Mike Clark 7 April 2009

1. Mike Clark 7 April 2009 Understanding what commissioners want & need from telehealth and telecare

2.  The story so far Progress since 2004  National and local priorities Joint Strategic Needs Assessment, Local Area Agreements  Who could benefit most from telecare and telehealth Which long term conditions? Which health, housing and social care pathways?  Which approaches are being adopted in the UK and around the world Services in the UK. Progress around the World  Service specifications and provider options The importance of outcome based specifications, choice of providers and monitoring  Benefits realisation How will benefits be identified? Will there be efficiencies?  Take home messages Some key points for taking services forwards

3. The story so far - England From pendant alarms to hubs and interoperable devices Community Alarms -environment sensors - Fire, smoke -personal sensors - Falls Telehealth, eHealth -vital signs -remote monitoring -alerts -disease management Interoperability -Continua Alliance -mobile platforms -end to end solutions 2005 2006 2007 2008 2009 Telecare -increased range of sensors -lifestyle monitoring Telehealth Telehealth -increasing number of projects in UK -GPS location -ECG monitoring -Met office alerts

4. The story so far - England Funding and outcomes • Progress • WSD Outcomes • Connectivity to records • New NHS PASA contract • Mobile health • Funding • Announcement of £80m grant funding • PTG Yr 1 • +£30m allocated • Aim for +60,000 users • White Paper – “Our health….” • Outcomes • Grant outcomes • +175,000 users • WSD and ALIP commences 2004 2005 2006 2007 2008 2009 2010 2011 • BTiE • Building Telecare in England (BTiE) • Preventative Technology Grant (PTG) • 1.4m users • Aim for +160,000 older people • PTG Yr 2 • +£50m allocated • Aim for +100,000 users • Mainstream • Telecare moving into mainstream • Up to 50 PCTs with telehealth plans • Interoperability • Innovation • Ambient and wearable sensors • Hub and interoperability developments • Impact on price • ALIP outcomes • P (Personal) - Health WSD – Whole system Demonstrator programme ALIP – Assisted Living Innovation Platform

5. Horizon scanning News alerts 2 April 2009 General Electric and Intel are forming a Healthcare Alliance and investing 250 million dollars to develop and market new "telehealth" technologies that will help patients with chronic diseases and their doctors manage their conditions from the comfort of their own home and also help seniors retain their independence.They estimate that the market for such products will grow from the current 3 billion US dollars to 7.7 billion by 2012. Source: http://www.intel.com/pressroom/archive/releases/20090402corp.htm RSS Feeds Announcements Twitter feeds Web site monitoring • Medical device connectivity for smartphones • ‘Satnav for dementia sufferers’ • Microsoft and Google health record systems (USA) – early trials and developments to improve security • US stimulus package – grant programme commences for health records and telehealth programme

6. Improved outcomes for all – national and local priorities • Transforming social care • Personalisation, personal budgets • Dementia strategy • Integrated care organisations • CQC registration Local Authorities/Social Care Joint Strategic Needs Assessment Commiss- ioning strategy, Local Area Agreement Improved outcomes for individuals Improved outcomes for population Indicators, incentives, targets • NHS Operating Framework, Darzi • WCC, Practice Based Commissioning • Payment by Results, QoF • Dementia strategy • Integrated care organisations • Personal health budget pilots • CQC registration NHS/Health Trusts

7. Who could benefit Evidence Evidence versus Activity • Use of PT Grant funding • Different evidence thresholds for health, social care, housing • COPD • Heart failure • Diabetes • Overnight care • Support for CHD • Intermediate care, re-ablement • Support for People living alone • Hypertension • Extra care, sheltered housing • Reducing hospital/A&E admissions • Other LTCs • Improving carers’ lives • Medication • Obesity/Diet • Falls • Reducing anxiety • Reducing care home admissions • Handling home emergencies • Outside the home • Palliative care • Supporting dementia (social care) Activity

8. Complexity, risk, high cost Who could benefit Long Term Conditions

9. Complexity, risk, high cost Who could benefit Adult Social Care Long Term Conditions

10. PARR ++ Predictive modelling Risk stratification Case reviews Referrals Adult Social Care Long Term Conditions

11. Intensive home care, day services, intermediate care, falls management FACS critical and substantial, co-morbidities, exacerbations Community Matron caseloads, emergency admissions – COPD, HF ? Could support people at home but some people may be too ill or too frail to benefit from technology Telecare Telehealth

12. FACS moderate/low and one long term condition, relatively stable £? Known to social care but may not be receiving a service Known to community matrons Larger numbers, more preventative, higher costs, possibly lower impact on admissions, some self-management Telecare Telehealth

13. www Very large numbers, longer term investment, higher costs, possibly lower impact on admissions, more self-management and self-purchase Generally not known to social care but often live alone sometimes with poor social networks - potential future social care users 3G/4G Generally not known to community matrons, undiagnosed LTCs, prevalence for obesity, smoking USB Bluetooth SMS Facebook eHealth NHS Choices Twitter NHS Healthspace Tyze MMS eMail Smartphones

14. The developing global picture Community Alarm Telecare Telehealth eHealth, mHealth, pHealth, telemedicine UK, Some parts of Europe, Australia, gaining ground in North America and parts of Asia UK, Some parts of Europe and Asia, Australia,gaining ground in North America and Canada • USA, Canada, UK, Parts of Europe, (Italy, Netherlands) some parts of Asia • Main drivers: • US Stimulus package • Health of rural communities • Telemedicine – USA, Europe, India, Africa, parts of Asia • eHealth/mHealth – global potential • Main drivers: • Fixed and mobile broadband, internet access, health of rural communities Illustrative only – DH Care Networks does not endorse individual suppliers or their products

15. Are we able to handle the data? BP Monitoring (59 pence software download from an app store) Glucose monitor linked to smartphone “Home monitoring devices poised to create flood of data” …..That being said, experts have already begun to warn that such devices, while beneficial, could generate more data than physicians can manage. While nurses can screen incoming data, physicians are ultimately responsible for patient management, and the volume of data remote monitoring generates can be formidable. This is likely to become a big issue as remote monitoring gets cheaper and more effective….. http://www.fiercehealthit.com/story/home-monitoring-devices-poised-create-flood-data/2009-02-17

16. Likely commissioning approaches ‘Go for it’ – initiate major programme Risk: infrastructure not in place, overwhelmed with data, unexpected outcomes Phased implementation Risk: infrastructure not in place to work at scale, resistance to change, programme stalls Stay with controlled pilots and projects Risk: No organisational transformation to handle scale, inconclusive local evidence Wait for the money Risk: No identified external funding, difficult to build a local business case Wait for the evidence Risk: Some findings not conclusive, difficult to build a local business case, missed opportunities Do nothing - its not a priority Risk: Unable to meet known/unidentified demand with existing services, demographic timebomb

17. S Strengths T Threats SWOT Analysis • Darzi Review – references to technology • Strong leadership and local champions • Successful outcomes and evaluations • Body of knowledge on what works • Some degree of integrated and partnership working promoted through technology support • Some well developed care pathways • Motivated, involved and trained workforce • Innovative commissioners and providers • Prevention, personalisation and care closer to home strategies • Links to JSNA, LAA, World Class Commissioning and key performance indicators • Health metrics and outcomes easier to monitor, users involved in their care plans W Weaknesses O Opportunities

18. SWOT Analysis • Leaders and decision makers sceptical • Local and wider evidence base is not convincing • Difficulties with mainstreaming and sustainability of projects and pilots • Fair Access to Care Services criteria or health priorities prohibit widespread adoption • Poor infrastructure and data management makes it difficult to identify beneficiaries and improved outcomes • ‘Traditional’ commissioning approaches • Resistance to change and innovation • Difficulties in building a business case • Services not fully costed for personal budgets • Organisational readiness W S Weaknesses Strengths T O Threats Opportunities

19. SWOT Analysis • Focus on outcomes, self care and management of long term conditions • Services and support for the wider population with stakeholder involvement • Transformation and service integration • Personalised services with budget options, choice and control • Alignment with other priorities eg LTC management, individual care plans vascular screening • Predictive modelling, risk stratification • Innovation during difficult economic times • World Class Commissioning requirements • Interoperability, caseload management • Carbon footprint • Digital inclusion, broadband access S W Strengths Weaknesses T O Threats Opportunities

20. SWOT Analysis • No additional funding – more from less • Rapid rate of technology adoption – difficult to scope out future investment • Disruptive technologies threaten traditional models of care • Consumer market develops at pace and services are left behind • Poor data management, data loss, unable to cope with amount of data • Technology investment with no improvement in outcomes • Stakeholder rejection • Consent, confidentiality and privacy issues not addressed • Technology causes social isolation S W Strengths Weaknesses O T Opportunities Threats

21. Telehealth versus Telecare Telehealth • Birmingham (BEN PCT) • Kent • Nottingham • Cornwall • Leeds • Hull • Newham • Barnsley • Swindon • Shefffeld • Southampton • Lincs • Essex • Northants • Sandwell • Main Group • Sunderland • Lancs • Durham Telecare Illustrative only – not too scale. Local services (does not include NHS Choices/NHS Direct)

22. careprofs Telehealth/Telecare as a system Records Cholesterol monitor • NHS • Social Care • Housing • Personal Health Record Telehealth Care professionals Blood-pressure cuff Glucose meter NHS Direct Medication tracking Telecare Sensor networks Hub(s) Service Hub Independent Living, care closer to home Tele-carer Pedometer Lights Doors / Windows Motion / Activity Bed Kitchen Bathroom Home automation Care response service Friends and family Emergency services Source: NHS Connecting for Health

23. Telehealth/Telecare as a service Identify service provider(s) and monitoring arrangements Prepare and commence service Procurement and service transformation Identify Need (JSNA etc) Build and cost service specification Review current services commissioned Monitor impact on individuals, stakeholders, other services. Make adjustments Review infrastruc-ture, workforce impact and changes Develop service metrics and pathways Consider service models/build capacity

24. Service providers Health Housing Local authorities Independent, commercial, third sector • Housing organisations for purchase of community alarm equipment, telecare sensors, installation, monitoring, response • Handyperson, care and repair schemes for installation • Provision of services in sheltered housing, extra care • Purchase of telehealth equipment and initial monitoring • Some out of area contracts • Primary care trusts for purchase of telehealth equipment, installation, data handling • Case management for LTCS (community matrons, specialist nurses etc) • Some hosptial based activity eg heart failure. • Some commissioning of out of hours services to provide support • Social care authorities for purchase of community alarm equipment, telecare sensors, installation, control centre monitoring, response • Some district councils provide similar services in county areas • Some social care authorities have purchased and installed telehealth equipment • Suppliers and manufacturers of equipment • Suppliers of installation, control centres, monitoring and response • Provision of nursing services, therapy and other services through commercial organisations and social enterprises • Sepcialist installation eg registered engineers for gas safety

25. Benefits realisation – VHA case • 17,025 patients, conditions as follows: • Diabetes 52% • Hypertension 44% • CHF 24% • COPD 11% • Depression 2% • Post Traumatic Stress 1% • 9.74% reduction in hospital admissions and 25.31% reduction in bed days of care (BDOC) following enrollment into the program. During the same time period, there was a reduction of 4.6% in BDOC for all patients enrolled within VHA that needs to be taken into account when interpreting this change. • The cost of telehealth was $1,600 per patient pa which compares favorably to the direct cost of VHA’s home-based primary care services of $13,121 per patient pa and nursing home care rates that average $77,745 per patient pa. • VHA consider the key to success of this systems approach was “standardisation of the clinical, educational, technical, business, and organisational elements of telehealth based upon experience gained from piloting it prior to its widespread implementation”. Reference :Care Coordination/Home Telehealth: The Systematic Implementation of Health Informatics, Home Telehealth, and Disease Management to Support the Care of Veteran Patients with Chronic Conditions TELEMEDICINE and e-HEALTH, DECEMBER 2008 Adam Darkins et al http://www.liebertonline.com/doi/pdfplus/10.1089/tmj.2008.0021 (VHA – Veterans Healthcare Administration)

26. Take home messages  Review current effectiveness of long term condition management  Identify people who could benefit from remote monitoring services  Agree commissioning approach – do nothing probably not an option  Engage stakeholders and build a realistic programme  Ensure infrastructure is in place – data handling, workforce etc  Use project management techniques, ensure there is accountability  Monitor performance and outcomes and make adjustments

27. Thank you www.dhcarenetworks.org.uk/telecare telecare@dhcarenetworks.org.uk www.wsdactionnetwork.org.uk wsdnetwork@kingsfund.org.uk Mike Clark