Lessons to be learned

The following lessons can be used for self-learning. To start, download the Service Implementation Simulator from the previous page and safe it to your local harddisk. Open the Simulator in Microsoft Excel. Make sure that both Macros and ActiveX elements are activated (see here for information how to do this).

Lesson 0: ASSIST tool basics

The first step in working with the tool is to make it your own, i.e. to configure it to your own service scheme. There are three levels on which this is done. First, a number of basic settings need to be made. Second, you include different types of individual and organisational stakeholders into your service model that will be involved in or affected by your new service. Third, you define what types of costs and benefits are relevant for each stakeholder.

To get you started, try and do the following:

  • Start with the “Intro” sheet and read the information provided.
  • Switch to the “Settings” sheet and check the different settings. Set the start date for the service to June 2016.
  • Switch to the “Stakeholders” sheet and compare the stakeholders that are activated (checkbox ticked) to those listed in this document. Anyone missing? Activate the “Third-sector provider” and its first two staff categories (“Carer support workers”, “Carer support managers”). Rename the Third-sector provider to “Carer support organisation”. Click on any other sheet, click “OK” on the dialogue that pops up and wait until the ASSIST tool has reconfigured itself.
  • Go to the sheet of the Physiotherapy provider (HPO_cns). Other than originally foreseen, the provider will not have to procure general hardware. Therefore switch off the relevant indicator by unchecking the checkbox in front of it.

Lesson 1: And who pays my bills?

For a business entity, a business case requires that the immediate benefits to the entity are higher than cost. For example, revenue generated from service provision needs to cover all costs related to buying hardware, employing staff etc. While losses can be sustained for a certain period, ultimately a profit needs to be generated. For non-business entities (such as public institutions) other rules may apply.

  • Is there a problem with the business case of the Telehealth Call Centre? You might go to the “Charts” sheet and select the Telehealth Call Centre to display its cumulative socio-economic return (top graph) and its cumulative net benefit (bottom graph). What do you notice?
  • Now go to the stakeholder sheet of the call centre (HPO_tcr) and have a look at the different costs and benefits. Especially look at the “Sum of all cost” and the “Sum of all benefits”. What is the current source of the problem?
  • Try and save the business case of the Telehealth Call Centre. What possibilities might there be to do so? Increase the fee paid by the patient? To what amount? Include additional payments from other providers or healthcare payers by switching on the respective indicators and entering values? Maybe a creative mix of fees paid by different stakeholders?

Lesson 2: Sorry, I’m out

One challenge in service implementation is from stakeholders who lose out due to the new service being put into place. There can be different scenarios of why and how a new service can result in more costs than benefits to a stakeholder. Losses may be monetary (e.g. a loss of actual income), but can also concern staff time or intangible factors such as influence or image. A stakeholder without incentives can cause problems because he is likely to leave the service if no solution is found. Depending on his position he might also become a veto player, jeopardizing the success of the entire service.

  • What is the GPs likeliest attitude towards the service as it currently stands? You might go to the “Charts” sheet and select the Primary care organisation to display its cumulative socio-economic return (top graph) and its cumulative net benefit (bottom graph). What do you notice?
  • What factual problem lies behind the GPs attitude? The service description provides a clue to this.
  • The GP is in a powerful position in the health system surrounding the service. Try and find ways to prevent him from becoming a veto player. What possibilities might there be to do so? Have the health and social care payer pay a compensation? What amount would be needed? Strengthen the role played by the GP by reducing the number of consultations relocated to the social care provider? What speaks against this?

Lesson 3: We are financed from a larger budget

In situations where a new service is only a (small) part of the whole portfolio of an organisation and where financing is done by a budget for the whole organisation, precise economic assessments can become challenging. Depending on the organisation’s accounting system it might not be possible to determine what share of the budget is being used for the new service. Practically this can mean that there is no immediate benefit to set against cost caused by the new service. Various possibilities exist to address this problem especially in relation to how the cost-benefit analysis results are being presented.

  • Is there a problem with the business case of the physiotherapy provider? You might go to the “Charts” sheet and select the Physiotherapy provider to display its cumulative socio-economic return (top graph) and its cumulative net benefit (bottom graph). What do you notice?
  • Switch to the stakeholder sheet of the Physiotherapy provider (HPO_cns) and check the cost and benefits, also read the stakeholder description in this document. In how far is the situation of this stakeholder different from that of the GP?
  • Switching back to the “Charts” sheet, how do you think the graph could be presented to correctly reflect the situation of the Physiotherapy provider?

Lesson 4: Schrödinger and integrated eCare

Ideally, an economic assessment takes place under controlled conditions, in accordance with accepted scientific practice in order to yield sound data for every relevant indicator. In reality, concessions might have to be made to circumstances, workload of staff involved, a lack of suitable data or other factors. In other words, there might be an element of uncertainty in the assessment. This should not be a reason to abandon the assessment, but needs to be addressed proactively. One way to do so is by documenting the kind of data sources being used as well as where and which assumptions were made in the assessment. Another element is commonly referred to as sensitivity analysis, i.e. determining in how far low-quality data or assumptions affect the results of the assessment.

  • Switch to the sheet of the Carer support organisation (HPO_tsc) and have a look at the indicators. In how far are the indicators and the data different from those used for the other stakeholders? How did you notice?
  • Under what circumstances might an assessment be based primarily on assumptions and estimates?
  • Did you know that on each stakeholder sheet you can change the degree of uncertainty for every indicator? Try and why where to do that. Hint: you need to turn on the “Time Series” to see this option.
  • Switch to the “Monte Carlo” sheet to carry out a sensitivity analysis for the Carer support organisation. In the drop-down menu, select the Carer Support organisation. Click “Start Monte Carlo”. Depending on the power of your computer, the Monte Carlo simulation will take several minutes. Do not use or quit Excel during that time. The graph will change visibly when the simulation is concluded. Look at the graph and compare it to the one displayed on the “Charts” sheet for the Carer support organisation. How are the two graphs different? What additional information can be deduced from the Monte Carlo graph? What does this tell you about the valu case of the organisation?

Lesson 5: Work, work, work – measuring impacts on staff time and the time of clients, patients and informal carers

Did you know that staff cost are a major factor in the implementation and operation of an integrated eCare service. Cost-benefit analyses of 10 integrated eCare services in 9 EU regions and involving 26 provider organisations showed that staff cost make up about 75% of all cost compared to 25% equipment and other financial cost. And beyond staff cost there are also efficiency gains to think about, i.e. staff time being liberated allowing people to do other work. In fact, you are likely to find both effects at the same time: more staff time in order to achieve integration (e.g. to enter data into joint care records) and less staff time as a result of successful integration (e.g. due to avoided repeat measures of vital signs).

This is reason enough to not neglect staff cost when doing your assessment but to make an effort to capture them in some way to include them. There exist different ways to do this ranging from more labour-intensive but exact methods to quicker but rougher approaches.

  • Let us stay with the Carer support organisation (HPO_tsc) and address those initial expert estimates related to extra staff time and resource liberation. We want to make the data on them more robust. What approaches can you think of? Are there maybe any data sources already available to you? Or would you have to measure staff time directly? How?
  • Take a look at the indicators for extra staff time and resource liberation on the HPO_tsc sheet and see how they are structured. They are split up into different types of activity (following the SmartCare pathways for integrated care). For each activity they ask for two different numbers. What are those? How do you have to enter those data, e.g. if the number of consultation stays the same but each consultation is now shorter? Or if the time stays the same but you now have more consultations than before? Hint: check the “Help” section of the sheet, it might provide some guidance.


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