implementing telecare. evidence from the ukfrom the uk · 2013-04-03 · implementing telecare....
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Implementing telecare. Evidence from the UKfrom the UK
Jane Hendy, James Barlow and Steffen Bayer
AAL Forum Vienna 30th September 2009
www.haciric.org
Overview
Th d f t d h t it i▬ The need for remote care – and what it is▬ UK policy agenday g▬ The future never arrives
P f t d i t i t▬ Progress so far towards mainstreaming remote care
▬ Potential benefits▬ The need for an evidence base▬ The need for an evidence base▬ Conclusions
Terminologygy
‘Telecare’▬ ‘Telecare’
▬ ‘Telehealth’
▬ ‘Telemonitoring’
▬ ‘Telemedicine’
▬ ‘Assistive technology’
‘S t h ’▬ ‘Smart homes’
▬All are used interchangeably to describe g ythe remote delivery of health and social carecare
Remote care
• Information & adviceInformation & advice• Safety & security monitoring• Vital signs monitoring
Lif t l it i• Lifestyle monitoring
The need for remote care
O l ti f i l ti d d▬ One solution for managing escalating demand for health and social care is technologies that
t t lsupport care remotely
▬ “We have to (introduce remote care systems)▬ We have to (introduce remote care systems) over the next five years if we are not to see the NHS go over the falls – the equivalent ofNHS go over the falls the equivalent of Niagara Falls – with or without a barrel” (Mike Bainbridge, NHS Connecting for Health, 23/06/08, eHealth Insider)g , g , , )
Policy driversy
Th UK h t k t▬ The UK has taken a strong lead. Over 20 government
t i 1998 hreports since 1998 have called for telecare
▬ New finance (£170m +) via Preventative TechnologyPreventative Technology Grant, Whole System Demonstrators and otherDemonstrators and other initiatives
▬ but despite thousands of… but despite thousands of pilot or trial projects remote care has not yet become acare has not yet become a mainstream part of care deliverydelivery
▬ Pockets of excellence don’t spreadspread
▬ Pilot projects are not sustained
L k f i UK ( d l h )▬Lack of progress in UK (and elsewhere) is largely due to:• organisational problems (esp. integration
within and between care providers)within and between care providers)• a lack of obvious business models• … and limited benefits evidence is also
playing a part
The existing evidence base
Focus of study Evidence on:
Individual outcomes, i.e. clinical or QOL improvement
Systemic outcomes, i.e. economic impact or impact on
processesimprovement processesSpecific application, e.g. aimed at patients with diabetes
Relatively good, growing – numerous individual studies on which to build
Limited, problematic – poor specification of assumptions, lack of robust datawith diabetes studies on which to build
systematic reviewslack of robust data
General application, e.g. aimed at a
l l ti
Largely anecdotal, growing – not yet peer
i d
Virtually unresearched –based on simulation
d lli ith li it d d tgeneral population (e.g.‘frail older people’)
reviewed modelling with limited data
Barlow et al: (JTT 2007)
What’s needed to stimulate remote care?Adoption Spread Mainstreaming
Evidence
‘Business case’
L d hi
Evaluation
uptakeAwareness
Champions
LeadershipProject mgt
Enthusiasts
Grants
Pump priming
timeSource: Barlow, Hendy, Chrysanthaki
We don’t even know how many remote ycare users there are
▬ Poor data due to inconsistent definitionsdefinitions
▬ Example from 5 leading LAs …
Source: Hendy & BarlowSource: Hendy & Barlow
Summary of current positiony p
▬ Growing evidence of clinical effectiveness of some specific telecare applications
▬ Very little no cost-benefit evidence
▬ Little published on remote care that meets orthodox quality standards for healthcareorthodox quality standards for healthcare evaluation
Solutions?
▬Solutions?
Whole System Demonstrator yprogramme
▬ DH White Paper, Whole System Long Term C diti D t t (2006)Conditions Demonstrators (2006):
• ‘Whole system demonstrators that test the benefit of ywholescale redesign of services for those with long term conditions’
• ‘The key challenge … is to provide credible evidence that comprehensive integrated care approaches combined with the use of advanced assistive technologies benefitthe use of advanced assistive technologies … benefit individuals and deliver gains in cost effectiveness of care.’
Exploring the potential impact on p g p phealthcare
▬ WSD can provide snapshot evidence for p pbenefits but we need to also consider potential longitudinal impact across the p g pwhole system
▬ Simulation modelling experiments can help▬ Simulation modelling experiments can help achieve this
th fi ’t i t t i th l▬ … the figures aren’t important in these examples
Frail elderly care
healthy HC fL HC fM HC fH
Inst fM
Inst fHfrom healthy toHC fL
from HC fL toHC fM
from HC fM toHC fH
aging
death rateh
death rateHC fL
death rateHC fM
death rateHC fH
death rate Instentry fMwaiting
Inst fM
waitingInst fH
from waiting toInst entry 3
from waiting toInst entry 4
from HC towaiting Inst entry
3
to waiting Instfrom HC fH
death r wInst fH
death r w InstfM
from HC fLto h
from hc fM tofL
from HC fHto fM death rate Inst
entry fH 500
550
600
are
TC fL TC fM TC fH
share toTC
from TC fL toTC fM
from TC fM toTC fH
death rateTC fH
effect of TC on fracrate to inst care entry
fH
TC fH towaiting Inst
to waiting Instfrom TC fM
effect of TC on fracrate to inst care entry
fM
death rateTC fL
from healthy toTC fL
from TC fH tofM
from TC fMto fL
from TC fLto h
300
350
400
450
Pop.
in in
stit.
ca
pessimisticoptimisticbest guessbase run
effect of TC on ftyprogression
200
250
300
1
Time (years)205 10 15
132Time (years)
124
126
128
130
ssio
ns /
mon
th
Base caseBest guess A 20% decline in
demand for care
120
122
124
0 2 4 6 8 10 12 14 16 18 20
Adm
is demand for care home places?Falling
(initially) hospital admissions?Time (Years)
Source: Bayer & Barlowadmissions?
Effect of telecare on care costs in year 20
3 - 5% reduction in costs
0 0%
2.0%Change in costs
4 0%
-2.0%
0.0%
8 0%
-6.0%
-4.0%
20% reduction
less
me 80% reduction
-8.0%
Effect of telecare i
20%
Sam
% m
ore
Cost of telecare package compared to a conventional
on entry into institutional care
40%to a conventional care package
Chronic heart failure
frac r dev HF
frac death r at risk frac death rasympt
frac death r sympt
dying at riskdying
asymptomatic
dyingsymptomatic
Stabilisation in the demand for hospital
high risk asymptomaticunknown
symptomaticusual care
symptomatic
developing HFdevelopingsymptoms
frac r devsymptoms transfer to TC
becoming highrisk
time constanttransfer to TC
asymptomaticand known
detection ofpresymptomatic
HF
developing symptknown disease
cost of riskreduction per
person
investment inprevention
screening costper person
investment inscreening
frac r dev symptknown
effectiveness ofmanaging
unsymptomatic
TC places
detection fractionwithout screening
leaving high risk
padmissions?
sy pto at cTC
frac death rsympt TC
dying sympt TC
TC effect on fracdeath r sympt
<frac death rsympt>
dying knownunsymptomatic
pe pe so
<frac death rasympt>
total hospital days100,000
90,00054 4 43 3 3 3 3 3 3 31 1 1 1 1 1 1 1 1
80,000
70,000
5 5 5 5 5 5 5 54 4 4 4 4 4 4 43 3 3 3 3 3 3 3 3
2 22
2 2 2 2 2 21 1
60,0000 25 50 75 100
Time (Month)
total hospital days : base hospital days/Month1 1 1 1 1total hospital days : TC 3M hospital days/Month2 2 2 2 2
Source: Bayer & Barlow total hospital days : TC 3M hospital days/Month2 2 2 2 2total hospital days : Prevention 3M hospital days/Month3 3 3 3total hospital days : Screening 3M hospital days/Month4 4 4 4total hospital days : TSP 1M hospital days/Month5 5 5 5 5
Conclusions
Remote care has great potential in managing LTCs▬ Remote care has great potential in managing LTCs and coping with aging population
Th i t f t t th i di id l l l▬ There is support for remote care at the individual level – the hurdles are at a system level
‘E id ’ f t / b fit b i▬ ‘Evidence’ for costs / benefits becoming more important as pilots move towards mainstream investment decisionsinvestment decisions
▬ WSD may help, but more use of modelling is needed
▬ We also need more realistic expectations about cost-benefits
