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

Transcription

1 A Maturity Matrix for Integrated Care Workshop European Summit on Active and Healthy Ageing - 10 th March 2015 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

2 Background National welfare & health s and regional/local support practices are developing more and more specialisation and clear boundaries closed them to cooperation Social care Today Healthcare Healthcare Informal care Today s reality is characterised by fragmentation and bureaucracy in current provision s resulting in disjointed and patchy support services Tomorrow Leading to inefficiencies, duplication of resources, and potentially to reduced levels of quality of care

3 SmartCare: from usual care to integrated care Integrated Care di Smart Care

4 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

5 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 Effective and efficient communication between all parties Better use of resources, less duplication and more streamlined care

6 Project aoroach Common SmartCare Support structure SmartCare coordination & management structure Expert advise & support (User Advisory Board, Industry Board, Committed Regions Board, Internal Scientific Board Local SmartCare Alliances / Stake Holder Partnerships Common SmartCare approach Common SmartCare work programme Requirements elicitation, use cases & integrated care pathways development Pilot service specification & process model development Joint definition of common building blocks for ICT integration infrastructure Pilot site preparation & operation in two waves Pilot evaluation & exploitation support Shared outputs Intehrated care pathways, validated service models & value chains Common ICT integration infrastructure architecture Operational guidance: guidelines for procurement, implementation & up scaling Synthesised evidence on impact Sustainable business models & transferability assessment Consensus building on further organisational & policy development Contribution to EIPonAHA by critical mass for large scale uptake

7 Integrated Long-Term Home Care Support Entering into service Receiving continuous personalised care Leaving service Entry point (1): Referral by health care provider Entry point (2): Referral by social 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 Personalised multi-provider service package On-site / home provision of informal care On-site / home provision of formal social care On-site / home provision of formal health care Remote provision of health & social care (telehealth, telecare) Shared documentati on of home care provided Monitoring / review / reassessment of care recipient s needs Temporary admission to institution (e.g. hospital, care home) Exit point: Disenrollmen t from SmartCare service (ICP- LTCare)

8 Integrated Home Support after Hospital Discharge Entering into service Receiving continuous personalised care Leaving service 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 Coordination of integrated care delivery / revision of initial integrated care plan Personalised multi-provider service package On-site / home provision of informal care On-site / home provision of formal social care On-site / home provision of formal health care Remote provision of health & social care (telehealth, telecare) Shared documentation of home care provided Monitoring / review / reassessment of care recipient s needs Readmission to hospital Exit point: Disenrollment from SmartCare discharge service Exit point: Transition into SmartCare longterm care service Discharge from hospital

9 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

10 Key Care Pathway implementation Services/Activities and associated ICT applications

11 Information collection and recording Systems Entering into service Receiving continuous personalised care Leaving service Entry point (1): Referral Health paper/er, GP Entry point (2): Referral Social care record - paper/er, GP Joint assessment Integrated H&SC paper/er Enrolment and consent Integrated H&SC paper/er, SmartCare database, GP Initial integrated care plan Integrated H&SC paper/er, GP Care coordination Integrated H&SC paper/er Personalised multi-provider service package Informal Carers onsite services Caseload management & appointment s, CR held record Social Care onsite services Caseload management & appointment s, CR held record Health Care onsite services Caseload management & appointment s, CR held record Remote provision of health & social care and support Online platforms, telehealth & telecare Integrated and shared documentation Integrated H&SC paper/er, CR self care plan Monitoring / review / reassessment info Integrated H&SC paper/er Temp admission to institution info Integrated H&SC paper/er, Hospital PAS, GP Exit point: Discharge info Integrated H&SC paper/er, SmartCare database, GP

12 Information, communication and sharing mechanisms Entering into service Receiving continuous personalised care Leaving service Entry point (1): Referral Health record Entry point (2): Referral Social care record Joint assessment H&SC record, integrated record, message Enrolment and consent H&SC record, integrated record, message, paper fax Initial integrated care plan Community H&SC record, , fax, phone Care coordination Community H&SC record, , message, fax, phone, letter Personalised multi-provider service package Informal Carers Integrated record, , message, fax, phone, shared paper diary Social Care Integrated record, , message, fax, phone, shared paper diary Health Care Integrated record, , message, fax, phone, shared paper diary Remote provision of health & social care and support , telemonitoring, web-based, integrated record, phone Integrated and shared documentation , integrated record, message, fax Monitoring/revie w / reassessment , integrated record, message, SMS, fax, phone, letter Temp admission to institution info , integrated record, message, fax, phone Exit point: Discharge info , integrated record, message, fax, letter

13 ICT infrastructure Entering into service Receiving continuous personalised care Leaving service Referral Community health LAN/WiFi,broadb and, paper filing, GP LAN Referral Community social care LAN/WiFi, broadband, paper filing, GP LAN Joint assessment Community H&SC LANs/WiFi, broadband, paper filing, GP LAN Enrolment and consent Community H&SC LAN/WiFi, Broadband, paper filing, GP LAN Initial integrated care plan Community H&SC paper/er, GP Care coordination Community H&SC LAN.WiFi, SPA, Call Centre, paper filing, GP LAN Personalised multi-provider service package Informal Carers Community LAN/WiFi, broadband, paper diary, CR home broadband, paper record Social Care Community LAN/WiFi, broadband, paper diary, CR home broadband, paper record Health Care Community LAN/WiFi, broadband, paper diary, CR home broadband, paper record Remote provision of health & social care and support CR home broadband, paper record, SPA, Call Centre LAN/WiFi Integrated and shared documentation Community LAN/WiFi, broadband, paper filing Monitoring / review / reassessment info Community LAN/WiFi, broadband, paper filing Temp admission to institution info Community LAN/WiFi, GP LAN, Hospital LAN, paper filing Discharge info Community H&SC LAN/WiFi, GP LAN, paper filing, SmartCare database

14 Workplan Requirements Elicitation & Care Pathway Development Organisational & ICT-related pilot preparation Pilot operation & evaluation WP1 Requirements & use case definition WP3 Integration architecture & service specification WP6/7 Pilot operation WP2 Service process models WP4 System implementation & test WP5 Pilot site preparation WP8 Pilot evaluation WP9 Exploitation support & dissemination WP10 Consortium management and performance monitoring

15 SmartCare deployment sites and users enrollment Region / Number of users Friuli- Venezia- Giulia South Deployment site users preliminary overview Older people (care recipients) Health professionals Social care professionals Informal carers Denmark Scotland Aragon Tallin South Karelia Attica North Brabant Kraljevo

16 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 codesigned 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

17 THANK YOU! Gian Matteo Apuzzo