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					Integrating stakeholder needs with telecare
service development. Lessons from the UK

James Barlow1
Hazel Aldred2
Steffen Bayer1
Simon Brownsell2
Richard Curry1
Mark Hawley2

1 Tanaka Business School, Imperial College London
2 Barnsley Hospital NHS Foundation Trust
About the research                                                                                                      2 Research objectives
                                                                                                                        • Our research aims to show how detailed user needs analysis
                                                                                                                          coupled with simulation modelling can inform telecare policy
                                                                                                                          and investment decisions.

1 Background                                                                                                            • The background to the research is the government’s current
                                                                                                                          programme to extend the use of telecare to support older people
• Policy makers and health professionals are seeking to develop
  innovative approaches to the delivery of care services for older                                                        within their own homes.
  people and those with chronic conditions. These include an
  increased emphasis on the delivery of care in new settings – such                                                     • Around £80m is being made available to pump prime new
  as in intermediate care facilities and the patients’ own home – and                                                     telecare schemes from April 2006. However, policy makers and
  the use of information and communications technologies (ICT) to                                                         care managers need clarity over which user groups and services
  support care delivery through telecare.                                                                                 should be prioritised.

• Providing older and disabled people with increased independence
  is a major element of the UK’s care policy agenda. The use of
  telecare to maintain people’s quality of life has been widely
  discussed and since 1998 at least a dozen government reports
  have argued for its introduction. There are now ambitious targets
  for full telecare coverage by 2010.

                                       Evaluation of factors          Evaluation of relationship          Research on perceptions                            • The poster draws on research from
                                       triggering increasing          between trigger factors and         and attitudes towards                               two major studies on the
                                       levels of care                 indicators of quality of life       telecare (not discussed in
                                                                                                          this poster)
                                                                                                                                                              implementation of telecare aimed at
                                                                                                                                                              maintaining older people’s
                                          Literature review: 158     Literature review:                                                                       independence.
      Connections                         papers included            24 papers included
                                                                                               22 focus groups (170 older
      between elements                                                                         people, carers, care profs)
                                                                                                                                                             • One study explored the needs of the
                                                                                                                                                               various stakeholders – end users and
      of the research                                                                                                                                          a range of care providers – likely to
                                     Workshop with care service
                                     stakeholders to prioritise                                                                                                be involved in the provision of
                                     the trigger factors                                                                                                       telecare services.
                                                                                       Indication of
                                                                                       individual attitudes
                                                                                       and interest in
                                                                                                                                                             • The second study is using systems
                                                                                       telecare                                                                dynamics and other modelling
                                  Mapping identified trigger                                                                                                   approaches to investigate how
                                  factors / QOL indicators against
                                  formal care services and                                                                                                     telecare impacts on patient flows and
                                  telecare technologies                                                                                                        costs and benefits within a local care
                                                                                                                         Simulation                            system.
                                                                                       Provides pointers to              modelling to
                                             Indication of generic user needs          help prioritise telecare          explore
                                             and factors influencing                   services but planners             resource
                                             increased care provision that             also need to consider             implications
                                             telecare could address                    resource implications             at local care
                                                                                                                         system level
What is telecare and what can it do?
                                                                                                                                                           Potential benefits to care
                                                                                                                                                           system stakeholders

3 What is telecare?                                                                                                                                        Stakeholder
                                                                                                                                                                                            Key benefits
                                                                                                                                                                              Quality of life – access to care in

• ‘Telecare’, ‘telehealth’, ‘telemonitoring’ and                    • We define telemedicine as ICT based                                                                     location of choice, reduction in anxiety,
                                                                                                                                                                              providing reassurance, sustaining or
                                                                      applications which support the exchange of
  ‘telemedicine’ are used interchangeably to describe                 information between health care professionals,                                       Informal carer
                                                                                                                                                                              regaining independence
                                                                                                                                                                              Quality of life – reduction in anxiety and
  the remote delivery of health and social care.                      generally for diagnosis or referral.                                                                    stress, providing reassurance
                                                                    • This distinction between telecare and
• We define telecare as a set of services bringing                    telemedicine is important because the latter is
                                                                                                                                                                              Additional options for care, better
                                                                                                                                                                              information on progress and outcomes
                                                                                                                                                                              for individual clients and across
  health and social care directly to the end-user.                    inherently simpler to implement since it focuses                                                        professional communities, reduction in
                                                                      on specific applications (e.g. teledermatology,
• Telecare is based on the premise that people in                     teleoncology) and involves fewer stakeholders                                        Statutory
                                                                                                                                                                              volume of inappropriate work
                                                                                                                                                                              Better management across populations,
  need of care should be able to participate in the                   from different parts of the care system.                                             services (health
                                                                                                                                                           and social care
                                                                                                                                                                              better resource management,
                                                                                                                                                                              development of self care and
  community as much as, and for as long as,                                                                                                                services)          prevention, clearer audit trails
                                                                                                                                                           Private care and   New market opportunities
  possible.                                                                                                                                                specialist

• Three bundles of telecare services can be identified:                                                                                                    housing
                                                                                                                                                           alarm service
    - safety and security monitoring                                                                                                                       providers

    - personal monitoring (physiological and activity)                                                                                                     Industry
                                                                                                                                                                              New market opportunities

    - information provision                                                                                                                                munication and
• Data from the use of electronic assistive                                              Safety and security                                               suppliers)

  technology – designed to provide the occupant                                          monitoring, e.g. bath
                                                                                         overflowing, unlit gas left on,
                                                                                                                                                           Government         Modern, responsive care service; better
                                                                                                                                                                              resource management; better co-

  with greater functionality in the home – could also                                    door unlocked
                                                                                                                           Mitigating risk
                                                                                                                                                                              ordination between different
                                                                                                                                                                              departments involved in care delivery

  be integrated into activity monitoring to provide
  more information on how individuals are coping.          Prevention
• Some telecare systems provide a response to an
  immediate need, for example a fall or a sudden
  change in an individual’s vital signs.                  Information &
                                                                                                   The individual in
                                                                                                   their home or wider             Personal monitoring:
• Other systems can provide evidence of changes to        communication,
                                                          e.g. health advice,
                                                                                                   environment                     • physiological signs

                                                                                                                                   • activities of daily living

  an individual’s health and social care status, and      triage, access to
                                                          self-help groups
  could therefore contribute to an individual’s chronic
  disease management programme.
                                                                         functionality        Electronic assistive technology,
                                                                                              e.g. environmental controls, doors
                                                                                              opening/closing, control of beds
Understanding user needs
                                                                                        Trigger factor                Fo    Cur   Em    No             Trigger factor                For   Cu    Em
                                                                                                                      rm    ren   erg    .                                           ma    rre   erg
                                                                                                                       al    t    ing                                                 l    nt    ing
                                                                                                                      car   TC    TC                                                 car   TC    TC
4 Identifying trigger factors                                           1    A fear of falling                        
                                                                                                                                      19   Inadequate home care provision          
                                                                                                                                                                                                
• The literature review identified 102 factors triggering greater       2    A major health event                                    20   Managing pressure sores                           
  amounts of care and support for older people. However, there          3    A perceived decline & concern for own                    21   Medication management                             
  appeared to be no ranking in terms of priority, making it hard for         health
  planners and policy makers to target resources where the greatest     4    A person feeling lonely                        ?          22   Mobility problems                                 
  returns may be observed.                                              5    Abuse (physical or mental)                              23   Moving to be near relatives
                                                                        6    Bereavement, of a family member or                         24   Multiple minor longstanding illnesses              
• To prioritise the trigger factors, a workshop was held with                friend
  participants from a range of relevant agencies such as health and     7    Cognition impairment                                    25   Needs assistance with personal care               
  social care, housing and voluntary services. The participants         8    Consequences of admission to hospital         ?          26   Occurrence of falls                               
  identified a further five trigger factors.                            9    Depression, mental breakdown or                          27   Person feels isolated                               
• All 107 trigger factors were randomly ordered and prioritised by
                                                                        10   Deteriorating physical functioning                      28   Poor nutritional/dietary intake                   
  the participants. A total of 36 were identified as being in the top
                                                                        11   Difficulty cooking for themselves                       29   Poorly maintained housing               
  three bands of importance.
                                                                        12   Difficulty in managing stairs or steps                   30   Presence of chronic disease                       
                                                                        13   Difficulty toileting/continence                         31   Recent onset of visual impairment                  
                                                                        14   Family etc can no longer provide                        32   Requiring regular trips to hospital                 
                                                                                                                                                                                            
5 Mapping trigger factors                                               15   Family/caregiver stress                                    33   Self perceived inability to manage
                                                                        16   Housework problematic                                     34   Self-management of health conditions              
 against telecare                                                       17   Inability to care for self at home                      35   Unsuitable accommodation                          

• The role of formal care services and current or emerging telecare     18   Inability to cope with IADLs                             36   Wound care                              

  (and other electronic assistive technology or EAT) in addressing or
  mitigating each of the 36 trigger factors was examined through a
  further literature review and consultation with healthcare
  professionals and other experts.
• Twenty-nine (81%) of the trigger factors are addressed by formal
  care services
• Twenty-three (64%) can be addressed by current telecare / EAT
  technology and an additional eight (22%) by emerging technology.
• Twenty-one (58%) of the trigger factors fall within the domains of
  formal care services and current or emerging telecare, suggesting
  that while it has a role to play, the support of formal care
  services is required in combination with telecare.
Trigger factors, telecare and quality
of life                                                                               Trigger factors indicating increasing care and
                                                                                      Abuse (physical or mental)
                                                                                                                                       Issues relating to quality
                                                                                                                                       of life

                                                                                      Depression, mental breakdown or deterioration    Cognitive problems

6 Trigger factors and quality of life                                                 Cognition impairment
                                                                                      Family/caregiver stress

  issues                                                                              Housework problematic
                                                                                      Inability to cope with IADLs
                                                                                                                                       Domestic activities

•   A literature review was conducted to identify factors commonly accepted as
                                                                                      Inability to care for self at home               Personal hygiene
    issues relating to quality of life.
                                                                                      Needs assistance with personal care              Grooming, general
•   For 33 of the 36 trigger factors there is a corresponding relationship            Difficulty toileting/continence management       appearance
    with QOL issues. For the others this does not necessarily mean that there         Self perceived inability to manage alone
    is no link, but rather no reference was observed in the QOL literature review.    Inadequate home care provision

•   This demonstrates how telecare, by addressing key trigger factors, also           Mobility problems, getting around the house      Reduced mobility
                                                                                      Poorly maintained housing                        Physical environments of
    has the potential to positively impact on quality of life issues.
                                                                                      Unsuitable accommodation                         home
•   However, further work is required to validate these findings and to identify at   Difficulty in managing stairs or steps           Frailty
    what point specific types of telecare technology should be implemented            A fear of falling                                Exercise
    against a certain trigger factor.                                                 Occurrence of falls
                                                                                      Deteriorating physical functioning
•   In addition, the multiple interplay of trigger factors needs to be better         Family etc can no longer provide support         Neighbours and family who
    understood.                                                                       Bereavement of a family member or friend         could provide support
                                                                                      Multiple minor longstanding illnesses            Health
                                                                                      A major health event                             Carrying an illness or
                                                                                      Consequences of admission to hospital            caring for someone
                                                                                      Presence of chronic disease                      within the family
                                                                                      Self-management of health conditions             Physical health
                                                                                      Requiring regular trips to hospital              Disability
                                                                                      Medication management problems
                                                                                      Wound care
                                                                                      Managing pressure sores
                                                                                      A perceived decline and concern for own health
                                                                                      Person feels isolated                            Good social relationships
                                                                                      A person feeling lonely                          Participation in activities at
                                                                                                                                       home and outside
                                                                                                                                       Recreational programmes,
                                                                                                                                       community events and
                                                                                      Poor nutritional/dietary intake                  Nutrition
                                                                                      Difficulty cooking
                                                                                      Recent onset of visual impairment                Loss of valued pastimes
                                                                                                                                       due to eyesight problems
    Planning new telecare services
7 Service development
  decisions                                                     8 Simulation modelling
•   Exploring how telecare can address broad, generic
    user needs at the individual level helps give care          • Simulation modelling can help organisations
    providers pointers to where telecare interventions            developing telecare services refine their initial
    should be targeted.                                           decisions by providing guidance on their
                                                                  implications for care system resources and costs
•   However, planning new services needs to take into
                                                                  over time.
    account their wider impact and resource
    implications across the health and social care              • The use of a dynamic approach (system
    system.                                                       dynamics modelling) is particularly appropriate
                                                                  since level of scale and scope of service, and
•   The cost of establishing and operating a telecare
                                                                  whatever procurement route is chosen, the effects
    service depends on two key decisions: on its scale
                                                                  of telecare will not be instantaneous.
    (the number and type of people to be supported) and
    scope (level of benefits to patients), and on the           • In previous work we have used this approach to
    procurement route (e.g. ‘in-house’ or via a third party).     investigate the effects of telecare on the care                                     Example: impact of telecare for frail elderly
                                                                  system over time based on national data and the                                     people under differing assumptions about
•   An understanding of the implementation, capital                                                                                                   effects on progression of frailty and rate of
                                                                  estimates of the effect of telecare on an aggregate
    and operational costs of each option over time is                                                                                                 telecare service implementation
                                                                  user groups.
    needed in order to inform more detailed decisions
    about financing options.                                    • Based on the research on trigger factors reported
                                                                  here and data from trials to be carried out later in
•   This may be complicated by the system wide costs                                                                                                      500
                                                                  2005 we will be able to carry this work forward
    and benefits falling across different budget                                                                                                                                                 TC 100%
                                                                  distinguishing different types of telecare and their                                    450

                                                                                                                         Patients in institutional care
    streams in health and social care provision.
                                                                  impact on the care system.                                                              400                                    TC 30%

                                                                                                                                                                                                 TC 30% effect
                                                                                                                                                                                                 on progression
                                                                                                                                                                                                 TC 100% effect
                                                                                                                                                                                                 on progression

                                                                                                                                                                                                 TC ramp up to
                                                                                                                                                          200                                    50% over 5


Key findings and conclusions

9 Key findings
• We conducted a detailed evaluation of factors triggering increasing
  levels of care and their relationship with indicators of quality of life.
• We mapped these against available and emerging telecare services
  and related assistive technologies.
                                                                                           10 Conclusions
• Together, this allowed us to develop a perspective on the individual                     • To meet government aspirations for mainstreaming telecare it is vital to identify areas
  user needs where telecare could help to maintain independence and                          where it is likely to deliver the greatest benefit. Policy makers and care providers need to
  quality of life.                                                                           make investment decisions on the basis of sound evidence for the impact of telecare at
                                                                                             the individual and care system level.
• This can provide an indication of generic user needs that could be
  addressed through telecare. Simulation modelling can help to                             • Research on the links between user needs, quality of life and factors triggering
  answer questions about where to target and how much to charge                              increased levels of care provides a baseline to inform the development of new
  for services.                                                                              telecare services. Simulation modelling is needed to explore their wider impact.

          Further reading                                                                                                                  The poster draws on research
          Aldred, H.; Barlow, J;. Brownsell, S;. Curry, R.; Hawley, M. Gerontechnology. Meeting whose need?                                funded by the Engineering and
          5th International Conference of the Society for Gerontechnology, 24-27 May 2005, Nagoya, Japan.                                  Physical Science Research
          Barlow, J.; Bayer, S.; Castleton, B.; Curry, R. Meeting government objectives for telecare in moving                             Council (grant nos.
          from local implementation to mainstream services. Journal of Telemedicine and Telecare, 2005, 11,                                GR/S29058/01 and
          S1.                                                                                                                              GR/N31320/02). The research
                                                                                                                                           was carried out collaboratively
          Bayer, S.; Barlow, J.; Curry, R. Assessing the impact of a care innovation: telecare. 22nd                                       by Imperial College London,
          International Conference of The System Dynamics Society, 25-29 July 2004, Oxford.                                                University College London,
          Brownsell, S.; Aldred, H.; Hawley, M. (2005) The role of technology in addressing the care and                                   Dundee University and
          support needs of older people. 5th International Conference of the Society for Gerontechnology, 24-                              Barnsley Hospital NHS
          27 May 2005, Nagoya, Japan.                                                                                                      Foundation Trust.
          Brownsell, S. et al (2001) An attributable cost model for a telecare system using advanced
          community alarms. Journal of Telemedicine and Telecare, 2001, 7: 63-72.

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