Copyright 2018 - Clinical Commissioning Groups Association

Getting smart: How digital can help solve the long-term disease management challenge - Accenture

Throughout the healthcare sector, it seems that everyone is talking about integrated care systems and population health. The race is clearly on to enhance integration in care models that span multiple teams and organisations. The reason? The ability to better address the population’s risks and needs. And that’s particularly the case for those who account for a disproportionate share of health services’ use and cost. But creating those integrated models involves major change to governance, culture, staff and staffing, location of work, processes, information flows and digital solutions. Essentially, entire ecosystems need to reinvent their own operating models - and do it rapidly. 

Integrated care - the health service challenge

There’s no question that developing integrated care is a formidable challenge. For most health services, available investment is limited and management’s time tends, naturally enough, to focus on addressing today’s challenges. To move forward with integrated care models, there is an urgent need for digital solutions coupled with change expertise and management focus to address the critical areas that can enhance system performance, including patient outcomes and demand reduction. And one of these critical areas is disease management.  

Since the 1990s, the NHS, for example, has made a priority of taking a structured and person-centric approach to long-term disease management. This focuses on addressing patients’ risks and their needs, by enabling them to gain control of their own care, with the support of relevant clinical services. The priority areas within this policy are the ‘triple aim’ of:

  • Better ways to involve patients in decisions about their own health to encourage and facilitate self-care.
  • The importance of personalised care planning.
  • Proactive care delivery to reduce unplanned care, including emergency re-admissions to hospitals for those people that could be managed in the community. 

Today’s long-term disease management spans professions, teams and organisations, including the voluntary sector. There’s widespread recognition that the current delivery of long-term care management varies considerably across health systems and is often sub-optimal in terms of approach, quality and outcomes. In many instances, the service is held back by the lack of rich digital solutions that could automate, streamline and enable key elements of the disease management approach for patients, carers and clinicians. 

When it comes to disease management, organisations tend to fall into one of the four categories below, varying in the extent to which they are either proactive and /or personalised around patients’ risks and needs:

  • Localised, reactive services not linked to a care plan.
  • Localised, proactive services but not linked to a care plan.
  • Digitally integrated, reactive services that are not personalised.
  • Digitally integrated, proactive services that are personalised to individuals. 

Most organisations should be able to recognise themselves in one, or a combination of, the descriptions above. Few will be able to claim that they belong in the category of digitally, integrated, proactive and personalised services. So what’s needed to make progress? 

Moving forward

For a typical Sustainability and Transformation Plan (STP) of one million people, around 300,000 patients will have a long-term condition. When the risk factors that lead to the onset and acceleration of long-term conditions aren’t properly addressed, the resulting crises create incredibly high demand on the system. Long-term conditions currently account for 50% of all GP appointments, nearly two-thirds of outpatient appointments and more than 70% of inpatient bed days1

Lifestyle risk factors such as smoking and lack of activity, which for many patients are deep lifestyle habits, need to be ‘treated’ in parallel and just as aggressively as symptoms and out-of-normal range clinical vital signs. That’s essential to ‘stabilise’ and thereby prevent frequent crises resulting in high demand for urgent care and in-patient hospital services. The current demand on healthcare indicates that there isn’t the required level of ‘control’ needed to achieve the triple aim. 

Addressing complexity

Health systems seeking to design, implement and maintain integrated disease management pathways face considerable complexity and effort, including:

  • Clinical best practice - this covers the management of disease templates to include interventions encompassing national / local best practice and the clinical rules for risk / needs assessments that inform the care plan tactics and schedule, including proactive care delivery.
  • Governance – how to make available and coordinate the necessary professionals, clinicians and other relevant resources to provide care as part of an integrated team with access to patient information.
  • Compliance – this encompasses checking care planned and delivered against established best practice and the care plan.
  • Core activities – these address the end-to-end clinical and clinical care delivery that cover: holistic assessment; identification of key risks and needs and the generation of personalised care plans. These require using tactics that span education, self-care and adherence, monitoring patients and providing proactive support when required.
  • Reporting – this covers both clinical service reports, national and local, and variances of the proposed care plan and outcomes. 

Digital: enable, automate, standardise

Even with dedicated clinicians going the extra mile for patients, overcoming the complexity of all this is an insurmountable barrier for already stretched clinical services. So what can help? Digital solutions that enable, automate and standardise three critical elements: 

  1. Personalised care plans that incorporate clinical best practice, patient education and self-care tactics across multiple domains, including health, social, psychological and lifestyle. Tailored to the patient’s risks and needs, these plans switch care provision from being reactive and static to proactive coaching and prevention via ‘bite-size’ patient encounters that address patients’ modifiable risks and needs. This reduces the ‘crises’, thereby reducing the time needed for reactive care delivery – making the shift to more efficient service and reducing total patient demand and cost.  
  2. A clinically-led design of the clinical and business rules to develop tactics, such as scheduling care interactions across teams and communication channels including face-to-face, phone, email and SMS interactions, with decision support to standardise care delivery. 
  3. Patient involvement and commitment to the ‘program’ with clear expectations and accountability agreed for clinical services and patients, with automated communications reinforcing behaviours and escalating non-compliance. Patients are coached to ‘Look, Track & Learn’ how positive changes in their lifestyle improve their vital signs, thereby creating a positive reinforcement loop. 

Empowering the few to manage the many

Personalised care plans that incorporate clinical best practice, patient education and self-care tactics across multiple domains, including health, social, psychological and lifestyle. Tailored to the patient’s risks and needs, these plans switch care provision from being reactive and static to proactive coaching and prevention via ‘bite-size’ patient encounters that address patients’ modifiable risks and needs. This reduces the ‘crises’, thereby reducing the time needed for reactive care delivery – making the shift to more efficient service and reducing total patient demand and cost.  

A clinically-led design of the clinical and business rules to develop tactics, such as scheduling care interactions across teams and communication channels including face-to-face, phone, email and SMS interactions, with decision support to standardise care delivery. 

Patient involvement and commitment to the ‘program’ with clear expectations and accountability agreed for clinical services and patients, with automated communications reinforcing behaviours and escalating non-compliance. Patients are coached to ‘Look, Track & Learn’ how positive changes in their lifestyle improve their vital signs, thereby creating a positive reinforcement loop. 

1 assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/216528/dh_134486.pdf

 

 

Content provided by Jagdip Grewal, Accenture Health & Public Services UK. For more information visit accenture.com/health or email This email address is being protected from spambots. You need JavaScript enabled to view it.

 

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