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

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Page 1: Joining up ICT and service processes for quality ...pilotsmartcare.eu/fileadmin/SmartCare/documents/SmartCare... · Joining up ICT and service processes for quality integrated care

Joining up ICT and service processes for

quality integrated care in Europe

Page 2: Joining up ICT and service processes for quality ...pilotsmartcare.eu/fileadmin/SmartCare/documents/SmartCare... · Joining up ICT and service processes for quality integrated care

The project is partially funded under the ICT Policy Support

Programme (ICT PSP), grant agreement number 325158

Background

• National welfare & health systems

and regional/local support practices

are developing more and more

specialisation and clear boundaries

closed them to cooperation

• Today’s reality is characterised by

fragmentation and bureaucracy in

current provision systems resulting in

disjointed and patchy support

services

• Leading to inefficiencies, duplication

of resources, and potentially to

reduced levels of quality of care

Healthcare Informal care Social care

Tomorrow

Today

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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 February 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

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The project is partially funded under the ICT Policy Support

Programme (ICT PSP), grant agreement number 325158

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

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The project is partially funded under the ICT Policy Support

Programme (ICT PSP), grant agreement number 325158

The SmartCare Solution

• Harnessing ICTs for the benefit of older persons people and

those with chronic diseases

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Integrated Long-Term Home Care Support

Personalised multi-provider service package

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:

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 plan On-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

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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

Entering into service Receiving continuous personalised care Leaving service

Personalised multi-provider service package

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

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The project is partially funded under the ICT Policy Support

Programme (ICT PSP), grant agreement number 325158

Key Care Pathway implementation Services/Activities

and associated ICT applications

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The project is partially funded under the ICT Policy Support

Programme (ICT PSP), grant agreement number 325158

Information collection and recording

Systems

Personalised multi-provider service package

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

Entering into service Receiving continuous personalised care Leaving service

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

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The project is partially funded under the ICT Policy Support

Programme (ICT PSP), grant agreement number 325158

Information, communication and

sharing mechanisms

Personalised multi-provider service package

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

Entering into service Receiving continuous personalised care Leaving service

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

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The project is partially funded under the ICT Policy Support

Programme (ICT PSP), grant agreement number 325158

ICT infrastructure

Personalised multi-provider service package

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

Entering into service Receiving continuous personalised care Leaving service

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

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The project is partially funded under the ICT Policy Support

Programme (ICT PSP), grant agreement number 325158

Workplan

Requirements Elicitation & Care Pathway Development

Organisational & ICT-related pilot preparation

Pilot operation & evaluation

WP1 Requirements

& use case definition

WP2 Service process models

WP3 Integration architecture &

service specification

WP4 System

implementation & test

WP5 Pilot site preparation

WP6/7 Pilot operation

WP8 Pilot evaluation

WP9 Exploitation support & dissemination

WP10 Consortium management and performance monitoring

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The 26 regions

participating in

SmartCare are members

of one of two different

groups:

• 9 regions will deploy

integrated health and social

eCare services

• 17 committed regions

participate to learn from

experience of the

deployment regions and go

through a programme of

service planning and

scenario-based piloting

SmartCare Regions

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• Aragón is a region located at

the North-East of Spain with

a population of 1.3 million

• The region comprises three

provinces (Zaragoza, Huesca

and Teruel) and 731

municipalities

• 50% of the population lives in

the regional capital city,

Zaragoza, while the

remaining 50% is sparsely

spread among the rest of the

municipalities

Aragón, Spain The region

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Healthcare system

• 1 only health provider (SALUD)

• Public body

• Primary Care + Specialized services + Mental health

• One only ICT Infrastructure. Same network, common DBs,

management APPs + Intranet giving access to all information to

all health professionals in all the territory,

Social care system

• Several providers (public & private)

• External funds (Public grants or membership + public grants)

• Each provider offers its own basket of services

• Users ask for services to any provider. Those can be granted if

the user fulfils requirements. There might be duplicities of

services

• Each provider has its own Information Systems

– Databases are independent

– No citizen’s data shared among them

Aragón, Spain Social and Healthcare Service provision

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• SALUD – Common ICT infrastructure for Primary Care &

Specialized Care

– Same network, common DBs

– SALUD IS: – EHR Viewer (Primary Care + Specialized Care

patient data)

– HIS: Scheduling & monitoring information apps

– Departmental apps (PCH, LIS, RIS, telemonitoring portal, Patient’s surveys, e-prescription)

– Videoconferencing system

– unique EHR for Primary Care + Specialized Care

– Help desk

• SOCIAL care providers – Social Services Recording IS

– Proximity Local App: Contact centre + agenda

– Citizens info databases

• Informal carers – Proprietary systems/None/paper

SALUD

PCH

(Urgencias) RIS

LIS

(Laboratorio)

HIS

(Admisión)

BDU

PACS

GESTOR

DE

PACIENTES

SALUD

INFORMA

EMPI OMI-

AP

Departamentales

Farmacia Informes

(HP-Doctor)

Cartera de

Servicios

AGENDA

PRIMARIA

AGENDA

ESPECIALIZADA

INTRANET

Motor

Integración

(Rhapsody)

Social providers

Aragón, Spain Existing IT infrastructure

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Common

Framework

CARE

RECIPIENT

INFORMAL

CARER

HEALTH

PROVIDER

SOCIAL

PROVIDER

Aragón, Spain SmartCare infrastructure

• Collaboration platform for the provision of Integrated Care - SmartCare platform – Accessible by all care agents involved on the provision of

care

– All agents share data (minimum data set) • SALUD shares IT and clinical data

• Social providers share social data

– Integration with the already existing information systems

• Unique point of data on integrated care provided to citizens – Sharing of clinical and social data

– Common basket of integrated-care services

• Collaboration platform to ease the collaboration among organizations & encourages participation of professionals – Collaboration framework to define commonly the integrated

care plan

– Schedule the activities for the provision of the services

– Documentation point

• SALUD & IASS under the same Aragon Government Department. Alignment of policies and strategies

– Single unique identifier of users in the social and healthcare Aragon Systems. (BDU)

• Initial deployment so as to lead and define the change management in SALUD

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Attikí, Greece The region

• Attica encompasses eight

dirstricts

• Social care services are delivered

through 193 community centres

and five day care centres

• Home help programme

• Healthcare services are provided

by a network of 199

public/private hospitals and

primary care centres

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SmartCare in Attica

• Implementation in Alimos, Agios

Dimitrios and Palaio Faliro

• Joining-up service delivery to older

people living with Type II diabetes

and their caregivers

• Service users will receive

personalised information and

guidance on how to self-manage

their condition through an Electronic

Platform

• Community nurses, dieticians, social

carers and diabetologists provide

coordinated care

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1

Care Recipients

Patient Record

Patient Record

ATTICA Pilot Porta;

Hospital nurse

Diabetologist

Community Nurse, Care Coordinator

CR

Record

Dietician

Patient record

Social Worker

client

record

CR, FC Record

Updates patient data

Updates patient data

Updates patient data Updates client data

Updates patient data

Family carer

Updates data ( e.g. self measurement), uses messaging & video consultations

Automatic monitoring data

Data reports, messaging, video consultations

Attiki: Concept & Approach

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Etelä-Kariala, Finland The region

• In Finland self-governed

municipalities have the main

responsibilities for providing basic

social and healthcare services

• South Karelia pursues a dedicated

policy ensuring equal access to

joined-up social and healthcare

services

• South Karelia Social and Health Care

District (Eksote) organises provision

of primary and secondary

healthcare, elderly care and social

care under a single roof

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SmartCare in Etelä-Kariala

• Enables better co-operation between social and healthcare

professionals operating under the same organization (Eksote)

• Aim is the keep elderly people at home by providing them the

wider range of services to home

• Support elderly daily living by developing more integrated

home care supported by telecare

• Social care support using telecare

– Video phone connection

– GPS tracker

• Shared Care plan accessible online by service user, family

carer and social care/healthcare professionals

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Etelä-Kariala: Concept & approach

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• Italian border

region located in

the heart of

Europe

• The capital is

Trieste. It has an

area of 7,856

km² and about

1.2 million

inhabitants

Friuli Venezia Giulia, Italy The region

Mar

ino

Ste

rle

©Marino Sterle

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• Friuli Venezia Giulia Region has defined a model of

integrated system of social and health care services: – The promotion of home care and community-based care through

the partnership between Municipalities and Local Health

Authorities and the involvement of the Third Sector

– Innovative models for integrated care: multi-dimensional and

cross-sectorial evaluation of needs, person-centered project,

integrated care provision, continuity of care

– Innovative tools for local integrated health and social planning:

Territorial Activities Program (PAT) and Local Plan for Social Policy

(PdZ, Piano di Zona)

– Joint initiatives with research/innovation (ICT) and housing

sectors

Friuli Venezia Giulia Background

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• Integrated care models implementing the two pathways

• 200 patients to be recruited, locally randomized study

design (100 in usual care control group, 100 in “new ICT

supported integrated care” intervention group).

• Health care, social care, third sector, informal care

enrolled

• Target population

- Age >50

- At least one moderate-to-severe chronic condition (HF,

diabetes mellitus, COPD).

- End users with social needs (social isolation, insufficient or

inadequate social, or family support, need for environmental

monitoring). Identification of social frailty to be made as per one

BADL missing item.

SmartCare in Friuli Venezia Giulia

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The project is partially funded under the ICT Policy Support

Programme (ICT PSP), grant agreement number 325158

Usual care

Intervention Group

Usual monitoring system

Permanent monitorin system

Outcomes

Initial evaluation data

Mid term evaluation data

Final evaluation data

Compared

analysis

Friuli Venezia Giulia Monitoring system - Smart Care Service vs. Usual Care

Enrollment

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• Located 180 km south of

capital Belgrade

• Inhabitants 125.500

• Average age is 42.3 years

• Over 31.500 are 60+

• From which 1.800 had some

form of social protection

• Healht Centre Kraljevo (PHC)

has a separate organisational

unit for Home care

• Center for Social Work is basic

unit that provides social

protection

Kraljevo, Serbia The region

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Challenge

• Currently no electronic

communication between

social and health

providers in Kraljevo

• Information exchanged

with paper documents

using post service

• Poor IT infrastructure

Our Goal

• To connect two

institutions using new ICT

technologies

• To create new services

from both social and

health domain

• Benefit for the end users

and care professionals

Kraljevo, Serbia Background

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SmartCare service in Kraljevo

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• Netherlands:

– Decentralized unitary state

– Bismarck care model

• Noord-Brabant:

Noord-Brabant, Netherlands The region

©Verse Beeldwaren

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• Decentralised service delivery system.

– National government is responsible for health

care and general insurance matters.

– Social services are provided by non-profit

organisations, which are funded by the state,

local authorities and social insurance.

– Recent health care sector reforms to introduce

more competition and to shift decision power

to regional and local governance levels.

Noord-Brabant, Netherlands Background

• Regional strategy.

– Facilitating the integration of hitherto separated care chains by the

development of an electronic platform enabling a reliable electronic

exchange of care related data across a variety of stakeholders.

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• Cardiac rehabilitation:

– Multidisciplinary intervention for physical and psychosocial recovery

after a cardiac event or intervention with proven beneficial effects

on morbidity and mortality.

– All stakeholders will work together and exchange data:

• Cardiac patient

• Informal carers

• Health care professionals

• Social workers

• Need for:

– Increased cardiac rehabilitation program uptake

– More sustained effects on cardiovascular risk behaviour

SmartCare in Noord-Brabant

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• Focus on cardiac telerehabilitation using a personalized

patient-centred ICT platform enabling self-management

and collaborative monitoring and coaching.

– Home-based exercise program comprising remote monitoring and

coaching of physical activity behaviour, by using wearable sensors.

– Various treatment modules such as education, dietary interventions,

weight reduction and smoking cessation.

– Improved impact on self-management skills and self-efficacy to

induce more sustainable lifestyle changes.

– Tool to enable collaboration, highly-secured exchange of medical

information, and sharing of treatment goals.

Noord-Brabant, Netherlands

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The project is partially funded under the ICT Policy Support

Programme (ICT PSP), grant agreement number 325158

Scotland, United Kingdom Background

• NHS 24 has a national

responsibility in Scotland as

advisor, facilitator and

promoter of technology

enabled health, care &

wellbeing for 5.2m population

• SmartCare’s overarching pop –

1.1m (20% of Scotland’s

population)

• Project involves :

– seven local authorities and three

territorial Health Boards

– Range of voluntary, charitable &

independent sector organisations

– Service users and carers

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The project is partially funded under the ICT Policy Support

Programme (ICT PSP), grant agreement number 325158

SmartCare in Scotland aims…

• To improve the health, care and wellbeing of 10,000

people aged 50+ within Ayrshire and the Clyde Valley.

• It will do this through better co-ordination and an

improved approach to falls prevention and

management.

• It will fully utilise ICT services and applications that are

vital in supporting integrated care

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The project is partially funded under the ICT Policy Support

Programme (ICT PSP), grant agreement number 325158

SmartCare in Scotland is…

• SmartCare is a new online person centred service which aims to

support people who are at risk of a fall or recovering from a fall.

• The service promotes enablement, self care, information sharing

and care coordination.

• The service will benefit people managing a long term condition

who want to remain independent in their own home

• It will also support their family, carers, Health and Social care

sector and providers supporting them.

• Integration on

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The project is partially funded under the ICT Policy Support

Programme (ICT PSP), grant agreement number 325158

Scotland User stratification

Intense

support

Rehabilitation and enablement

Staying independent

Community wellbeing

38

Hospital or care home

Incre

asin

g F

railty

Diary and PHF

Diary and PHF

Self Assessment

Tool

LiU – Self Care Hub

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The project is partially funded under the ICT Policy Support

Programme (ICT PSP), grant agreement number 325158

ICT-enablers in Scotland

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The region

• 1 of 5 administrative Regional Authorities in Denmark

• Inhabitants: 1.2 Million

• Main responsibility:

– Health provision

– Regional development

• 22 Municipalities (social care)

• 800 GP’s

• 4 hospital units – 1 university hospital

• Driving force behind the establishment of MAST

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The structure - Health and social care needs to collaborate to take into account continuous care

The mentality -New cross-sectorial mindset was needed to focus on the care pathway and a citizen-centered approach

We needed IT to support the patient-centered focus across sectors

Challenge

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Homecare

systems

- EPR

Electronical

patient record -

EPR

Medical system

Data

collection

Platform

The patient’s

individual plan

Information about own

conditiom

Entering data and

measurements

Questionnaire

Social care Hospital Medical practice

We needed...

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Hospital Municipality GP

EHR ESR EHR

Shared Care Platform

Smar

tCar

e

SmartCare service in RSD

Existing Infrastructure + Electronic Messages (MedCom) +

Collaboration guidelines (SAM:BO) + Shared Care Platform

=

SmartCare service in RSD

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Tallinn, Estonia Background

• The region of Tallinn

encompasses 8 districts

• Healthcare services tend to be

delivered mainly by publicly

owned hospitals under private

regulation and private primary

care units.

• Responsibility for social care

rests with more than 200

municipalities throughout the

country.

• Implementation of a nation-wide

electronic health information

system

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SmartCare services in Tallinn

• Provides better joining-up of service

delivery across all districts.

• Care coordinators at the municipal

level are enabled to access the

SmartCare integration

infrastructure through a dedicated

portal with the help of the national

ID card used to access the national

health information system.

• Health care professionals and family

carers – on consent – will be granted

access as well.

• A dedicated contact centre serves

as a coordination hub vis-á-vis

further service providers, including

telemonitoring services and a social

alarm service.

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Tallinn Service Specification

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The project is partially funded under the ICT Policy Support

Programme (ICT PSP), grant agreement number 325158

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

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The project is partially funded under the ICT Policy Support

Programme (ICT PSP), grant agreement number 325158

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

6. Organisational aspects

6. Organisational aspects

6. Organisational aspects

7. Socio-cultural, ethical and legal aspects

7. Socio-cultural, ethical and legal aspects

7. Socio-cultural, ethical and legal aspects

7. Socio-cultural, ethical and legal aspects

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The project is partially funded under the ICT Policy Support

Programme (ICT PSP), grant agreement number 325158

Study design

• Deployment sites

– Intervention

– Control

• SmartCare

– Meta-analysis

– Meta-regression

– If possible, individual patient data meta-analysis

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The project is partially funded under the ICT Policy Support

Programme (ICT PSP), grant agreement number 325158

Outcomes, database

MAST domain Health care Social care Volunteers/relatives

2. Safety Deaths, Technical safety

3. Clinical effectiveness

Health and social care services’ effectiveness

Number of contacts: Physical, mail, telephone

4. Patient perspectives

End-user perspectives Empowerment

5. Economic aspects WP 9

6. Organisational aspects

SmartCare questionnaire + process evaluation

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The project is partially funded under the ICT Policy Support

Programme (ICT PSP), grant agreement number 325158

Supporting service mainstreaming

Policy level

Service level

Individual / organisational level

•Upscaled, societal SER

•„Should this become the way of doing things?“

•Service SER, ROI and time to break even

•„Under what conditions is the service viable?“

•Service-related costs and benefits

•„Under what conditions do we want to get involved?“

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

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

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The project is partially funded under the ICT Policy Support

Programme (ICT PSP), grant agreement number 325158

Cost-benefit analysis

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

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The project is partially funded under the ICT Policy Support

Programme (ICT PSP), grant agreement number 325158

User Advisory Board

• AGE Platform Europe

• European Patients’ Forum

• European Federation of Nurses

• Eurocarers

• AOK (insurers)

• International Federation for Integrated Care

(IFIC)

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The project is partially funded under the ICT Policy Support

Programme (ICT PSP), grant agreement number 325158

Objectives of the UAB

• UAB: a group aiming to gather information and

reflect on all users-related aspects

• Integrated care with users and not only for

users

• Capacity to support exchange and sharing of

practices among deployment sites from a user

perspective

• EU-wide organisations: multiplier effect

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The project is partially funded under the ICT Policy Support

Programme (ICT PSP), grant agreement number 325158

Investigation of:

• Structures, means and resources available for

the ICT solutions for integrated care

• Involvement of informal carers

• Management of the SmartCare process

• Quality of service

One main UAB activity: Visits to

SmartCare deployment sites

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The project is partially funded under the ICT Policy Support

Programme (ICT PSP), grant agreement number 325158

Committed Regions Board

• Regions being SmartCare partner already (13)

• New regions joining the CRB (7+)

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The project is partially funded under the ICT Policy Support

Programme (ICT PSP), grant agreement number 325158

Objectives

Prepare regions for future deployment of

integrated eCare service:

• Use experience from deployment sites to boost

preparation

• Follow process design & implementation

• Stimulating political leadership in the regions

• Raise awareness and inform regions for the

uptake of integrated care service across Europe

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The project is partially funded under the ICT Policy Support

Programme (ICT PSP), grant agreement number 325158

Consortium

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The project is partially funded under the ICT Policy Support

Programme (ICT PSP), grant agreement number 325158

Information & Contact

For more information please visit

www. pilotsmartcare.eu/

and follow us on Twitter @PilotSmartCare

Or contact us at

[email protected]

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The project is partially funded under the ICT Policy Support

Programme (ICT PSP), grant agreement number 325158

ADDITIONAL SLIDES

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The project is partially funded under the ICT Policy Support

Programme (ICT PSP), grant agreement number 325158

Formal side of SmartCare

• Funding programme: Competitiveness and Innovation Programme (CIP), ICT Policy Support (ICTPSP) sub-programme

• Funding instrument: Pilot type A (main beneficiaries are governmental bodies)

• Starting date: 1st March 2013

• Total investment: 16,000,000€

EU Contribution: 8,000,000€

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The project is partially funded under the ICT Policy Support

Programme (ICT PSP), grant agreement number 325158

Integrated Care – supporting key

functions through ICT

• Care co-ordination

• Information sharing

• Joint, integrated assessment and care planning

• Support for self care and self management

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The project is partially funded under the ICT Policy Support

Programme (ICT PSP), grant agreement number 325158

SmartCare deployment sites

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The project is partially funded under the ICT Policy Support

Programme (ICT PSP), grant agreement number 325158

Dissemination strategy

Publications in / special issue of the

Early adopter regions Local/regional/national-level service providers & funders

User organisations (older people, informal/voluntary carers)

Relevant research / policy actors

Relevant technology providers/ integrators

Project leaflet, brochure, newsletter

Approach, objectives Requirements

Partner regions

Useful integrated care

pathways

Useful integrated care pathways Fit-for purpose service

specifications/design

Preliminary expectations on benefits &

economic validity

Evidence on user acceptance Technical infrastructure & integrated service model

SmartCare guidelines and specifications

Benefits & economic viability, business models

Project Phase I: Integrated care pathways

development

Project Phase II: Organisational & ICT related pilot preparation

Project Phase III: Experiencesfrom pilots & transferability

Fo

cu

s

Ta

rge

t a

ud

ien

ce

D

iss

em

ina

tio

n c

ha

nn

els

Dispersed audience: Interested expert

circles

Public at large

EIP AHA Action Groups (B3)

Project website SmartCare: http://www.SmartCare.eu (tentative)

Social media sites

representations

Prevention, screening

& early diagnosis

Care & Cure Active ageing &

independent living

•Health literacy, patient

empowerment, ethics and

adherence

•Personal health

management

•Prevention, early

diagnosis of functional

and cognitive decline

•Guidelines for care,

workforce

(multimorbidity,

polypharmacy, frailty

and collaborative care)

•Multimorbidity and R&D

•Capacity building and

replicability of successful

integrated care systems

•Assisted daily living for

older people with

cognitive impairment

•Flexible and

interoperable ICT

solutions for active and

independent living

•Innovation improving

social inclusion of older

people

Vision / Foundation

•Focus on holistic and multidisciplinary approach

•Development of dynamic and sustainable care

systems of tomorrow

•New paradigm of ageing

•Innovation in service of the elderly people

•Regulatory and standardisation conditions

•Effective funding

•Evidence base, reference examples, repository for age-friendly

innovation

•Marketplace to facilitate cooperation among various stakeholders

Horizontal issues

Presentations Workshops

Special events,

supported by:

Presence in the media in participating regions

Final

SmartCare

Confe-

rence

Links to other

projects, initiatives

Marketplace

IFIC

Re

qu

ire

me

nts

&

pa

thw

ays

Te

ch

no

log

y

& E

va

lua

tio

n

Ec

on

om

ics

&

Eu

rop

e