SmartCare pathway for long-term care

“You can’t integrate all of the services for all of the people all of the time.” (Leutz 1999) This fundamental dilemma of integrated care points to the need to clearly identify individuals who may benefit most from the integrated delivery of health and social care. In general, these are care recipients who require a whole-life approach, in order to be supported both in the health and social domain (“complex needs”).

This situation is typical for a SmartCare service configuration in the deployment sites that are implementing the hospital discharge pathway. Jose (click on first photo) is a clinically stable patient with social care support needs at home and with his COPD condition likely to benefit from regular monitoring, possibly through a telehealth monitoring and telecare application and from receiving social care services such as meals on wheels for a certain time. He also fulfils the age related inclusion criteria and may have problems coping with daily household duties. Before actual service delivery begins, a potential SmartCare service user needs to be referred by either a healthcare or a social care provider. Depending on the characteristics of the health and social care system, direct subscription by a service user themselves or a family member is also possible. When it comes to hospital discharge in particular, the entry point is usually defined by a pending discharge event.

The referral is followed by a needs assessment which targets both health and social care needs. It is a first junction for collaborative work of health and social care service providers and focuses on assessing the individual service user in relation to any home care need they may have. It should enable the identification of health-related needs as well as needs for other forms of home support. Upon completion of the assessment, the service user is enrolled into the services and an integrated care plan is agreed jointly by health and social care providers. The integrated care plan is a formal document that also feeds on input by the service user to describe the care interventions to be provided and the appropriate intervals. The focus is on achieving the highest level of empowerment of the care recipient and her/his family. The care plan guides the care team by establishing a course of client care, priorities and selecting a course of action from identified alternatives. It is regularly revised according to the (changing) social and healthcare needs of the service user and his or her preferences (e.g. they are consulted on organisational matters such as the preferred day of the week and time for nurse or social care worker visits or follow-up phone calls and on any other relevant matter related to his or her care).

Service users in the SmartCare deployment regions benefit from different service configurations that are augmented by technology and backed up by the cooperation of service providers and the joint documentation of care. This is crucial for the effective coordination of care delivery. The personalised care delivery package at the centre of the SmartCare pathways combines both informal and formal care delivery as well as remote support delivered via telecare and/or telehealth services.

The story of Solidea is taken from the Italian deployment region of Trieste. Field visits by the SmartCare User Advisory Board have identified the particularity of this personalised service delivery model. It builds on the traditionally strong role of nurses and a strong collaboration of health and social care professionals. The shared care record is predominantly used by nurses, but is also accessible to other care professionals as well as the service user and informal carers. The clinical adjustment to medication and alert levels is done by a GP in close consultation with the nurses. For service users in remote areas living in isolation, a social care worker is also available. Information from the encounters is also integrated into the shared care record system.

The service user story clearly shows the pathway steps concerned with the care delivery, the joint documentation and the continuous re-assessment of the service user’s needs. Joint coordination of integrated care service delivery focuses on the continuous tracking of SmartCare service users when they receive professional home care, remote care in the form of telehealth and telecare and/or informal support from different parties as identified in the initial care plan. It enables carers to coordinate delivery of required care interventions and to effectively utilise available resources. As a consequence, the right mix of clinical, social and informal care in line with the care plan is delivered. The documentation of any care provided to the service user needs to be available in an integrated manner and serves as a basis for ongoing decision making within the overall care process between all involved caregivers.

Integrated care provision following the SmartCare pathways also includes a regular monitoring and re-assessment of the needs of the service user and adaptation of the care plan accordingly. Should a service user no longer require care in one of the two pathways, the transfer to usual care is initiated.

The decision to transfer a user from the SmartCare pathway to usual care can be triggered by two scenarios:

1) Changed needs requiring to adapt the services provided to the client
2) Voluntarily leaving the service

Under the first scenario, it is possible that patients develop a clinical condition under which they can no longer be considered to stay safely in their home environment. If institutionalisation is temporary, a re-admission to the SmartCare pathway is possible. It can also happen that the patient’s overall condition improves so that they do no longer need integrated eCare services.

However, there may also be transitions into irreversible clinical conditions or severe cognitive impairment that effectively prevent the patient from using certain tools such as the blood pressure, blood sugar or body weight telemonitoring device.

If consent for participation becomes invalid, the SmartCare user is leaving the service, but the follow-up and usual care will continue, in order to protect the person. This may relate to changing personal circumstances or challenges with using the technology.

Entry points into both SmartCare pathways may vary according to individual service users and pilot regions. Individual end users may for instance be referred into the SmartCare service by health or social care professionals already working with them in other contexts. Depending on the “business” model intended to be adopted for mainstreaming purposes, direct subscription to the SmartCare services by older people and/or their family may be an option as well. Examples of the latter can for instance be found in countries where non-clinical telecare schemes (e.g. social alarms, home security and environmental sensing) are usually not provided as a public duty under the auspice of the municipality or regional government.

When it comes to hospital discharge in particular, the entry point is usually defined by an impending discharge event. Here, the SmartCare pathway would need to link into discharge pathways and processes already existing internal to a given hospital in an appropriate manner.

The discharge of a patient from hospital marks the beginning of home care provision.

This step focuses on assessing the individual service user in relation to any home care needs he/she may have. This should be a systematic process which relies on pre-defined assessment criteria/procedures. These should enable identification of health related needs as well as needs for other forms of home support. Implementation of this process is thus likely to require involvement of multi-disciplinary expertise. Generally, it should focus on client-specific risk factors and clinical outcomes that can be realistically anticipated and informed from relevant professional perspectives for the individual service user.

This element stands for the process by which individuals register to become a participant in the service to be piloted. Appropriate eligibility criteria and consent procedures need to be available and applied respectively.

This step focuses on an initial plan for joined-up provision of home support through the SmartCare service. It should respond to the previously identified care needs in a holistic manner. The documentation of the plan is an analytical process of activity designed to establish a course of client care, potentially establishing priorities and selecting a course of action from identified alternatives. The result should be documented in a systematic manner and set out inputs, delivery, management and organization of services and support delivery to the home.

This element focuses on the continuous tracking of SmartCare users when they receive professional home care and/or informal support from different parties as identified in the initial care plan. It should enable professional and informal carers to coordinate delivery of required care interventions and utilise potentially available resources. In the sense of a cross-cutting task, the main aim is to effectively manage a system of targeted collaboration over time, thereby involving all relevant parties including the SmartCare service users themselves. A “link person” function may need to be established to ensure that any changing needs of the SmartCare users are identified. In response, the right mix of clinical, social and informal care in line with user expectations is delivered. Beyond the involvement of health and social care expertise, a clear assignment of responsibilities is required when it comes to decision making on any care plan adaptations potentially required.

It is likely that not all personal care needs can be met by ICT-enabled remote interventions. This step focuses therefore on the coordinated performance of care-related measures through professional health/social care staff and informal carers who provide care, services and support in the older person’s home. The range of tasks may require on the one hand clinical interventions or on the other hand non-clinical tasks or social care support, such as assisting with normal daily tasks like dressing, bathing, using the bathroom, provision of meals or befriending services.

It is likely that not all personal care needs can be met by ICT-enabled remote interventions. This step focuses therefore on the coordinated performance of care-related measures through professional health/social care staff and informal carers who provide care, services and support in the older person’s home. The range of tasks may require on the one hand clinical interventions or on the other hand non-clinical tasks or social care support, such as assisting with normal daily tasks like dressing, bathing, using the bathroom, provision of meals or befriending services.

It is likely that not all personal care needs can be met by ICT-enabled remote interventions. This step focuses therefore on the coordinated performance of care-related measures through professional health/social care staff and informal carers who provide care, services and support in the older person’s home. The range of tasks may require on the one hand clinical interventions or on the other hand non-clinical tasks or social care support, such as assisting with normal daily tasks like dressing, bathing, using the bathroom, provision of meals or befriending services.

The remote exchange of data and/or electronic communication between the SmartCare service user and health care professionals is one example of remote provision of care. This may be necessary to assist in the diagnosis and/or management of a health care condition. Examples include blood pressure monitoring, blood glucose monitoring and medication reminders. Potentially, remote transmission of patient information, e.g. symptom reports, to a clinician for an expert diagnosis and/or management may be involved as well.

On the other hand, remote care provision may include ICT-based services involving data exchange and/or electronic communications between the SmartCare service user and non-clinical professionals (telecare). Here, examples include (active) push-button alarms and automatic (passive) monitoring of changes in an individual’s condition or lifestyle, including emergencies, to manage the risks of independent living. The latter may require installation of one or more types of sensors in the service recipient’s home such as movement sensors, falls sensors, bed/chair occupancy sensors and the like.

The documentation of any care-related measures performed for the patient needs to be available in an integrated manner. It serves as a basis for ongoing decision-making within the overall care process between all involved caregivers.

A number of aspects may deserve attention, such as the tailored presentation of information for the needs of health care professionals, social care professionals or informal carers. This may take the form of a client/patient summary. The eligibility for reimbursement under certain Government care Acts is another example. Documentation can also serve auditing purposes when it comes to the quality of care provided. In addition to care interventions, documentation may also include information relating to various types of assessments performed at the point of care, e.g. fall risk assessment, restraint needs assessment, pain assessment for those with communication barriers and the like.

This step focuses on systematically monitoring documented care interventions, services and support and related outcomes, with a view to enabling meaningful adaptation of the initial care plan over time.

Depending on the SmartCare service user’s status, a temporary admission or re-admission into a residential care setting may be required, e.g. a hospital or residential / nursing care home.

Exit points from the pathways may vary according to individual service users. When it comes to the discharge pathway (ICP-Discharge) in particular, transition into the long-term home care pathway (ICP-LTCare) may happen at a certain point in time.

Jose Antonio is a 72 year old with long standing chronic obstructive pulmonary disease (COPD). He is living alone in his house but needs support from his daughter Anna from time to time since his wife Maria died a few years ago. After a recent fall in his home, Antonio had to undergo hip surgery. As discharge from hospital is pending, Jose is approached by the general care nurse working at the hospital. She tells him of a new support scheme that the regional health services in Aragon now offer to people like him.

Solidea is a 89 year old lady with diabetes and is a long time smoker. Monitoring her blood pressure and blood sugar levels has become an everyday habit that she masters without any help. A short beeping sound of the telehealth box confirms the successful transmission of the clinical values to the SmartCare call centre in Trieste. Once in a while, Solidea’s neighbour visits her small apartment to help with grocery shopping and assist with household work. Together, they have built a relationship of trust with the nurse working in the local district who is also regularly visiting Solidea. The alert level configuration of the SmartCare call-centre guarantees that all deviations from pre-defined blood sugar or blood pressure levels trigger an SMS alert on the nurse’s mobile phone.

Every single visit, medication prescription and care process step is documented, allowing for free text commentary where necessary. Nurses are the most active users of this information, showing clearly that there is a benefit to their everyday care practice. Moreover, patients as well as family members/caregivers and the GP may also access the platform to write notes and actively contribute to self-care.

Ana is a district medical doctor with responsibility for about 1,500 inhabitants. He has recently volunteered to monitor 10 of his patients who have enrolled into an integrated care program focussing on COPD, heart failure and diabetes monitoring. The new responsibility means that a different documentation system is now available to him. Every morning, John logs into the SmartCare central documentation hub. With his read/write privileges, he is able to see the full record of interactions that has taken place between the nurses working in primary care, social carers and physiotherapists who visit his patients. A few additional clicks bring up the history of vital clinical parameters such as blood pressure values, body weight and blood sugar.

This morning, an alert message pops up immediately after log-in: the nurse working in primary care has escalated the case of Ms. Thompson. For the second time in a week, Ms. Thompson has complained about early morning dizziness and nausea. The nurse suspects that this may be related to the new medication that Ms. Thompson has received ten days ago after being discharged from hospital. Ms. Thompson’s timeline allows John to navigate back to the discharge record produced by the hospital. Indeed, pain medication was prescribed to alleviate the effects of a hip replacement surgery. John puts the “dispense” button for the medication on “hold/review.” This triggers an automatic appointment request sent out to the nurse. She will now ask Ms. Thompson to see John personally to discuss the medication plan. As soon as Ms. Thompson agrees to the appointment proposal, John’s calendar will be blocked for the meeting.

Miguel is a 92 year old heart failure patient who has been receiving the SmartCare service for several months. He was and still is quite happy with the support he gets at home, including meals on wheels and a nurse visiting him every day to help him getting dressed and taking his medication. His daughter Lupe lives a few hundred kilometres away with her own family and cannot visit him very often, unfortunately. However, since Miguel is enrolled in the SmartCare service, Lupe can better follow-up what is going on with her father as he has granted her access to his integrated care record.

Two weeks ago though, Miguel experienced a serious fall in his house and was admitted to hospital. Although he feels a bit better now than last week, it seems as it would be best for him to try to find, together with Lupe and nurse responsible for the discharge of course, an apartment in a sheltered housing estate as he feels not really comfortable and safe anymore to live alone in his house. His view is strongly supported by the nurse responsible for the discharge and last but not least by Lupe, who promised to support him in his new life situation as good and often as she can. The nurse responsible for the discharge in cooperation with Miguel’s social care provider and nurse working in the community initiates the necessary actions, in close cooperation with Miguel and Lupe.

Exit points from the pathways may vary according to individual service users. When it comes to the discharge pathway (ICP-Discharge) in particular, transition into the long-term home care pathway (ICP-LTCare) may happen at a certain point in time.