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www.haciric.org Technological innovation for elderly care. Reconfiguring services and reconfiguring infrastructure Improving the Hospital Performance in Economic Crisis EUREGIO III Masterclass Programme 23 March 2011 Instituto De Higiene E Medicina Tropical Universidade Nova De Lisboa Lisbon James Barlow

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Part 1 the innovation paradox in healthcare

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We need technological innovation to cope with the big 21 st century healthcare challenges...

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... but while innovation is part of the solution, its also part of the problem Medical & diagnostic equipment innovations increase access to care close to / at home....... New pharmaceuticals reduce the requirement for in- patient care....... Advances in surgery improve outcomes and reduce lengths of stay.......... this generates new costs in primary / social care sector.... this increases demand for long term support... this extends the range of eligible patients but

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Remote care = good example of a technological innovation that offers huge potential But it also unlocks new challenges Some of these impact on the built infrastructure for healthcare

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Part 2 What is remote care?

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Remote care Information & advice Safety & security monitoring Vital signs monitoring Lifestyle monitoring

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Practice by Telephone The Yankees are rapidly finding out the benefits of the telephone. A newly made grandmamma, we are told, was recently awakened by the bell at midnight, and told by her inexperienced daughter, "Baby has the croup. What shall I do with it?" Grandmamma replied she would call the family doctor, and would be there in a minute. Grandmamma woke the doctor, and told him the terrible news. He in turn asked to be put in telephonic communication with the anxious mamma. "Lift the child to the telephone, and let me hear it cough," he commands. The child is lifted, and it coughs. "That's not the croup," he declares, and declines to leave his house on such small matters. He advises grandmamma also to stay in bed: and, all anxiety quieted, the trio settle down happy for the night The Lancet 29 Nov 1879, Page 819 With thanks to Nicholas Robinson

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its arrival has been heralded throughout the last decade "The innovations we will encounter as we step beyond feasibility are dazzling in their potential" R. Merrell, Yale University School of Medicine, 1995 "Over the next decade, the telemedicine industry will expand into new markets and service areas. Furthermore, its rapid rise will have a profound impact on the delivery and quality of medical care worldwide. In the United States alone, we expect telemedicine will represent at least 15 percent of all health care expenditures by 2010 Telemedicine Industry Report 2000 Telecare has arrived. This years annual review reflects the transformation of our sector from social alarms to Telecare, and the repositioning of the Telecare service model from the periphery of housing, social care and health to centre stage Association of Social Alarms providers, 2004 2008: The year telecare grows up? E- Health Insider, 2007 With thanks to ?What If!

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The terminology Telecare Telehealth Telemonitoring Telemedicine Assistive technology Smart homes All are used interchangeably to describe the remote delivery of health and social care

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Some remote care is relatively simple... TelemedicineTelecare / telehealth Aimed at diagnosis or referral, usually focusing on specific conditions Brings care directly to the end-user generally in a non-institutional setting Lots of tele-ologies (e.g. teledermatology, teleradiology) Focus on monitoring for prevention or safety and security, or advice and support Essentially a B2B model (patient may or may not be present) Essentially a B2C model (patient always present) Few stakeholders so relatively easy to implement Many stakeholders so far more complex and inherently harder to implement

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TelemedicineTelecare / telehealth Aimed at diagnosis or referral, usually focusing on specific conditions Brings care directly to the end-user generally in a non-institutional setting Lots of tele-ologies (e.g. teledermatology, teleradiology) Focus on monitoring for prevention or safety and security, or advice and support Essentially a B2B model (patient may or may not be present) Essentially a B2C model (patient always present) Few stakeholders so relatively easy to implement Many stakeholders so far more complex and inherently harder to implement but some is complex...

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TelemedicineTelecare / telehealth Aimed at diagnosis or referral, usually focusing on specific conditions Brings care directly to the end-user generally in a non-institutional setting Lots of tele-ologies (e.g. teledermatology, teleradiology) Focus on monitoring for prevention or safety and security, or advice and support Essentially a B2B model (patient may or may not be present) Essentially a B2C model (patient always present) Few stakeholders so relatively easy to implement Many stakeholders so far more complex and inherently harder to implement

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Remote care applications Information & communication, e.g. health advice, virtual self-help groups Safety and security monitoring, e.g. Bath overflowing, gas left on, door unlocked Individual monitoring: Physiological signs Lifestyle / activities Electronic assistive technology, e.g. environmental controls, doors opening/closing, control of beds Improving functionality Mitigating risk The individual in their home or wider environment Prevention

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Remote care applications Information & communication, e.g. health advice, virtual self-help groups Safety and security monitoring, e.g. Bath overflowing, gas left on, door unlocked Individual monitoring: Physiological signs Lifestyle / activities Electronic assistive technology, e.g. environmental controls, doors opening/closing, control of beds Improving functionality Mitigating risk The individual in their home or wider environment Prevention UK 1 st generation (1970s - ) UK 2 nd generation (2005 - ) UK minor development so far

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Part 3 why remote care is important

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ageing population public expenditure constraints healthcare cost inflation rising chronic disease Based on a figure by Laurie McMahon A perfect storm for health and social care budgets is emerging 2008

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Dealing with this perfect storm will require innovative healthcare business models new configurations of services, technology and infrastructure ... including remote care

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Potential remote care benefits Risk management: move patients from expensive care settings (e.g. hospitals, nursing homes) to lower cost environments (patients home, intermediate care facility) Prevention: monitor at risk populations more closely to enable earlier identification of problems and earlier intervention Patient-centred approach: choice over care packages, location of care delivery Better quality of life / better outcomes (?)

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Part 4 progress made towards remote care implementation

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Policy in the United Kingdom The UK has taken a strong lead. Well over 20 government reports since 1998 have called for telecare Finance (170m +) via Preventative Technology Grant, Whole System Demonstrators and other initiatives Organisational infrastructure for support

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There are many case studies and other reports

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What does the remote care evidence base look like? Source: Barlow et al (2007) Very large number of studies around the world (10,000+ published reports?) Clinical / QoL benefits are being shown But very little robust economic evidence but modelling highlights the potential benefits Bulk of studies are targeted at diabetes and heart disease

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Growth in remote care users in England... with many assumptions Source: Based on CQC returns, JIT (Scotland) data, and authors research for WAG. Includes LA and other agency services. Assumes 30% drop-out rate each year With Scotland & Wales Assumes 15,000 remote care users (2005) and 5000 users (2000)

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How big is the potential market? Potential remote care market 2010 1,400,000 Actual remote care market 2010 350,000 Potential telehealth market 2010 450,000 Actual telehealth market 2010 22,500 Source: based on CQC returns, JIT (Scotland) data, and authors research for WAG. Telehealth figures from Minutes of the Strategic Intelligence Monitor on Personal Health Systems [SIMPHS] meeting, Brussels, 17-18 November 2009. Assumptions: UK population aged 75+ rises from 4.9m (2010) today to 11.4m by 2050 c85% of older people wish to remain at home as long as possible 1/3 needs remote care at any given time

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Telemedicine in Portugal Telemedicine has been developing, e.g. in Alentejo 90,000 consultations using telemedicine 1998 2009 Teleconsultation (cardiology, dermatology) and teleradiology Local health providers, hospitals in Lisbon, Oporto and other Portuguese cities, and regional Spanish hospitals Quicker than face-to-face consultations Provides GPs with specialist knowledge thus reducing referrals Changes the distribution of health expertise, services and infrastructure Tiago Cravo Oliveira Doctoral Candidate, Imperial College Business School tiago.oliveira@imperial.ac.uk

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Part 5 what are the implications of remote care for healthcare infrastructure?

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Remote care is part of the next generation of healthcare infrastructure renewal

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There are tantalising glimpses into the potential of remote care

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Simulation modelling can help us think about how remote care might change care services and what the potential impact might be NB the figures arent important in these examples

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Frail elderly care 2051015 Source: Bayer & Barlow (2007) A 20% decline in demand for care home places? Falling (initially) hospital admissions?

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20% reduction Cost of telecare package compared to a conventional care package Change in costs Effect of telecare on entry into institutional care Effect on frail elderly care costs 3 - 5% reduction in costs

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Chronic heart failure Source: Bayer & Barlow (2006) Stabilisation in the demand for hospital admissions?

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Stroke care Source: Cox et al (2010) c20% decline in hospital bed days and c5% decline in care home bed days?

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Will remote care reinforce the emerging faultline in healthcare infrastructure? Tertiary care Traditional in-patient hospital care Community care Home and family With thanks to Laurie McMahon

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... and will hospitals be able to cope?

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The challenge How to coordinate, plan and deliver Healthcare infrastructure Services Technology investment In highly complex, fast- moving environments

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Lessons 1 New technologies can help to address the big challenges in care provision how to do more for less Remote care will play a part in shifting the balance of care from high cost to lower cost settings So we need to think about the future role of hospitals and other expensive infrastructure But it wont necessarily reduce overall healthcare costs

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Lessons 2 Its about understanding services, technologies and infrastructure as a system

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Thank you James Barlow j.barlow@imperial.ac.uk