the smartcare project joining up ict and service processes...
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The SmartCare Project
Joining up ICT and service processes for
quality integrated care in Europe
Gian Matteo Apuzzo A.A.S. n. 1 Triestina - Local Health Authority 1 Trieste
SmartCare Project Coordinator
AZIENDA PER L’ASSISTENZA
SANITARIA N.1 - TRIESTINA
A Maturity Matrix for Integrated Care Workshop
European Summit on Active and Healthy Ageing - 10th March 2015
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
SmartCare: from usual care to
integrated care
What is SmartCare about
• Implement and validate integrated care services in 9 European regions (deployment sites):
• ICT-based support to integrating healthcare, social care and self-care (informal care) for different health / living conditions, along integrated care pathways for improved health and wellness
• the underlying organisational models
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
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
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
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
Key Care Pathway implementation Services/Activities
and associated ICT applications
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
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
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
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
SmartCare deployment sites
Some lessons learnt so far
• Europe may sound like one, but...diversity prevails
(governance, financing, provider responsibilities,..)
• Narrative must go beyond ICT and care issues – an agile co-
designed organisational vision
• Integration takes more than simple goodwill: it requires vision,
structure, organization, supervision, and leadership
• Simply moving the location of care without re-design will not
work
• Technology is not an issue! implementation is usually delayed
for reasons other than technical ones (bureaucracy,
procurement process, contractual issues, as well as reluctance
to change)
• culture issue and change management
THANK YOU!
www.pilotsmartcare.eu
@PilotSmartCare
Gian Matteo Apuzzo