Presented by: Ronan Rooney, IBM Research, Director of Care Programs Learn more: http://www.ibm.com/software/products/en/category/health-social-programs

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Opening General Session: Improving Outcomes, Changing Lives with
Smarter Care and Social Programs
1. Welcome
John Hearne, IBM General Manager Smarter Care & Social Programs
2. IBM commitment & investment in health & social programs
Steve Mills, IBM Senior Vice President, Group Executive, Software & Systems Group
3. Health and Social Programs as a Cornerstone of Economic Vitality
Dan Pelino, IBM General Manager, Public Sector
Outcomes: the imperative for change in H&SP service delivery
The Honorable Patrick Kennedy, Former US Representative (no presentation, video replay only)
Re-opening the session after break – and introduction of Judge Leifman by Farhana Alarakhiya, IBM Director, Smarter Care
The Realities and Impact of Mental Health Care Approaches
The Honorable Judge Steven Leifman, 11th Circuit District Court, Miami Dade County (no presentation, video replay only)
4. Innovations in access and engagement: Mobile strategies and solutions for health and social programs
Nicole Gardner, IBM Global Industry Leader, Government Healthcare and Social Services
5. Person-centered Team-based Care: Adventures Through Space and Time
Ronan Rooney, IBM Research, Director of Care Programs
Q&A moderated by Farhana Alarakhiya, IBM Director, Smarter Care

4. © 2014 IBM Corporation
Ronan Rooney
Director, Programs of Care, IBM Research
#ibmhsps14
Person-centered, Team-based Care Adventures in Time and Space

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Really?

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The Challenge: Improve the lives of our vulnerable populations while
lowering the unsustainable growth in cost to care for them
Slide 10, http://www.hfma.org/anihandouts/xtbce9adrpp1/A03.pdfSource: Commercial Sample – MarketScan
Commercial claims data; Medicare Sample – Medicare 5% sample.

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... If data is considered oxygen for
super-utilizer programs, the care
management team and its
interventions are considered the
“secret sauce” … ... Invest heavily in
“boots on the ground”

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The Need for a New Approach
Australian Social Work
Volume 22, Issue 4, December, 1969
“Lack of coordination in
the social welfare field has
commonly presented
communities with major
problems…
…ineffectual use of
already available
resources, or, in services
for maltreated children,
further injury or even
death to the child.”
Care
Network

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Key Objectives – Improve The Efficacy Of Care
How do the planned
interventions improve
the quality of care
and care goals?
What are the estimated and actual costs
for different planning and delivery options?
How appropriate is the
execution of the plan for
the citizen, their family
Experience and the care team?
Cost
Effectiveness
Efficacy
of Care
Planning
Delivery

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Reimaging - Person-centered, Team-based Care
Chris
! Wheelchair
! Sandra cannot take day off
7:00 9:00 12:30 14:00 18:00 21:00
Dressing
Meals
Get up/Go to bed
Medication
S-Dressing up
S-Breakfast
S-Getting up
S-Medication T-Medication M-Medication T-Medication
M-Lunch
S-Medication
S-Dinner
Responsibility Sandra Teresa Mary Teresa Sandra + Chris
WEEKDAYS Foreseen Anomaly Urgent Emergency
1.2 Doctor’s
appointment
10:30, 5KM away
1.1 Sandra on
vacation, Chris
on Business trip
Teresa needs support,
Sandra and Chris need
updates that are non-intrusive
for Teresa
3. The night
before, Sandra
falls ill is
unreacheable.
Chris on
Business trip.
4. Teresa falls
and gets
injured
2. Teresa
deviates from
typical route
Teresa needs support
from the Safety Net to
get assistance in going
to the doctor
Teresa goes to the
weekly seniors’
club meeting
Using GPS sensor,
detect deviation
from typical route
Subtle
Notification
for Teresa
Sandra
Teresa Panics
Teresa Dismisses
message
Teresa Changes
Course
Teresa
Late
Notify
Chris
MDT
Teresa could be in
trouble. Early
intervention either
through relatives or
through safety net
MDT
MDT MDT
MDT MDT
The family is in need
of help. The primary
caretaker has fallen ill,
a new person will need
to be found on short
notice to get through
the day
FALL!
Sandra Teresa Mary Chris MDT Alfred
Sandra
Once the fall is
detected, a neighbour
(with a key) is notified
to go over. He waits
for the emergency
services. Family is
notified.
MDT
Alfred

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Holistic
Adaptive
Multi-disciplinary
Understanding, adapting and
responding to the Citizen,
environment, the context, the
situation and the team
Enabling the multidisciplinary
team to be more effective and
efficient across the Planning
and Delivery phases
Inclusive understanding of the
client, their social network, and
their engagement with the care
network
Person-centered Design Principles

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Planning Optimization
Social
Context
Inherent complexity across
needs, services, providers
and the connections between
them
BioPsychoSocial
Reference
Model Biological
Psychological Social
Safety Network Vulnerability Index
Find temporary foster
care placement and
child care options for
Sandra’s two children
that are near her
employer, her mom’s
house and with easy
access to their two
schools

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Planning Optimization
Social
Context
Inherent complexity across
needs, services, providers
and the connections between
them
BioPsychoSocial
Reference
Model Biological
Psychological Social
Safety Network Vulnerability Index
Find temporary foster
care placement and
child care options for
Sandra’s two children
that are near her
employer, her mom’s
house and with easy
access to their two
schools

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Planning Optimization
Social
Context
Inherent complexity across
needs, services, providers
and the connections between
them
BioPsychoSocial
Reference
Model Biological
Psychological Social
Safety Network Vulnerability Index
Find temporary foster
care placement and
child care options for
Sandra’s two children
that are near her
employer, her mom’s
house and with easy
access to their two
schools

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Delivery Optimization – Micro-Planning - Adventures in Time and Space
Social
Context
Time Care Team
Inherent complexity
across needs, services,
providers and the
connections between
them
Safety Network Transportation Location

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Delivery Optimization – Micro-Planning - Adventures in Time and Space
Social
Context
Time Care Team
Inherent complexity
across needs, services,
providers and the
connections between
them
Safety Network Transportation Location
Find the closest
care worker to
Teresa that has free
time from 11 to 12.
Which family
member is available
to come and chat with
Teresa at the
hospital?

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Delivery Optimization – Micro-Planning - Adventures in Time and Space

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Delivery Optimization – Micro-Planning - Adventures in Time and Space
• No food ahead of
10:30 appointment
• Check in with
secretary on arrival
Hospital Information:

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Key Benefits
Improved
Care
Experience
Optimized
Care
Planning
More Time
with Clients
Location, Temporal,
Transportation and Care
Network analytics evaluate
service delivery options to
enable Care Teams to develop
efficacious care plans
Real-time analytics deliver
prioritized, accurate and situation-aware
information to Care Teams so
that they can spend more time with
their clients and make better
informed decisions
A suite of IBM MobileFirst apps
deliver a transformative and
person-centered user
experience for the Client, the
Family and the Care Team

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Business Process Model
IDENTIFY
ASSESS
RESPOND
MANAGE
MEASURE

21. End of Day 1 General Session