Modelling the impact of service innovation in stroke care

Information and Communication Research Initiative 2 (ICTRI 2) Research Seminar

15 February 2007

Research team

• Core team

– Dr Baggy Cox (Project Leader)

– Prof. James Barlow (telecare)

– Dr Christina Petsoulas (qualitative research)

– Dr Steffen Bayer (modelling)

• Specialist team

– Dr Stephen Morris (Brunel, cost analysis)

– Dr Martin Fisher (King’s Fund, dissemination

– Dr Alasdair Honeyman (care processes / policy)

Project aims

• To map out the care journey for stroke patients

• To identify components in the care journey which could potentially be improved

• To identify appropriate interventions (ICT or others) that might improve stroke care delivery in line with new policy guidelines

• Support local care community with planning stroke services (Greenwich SHA, Queen Elizabeth Hospital Trust)

Policy relevance

• NSF for Older People, standard 5 (2001)

• National Audit Office, Reducing Brain Damage. Faster Access to Better Stroke Care (2005)

• National Stroke Strategy (2006-07)

• NSF Long-term (neurological) conditions (2005)

• The NHS and Social Care long-term conditions model

• Our Health, Our Care, Our Say (2006)

• Telecare programme (PTG, Whole System Demonstrators etc.)

Methods

• Literature searches – technology and service delivery innovation for stroke care

• Map of Medicine – understanding stroke care pathways

• Interviews with key stakeholders within the local care system (acute, primary, social)

• Interactive workshops with key stakeholders (data collection for simulation modelling)

• Simulation modelling and cost analysis of alternative delivery models

System dynamics modelling

• Using simulation modelling to study actual and potential care delivery processes

• System dynamics can help to explore

– Capacity requirements and bottlenecks

– Distribution of resource demands across the care system

– Intended & unintended consequences of ICT implementation and service change

Example: telecare and demand for institutional care

healthy HC fL HC fM HC fH

Inst fM

TC fL TC fM TC fH

Inst fH

effect of TC on ftyprogression

share toTC

from healthy toHC fL

from HC fL toHC fM

from HC fM toHC fH

from TC fL toTC fM

from TC fM toTC fH

death rate TCfM

death rate TCfH

aging

effect of TC on fracrate to inst care entry

fH

death rate hdeath rate HC

fL

death rate HCfM

death rate HCfH

death rate Instentry fMwaiting Inst

fM

waitingInst fH

from waiting toInst entry 3

from waiting toInst entry 4

from HC to waitingInst entry 3

TC fH towaiting Inst

to waiting Instfrom TC fM

to waiting Instfrom HC fH

death r w InstfH

HC f2 to fL

effect of TC on fracrate to inst care entry

fM

death rate TCfL

from healthy toTC fL

from HC fL toh

from hc fM tofL

from HC fH tofM

from TC fH tofM

from TC fM tofL

from TC fL toh

death rate Instentry fH

0 12 24 36 48 60 72 84 96108120132144156168180192204216228240350,000

450,000

550,000

C lie n ts in institu tiona l c a re

run 1 (person)run 2: 50% share to telecare but no effect of telecare (person)run 3: run 2 plus best guess Effect of telecare on frac rate to institutional care medium frailty entry =0.2 (person)run 4: run 3 plus best guess Effect of telecare on frac rate to institutional care high frailty entry =0.8 (person)run 5: run 4 plus best guess Effect of telecare on frailty progression = 0.8 (person)

Cost at 240 months relative to base case(reduction of frailty progression to 80%, reduction of entry from high frailty to 80%)

  TC costs as share of standard HC costs

effect of T

C o

n frac rate to

inst care en

try fM 0.8 1 1.2 1.4

0.2 -9.51% -4.97% -0.42% 4.12%

0.4 -8.38% -3.96% 0.46% 4.88%

0.6 -7.37% -3.06% 1.25% 5.56%

0.8

-6.44% -2.23% 1.98% 6.18%

Timetable

  

 2007

Dec Jan Feb Mar Apr May June July Aug Sept Oct Nov

1 Project start: interviews with local stakeholders, background research                        

2 Generate a model of current stroke care delivery (desk-based research, two interactive workshops)

                       

3 Create simulation model and analyse current care process (e.g. examine bottlenecks, identify potential information and co-ordination problems)

                       

4 Identify promising interventions and test their desirability with patients and care providers

                       

5 Develop recommendations and disseminate outcomes to local stakeholders                        

6 Final report                        

Progress: Dec. 2006 – Feb. 2007

• Literature searches on optimisation of stroke care provision (including telecare)

• Initial interviews with local stakeholders

• Formulated preliminary picture of local stroke care delivery (current practice and future directions)

Current local picture

• Capacity pressures in the acute hospital– Prompt CT scanning – Lack of thrombolysis facilities– Hospital rehabilitation

• Capacity pressures in the community– Workforce availability– Discharge coordination– Equipment provision

Potential improvements identified in stroke literature

• Better and more efficient stroke treatment is achieved in ‘stroke care systems’

– integrated services involving close communication among all individual components

– organisational change + ICT needed

• Telecare & telemedicine (e.g. telerehabilitation, teleradiology, vital signs monitoring) can improve existing and stimulate new processes

Potential service improvements for investigation locally

• Move towards specialised, regionally merged or coordinated stroke services (incremental approach)

• Use of telecare in community rehab (radical approach):– Monitoring equipment

– Smart home technologies

– ICT tools for staff and patients

– Virtual visits

Next steps

• Identify and engage further stakeholders

• Organise interviews and interactive workshops

• Continue literature scanning

• Simulation modelling

• Cost analysis of possible alternatives