James Barlow


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James Barlow

  1. 1. Mainstreaming remote care in the UK. Lessons from the Preventative Technologies Grant and Whole System Demonstrators programmes James Barlow NHS Connecting for Health Evaluation Programme 2009 Masterclass 17 September 2009 www.haciric.org
  2. 2. Overview ▬ Research background ▬ Remote care ▬ The future never quite arrives ▬ What we know from existing experience and research ▬ Conclusions
  3. 3. Research background ▬ Initial EPSRC funded projects on telecare planning and implementation, 2000-03 and 2003-2006 ▬ Evaluation of Welsh telecare programme (continuing) ▬ EPSRC funded project on PTG implementation (2006- 2008) ▬ Part of DH funded consortium evaluating the WSD programme and WSDAN (Imperial, King’s Fund, UCL, Oxford, Manchester, LSE) ▬ James Barlow, Steffen Bayer, Jane Hendy, Theti Chrysanthaki
  4. 4. Terminology ▬ ‘Telecare’ ▬ ‘Telehealth’ ▬ ‘Telemonitoring’ ▬ ‘Telemedicine’ ▬ ‘Assistive technology’ ▬ ‘Smart homes’ ▬All are used interchangeably to describe the remote delivery of health and social care
  5. 5. Remote care applications Mitigating risk Safety and security monitoring, e.g. Bath overflowing, gas left on, door unlocked Prevention Prevention Information & The Individual monitoring: communication, e.g. • Physiological signs health advice, virtual individual in • Lifestyle / activities self-help groups their home or wider environment Improving functionality Electronic assistive technology, e.g. Prevention environmental controls, doors opening/closing, control of beds
  6. 6. Policy drivers ▬ The UK has taken a strong lead. Over 20 government reports since 1998 have called for telecare ▬ New finance (£170m +) via Preventative Technology Grant, Whole System Demonstrators and other initiatives
  7. 7. Remote care is not new ...
  8. 8. 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
  9. 9. … 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 year’s 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!
  10. 10. Diffusion of telecare in Surrey 1998-2005 COPD Project Brockhurst Dementia unit LAA: Safe Thames Ward, Molesey Hospital At Home Columba MEWS Hospital Discharge project NEECH videophone pilot Leatherhead Hospital Mid Surrey Falls Project Dormers SMART House Guildford Falls Project Dray Court Telecare flat Mid Surrey Wristcare pilot Tandridge Telecare Flat COPD at Home Project Community Alarm Teams, Elmbridge, Guildford, Mole Valley 10 & Runnymede
  11. 11. ▬ … but despite thousands of pilot or trial projects remote care has not yet become a mainstream part of care delivery ▬ Pockets of excellence don’t spread and pilot projects are not sustained
  12. 12. ▬Lack of progress in UK (and elsewhere) is largely due to: • organisational problems (esp. integration within and between care providers) • a lack of obvious business models • … and limited benefits evidence is also playing a part
  13. 13. What’s needed to stimulate remote care? Adoption Spread Mainstreaming ‘Business case’ Evidence Evaluation Awareness uptake Project mgt Leadership Champions Enthusiasts Pump priming Grants time Source: Barlow, Hendy, Chrysanthaki
  14. 14. The existing evidence base Focus of study Evidence on: Individual outcomes, i.e. Systemic outcomes, i.e. clinical or QOL economic impact or impact on improvement processes Specific application, Relatively good, growing Limited, problematic – poor e.g. aimed at patients – numerous individual specification of assumptions, with diabetes studies on which to build lack of robust data systematic reviews General application, Largely anecdotal, Virtually unresearched – e.g. aimed at a growing – not yet peer based on simulation general population reviewed modelling with limited data (e.g.‘frail older people’) Barlow et al: (JTT 2007)
  15. 15. A lack of evidence isn’t always a barrier to government policy initiatives …
  16. 16. … but it is now becoming important for remote care implementation because … … for social care organisations, ▬ Remote care now embracing new research, … we’re stakeholders across the care system – very practical, … to move from social to health care have (evidence), that fits more with health ▬ Financial investment beyond the pilot stage needs to be made ▬ More robust evidence needed to build business cases for all parties – provider, commissioner, technology … you need the supply chain evidence, … when you ▬ Evidence increases stakeholder get the evidence you receptiveness get true buy-in
  17. 17. ▬ But we actually know very little!
  18. 18. We don’t even know how many remote care users there are ▬ Poor data due to 4000 inconsistent 3000 definitions 2000 ▬ Example from 5 1000 0 leading LAs … Site Site Site Site Site 1 2 3 4 5 Recorded users 2006 Recorded users 2008 Source: Hendy & Barlow New users claimed in 2008
  19. 19. ▬ And despite the reported benefits in terms of admissions avoidance, speedier discharges etc, this is largely based on anecdote or poorly designed studies
  20. 20. Exploring the potential impact on healthcare ▬ Simulation modelling experiments can help us think about how remote care might change services ▬ … the figures aren’t important in these examples
  21. 21. Frail elderly care death r w Inst from HC to waiting Inst entry 3 fM death rate Inst 600 waiting entry fM Inst fM from waiting to Inst fM Inst entry 3 death rate death rate 550 HC fL HC fM death rate from HC fL from hc fM to from HC fH h to h fL to fM to waiting Inst from waiting to death rate Inst from HC fH healthy HC fL HC fM HC fH waiting Inst entry 4 entry fH aging from healthy to from HC fL to HC fL HC fM from HC fM to HC fH death rate Inst fH Inst fH 500 Pop. in instit. care HC fH death r w Inst fH share to TC 450 pessimistic from healthy to effect of TC on frac rate to inst care entry TC fH to optimistic TC fL fM to waiting Inst waiting Inst 400 from TC fL to h from TC fM effect of TC on frac rate to inst care entry fH best guess from TC fH to death rate TC fL from TC fM to fL TC fM fM TC fH 350 base run TC fL from TC fL to from TC fM to death rate TC fM TC fH TC fH effect of TC on fty progression 300 250 200 132 1 5 10 15 20 Time (years) 130 Admissions / month 128 Base case 126 Best guess A 20% decline in 124 demand for care 122 Falling home places? (initially) 120 0 2 4 6 8 10 12 14 16 18 20 hospital Time (Years) admissions? Source: Bayer & Barlow
  22. 22. Effect of telecare on care costs in year 20 3 - 5% reduction in costs Change 2.0% in costs 0.0% -2.0% -4.0% -6.0% 20% reduction -8.0% 20% less Same 80% reduction Effect of telecare on entry into 40% more Cost of telecare institutional care package compared to a conventional care package
  23. 23. Chronic heart failure frac death r at risk frac death r asympt frac death r sympt Stabilisation in the dying at risk frac r dev HF dying asymptomatic dying symptomatic demand for hospital admissions? asymptomatic symptomatic time constant high risk transfer to TC becoming high unknown developing usual care risk developing HF symptoms investment in leaving high risk frac r dev prevention detection of symptoms transfer to TC detection fraction presymptomatic effectiveness of cost of risk without screening HF managing reduction per frac r dev sympt unsymptomatic investment in known person screening TC places asymptomatic screening cost and known developing sympt per person known disease symptomatic dying known TC total hospital days unsymptomatic dying sympt TC frac death r <frac death r asympt> sympt TC 100,000 <frac death r 1 1 1 sympt> TC effect on frac death r sympt 90,000 1 1 1 1 3 1 3 3 3 3 1 34 34 345 4 45 45 5 2 23 5 5 45 45 2 80,000 2 2 2 2 2 2 70,000 60,000 0 25 50 75 100 Time (Month) Source: Bayer & Barlow total hospital days : base 1 1 1 1 1 hospital days/Month total hospital days : TC 3M 2 2 2 2 2 hospital days/Month total hospital days : Prevention 3M 3 3 3 3 hospital days/Month total hospital days : Screening 3M 4 4 4 4 hospital days/Month total hospital days : TSP 1M 5 5 5 5 5 hospital days/Month
  24. 24. Conclusions ▬ Remote care has potential in managing LTCs and coping with aging population ▬ There is support for remote care at the individual level – the hurdles are at a system level ▬ ‘Evidence’ for costs / benefits becoming more important as pilots move towards mainstream investment decisions ▬ … but stories still crucial in convincing sceptics ▬ WSD may help, but need more resources to support gathering local data on consistent basis
  25. 25. Thank you James Barlow j.barlow@imperial.ac.uk