Integrated eCare pathways

BeyondSilos develops and pilots integrated care services delivered with the help of suitable ICT systems. These services are based on care pathways cutting across boundaries which typically separate healthcare from social care. Such boundaries can be identified at both the level of service provision and technology. In this sense, BeyondSilos achieves – with help of ICT – what has frequently been called “horizontal integration” of care delivery rather than “vertical integration”.

While vertical integration approaches tend to focus on joining up services delivered within a single care domain (e.g. primary healthcare and secondary healthcare) a horizontal integration approach aims at better joined-up care services across established domain boundaries (social care and medical care).

Successful service integration requires both technology innovation and service process innovation being pursued at the same time. In the care domain, ICT-based services tend to be delivered within sociotechnical systems, and value is frequently achieved by people applying technology for dedicated tasks rather than technology on its own. Hence, ICT can effectively support well-designed care service delivery processes, but it cannot substitute for them. Within the work plan of BeyondSilos, the first step in achieving such a combined innovation approach is the development of common integrated care pathways which are supported by ICT.

Two generic pathways were introduced that form the basis of the project’s service development and implementation work and hold the potential to deliver significant benefits through better joined-up care delivery. These are:

1. Integrated short-term home support after an acute episode.
2. Integrated long-term home support.

Pathway #1 (ICP-Short) is designed to support people who have experienced a significant ‘event’ such as stroke, MI, fractured neck of femur, or other injuries and illnesses which impact adversely on the person’s ability to live independently. The activities in this pathway focus on delivering time-limited interventions.

On the contrary, pathway #2 (ICP-LTCare) is designed to support people living with complex needs whose joint care assessment indicates that ongoing health and social care services and wellbeing assistance is required.

Both generic pathways were jointly elaborated by the BeyondSilos consortium, based on previous work conducted in the Pilot A project SmartCare. The pathways present a high-level view of a typical service process flow involving health, social and informal care interventions.

Entry points into both BeyondSilos pathways may vary according to individual service users and pilot regions, but are usually defined by an impending discharge event. Further, individual end users may be referred to the BeyondSilos services by associated health or social care professionals or directly subscribe to the services by themselves and/or their family. Before individuals officially register to become a participant in the BeyondSilos services, the identification of client-specific health related needs as well as needs for other forms of home support will be performed on the basis of multi-disciplinary expertise and pre-defined assessment criteria/procedures. After this pivotal process, clients are enrolled into the service to be piloted, each receiving a personalised initial integrated home care plan which is designed to analytically establish and select a course of action for client care. This initial plan for joined-up provision of home support through Beyond Silos responds to the previously identified care needs in a holistic and integrated manner and is systematically documented to adapt the service to clients’ changing care needs and priorities. In the case of the generic pathway #1 (ICP Short) the next step focuses on the coordinated transition of the patient from hospital or ER to home to establish an integrated overall care plan. Here, coordinated discharge planning relies on the cooperation of patients, family caregivers and professional care providers to maintain the patient’s health and well-being after the critical episode of discharge.

For both pathways the ongoing coordination of integrated care delivery constitutes a crucial element for the provision of professional and informal care. The main aim is to effectively manage a system of targeted collaboration over time, thereby involving all relevant parties including the BeyondSilos service users themselves. Hence, the coordination of the tracking and potential revision of the initial care plan functions to maintain the delivery of required care interventions while utilising all potentially available resources. On-site provision of care in the older person’s home is performed by both formal and informal health and social carers. The coordinated performance of care-related measures through professional health and social care staff and formal carers may require both medical interventions and/or non-medical custodial tasks and/or non-skilled care. Beyond care provided by professional care staff, non-professional care may be provided by family members and/or other informal carers. The next constituent of the personalised care service package represents the remote exchange of data and/or electronic communication between the BeyondSilos service user, healthcare and non-medical professionals enable a continuous monitoring of the client’s care needs. This may include ICT-based services involving data exchange and/or electronic communication to assist in and manage the patient’s healthcare conditions and the risks of independent living. Further, 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 carers. Moreover, all documented care interventions and related outcomes are to be systematically monitored, with a view to enabling meaningful adaptations of the initial care plan over time.

In the case of the generic pathway #2 (ICP-LTCare) a temporary admission or re-admission into a stationary care setting may be required depending on the BeyondSilos service user’s status. Hence, the client’s social and healthcare needs will be reassessed and service delivery adapted accordingly. When it comes to minor deterioration of the chronic condition(s), BeyondSilos processes lead to the reassessment of their social and healthcare needs with the main aim of keeping the clients in their own home for as long as possible, as this usually has a positive influence on their quality of life. However, exacerbations in functional status may lead to a temporary admission to a hospital in order to adequately help and support the BeyondSilos service user. In the latter scenario, the client is transferred to the ICP-Short pathway. Exit points from the pathways may vary according to individual service user. When it comes to the acute pathway (ICP-Short) in particular, transition into the long-term home care pathway (ICP-LTCare) may happen at a certain point in time.

The pathways are part of the overall project approach, being the first in a series of steps leading to the eventual operation of specific integrated social and health care service at each of the pilot sites. These integrated services are implemented and piloted in the regions of Northern Ireland, Sofia in Bulgaria, Badalona and Valencia in Spain, Campania in Italy, Amadora in Portugal and the Kinzigtal in Germany. All BeyondSilos pilot sites share a common view that a better joining-up of social care and health care delivery processes holds considerable potential for better responding to a number of challenges in care for older citizens. However, although many pilot sites start with facing similar challenges in the organisation of care services for older people, there is considerable diversity across the BeyondSilos pilot sites. This concerns for example the structural framework conditions within which integrated care service delivery is to be ultimately achieved, or the extent and nature of formal and informal support that is available to older people. In view of this situation, a context-sensitive service integration strategy is being pursued in BeyondSilos, both technology wise and service process wise. As such, both generic pathways are adapted to the specific framework conditions at each of the pilot sites, responding to site-specific requirements and existing work practices and technologies, while at the same time enabling a controlled migration towards a common approach. 

 More information can be found in D1.2 here.