the âHome Sweet Homeâ project by the Badalona Serveis Assistencials (BSA), an integrated private health and social care organisation ... (A) the potential Value if that class of Unmet Needs is fully addressed; ... fire detector, movement detector, etc. 3 .... 12". Area"COL.1"""". On"the"management"of"an"individual"care"plan".
This document represents a Value-‐Oriented Map (VOM) about the following initiative:
Home Sweet Home: a telemonitoring solution to support independent living Topic: Health monitoring and social integration to extend the independent life of elderly people Where and when: The activities were performed in the town of Badalona (Catalonia) from 2010 to 2014 within the “Home Sweet Home” project by the Badalona Serveis Assistencials (BSA), an integrated private health and social care organisation with entirely public capital. abstract: The Project HOME SWEET HOME (HSH) brings together a set of services which, combined, allow extending the independent life of elderly people. HSH is trialling a new, economically sustainable home assistance service which extends elders independent living. HSH provides a comprehensive set of services which support elders in their daily activities and allows carers to remotely assess their ability to stay independent. HSH privileges features which the elders themselves can use and limits the need for other people to interfere with their private life, unless the system detects a clear need. In Badalona, the project adopted for the first time a telemonitoring solution, which was deployed on the top of the local initiative on Home hospitalization (HDI). The project measures the impact of monitoring, cognitive training and e-‐Inclusion services on the quality of life of the elderly, on the cost of social and healthcare delivered to them, and on a number of social indicators. GLOSSARY: Home Sweet “Health monitoring and sOcial integration environMEnt for Supporting WidE ExTension of Home (HSH) independent life at HOME”, a European Project in the ICT Policy Support Programme (ICT PSP), Project ID 250449, See https://cordis.europa.eu/project/rcn/191712_en.html and https://apps.bsa.cat/drupal/?q=node/22 BeyondSilos a European Project in the ICT Policy Support Programme (ICT PSP), Project ID 621069, http://beyondsilos.eu/project/project-‐overview.html – See the related Value-‐Oriented Maps (VOM) in the documents CB14 (program #1 on short-‐term rehabilitation) and CB15 (program #2 on long term maintenance of stable conditions) of this series geriatric team
the patient was identified by the geriatrician at the intermediate care centre, which was also managing the follow-‐up at home together with a nurse. See the local initiative on Home hospitalization (HDI) Home a local initiative in Badalona. In its first period (from 2012 to 2010) it was targeting elderly hospitalization patients at home coming from the intermediate center care, and the patient remained under (HDI) the responsibility of the geriatrician. See the related Value-‐Oriented Map in the documents CB01 of this series. The following tables contain in the right column a qualitative assessment of the CV brought to the care model of this local initiative in correspondence to each class of the Classification of Unmet Needs (in the first column); the second column provides annotations related to the local deployment. The CVs result from a combination of two criteria: (A) the potential Value if that class of Unmet Needs is fully addressed; (B) the ability of the innovative components in the local model to address that class of Unmet Needs. The scores are as follows: 0 = class of Unmet Need not addressed; 1 = class indirectly addressed; 2 = the induction of spontaneous innovation of care processes yields a partial satisfaction of criteria; 3 = a significant influence on roles of professionals and recipients fully satisfies just one criterion; 4 = the structural innovation of care processes fully satisfies both criteria.
Pillar COL – Needs to improve the collaboration among the actors of the care process Area COL.1 On the management of an individual care plan a. set up, refinement and update of individual care plans by a multidisciplinary team
Care plan is decided among the geriatric team at the intermediate care centre.
b. a systematic medical supervision in the course of a care plan
The geriatric team takes care of the supervision.
c. coordination in implementing the tasks within an individual care plan
The geriatric team coordinates with other units outside of the project.
Area COL.2 On the collaborative tasks among the professionals taking care of a patient
3 3 3
a. reciprocal awareness of patient’s contacts and health problems among involved professionals
Full registration of contacts of the patient with the health and social care system through the EMR and ICR
4
b. direct interaction among concerned professionals (incl. consultation)
Good connection among the involved team in the project and the rest of homecare teams.
3
c. recording and sharing of relevant patient All patient data is recorded and shared through the specific platform provided data by the project. Not integrated with the EMR though, so need to go to it “on 3
purpose”. Same platform as in BeyondSilos but less integrated.
Area COL.3 On the remote provision of care and cure services
a. coping with the distance between professionals and patients (incl. tele-‐ health, tele-‐care)
Full telehealth and telecare solution including domotics, panic button (indoors 4 and outdoors), medical devices, cognitive training, etc.
b. handling predictable incidental situations
The telemonitoring solution allows to predict exacerbation of the chronic conditions and to effectively deal with them.
Area COL.4 On the transition between care settings a. patient’s transition from hospital to primary care facilities
N/A (tackled in other initiatives)
Pillar ENG – Needs to improve the engagement of patient and caregiver Area ENG.1 On the management of general information and knowledge
4 0
a. patient involvement in defining the care N/A (in the Catalonian environment) contract and allocating its personal budget
0
b. patient’s awareness on facilities and procedures
3
Full information set delivered to patients and caregivers on procedures
Area ENG.2 On the patient and the caregiver managing their health The technological platform giving pre-‐defined recommendations according to the chronic conditions and also personalized messages coming from the formal caregivers (project team) b. patient’s adherence to the individual Continuous follow-‐up by the technology on accomplishment on the care plan care plan (even including medication intake) c. timely interactions with patient / Both patients and informal caregivers trained to manage their own chronic caregiver on issues arising during self-‐care conditions. a. patient’s skills on healthy life styles, clinical knowledge, therapies
activities
Area ENG.3 On the suitability of the patient’s environment The platform includes a built-‐in videoconferencing system installed at the TV set to contact relatives and friends b. supporting ADLs and IADLs Follow-‐up by the project team. No specific actions taken in that sense. a.-‐ social inclusion
c. “age friendly” buildings, cities and environment
3 4 3 3 2
Installed at home automatic locks for doors and windows. Also flood detector, 3 fire detector, movement detector, etc.
Pillar DEC – Needs to improve the strategic, managerial and clinical decisions
Area DEC.1 On feeding dashboards and producing reports a. exploitation of regional / national Not used in the context of the project managerial and administrative data streams b. exploitation of routine data collected in Used at local level service delivery for management purposes c. exploitation of routine data collected in Used at local and regional level service delivery for strategic decision-‐ making
1 3 3
Area DEC.2 On supporting decisions on individual patients a. supporting clinical decisions by the professionals taking care of a patient b. redundant or contrasting multi-‐drug N/A not the objective of this project therapy c. risk assessment and citizens stratification Not used in this project. for enrolment in specific programs
3 0 1
Disclaimer: the CV scores in the above tables depend on the local context in the particular timeframe. In case of similar initiatives in other localities the CV scores must be re-‐assessed by the local stakeholders with Delphi cycles alternating individual assessments and panel discussions. Discussion: The main goal of the project was to extend the opportunity for independent life of elderly people at home through telemonitoring. As it could be expected, the components that bring most of the Value to the Care Model are addressing the Unmet Needs in the Areas COL.2 (on the collaborative tasks among the professionals taking care of a patient) and ENG.2 (on the patient and the caregiver managing their health). Further contribution to the overall Value is given also by the Areas COL.1 (on the management of an individual care plan) and ENG.3 (on the suitability of the patient’s environment). The initiative reach an overall high score of the Contingent Complexity of Deployment Index: CCD = 64%. The HSH Project started in 2010. It may be compared with the subsequent BeyondSilos project, which started in 2014, and was based on the same platform. BeyondSilos deployed two different Integrated Care Pathways (ICPs): the program #1 on short-‐term rehabilitation with a CCD = 68% (see CB14) and the program #2 on long-‐ term maintenance of stable conditions with a CCD = 75% (see CB15). In other words, the care models in both programs in BeyondSilos were more complex and integrated, yielding a higher CCD Index. The technologies played an important role in this project. HOME SWEET HOME (HSH) trialed a new, economically sustainable home assistance service. HSH achieved this by providing a comprehensive set of services supporting elderly people in their daily activities and allows carers to remotely assess their ability to stay independent. While systems of this kind inevitably represent an intrusion in the elders' private life, HSH privileged features which can be used by the elders themselves and limits to a bare minimum the need for other people to interfere with their private life unless a clear need is detected by the system. It comprised the following services: • The Monitoring and Alarm Handling is based on a DSS which analyses in real time data collected from medical and environmental sensors, fall detectors and geopositioning systems. Standard behavioural patterns are established for individuals and sudden, major changes trigger alarms. • eInclusion is achieved through intuitive videoconferencing based on the familiar TV paradigm and adapted to use by people unfamiliar with IT technology. • Domotics and Daily Scheduler help elders to organise their daily activities and to manage the house in spite of growing physical and mental impairments. • The navigation system takes people who got lost to the closest safe place. Cognitive training is implemented through interactive games based on cognitive adaptive technology. Complexity of exercises is adjusted to the performance and current mental level of the user.
From one side the telemonitoring solution allows to increase the contacts with the patient and thus a more continuous presence, alternating the virtual sessions with in-‐person presence. From the other side the Integrated Care Record allows to maintain a precise history of the evolution of the patient’s conditions; moreover all the professionals can be reciprocally aware of the activities performed on the patient and by the patient, as well as they can set automatic alerts that may require specific interventions.
HomeSweetHome"2008!! 0"
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Area"COL.1"""" On"the"management"of"an"individual"care"plan" Area"COL.2"""" On"the"collabora?ve"tasks"among"the"professionals"taking"care"of"a"pa?ent" Area"COL.3"""" On"the"remote"provision"of"health"services"
a"
Area"COL.4"""" On"the"transi?on"between"care"seDngs"
b"
Area"ENG.1"""" On"the"management"of"general"informa?on"and"knowledge"
c"
Area"ENG.2"""" On"the"pa?ents"and"the"caregivers"managing"their"health" Area"ENG.3"""" On"the"suitability"of"the"pa?ent’s"environment" Area"DEC.1"""" On"feeding"dashboards"and"producing"reports" Area"DEC.2"""" On"suppor?ng"decisions"on"individual"pa?ents"
BeyondSilos, Program #2 on long-‐term maintenance of stable conditions (see CB15) BeyondSilosMlong"2013!! 0"
2"
4"
6"
8"
10"
12"
Area"COL.1"""" On"the"management"of"an"individual"care"plan" Area"COL.2"""" On"the"collabora?ve"tasks"among"the"professionals"taking"care"of"a"pa?ent" Area"COL.3"""" On"the"remote"provision"of"health"services"
a"
Area"COL.4"""" On"the"transi?on"between"care"seDngs"
b"
Area"ENG.1"""" On"the"management"of"general"informa?on"and"knowledge"
c"
Area"ENG.2"""" On"the"pa?ents"and"the"caregivers"managing"their"health" Area"ENG.3"""" On"the"suitability"of"the"pa?ent’s"environment" Area"DEC.1"""" On"feeding"dashboards"and"producing"reports" Area"DEC.2"""" On"suppor?ng"decisions"on"individual"pa?ents"
doc ID: CB13 v.06
date: 2018-‐08-‐28
authors: JPJ (ARM)