifications R PU M30 = August 2015



Title Nature

Dissemination Level

Delivery Date

D6.2 Report on Operation of Deployment sites R PU M36 = February 2016

D8.2 First interim process evaluation report R PU M22 = December 2014

D8.3 Second interim process evaluation report R PU M28 = June 2015

D8.4 SmartCare deployment Outcomes R PU M36 = February 2016

D9.2 Interim report on dissemination & exploitation activities R PU M24 = February 2015

D9.3 Guidelines for deployment R PU M36 = February 2016

D9.4 Deployment plans for SmartCare Pathways & Integration Infrastructure R PU M36 = February 2016

D10.6 Project periodic progress report RP2 R CO M24 = February 2015

D10.7 Interim periodic progress report R CO M30 = August 2015

D10.8 Project final report incl. PR for RP3 & report on the distribution of the financial contribution

R CO M36 = February 2016



Workplan

Requirements Elicitation & Care Pathway Development

Organisational & ICT-related pilot preparation

Pilot operation &evaluation

WP1Requirements

& use case definition

WP2 Service process models

WP3Integration architecture &

service specification

WP4System

implementation & test

WP5 Pilot site preparation

WP6/7 Pilot operation

WP8 Pilot evaluation

WP9 Exploitation support & dissemination

WP10 Consortium management and performance monitoring





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



Two generic pathways

Integrated Long-Term Home Care Support

Personalised multi-provider service package

Entry point

(2):

Referral by

social care

providerTemporary

admission to

institution

(e.g.

hospital, care

home)

Monitoring /

review /

reassessment

of care

recipient’s

needs

Exit point:

Disenrollmen

t from

SmartCare

service (ICP-

LTCare)

Entry point

(1):

Referral by

health 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 planOn-site /

home

provision of

formal social

care

Remote

provision of

health &

social care

(telehealth,

telecare)

Shared

documentatio

n of home

care provided

On-site /

home

provision of

formal health

care

On-site /

home

provision of

informal care

Entering into service Receiving continuous personalised care Leaving service



Integrated Home Support after Hospital Discharge

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

Discharge from

hospital

Coordination of

integrated care

delivery /

revision of initial

integrated care

plan

Shared

documentation

of home care

provided

Readmission to

hospital

Monitoring /

review /

reassessment of

care recipient’s

needs

Exit point:

Transition into

SmartCare long-

term care

service

Exit point:

Disenrollment

from SmartCare

discharge service



On-site /

home

provision of

formal social

care

Remote

provision of

health &

social care

(telehealth,

telecare)

On-site /

home

provision of

formal health

care

On-site /

home

provision of

informal care



The 22 Regions

participating in

SmartCare are members

of one of two different

groups:

• 9 regions will deploy

integrated health and social

eCare services

• 13 committed regions

participate to learn from

experience of the

deployment regions and go

through a programme of

service planning and

scenario-based piloting

SmartCare Regions

Wave 1 regions

Aragon

Southern Denmark

Scotland

Friuli Venezia Giulia

Wave 2 regions

Tallinn

Attiki

Etelä-Kariala

Noord-Brabant

Kraljevo



Information collection and recording systems



Entry point (2):

Referral

information

Social care

record -

paper/ER, GP

system

Temp admission

to institution info

Integrated H&SC

record –

paper/ER,

Hospital PAS, GP

system

Monitoring /

review /

reassessment info

Integrated H&SC

record –

paper/ER

Exit point:

Discharge info

Integrated H&SC

record –

paper/ER,

SmartCare

database, GP

system

Entry point (1):

Referral

information

Health 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

Integrated and

shared

documentation

Integrated H&SC

record –

paper/ER, CR self

care plan


Social Care onsite

services

Caseload

management &

appointment

systems, CR held

record

Remote provision

of health & social

care and support

Online platforms,

telehealth &

telecare

Health Care

onsite services

Caseload

management &

appointment

systems, CR held

record

Informal Carers

onsite services

Caseload

management &

appointment

systems, CR held

record

Information collection and recording Systems



Information, communication and sharing mechanisms



Entry point (2):

Referral

information

Social care

record Temp admission

to institution info

Email, integrated

record, system

generated

message, fax,

phone

Monitoring/revie

w / reassessment

Email, integrated

record, system

generated

message, SMS,

fax, phone,

letter

Exit point:

Discharge info

Email, integrated

record, system

generated

message, fax,

letter

Entry point (1):

Referral

information

Health 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, email,

fax, phone

Care coordination

Community H&SC

record, email,

system generated

message, fax,

phone, letter

Integrated and

shared

documentation

Email, integrated

record, system

generated

message, fax


Social Care

Integrated record,

email, system

generated

message, fax,

phone, shared

paper diary

Remote provision of

health & social care

and support

Email,

telemonitoring

system, web-based

system, integrated

record, phone

Health Care

Integrated record,

email, system

generated

message, fax,

phone, shared

paper diary

Informal Carers

Integrated record,

email, system

generated

message, fax,

phone, shared

paper diary

Information, communication and sharing mechanisms



ICT infrastructure



Referral

information

Community social

care LAN/WiFi,

broadband,

paper filing, GP

LAN

Temp admission

to institution info

Community

LAN/WiFi, GP

LAN, Hospital

LAN, paper filing

system

Monitoring /

review /

reassessment info

Community

LAN/WiFi,

broadband,

paper filing

system

Discharge info

Community H&SC

LAN/WiFi, GP

LAN, paper filing

system,

SmartCare

database

Referral

information

Community

health

LAN/WiFi,broadb

and, 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

Integrated and

shared

documentation

Community

LAN/WiFi,

broadband,

paper filing

system


Social 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

Health Care

Community

LAN/WiFi,

broadband, paper

diary system, CR

home broadband,

paper record

Informal Carers

Community

LAN/WiFi,

broadband, paper

diary system, CR

home broadband,

paper record

ICT Infrastructure



From pathways to service process models

How the process models were

developed

HCP #1:

Hospital

HCP #2: GP

SCP #1:

Commu-

nity care

organisa-

tion

SCP #2:

Meals on

wheels

service

provider

TPC:

Voluntary

home help

oragnisa-

tion

I/FC :

Relative

Check available admission related

info (e.g. in existing HIS, paper

records)

1

Social care received priorto admission ?

Yes

2According to jointly defined protocoll

No NoPatient discharge

Enrol client to SmartCare

ICP- Discharge

Inform social care provider (SCP #1)

Enrol client to SmartCare

ICP- Discharge

Home care plan stored

in ICR

Develop initial medical home

care plan

Social care required afterdischarge ?

1

Yes

2

According to jointly defined template / structure

Develop initial social home

care plan

Meals on wheels to be provided?

Confirm receipt of service request

Inform meals on wheels service

(SCP #2)

Yes

No action

Home care plan stored in

ICR


ICR2

Inform GP, e.g. message,

report?

No action

No

Inform GP (HCP #2)

Yes


Joint home care plan

stored in ICR2

1

1

2

Voluntary home help to be provided

1

No action

No

Inform voluntary home help

service (TPC)

Yes No

Any relatives to be

informed ?

No actionInform relative

(I/FC)

1

No Yes

Confirm receipt of service

request


in ICR2

Look up initial home care plan


ICR

No

Develop initial medical home

care plan


ICR

Develop initial social home care

plan


in ICR2

No action

No

Meals on wheels to be provided?

Yes

1

Inform meals on wheels service

(SCP #2)



ICR 2

Voluntary home help to be provided

1

No actionInform voluntary

home help service (TCP)

No Yes

Any relatives to be

informed ?

1

No action

No

Inform relative (TPC)

Yes



ICR2

Loo up initial home care plan


ICR

End

End

End End

End End

End End

End End

Starting point of SmartCare ICP-Discrage components: 1) Needs assessment, (2) Service enrolment, (3) Initial integrated home care plan & (4) Discharge

Starting point of ICP-Discharge component: (5) Coordination of delivery / revision of initial home care plan

Inform social care provider (SCP

#1) 2

Endpoint of (potentially) existing pathways related to patient's hospital stay / discharge

Hospital discharge impending

Patientdischarge

Patientdischarge

HIS : Hopital Information sytem ICR: Integrated Care Recordm


Entry point

(2):

Referral by

social care

provider

Temporary

admission to

institution

(e.g. hospital,

care home)

Monitoring /

review /

reassessment

of care

recipient’s

needs

Exit point:

Disenrollment

from

SmartCare

service (ICP-

LTCare)

Entry point

(1):

Referral by

health 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

On-site / home

provision of

formal social

care

Remote

provision of

health & social

care

(telehealth,

telecare)

Shared

documentation

of home care

provided

On-site / home

provision of

formal health

care

On-site /

home

provision of

informal care


Generic SmartCare pathways

(ICP-LTCare, ICP-Dischage)

Requirements for implementation

within given regional context

Transformation into formalised

workflows within regional context

WP 1 WP2



Lessons learned (I)

• All generic pathway element addressed at each site in one

way or another

• Transition points between ICP-LTCare & ICP-Discharge

• Some structural commonalities:

• Two staged needs assessment (validation of initial

assessment by collaborating stake holders)

• Service integration involves (a) primary health care

actors, (b) public sector social services & (c) family

carers in each case

.... albeit involvement of further stakeholders may vary

(e.g. tertiary care, Third Sector, private sector social

care)

Lessons learned (II)

• Some structural differences:

• Primary entry point into the integrated service varies:

– single access point for health & social services (4)

– primary care (1)

– hospital (2)

– various (2)

• Initial needs assessment by primary heath care with

subsequent validation by other actors (4) or hospital (2),

initial assessment by joint team in (3)

• Development on initial integrated care plan: dedicated lead

function (5) vs. distributed responsibility across actors (4)

• Permanent monitoring of care delivery: Dedicated lead

function for (7) vs. distributed responsibility across actors (2)



Lessons learned (III)

• Re service modelling process:

• Pay attention to framework conditions potentially

acting as constraining factors for the operational

implementation of a cross-organisational service model

at an early stage

• Balance out diverging interests of individual

stakeholders to be involved in joined-up service delivery

in a sensible way

• As far as achievable under given circumstances,

underpin the service modelling process by evidence



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



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

3. Clinical effectiveness

3. Care effectiveness 3. Clinical and care effectiveness

4. Patient perspectives

4. Patient perspectives

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






Study design

• Deployment sites

– Intervention

– Control

• SmartCare

– Meta-analysis

– Meta-regression

– If possible, individual patient data meta-analysis



Exploitation support



Supporting service mainstreaming

Policy level

Service level

Individual / organisational level

•Upscaled, societal SER

•„Should this become the wayof doing things?“

•Service SER, ROI and time tobreak even

•„Under what conditions is the service viable?“

•Service-related costs andbenefits

•„Under what conditions do wewant to get involved?“

SER = Socio-economic return, ROI = Return on investment

• Cost-benefit analysis and business modeling will underpin the evaluation. Outcomes will provide the regions with the necessary evidence-base tomainstream the delivery of integrated care services for other population cohortswithin their deployment and elsewhere.

The assessment is done in three steps:

In Step 1: Service Assessment Model Setup, the service change to be evaluated is analysed to identify key

components such as the applicable governance & reimbursement model(s) and other relevant framework

conditions, the stakeholders involved, and the envisaged impacts (in terms of costs and benefits) on each

stakeholder. The latter includes identifying possible business models for a sustainable service operation for the

organisational stakeholders involved. The resulting service-specific stakeholder and indicator set is entered

into the software toolkit as a prerequisite for the following steps.

In Step 2: Data Collection and Monetarisation, data on all identified indicators is collected and fed into the

software toolkit. Data is usually collated from various sources including an evaluation of the pilot operation of

the service under analysis, data logs of health and social care IT systems, fact finding interviews with key

informants in the pilot site (e.g. managerial staff, care professionals, accountants) and other primary sources,

all of which are planned to be used in the framework of SmartCare. Furthermore, data from secondary sources

such as literature or datasets from other studies will be used where appropriate. The software toolkit

comprises a graphical user interface where the data can be entered in different formats. For subsequent

analysis, all input data needs to be monetarised, i.e. be available in currency values. This is straightforward for

financial input data, i.e. data for which a market price exists, such as costs for hardware or software.

Personnel resources or staff time are usually transformed using full labour costs, i.e. wages plus employer

contributions. Intangible costs and benefits require more complex transformation approaches, such as

calculation of time cost, use of suitable monetary proxies, or valuation approaches (i.e. a subject’s perception

of the relative or absolute value of a thing) such as willingness-to-pay.

Step 3: Calculation of Performance Measures. On the basis of the input data, different performance measures

or return indicators are calculated, as shown in the figure below. The performance measures are expressed as

ratios of different kinds of costs and benefits. The main outcome measure is based upon the ratio of total costs

to total benefits, i.e. including financial costs and benefits, resource costs and benefits, and intangible costs

and benefits. This overall ratio is referred to as socio-economic return (SER). At the overall service level, it can

be seen as reflecting the perspective of a higher-level decision maker (e.g. a national policy maker); the SER

can support the assessment and evaluation of options and decisions for improved service delivery. Ratios of the



financial costs and benefits indicate cash flows and the affordability of the service, sometimes called the cash

flow return on investment (CFROI). Ratios using the totals of financial and resource costs and benefits are

tangible and a measure of an economic ROI because they measure the potential net income for the service.

Download - The Beginner's Guide to SmartCarepilotsmartcare.eu/.../documents/The_Beginner_s_Guide_to_SmartCa… · The Beginner's Guide to SmartCare The Beginner's Guide to SmartCare. The project

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