Simulator model case

The case scenario is built on a service supporting older people suffering from COPD (Chronic Obstructive Pulmonary Disease) and possible co-morbidities, as well as their family members or friends caring for them (informal carers). As an integrated service, it amalgamates services provided to patients and their carers by different stakeholders, including healthcare providers, social care providers and third-sector providers. ICT systems are used to support service delivery.

The service was set-up in three stages, beginning with a 6-months development and implementation stage, followed by a 12-months evaluated piloting period, after which the service began routine operation.

Elements of the service

The service is conceived as a socio-technical system bringing together elements provided by (individual and organisational) human stakeholders and different ICT systems, both working in close relationship. It consists of three core elements:

  1. An early supported discharge (ESD) programme for COPD patients following an exacerbation of their condition. The ESD programme uses home telehealth to provide monitoring and guidance to the patients after their discharge from hospital. Follow-up, e.g. in case of out-of-threshold telehealth readings, is relocated from primary care (GPs) to a social care providers. Patients can be re-admitted to hospital or referred to the GP if required.
  2. Eligible patients are furthermore enrolled in a video-based physiotherapy programme to improve or maintain their physical fitness. Patients can participate in guided online physio sessions at regular intervals, using a computer with webcam and headset or microphone and speakers in their home.
  3. A voluntary organisation (third-sector provider) supports informal carers (family members or friends) in caring for the COPD patients, by means of counselling, self-help meetings, information provision and other offers.

For the start of the service, the provider organisations involved agreed on a general collaboration mechanism that is based on a common care pathway. The pathway foresees joint care planning as well as sharing of relevant patient or client data in a joint care record. All providers have access to that record in compliance with data protection legislation and based on informed consent given by the patient. Informal carers can be granted access to parts of the record under the same conditions.

1.2    Stakeholders

The following stakeholders are either actively involved in the service or passively affected by it:

  • The COPD patients will usually be 60 years old or older, diagnosed with COPD and possible co-morbidities. A considerable share of the patients will be smokers. They enter the service after hospital admission following an exacerbation of their COPD and prior to hospital discharge. They pay a monthly fee to the Telehealth Call Centre and the physiotherapy provider. An evaluation of the service showed that patients are satisfied to very satisfied with the service and how it effects life with their chronic conditions.
  • The informal carers are family members or friends of the patient who have taken over some or all caring responsibilities for the patient. They will usually be 50 years or older, with at least half of them in part- or full-time employment. They can but do not have to live in the same household as the patient. They pay a nominal fee to the carer support organisation. An evaluation of the service showed that informal carers are by and large satisfied to very satisfied with the service and how it affects themselves and the people they are caring for.
  • The Telehealth Call Centre is a private business entity providing home telehealth to the patient. It is responsible for the provision and installation of the telehealth hardware, for training of the patients as well as for technical maintenance and support. They monitor telehealth readings, including technical triaging, and pass alerts on to the social care provider, the GP or the hospital, as the situation demands. The call centre receives a service fee paid by the COPD patients. Under the current service model, this fee covers about 50% of the costs.
  • The primary care organisations (GP practices) are private organisations reimbursed from a public budget (held by the health and social care payer). Usually, they provide day-to-day healthcare to the COPD patients. The early supported discharge programme means that a considerable amount of care is now being provided by social care providers. The GP remains responsible only for certain types of follow-ups requiring the attention of a doctor. As a consequence, the number of consultations that the COPD patients used to have at the GP practice is being reduced. As the GP is reimbursed on a DRG basis (i.e. per treatment) the immediate effect is a loss of income.
  • The hospitals are public institutions financed by their own budgets which they receive from the state. They provide care to the COPD patients, especially in case of exacerbations. The early supported discharge programme and the home telehealth monitoring substantially reduces admissions due to exacerbations as well as readmissions. For the hospitals this means that a considerable amount of staff time is being saved, beds are freed and the waiting lists shortened. Since the hospitals’ budgets remain unchanged, this is an immediate benefit for them.
  • The physiotherapy provider is part of a larger public institution providing different types of health and social services, not only to older people but also to children, people with disabilities and people receiving welfare benefits. The whole institution finances itself via a budget received from the state. For the physiotherapy team, the introduction of video training allows them to take on more clients than before. Clients pay a monthly fee for the video service, which however is not intended to cover the operational costs.
  • The social care providers are private business entities, financed from a state budget on a case basis. They take on the immediate follow-up of the COPD patients, based on the technical triaging done by the Telehealth Call Centre. They take over much of the work originally done by primary care organisations and receive additional reimbursement for this, allowing them to break even on the new service after about 1.5 years.
  • The carer support organisation is a volunteer organisation that funds itself through membership fees, fundraisers and various state aid schemes. Furthermore, informal carers receiving support pay a nominal monthly fee. A major part of the support services provided is delivered by unpaid volunteers. A small core team of employed staff deals primarily with managerial and administrative work. For the carer support organisation, the new service resulted in the wide-spread implementation of IT (mostly computers and mobile devices) into their offices and work processes. After initial problems, this has led to considerably efficiency gains in the organisations’s administration.


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