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
spend
Department of Health (2008 ) Raising the profile of long term conditions care
INIsPHO (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/Reward
Provider 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 to
delivery 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 services
In Northern Ireland
Patient Selection • Patient Assessment
• Patient Care Plan
and Referral • Patient and clinician engagement
• Programme Governance
Governance • Programme Management
• Stakeholder Communications
• Clinical
Service Design • Business Processes
• Technical
• Clinical Service Delivery
Service Delivery • Clinical Service Management
• Patient service Delivery
Service • Patient equipment
• Managed Service Platform
Infrastructure • IT Infrastructure
12. Partnering to deliver integrated services
In Northern Ireland
• Patient Assessment
Patient Selection • Patient Care Plan
and Referral • Patient and clinician engagement
• Programme Governance
Governance • Programme Management
• Stakeholder Communications
• Clinical
Service Design • Business Processes
• Technical
• Clinical Service Delivery
Service 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 Assess
Identify 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 Assess
Identify 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 People
Process Definition Programme Non-clinical Service integration Process
Service 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
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 Platform
Decision support software Referral, Reporting Service Support Patient Portal
31. Managed Services Model – Lessons Learned
Delivering 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