TKN -THE WAY FORWARD

A CLINICIANS PERSPECTIVE

Dr Beverly Castleton

Consultant Physician, Surrey PCT

9th February 2007

• Introduction• Model of Care – CDM – “Out of Hospital”• Pilot to Practice – Mainstream Telecare• WSD – Other DOH initiatives• SAP – CAF – eSAP/CAF• Technological developments• Evaluation and Commissioning• Conclusion

MODEL OF DELIVERY FOR CHRONIC DISEASE

• Out of Hospital• Single Assessment Process Delivery• Common Assessment Framework• Risk Management• Reshaping Patient-Centred Care• White Paper – Our health, our care, our say• A New Ambition for Old Age

RISK STRATIFICATION

Disease Management

Supported self-management 70-80% of people with chronic conditions

Population-wide prevention

Case Case ManagemenManagementt

Highly complex patients

High risk patients

Managed care in the community and hospital settings covers all levels of the triangle

TELECARE DEFINITION

Telecare is the delivery of health and social care services to people usually in their own homes using a combination of sensor and information and communication technologies (ICT).

COLUMBA

LESSONS LEARNT

1997 - 2006

TELECARE

The individual in their home or wider environment

Electronic assistive technology, e.g.

Environmental controls, doors opening/closing, control of beds

Personal Monitoring: Physiological signs Activities of daily living

Information & Communication, e.g. health advice, triage, access to self-help groups

Safety & security monitoring, e.g. bath overflowing, gas left on, door unlocked

Improvingfunctionality

Prevention

Mitigatingrisk

Prevention

Response protocol

Call centreResponse provider:

neighbour, relative, ambulance, HCA, fire, police

NCRS

Response: home visit, emergency services,

remote change

Alarm !

Check status

Record event

The individual in their home

Check

THE EMERGING INFRASTRUCTURE

• Assessment & referral

• Equipment

• Monitoring

• Response

• Review

LOGISTIC & INFORMATION PATHWAY OF A TELECARE SERVICE

Entry

(Re) Assessment of Need (SAP)

Care Package Development

Home survey

Telecare Prescriptionand a Response Protocol

Equipment Provision

Installation and Maintenance

Monitoring

Call Handling

Community Response

Review

PARTNERS IN PROVISION• Intermediate Care/Older Peoples’ Services• Dementia Care• Falls Services• Primary Care – GP/DN/Out of Hours• Community Alarm Service• Ambulance Service• ANPs (Advanced Nurse Practitioners)• Community Matrons• SWOPs (Specialist Workers for Older People)• Specialist Nurses in Chronic Disease Management• Patients, Carers and Relatives• Home Care?

PARTNERS IN PROVISION

• Flexible Systems

• Quality

• Not necessarily hours

TELECARE IS AN ADJUNCT TO THE SYSTEM NOT A

SUBSTITUTE FOR CARE AND HANDS-ON DELIVERY

3 MIGRATION PATHWAYSREDESIGN

IT Asst Interagency Skills Work

Integration Clinical Networks Whole System Delivery

TRUSTED ASSESSOR

TRAINING

CONTEXT

• At least 12 major government reports since 1998 have called for telecare

• Delivering 21st century IT support for the NHS: ‘home telemonitoring’ to be available in 100% of homes requiring it by Dec 2010

• £80m in Comprehensive Spending Review for developing telecare and social alarm services

• The elements of a telecare framework are in place – NCRS, social alarm service, ICES

• Numerous trials shed light on implementation problems and individual outcomes

TECHNOLOGY IMPACT

• Reduces patient journeys, hospital visits and hospital admissions

• Saves the time of healthcare professionals• Supports individuals living at home to look

after themselves• Improves the quality or effectiveness of the

care or treatment that is delivered• Helps to manage the risk

TELECARE – The Challenge• Limited mainstream telecare in England as yet, no

joint commissioning – telecare not provided as a ‘care option’, what happens with practice-based commissioning?

• 150 SSDs, 152 PCTs, 238 DCs, housing assns, alarm providers would need to be involved in assessment and care planning via SAP/FACS etc with information sharing

• Who is the client?• Who pays?

TELECARE – The ChallengeMainstreaming

• Creating the organisational structure for implementation

• Retraining staff

• Apportioning costs

• Deciding eligibility

• NEEDS IT BACK UP TO IMPROVE INFORMATION FLOW

PTG

• Walton Community Hospital Project – Physically & mentally frail patientsWard multi-disciplinary TeamsTelecare Assessor – Team Member

• Multi-disciplinary Assessment Panels (MAPS)

Community basedVery complex frail elderly

SINGLE ASSESSMENT PROCESS

• Common Assessment Framework

Who Leads?What Criteria?All Levels of Need

“There is the tantalising possibility for public policy to meet more people’s desire to remain independent for longer, while at the same time

saving money overall”

Source: “Assistive Technology – Independence and Well-being 4” Audit Commission, Feb. 2004

CORE PROCESSES FOR CHRONIC DISEASE MANAGEMENT

• Involve the patient and customise for their needs• Easy access• Manage populations through integrated databases –

screen and risk manage• Develop robust networks between: - patients (support groups) - patients and professionals (communities of care) - professionals (communities of practice)

CORE PROCESSES FOR CHRONIC DISEASE MANAGEMENT

• Training and development for patients and professionals

• Develop expert systems:

- expert patients

- expert professionals

- expert ICT with protocols, guidelines etc that develops shared knowledge

• Clinical governance that depends on good evaluation and the ability to track the patient in the system

MAJOR SWOP/STOP NETWORKS

SWOP System

Specialist based assessment

A&E

MAUWards

Rehabilitation

Social ServicesCommunity

Information, skills flow

PARKINSONS DISEASE MANAGEMENT

PDLNEPICS/Comm. Matron

Day Resource Unit

Pt with PD

Neurologist Geriatrician

Primary Care Team

Arrows indicate flows of information, skills and care

PD Society

Home Care?

THE PARKINSON’S DISEASE SUPPORT NETWORK

New Electronic Support Network for People with Parkinson’s Disease

• A collection of linked websites, or “virtual communities” to help patients, their families and healthcare professionals to support sufferers of Parkinson’s Disease

• Medixine/North Surrey PCT/Imperial College, London

KEY ISSUES

• Who is offered Telecare?

• What levels of sophistication of equipment?

• Do we need national criteria?

• Should the equipment be free?

• Should the revenue cost be means tested?

• Should it be disease led?

DEPARTMENT OF HEALTH

• Long-term conditions

• CAF & Care Planning

• e SAP/ e CAF

• NSF’s

• A Recipe for Care – Not a Single Ingredient

WANLESS Social Care ReviewImpact of Telecare on the need for Domiciliary

Care,*2005/6 to 2014/5

680

700

720

740

760

780

800

820

840

860

2005/6 2007/8 2009/10 2011/12 2013/14

No TelecareTelecare

*Potential impact of the 2006-08 Preventative Technology Grant investment on the estimated number of hours of domiciliary care needed in Telecare Valley (excluding care homes).

Hours of care (thousands)

• The provision of telecare has an immediate impact on total staffing levels. When assessing staffing, it is not only formal carers who need to be included, but also the call centre staff and response teams on which telecare networks crucially depend. The demand for staff is particularly high at the beginning of a telecare investment project when this human infrastructure needs to be set up, the telecare equipment installed and everyone trained to use it.

TECHNOLOGY MOVES ON

Digital TV

Flexible Platforms for Chronic Disease management delivery

Frailty Registers

Compliance improvement

CONCLUSIONS• Major Service Redesign

• Whole System Integrated Approach

• Use the IT Agenda as a catalyst for change

• Single Assessment Process to mainstream Telecare

• Cross Organisational Workflow and Workforce required

• Managing the Risk is essential

• Patient and Carers need to be part of the team

• Accuracy of Data essential

• Win Win

CONCLUSIONS

TELECARE CANPostpone and divert people from RH/NHReduce the need for hospitalisation• BUTNeed robust data for reapportioning costsLets resist short-termism getting in the wayTelecare is a useful adjunct to careNeeds to be part of a care prescription to reduce

routine tasks and improve quality and flexibility of Care Delivery at Home

Research &

Evaluation & Commissioning

PAYOR

PROVIDER

PATIENT (& CARER)

DATA

REFERENCES

• Audit Commission, Assistive Technology: Independence and Well-being 4, February 2004

• Audit Commission, Older people – implementing telecare, July 2004

• Department of Health, Building Telecare in England, July 2005

• Department of Health Health and Social Care Change Agent Team (CAT), Housing LIN Factsheet no 5 – Assistive Technology in Extra Care Housing, August 2004

REFERENCES• Department of Health ICES (Integrating Community

Equipment Services, Telecare Implementation Guide and numerous fact sheets, July 2005 onwards

• Health Select Committee, The Use of New Medical Technologies within the NHS, Fifth Report of Session 2004-05, April 2005

• Department of Health Application of Telecare and Long Term Care

• Telecare Alliance, Website address: www.telecarealliance.co.uk

• Wanless Social Care Review, King’s Fund, 2006