Delivering Telehealth At Scale In Northern Ireland - Jim O'Donghue

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  • 1. TelehealthDelivering Telehealth at scale in Northern IrelandA Service Provider Perspective Jim O’DonoghueCopyright © S3 Group S3 Group
  • 2. Northern Ireland Chronic Disease 2/3s of over 75s Population 1.8M 60% of all GP visits H&SC budget £4.3Bn Rising to £4.66Bn in 2014/2015 72% acute bed days 69% of health & social care spendDepartment of Health (2008 ) Raising the profile of long term conditions careINIsPHO (2010) Making Chronic Conditions Count S3 Confidential Slide 2
  • 3. NI Vision for Remote Telemonitoring• Bring information to professionals, enabling more proactive, effective and co-ordinated community based care• Provide greater support for self-care and for carers• Part of a new way to manage increasing burden of chronic disease which is both more efficient and better quality “…investing to build the capacity to cope”
  • 4. First Questions for NI Authorities• Should the remote telemonitoring service be provided from within the public sector or outsourced to the private sector ?• If outsourced • What should be procured – products ? Technology ? Services ? • What should the scope of the service be? • How would the service be used and how would it integrated with other aspects of care delivery ? • How can it be designed to be scalable?
  • 5. Models for procuring Telehealth Managed Service - Outcome Based Risk/RewardProvider Responsibility & Risk Flexibility and Scalability Partnership Working Contract Complexity Managed Service - PAYG Customised / integrated service Combined Technology Purchase + Service Purchase Technology Purchase + Service purchased separately
  • 6. Managed Service Model – Commissioner Responsibilities • Defining Service Requirements Managed Service - Outcome Based Risk/Reward • Defining KPIs (as SLAs and Quality Metrics) RTNI - Managed Service - PAYG • Defining how health professionals Customised /Integrated Service will interact with and support the service interface points (e.g. escalations from Triage) Combined Technology + Service Purchase • Stakeholder engagement • Selecting patients to be referred Technology Purchase + Service purchased separately on to the service
  • 7. Managed Service Model - Provider Responsibilities• Providing all aspects of a joined- up service involving Managed Service - Outcome Based Risk/Reward people, process and technology• Responsible from Referral to RTNI Managed Service - PAYG discharge Customised /Integrated Service• Meeting defined service requirements & SLAs Combined Technology + Service Purchase• Technology selection, maintenance and equivalence Technology Purchase + Service purchased separately• Incentivised to generate service delivery efficiencies
  • 8. Managed Service – A Shift in Concept and Language Buying Becomes Buying a Technology service Selecting Becomes Defining your Technology service requirements Buying Kit / Becomes Buying Units Monitoring days Building service Becomes Building capability todelivery capability use the service
  • 9. RTNI Programme Structure • 6 year contract awarded March 2011 • Procurement, service definition and implementation process led by ECCH – a part of Public Health Agency • 1 Service Definition, 5 customers • 3,500 patients per annum • 12 condition categories • 2 - 52 week monitoring periods • >2.8 million monitored days • £18m investment
  • 10. Overview of the Basic Service escalation Community Daily Daily Nurse Readings Monitoring GP/Clinician
  • 11. Partnering to deliver integrated servicesIn Northern IrelandPatient Selection • Patient Assessment • Patient Care Plan and Referral • Patient and clinician engagement • Programme Governance Governance • Programme Management • Stakeholder Communications • ClinicalService Design • Business Processes • Technical • Clinical Service DeliveryService Delivery • Clinical Service Management • Patient service Delivery Service • Patient equipment • Managed Service Platform Infrastructure • IT Infrastructure
  • 12. Partnering to deliver integrated servicesIn Northern Ireland • Patient AssessmentPatient Selection • Patient Care Plan and Referral • Patient and clinician engagement • Programme Governance Governance • Programme Management • Stakeholder Communications • ClinicalService Design • Business Processes • Technical • Clinical Service DeliveryService Delivery • Clinical Service Management • Patient service Delivery Service • Patient equipment • Managed Service Platform Infrastructure • IT Infrastructure
  • 13. RTNI Managed Service Requirements Definition Service Service Service Requirements Design Operation Define Model & Define Desired AssessIdentify Drivers of Change Implementation Benefits Cost/Benefits Approach Clinical Outcomes Service Model Clinical outcomes National Roles/Responsibilities Financial benefits Local Patient Experience Clinical Staff Pathway Changes Implementation costs Financial Delivery model
  • 14. Service Requirements Definition – Iterative Approach What’s What’s desirable possible Commissioner Provider What’s practical Define Model & Define Desired AssessIdentify Drivers of Change Implementation Benefits Cost/Benefits Approach
  • 15. Capturing Requirements in a Contract• Comprehensive and robust Office of Government Commerce contract detailing all aspects of Commissioner and Provider responsibilities• High level of detail of service definition & contractual requirements: • Detailed definition of every aspect of the service to be provided (221 Authority requirements) • Detailed service levels and associated penalties (20 for „core‟, 8 for „additional‟ & a further 19 quality markers) • Extensive reporting, automated performance monitoring• 1 Service definition with 5 customers: • Joint specification, governance and central infrastructure • 5 local implementation plans
  • 16. Service Design Processes Service Service Service Requirements Design Operation Establish Design Design Service Service Planning Service Service Service Readiness Governance Delivery Infrastructure Testing Pathway Design Clinical Clinical processes Solution Design PeopleProcess Definition Programme Non-clinical Service integration ProcessService Interfaces Financial Operating Service platform Technology Metrics Procedures Service IT Process/Policies
  • 17. Service Design – Collaborative Process Usability Plan Tests Commissioner Workshops Provider / Expert Design Feedback Process and interface Definition Establish Design Design Service Service Planning Service Service Service Readiness Governance Delivery Infrastructure Testing
  • 18. Elements of service to be delivered Referral to Discharge• Clinical Triage• Service Desk• Clinician Portal• Patient Portal• Reporting• Performance Management• Service Integration• Patient services• Training
  • 19. Patient Pathway – Service Design Considerations
  • 20. Patient Selection Process• Patient Selection Process Service Delivery Components – Driven by the risk stratification approach and specific goals and focus of each Trust – Captured in Trust implementation plans – Rolling forecast of patients per condition communicated to provider
  • 21. Patient Referral Process• Patient Referral Process – Online Referral Form is completed with all the required information to enrol the Patient on to the Telemonitoring service – Referrer specifies the priority of the Referral – “Urgent” to be completed within 20 working hours or “Standard” within 48 working hours (SLA) – Notifications on progress through referral process or issues encountered – On receipt of the Referral, the Clinical Triage Team will review the Clinical information and will seek clarification from the Referrer if necessary
  • 22. Patient Referral Process – Design Considerations• Service Design Considerations – Comprehensive referral information required to support clinical triage – Maximise auto-population of data to speed filling of forms – Access from inside and outside of Trust networks (single sign-on) – Need for an integrated service desk to co-ordinate tasks – Need for an automated tracking of and reporting against SLAs
  • 23. Patient Set-up Process• Patient Set-up – Service Desk contacts the Patient to arrange an Installation Appointment – Referrer is informed by the Service Desk of the appointment details – Installers train the Patient on how to use Equipment and access the Patient Portal – Test Readings are completed – the Service Desk notifies referrer of the completion of Installation and the Patient is now set-up on the Telemonitoring Service
  • 24. Patient Set-up Process – Design Considerations • Service Design Considerations – Tracking of each stage of the process co-ordinated by a Service Desk application – Being able to report on where patients are in the process – Automatic notifications to referrers on completion or issue – Ability to co-ordinate and manage issues throughout the process
  • 25. Patient Triage• Patient Triage – There are two services available – “Track and Trend” (no provider triage) or “Triage” - covering 12 disease packages – Each disease package has vitals, questions, default thresholds, planned monitoring period – Provider Clinical Triage Team responsible for Triaging Patients by phone – Definition of Level 1, 2 and 3 Local response
  • 26. Patient Triage - Design Considerations• Service Design Considerations – Triage SLAs – to align timing of escalations with availability of local response – Clear definition of what providers clinical triage team can and can‟t do – Medication updates ? Changing monitoring parameters ? – Method of escalation (phone, email, sms); Method of closing the escalation – Clinical governance procedures
  • 27. Monitoring of Care – Reviewing Parameters• Monitoring Care – Setting and Reviewing Parameters – Default monitoring parameters per vital defined on referral form – Defaults parameters can be changed to Patient specific parameters – Referrer responsibility to review parameters to avoid unnecessary alerts and escalations
  • 28. Monitoring Care – Design Considerations• Design Considerations – Threshold setting and scope of triage activity has a big influence on provider triage staffing levels – Key is to train clinicians and have agreed protocols – Need automated SLAs/Performance Tracking to monitor triage process – Need an audit trail of all changes to plan and monitoring regime
  • 29. Patient Review & Discharge Process• Patient Review & Discharge – On the Referral form the Monitoring Period is requested and will automatically show the anticipated patient review date – The Referrer is notified 3 weeks, 2 weeks and on the anticipate review date for a Patient Review – This involves the Referrer completing a Patient Outcome Review Online Form – If no response is received, we continue to monitor the patient until notified differently – Unscheduled reviews may also be completed at intervals decided by the Referrer – Referrer discharges via an on-line form
  • 30. Our Integrated Managed Service PlatformDecision support software Referral, Reporting Service Support Patient Portal
  • 31. Managed Services Model – Lessons LearnedDelivering at Scale • Pressure is on the provider to deliver services that the commissioner wants NOT on the commissioner to map the available technology to meet their requirements • Significant up-front investment on both sides to define service requirements and design how the service will integrate with other services • Keeps the commissioner “out of the weeds” – Defining what service is required and not how to arrange people, process and technology to deliver the service • Demands a high level of working in partnership through service definition and design • Shares the risk of delivery between the commissioner and provider