the beginner's guide to...
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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
The Beginner's Guide to SmartCare.
List of partners
The Beginner's Guide to SmartCare
The Beginner's Guide to SmartCare.
The Beginner's Guide to SmartCare
The Beginner's Guide to SmartCare.
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
The Beginner's Guide to SmartCare
The Beginner's Guide to SmartCare.
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
The Beginner's Guide to SmartCare
The Beginner's Guide to SmartCare.
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
R PU M13 = March 2014
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)
R PU M13 = March 2014
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
The Beginner's Guide to SmartCare
The Beginner's Guide to SmartCare.
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
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
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 Beginner's Guide to SmartCare
The Beginner's Guide to SmartCare.
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
The Beginner's Guide to SmartCare
The Beginner's Guide to SmartCare.
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
The Beginner's Guide to SmartCare
The Beginner's Guide to SmartCare.
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
The Beginner's Guide to SmartCare
The Beginner's Guide to SmartCare.
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
The Beginner's Guide to SmartCare
The Beginner's Guide to SmartCare.
Information collection and recording systems
Personalised multi-provider service package
Integrated Long-Term Home Care Support
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
Information collection and recording Systems
The Beginner's Guide to SmartCare
The Beginner's Guide to SmartCare.
Information, communication and sharing mechanisms
Personalised multi-provider service package
Integrated Long-Term Home Care Support
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
Information, communication and sharing mechanisms
The Beginner's Guide to SmartCare
The Beginner's Guide to SmartCare.
ICT infrastructure
Personalised multi-provider service package
Integrated Long-Term Home Care Support
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
ICT Infrastructure
The Beginner's Guide to SmartCare
The Beginner's Guide to SmartCare.
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
Home care plan stored in
ICR2
Inform GP, e.g. message,
report?
No action
No
Inform GP (HCP #2)
Yes
Confirm receipt of service request
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
Home care plan stored
in ICR2
Look up initial home care plan
Home care plan stored in
ICR
No
Develop initial medical home
care plan
Home care plan stored in
ICR
Develop initial social home care
plan
Home care plan stored
in ICR2
No action
No
Meals on wheels to be provided?
Yes
1
Inform meals on wheels service
(SCP #2)
Confirm receipt of service request
Home care plan stored in
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
Confirm receipt of service request
Home care plan stored in
ICR2
Loo up initial home care plan
Home care plan stored in
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
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:
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
Entering into service Receiving continuous personalised care Leaving service
Generic SmartCare pathways
(ICP-LTCare, ICP-Dischage)
Requirements for implementation
within given regional context
Transformation into formalised
workflows within regional context
WP 1 WP2
The Beginner's Guide to SmartCare
The Beginner's Guide to SmartCare.
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)
The Beginner's Guide to SmartCare
The Beginner's Guide to SmartCare.
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
The Beginner's Guide to SmartCare
The Beginner's Guide to SmartCare.
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
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
The Beginner's Guide to SmartCare
The Beginner's Guide to SmartCare.
Study design
• Deployment sites
– Intervention
– Control
• SmartCare
– Meta-analysis
– Meta-regression
– If possible, individual patient data meta-analysis
The Beginner's Guide to SmartCare
The Beginner's Guide to SmartCare.
Exploitation support
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 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
The Beginner's Guide to SmartCare
The Beginner's Guide to SmartCare.
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.