Handbook - Experiences on scaling Care Coordination and Telehealth Best Pratices - ACT@Scale
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Handbook Experiences on scaling Care Coordination and Telehealth Best Pratices
Advancing Care Coordination and Telehealth Consortium
deployment at Scale
The work leading to these results arises from the ACT@Scale (Advancing Care ACT@Scale is a partnership of innovative European healthcare regions, industry
Coordination and Telehealth deployment at Scale) Programme, which has received and academia with potential to transform cure and care delivery services from
funding from the European Union, in the framework of the Health Programme pilots to scaled up, routine care practice for the benefit of the European population.
under grant agreement 709770. ACT@Scale builds on the expertise and successful The project comprises 15 partners from 8 EU and associated countries including
experiences of the ACT programme and will use tested collaborative methods and 6 deployment sites across 6 of the countries coordinated by Philips Healthcare in
tools to implement improvements. The ACT@Scale programme is fully aligned Germany.
with the European Innovation Partnership on Active and Healthy Ageing objectives
to deploy integrated care for chronically ill patients.
Editors: H. Schonenberg (Philips Research)
E. Nielsen (Region Southern Denmark)
T. Syse (Region Southern Denmark)
C. Bescos (Philips Healthcare)
First edition: April 2019
The content of this report represents the views of the author only and is his/her sole responsibility; it cannot
be considered to reflect the views of the European Commission and/or the Consumers, Health, Agriculture and
Food Executive Agency or any other body of the European Union. The European Commission and the Agency
do not accept any responsibility for use that may be made of the information it contains.
Acknowledgements
We acknowledge the contribution of the following researchers participating in ACT@Scale:
C. Bescos (Philips Healthcare); H. Schonenberg, R. v. d. Heijden (Philips Research); D. Filos, K. Lourida, I. Chou-
2 varda, N. Maglaveras (Aristotle University Thessaloniki); S. Newman (City, University of London); J. Roca, C. 3
Hernandez , Anael Barberan-Garcia, J. Escarrabill (IDIBAPS); M. Moharra, T. Salas, N. Rodríguez (AQuAS); C.
©2019 All rights reserved. Specifications are subject to change without notice.
Buchner, S. Hun, E. Ritson (Public Health Agency NI NRE); C. Pedersen, E. Nielsen, M. Craggs, T. Syse (Region
Trademarks are the property of ACT@Scale or their respective owners. https://www.act-at-scale.eu South Denmark); D. Barrett, J. Hatfield (University of Hull); A. Fullaondo, D. Schepis, J. Txarramendieta, E. de
Handbook
Manuel (Kronikgune); E. Buskens, M. Lahr, S. Holterman (UMCG); I. Zabala (OSAKIDETZA); S. Störk (University
The copyright for all images in this document is owned by Koninklijke Philips N.V. of Würzburg); N.Adrion, C. Weber, O. Groene (Optimedis); N. Stoerr (Gesundes Kinzigtal) B. Allardice , S. Cun-
ningham (University of Dundee)
© Koninklijke Philips N.V., 2019
Contents My Diabetes Footcare Programmes
P 30
My Diabetes My Way
P 52
1 Scope 8
2 Collaborative Methodology 10 Video Consultation for Relatives
P 34
3 Drivers for Scaling 12
Asthma / COPD
Scotland
4 Data Collection and Knowledge Transfer 14 P 44
Southern
5 Deployment Recommendations 18 Effective Cardio
Denmark
Citizen Empowerment 18 P 40
Stakeholder and Change Management 20
Northern
Service Selection 22 Embrace
P 56 Netherlands
Sustainability and Business Models 24
Southern
6 Good Practices 26 World of Training Germany
P 32
New deployments 28
My Health
My Health 28
P 28
My Diabetes My Way Foot Screening 30
Advancing deployments 32 Basque
World of Training 32 Multimorbid Integration Country
Video Consultation for Relatives 34 P 54
Catalonia
Telemonitoring Services CHF 36
CHF Telemonitoring
Promoting Healthy Lifestyles: Physical Activity 38
P 36
Full deployments 40
Effective Cardio 40
Support for Complex Case Management 42 Nursing Homes
Asthma/COPD Telehealth Service 44 P 46
4 Healthcare Support Programmes for Nursing Homes 46 5
The Chronic Patient Programme 48 Chronic Care
Integrated Care for Subacute and Frail Older Adults 50 P 48
Handbook
My Diabetes My Way 52 Frail Older Adults
Multimorbid Integration Programme 54 P 50
Redesign & improvement 56
Embrace 56 Complex Case Management
P 42
7 Closing Remarks 58
Physical Activity
P 38
Executive Summary Foreword
Building on the expertise and experience from the ACT programme 1 , the over- This handbook documents the advances
all goal for ACT@Scale was to identify, transfer, and scale-up existing Care made by the participants in ACT@Scale
Coordination and Telehealth good practices with the target of reaching a total of and demonstrates the palpable advances
100,000 care recipients across programmes across Europe. made in coordinated care and telehealth
across Europe.
Kicking-off in March 2016, this EU-funded project included a consortium of health
care authorities, clinical experts, universities, and industry partners. ACT@Scale has It is important not to underestimate the efforts made by the health care organ-
been fully aligned with the European Innovation Partnership on Active and Healthy isations in bringing about change in practice in health care. The coordination of
Ageing (EIP on AHA) and the scaling-up strategy of the European Commission. care and telehealth are disruptive to many aspects of current health care practice
After having identified, deployed, and monitored best practices in the field of care and overcoming resistance to change and persuading health care professionals,
coordination and telehealth in Basque Country (ES), Catalonia (ES), Gesundes Kinzigtal patients, and their families as well as managers and those who finance care is not
(DE), Northern Netherlands (NL), Northern Ireland (UK), Region of Southern an easy task. What is heartening is how much has been achieved in those involved
Denmark (DK), and Scotland (UK), ACT@Scale now presents this handbook as a in ACT@Scale.
manual for other regions aiming to scale.
This document provides many insights and advice from the programmes for others
ACT@Scale has used tested collaborative methods (PDSA) and tools to implement to learn how to scale-up these types of programmes. One important issue is to
improvements supporting successful scaling of programmes. These methods have clearly defined processes that are also flexible to enable change in different
proved to have great impact in the regions as the methodology provided an areas. In tackling a region as large as Europe, it is necessary to nuance any pro-
iterative process, supporting the programme managers in implementation of the posed solution on the basis of local culture and the local organisation of health
local changes. In the process of deploying and scaling-up best practices ACT@Scale care to achieve the best outcomes. However this needs to be balanced to ensure
focused on four drivers that were identified as essential in supporting successful cross system and cross culture learning. Fundamental to the success of ACT@Scale
scaling processes; Stakeholder and Change Management, Service Selection, Business was having a common collaborative evaluation methodology along with an inter-
Models and Sustainability, and Citizen Empowerment. To measure progress in the vention on quality improvement. Although the interventions were very different,
regions, ACT@Scale developed an Evaluation Framework based on experience, the general issues faced by programmes in scaling-up were often common. It was
practice, and evidence. The framework succesfully supported the measurement of important that the programmes used common methods and an agreed common
outcomes, processes, and the structure to assess the quality of care. language that facilitated shared learning and enhanced scaling-up. This also
enabled participants to see the bigger picture of coordinated care and telehealth
It has been important for ACT@Scale to support knowledge transfer across Europe across Europe.
6 and beyond. As a means to support this, a brochure 1 was published presenting the 7
experiences with the collaborative methodology. Now, this handbook is intended This handbook contains a host of important recommendations to achieve change
to assist other regions in their efforts to scale good practices for the benefit of at scale and an impressive insight into some of the best successes in Europe in
Handbook
European citizens. care coordination and telehealth.
Professor Stanton Newman
Vice-President (International)
1 https://www.act-programme.eu/
2 https://www.act-at-scale.eu/wp-content/uploads/2014/08/ACT@Scale-Telehealth-and-Care-Coordination- City, University of London
Lessons-Learned-WHINN-2017.pdf
1 Scope
Introduction and purpose of ACT@Scale Contribution to EC Strategy
The ACT@Scale project aims to develop, test and consolidate “best practice” in Care The concept of scaling Care Coordination & Telehealth “best practices” applied
Coordination and Telehealth in all participating healthcare regions. Key to the process in ACT@Scale is aligned with the European Innovation Partnership on Active and
was the sharing of information so that the experiences of all participating healthcare regions Healthy Ageing (EIP on AHA) and the scaling-up strategy of the European Com-
can be leveraged by others to expedite the scaling-up of their services. The learning of the mission.
group is also intended to inform and assist other regions in Europe and beyond who are The ACT@Scale programme has been active in delivering input and knowledge to
involved in scaling-up their services. the the EIP on AHA partnership. The findings in this report are intended to sup-
port decision-making at EU policy level, and to demonstrate to payers, practitio-
The project has deployed integrated care, telehealth and care coordination in two ners and providers how patient care can be scaled and improved in the context of
waves across 6 European regions. ACT@Scale was initiated in March 2016 with a an ageing society and care systems under restricted budgets.
duration of 3 years and is led by Philips Healthcare. The project has been co-funded
with 3.5 M Euro by the EU Health Programme. Liaison with other EU projects
ACT@Scale has collaborated with a number of European projects. These include
Powerful partnership the SCIROCCO project, which aims to further advance the EIP on AHA Maturity
ACT@Scale is an innovative partnership of leading European healthcare regions Model into a validated and tested self-assessment tool. ACT@Scale has used the
working with industry and academic partners. The partners are all highly committed Maturity Model3 to monitor the healthcare system structure in the regions in the
to transform telehealth and care delivery services for the benefit of frail elderly process of deploying integrated care.
and those with chronic conditions from pilots and experiments to scaled-up services Other collaborations include SELFIE 4, SUSTAIN 5, TOPICS-MDS 6, ZonMw 7, Optimity
that are integrated into routine care. Advisors 8, where the focus has been on transferability and sharing knowledge and
experiences.
Draws on successful experience of the ACT project
The previous programme, Advancing Care Coordination & Telehealth Deployment Transfer of knowledge
(ACT) was the first to explore the organisational and structural processes necessary This handbook provides key learnings and practical recommendations in the area
to successfully implement care coordination and telehealth services on a large scale. of scaling integrated care. The ACT@Scale partnership considered it essential
ACT@Scale built on the expertise and experiences of the ACT programme and to translate their experiences and key learnings into useful tools to enable easy
utilised established collaborative methods and tools to implement improvements adoption by other regions aiming to deploy integrated care. Finally, we wish to
at scale. contribute the knowledge base in the area of implementation and large-scale
deployment in healthcare.
8 Experiences in CC&TH ACT ACT@Scale 9
Handbook
Small
Scale EU Scaling-up
Evaluation
Tests Framework Transfer/Coaching
of good practices
Limited
Evaluation
+ Evidence Regional Evaluation
Evaluation + Quality
Focus on CC&TH Engine
Technology Programmes Improvement
3 https://www.scirocco-project.eu/maturitymodel/ 6 https://topics-mds.eu/
2000’s 2013-2015 2016-2019 4 https://www.selfie2020.eu/ 7 https://www.zonmw.nl/en/
5 https://www.sustain-eu.org/ 8 http://optimityadvisors.com/homepage
2 Collaborative Methodology
The collaborative approach is increasingly being used to carry out widespread Learnings from the collaborative methodology in ACT@Scale
improvements in care. This methodology requires multidisciplinary groups to
come together periodically to exchange experiences and ideas about imple- • Collaborative methodology increases success by engaging teams
menting change and quality improvements. in collaborative problem solving.
• It provides a well-defined structure and schedule.
ACT@Scale applied and adapted multi-organisational structured collaborative • Its flexibility and adaptation to different environments allows different
quality improvement methods to scaling-up integrated care. The key advantage of
regions and partners to adopt it without disrupting their normal workflows.
the adaptive and flexible collaborative model used in ACT@Scale is that the
• Use of an iterative approach enables rapid assessment and ensures
methodology enables similar processes to be applied in all regions whilst enabling
fit-for-purpose solutions development.
these to be adapted to incorporate the particular features of practice at the local level.
• Results from ACT@Scale show that it has been used to address change
The process for the collaborative methodology in ACT@Scale was: and that it has improved healthcare in the selected areas.
• Each region selected its good practices to scale-up.
• Each region worked on at least two of the drivers: (1) Stakeholder and
Change Management; (2) Service Selection; (3) Sustainability and Business 8 Tips for implementing collaborative methodology10
Models; and (4) Citizen Empowerment.
• At least two regions used the same driver to facilitate collaborative work. The tips present different aspects and lessons learned in the implementation
and scaling-up of health and care services during the ACT@Scale project
The collaborative methodology follows 4 phases: Plan-Do-Study-Act (PDSA)
1 Select a programme with convincing evidence.
PLAN PLAN
2 The maturity level of the service and management engagement is key.
Baseline ACT Learning DO ACT Coaching DO Dissemination 3 Ensure effective running of the collaborative meetings.
phase cycles cycles phase
4 Ensure you have ambassadors to promote the programme.
STUDY STUDY
10 11
5 Build a collaborative team representative of all stakeholders.
The regions focused on sustainable transformations in order to integrate the
Handbook
methods and the changes into routine practice. They identified achievable targets 6 Enable adaptation of priorities and strategies in programme’s
directly related to scaling-up. Every PDSA stage was documented to ensure quality implementation process (Do Phase).
of information and to facilitate organisational learning both locally as well as to
other regions. A key success factor for sustainability was to train local experts on
7 Implement the programme into the existing care model using
substitution of pathway elements.
the methodology, such that that the process is able to work autonomously when
the EC funding is finished. 8 Make use of proven care models.
10 http://www.act-at-scale.eu/recommendations
3 Drivers for Scaling
Stakeholder
& Change
Management
Service
Tackling all aspects of care coordination and telehealth is a vast challenge. ACT@Scale Selection
focused on 4 drivers; 4 areas that were considered to be the most essential to steer scaling-up
and adoption of innovations. It is our view, both from the literature and extensive experience
that improvements in these 4 areas largely contribute to extended coverage and sustainability
of services:
Outcomes
Citizen Empowerment
Citizen-centred care is essential to deliver
Service Selection
This driver focused on the achievement of
Process
integrated care. This driver focused on the an appropriate distribution of health and Structure
elements that can achieve significant en- care resources to cover the dynamic needs
gagement of users and to make the strategy of the patients and populations as well as
self-sustaining. These included shared de- enhancing risk stratification and prediction.
cision making, attention to patient journeys, This had three steps: Description, identifica-
development of empowerment skills and tion and selection of patients; Adaptation of Sustainability&
citizens networks. Satisfaction (Net Promoter services to respond to patients´ needs; and Business Models
Citizen
Score-NPS), Patient Activation Measure On-boarding required for professionals and Empowerment
(PAM 11) in comparison to staff (Clinician the services.
Support for Patient Activation Measure - CS- To monitor progress on service selection, a
PAM 12), psycho-social profile and patient´s dedicated survey was used which had qualita-
abilities were monitored in 870 surveys. tive indicators for scope and ambition, and
In addition, surveys to managers were com- quantitative indicators to represent utilisation Citizen Empowerment
pleted to provide an overview of the strategy and coverage.
To establish patient-centered care, we focused on elements
and operational plans.
enabling significant engagement of users and on making the
Stakeholder and Change Management Sustainability & Business Models
strategy self-sustaining, such as shared decision making,
Organisational adaptions are essential to For the long-term adoption and integration attention to patient journeys, development
Stakeholder
of empowerment
scale-up integrated care. The main areas into routine care, we examined innovations skills, and citizens networks. Management
& Change
Service
for this are: Stakeholder Management (SM), in business models, reimbursement methods, Selection
Change Management (CM) and Staff Engage- cost-efficiency and reorganisation of care Stakeholder and Change Management
ment (SE). The EIP on AHA-B3 change and structure. Individual cost and total cost per To support essential organisational adaptations, stakeholder
stakeholder management survey13, quanti- programme were assessed.The SUSTAIN tool14 management, change management and Outcomes
staff engagement
tative regional data, and 54 responses from was used to assess sustainability capacity strategies were applied.
programme managers have been used to as- and a typology for payment models15 was
Process
12 Structure 13
sess the stakeholder and change management used to monitor progress, in combination
Service Selection
in ACT@Scale. To assess Staff Engagement with the local cost-efficiency studies run by
To achieve an appropriate distribution of health and care
a survey designed for the previous ACT the programmes.
Handbook
programme was answered by 354 frontline resources to cover the dynamic needs of the patients and
Sustainability&
Business Models
clinical staff, this collected quantitative and populations as well as enhancing risk stratification and Empowerment
prediction,
Citizen
qualitative data, and comparative responses service selection concepts were applied.
were elicited from managers.
Stakeholder
Sustainability & Business Models & Change
Management
Se
To attain adoption and integration in routine care, innovations Se
11 https://www.insigniahealth.com/products/pam-survey 15 Stokes J, Struckmann V, Kristensen SR, Fuchs S, van in business models, reimbursement methods, cost-efficiency,
12 https://www.england.nhs.uk/wp-content/uploads/ Ginneken E, Tsiachristas A, Rutten van Mölken M, Sutton.
and reorganisation of care structures were examined.
Stakeholder
2015/11/cspam-report.pdf Towards incentivising integration: A typology of & Change
13 https://www.surveymonkey.com/r/B3change payments for integrated care. Health Policy. 2018 Management
Stakeholder Outcomes Se
Sel
14 https://sustaintool.org/ Sep;122(9):963-969.
& Change
Management
Process
Service
Structure
Selection
4 Data Collection and Evaluation Framework
Knowledge Transfer Outcomes Experience Population Cost Staff
Scaling
Transferability of learnings and dissemination of knowledge was a core aim of
ACT@Scale so as to contribute to the European knowledge in the area of sca-
ling and deploying integrated care. In ACT@Scale, as in similar projects, techno-
Cluster
logy and data are the pillars for the knowledge base. The evaluation framework
captured the process and outcomes of the scaling-up interventions. This was
supported by the ACT@Scale evaluation engine that captures a unique set of data
Programme
on experience, status, progress and success of scaling-up integrated care services.
Scaling-up
The definition of an appropriate project framework with measurements and the
Impact
data collection takes significant time. It is recognised that it may take 3-5 years
before impact on outcomes can be properly assessed. ACT@Scale has set the basis
for the current projects to continue so that they may focus on assessing long
term effects of the programmes. This will enable the regions to strengthen their Process
evaluation strategies and embed them into routine practice.
Key results
The ACT@Scale framework provides a state of the art evaluation framework for Structure Maturity Model (EIP on AHA / SCIROCCOJ
the evaluation of practical problems, based on the design principles and uses the
Donabedian framework 16 to measure processes, structures and outcomes.
The process was measured by the drivers of upscaling. The structure of the health
system was measured by the Maturity Model17. The outcomes were linked to The distributed evaluation approach is technically possible, but in the deploy-
the pillars of the Triple Aim 18, taking staff experience into account as well. The ment of the evaluation engine in ACT@Scale a number of non-technical barriers
framework provides a layered approach with core indicators (the Minimum Data were encountered. Below we present an overview of the main challenges.
Set) and optional indicators to address target population specific outcomes and As expected, consent management and ethical approval procedures took time. In
programme specific outcomes. We developed an evaluation engine to support the distributed approach only aggregated data were shared. This required intro-
the data collection, storage and visualisation. It was used to deploy the surveys to ducing an external technology (scripts) to do the aggregation. This created an
programme managers, staff and patients in the regions and used a consistent way additional level of complexity which began with lengthy legal processes related
to collect and store the responses while being able to monitor the data collecti- to the use of external software. While the feedback was that it was not hard to
on process centrally. The engine provided dashboards, based on the evaluation install the components of the engine (MySQL and R), the local IT needs to have
14 framework, for programmes to monitor their progress. expertise and tools to extract, transform, and load (ETL) the data. Availability and 15
good communication with the local IT and clinical leaders was essential to transfer
Conclusions & lessons learned the correct data to the local engine. This required a relatively big effort and was
Handbook
In healthcare practice the standardisation of data is yet to be achieved. Existing treated as a one-off project, particularly so as it is not part of a continuous rou-
frameworks provide some suggestive examples but there remains no clear central tine longitudinal evaluation. ACT@Scale demonstrated that these barriers can be
agreed guidance for measures. Standardisation has not happened in the EU or overcome, given sufficient time and adequate resources and planning even with
even at national level. Currently, it requires a pragmatic approach to deal with the the increased sensitivity around privacy and data protection following the intro-
variety of indicators and definitions to achieve some level of harmonisation. duction of General Data Protection Regulation (GDPR).
16 https://www.nejm.org/doi/full/10.1056/NEJMp1605101 18 http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/
17 https://www.scirocco-project.eu/maturitymodel/ default.aspx
Recommendations Collected responses
Facilitate flexible data collection approach to support variety of measures.
Here we summarise the most important design principles from ACT@Scale.
Iteration Programme Staff Patients
• Use the dimensions of the Triple Aim. These provide a solid base how to manager
measure Triple Aim outcomes and give examples in each area. Baseline 19 N/A N/A
• Extend this with Quadruple Aim19 measurements to include staff satisfaction. Iteration 1 17 173 99
• Include a process-structure-outcomes approach to not only focus on “if it Iteration 2 18 181 417
works”, but also on “how it works” and in “which context”. TOTAL: 924 54 354 516
• Facilitate flexibility and harmonisation by a layered approach with core outcomes
linked to the strategic objectives, and optional programme specific outcomes.
If needed, add a layer to capture population specific outcomes to deal
with variety of target populations. Programme Dashboards
• Check local and national availability of measures and agree on measurement
criteria based on standards that can be applied. Population served
• Incorporate data collection as part of a learning system to promote a routine 260
quality improvement and evaluation culture. Measures should be actionable. 130
65
0
Co-design with end users 2015 2016 2017
The distributed evaluation engine monitors and visualises the effect of quality
improvement interventions of programmes. Such tools can be used at micro Population coverage
(operational), meso (management), or macro level (policy makers, payers). 3.4
1.7
0.85
• Identify the intended end user. 0
• Co-design with end users to establish their information needs. 2015 2016 2017
• Train the end user and monitor usage of the evaluation tool.
Dropout
100
Sustainability of EU actions linked to local adoption
50
16 ACT@Scale has provided regions with the framework and methodologies to 25
17
perform continuous quality improvement. This continuous improvement should 0
dropout
become part of the culture at all levels within the organisation. 2015 2016 2017
Handbook
Reason for dropout
• Use in EU projects to move forward evaluation strategies.
80
• Develop a strategy to continue monitoring long term effects of the
40
interventions on programme outcomes, beyond the scope of the EU project. 20
0
2015 2016 2017
death other end of programme
.
5 Deployment
Recommendations
This section presents ACT@Scale’s insights and conclusions on how to deploy care Online training provided regularly and/or when changes were introduced, helped
coordination and telehealth in European regions. The deployment recommendations ensure the programme remained a focus of all impacted staff. Having a local
build on the four drivers that were identified as key elements to be addressed for skilled leader and involving teams within the organisation was an excellent way to
a successful scaling process. In ACT@Scale the drivers have proven to be useful ensure that training was provided and that the continuation was independent of
and valuable in supporting the scaling of Care Coordination & Telehealth deployment. the scope of an individual project. It was important to train and deliver education-
The 4 drivers are Citizen Empowerment, Stakeholder and Change Management, al material and communication, which are adapted to the patient’s coping styles.
Service Selection, and Sustainability and Business Models. They have been When dealing with improvement cycles, there may be some resistance from staff.
assessed in ACT@Scale using different approaches. Collaborative methodologies can help to manage differences in participants’ sta-
tus and help to promote openness to adjustments.
Citizen Empowerment Recommendations
• Embed a method to collect patient-related outcomes and experience measures.
Stakeholder
& Change These should be adapted to the capabilities of the target population and
Management
Citizen and patient empowerment and participation are crucial elements for Service embedded in the workflow of the professionals.Ensure knowledge is fed back
Selection
the promotion of sustainable health and wellbeing. It facilitates independence, to those in practice. Collecting patient information outside a standard clinical
self-management, and self-efficacy, supporting patients from diagnosis onwards process requires ethical approval, consent management, licenses, supporting
enabling them to have the capacity to deal with their needs along the trajectory technology for collection, storage and analysis.
Outcomes
of their condition. Citizen empowerment is still not well-defined and there is no • Regularly collect indicators on patient activation and/or engagement, including
Process
consensus on how to operationalise or measure it. The EIP on AHA is working in- caregiver and informal caregiver, in order to identify those that require em-
Structure
tensively on reaching European consensus on definition, methods, and technology powerment interventions. The findings suggest that the Patient Activation
as enabler and assessment tools. Measurement (PAM) survey might be a useful instrument for clinical practices
Sustainability& to identify patients that are most in need of support and education.
Business Models
Most of the interventions reported by the partners addressed patients’ needs
Citizen • Define and review guidelines and perform a regular review and validation of
Empowerment
at micro or meso level. In ACT@Scale, there appeared to be a predominance of standardised training materials for patients and professionals. There is no
interventions targeting the provision of information as a tool for empowerment. single best approach to engaging the public in long-term decision-making -
In addition, a majority of interventions focused on self-management, followed activities such as networks need to be tailored to suit specific arrangements in
by education and health literacy, with shared-decision making being the least regions and programmes.
represented. • Decision makers need to be much clearer about the purpose of any specific
engagement exercise and how they ‘frame’ the engagement activity to ensure
18 Clinicians have an important role both in supporting people to self-manage their that expectations are not misplaced. Dedicated resource and sustained gover- 19
conditions, and in helping to build their level of activation. Overall, we see a very nance are key enablers to citizen engagement activity.
high level of the clinician activation across all ACT@Scale programmes.
Handbook
ACT@Scale programmes with focus on citizen empowerment showed better results
in satisfaction (NPS score) and patient activation (PAM). Participants also reported
significantly higher on self-care behaviours, were better in dealing with the
impact of their condition, and were more comfortable using technology. We saw
greater activation levels in participants with higher education level (university,
post-graduate), and the opposite for participants that were divorced or widowed.Stakeholder and
Culture
Change Management Monitoring Strategy
Organisational
Change
Leadership
Stakeholder Management Towards
Creating
Psychological SE Awareness
Ownership
Although there is consensus that all key stakeholders should be involved in the Financing
and Integrated Leadership
scaling-up process, it is not fully embraced in the culture of many organizations. Incentives
• Patients are considered key stakeholders, but they are usually not Stakeholder
sufficiently
Care Worldforce Motivation
& Change Development
Management
involved in the planning phase and have no or limited power to implement changes. Service
en e-
Selection
m iev
t
• Healthcare professionals were seen by managers as resistant to change.
h
Ac
Alignment Communi-
cations /
• Most often, programmes used processes based on formal and informal networks rity
tho er
Capabilities Au Pow
to identify stakeholder involvement. Only few programmes analysed, mapped Affilatio
n
Outcomes
and prioritised national health recommendations. Process
Structure Change Management Staff Engagement
Sustainability&
Business Models
Citizen
Empowerment • ‘Organisational Models’ and ‘Integrated Care Pathways’ were selected as areas for
programme improvement.
Recommendations
• Introduce internal communication strategies and tools to improve the dissemination
of results and progress to stakeholders as a way to support change management.
• New engagement strategies, based on collaborative methodologies, should be em-
bedded in organisation to advance change management. This promotes new leader-
Recommendations ship roles.
• Identification of stakeholder should be based on formal and informal networks, inclu- • Encourage care professionals to participate in the definition and content of training
ding regional stakeholder meetings. Extend the focus beyond the classical stakeholders on patient management in integrated care.
and include new professional profiles, roles, actors, and competences in integrated
care. Staff Engagement
• Introduce iterative participatory and co-production strategies for all stakeholders Staff plays a crucial role in the daily routines of programme interventions. The level of
involved to improve quality of integrated care and reduce stakeholder resistance. engagement of staff in ACT@Scale programmes was generally high, especially in the
20 terms of awareness and motivation but some gaps were identified in organisational 21
Change Management changes and workforce development.
Change management is considered a key area in integrated care deployment but often
Handbook
there are no structured change management methodologies. ACT@Scale addressed differ- Recommendations
ent elements of change management to overcome resistance to change. The programme • Ensure quality of care by offering formal and regular training for professionals.
managers identified areas requiring attention and prepared new strategies for programme • Allocate sufficient time, in addition to the daily duties, to enable adaptation to new ways
improvements: of working.
• Ensure that staff are empowered to identify, escalate and solve challenges in imple-
• The main barriers to successful change management were stakeholder resistance, mentation early. Successes should be celebrated and drive further service enhance-
an unstructured approach to change management, and lack of time to carry out the ment.
implementation processes.Service Selection
CHF CHF
Telemonitoring Telemonitoring
2016 2016
Service selection had two approaches that needed to be combined: population and 2017
2017
individual clinical level. Population-based risk assessment may be used to identify 2018 2018
patients that either are not on the radar of service providers and/or have presently
unmet needs. Despite the increasing demand of chronic care in an ageing popula-
tion, the coverage of integrated care programmes is increasing at an even higher
rate. Service selection has been considered a usefulStakeholder
tool in responding to this Physical Physical
& Change Multimorbid Multimorbid
Activity Activity
demand by the majority of the ACT@Scale programmes. Management Integration Integration
Service
Selection
Service selection expected outcomes are organised in three dimensions:
Outcomes
Process
1. Description, identification 2. Services responding
Structure to
and selection of patients patient’s needs
Frail Older Complex Case Frail Older Complex Case
Sustainability&
Adults Management Adults Management
Identification of potential candidates (case Services
Businessresponding
Models to patients needs is based
Citizen
identification); inclusion into the programme on case evaluation, follow-up and dynamic
Empowerment
Utilisation and Coverage Scope and Ambition
(case selection) and assessment of clinical adaptation according to the evolution of the
requirements (case evaluation). Identification patient. Service Selection aims to have well Figure 2 Overview of 5 programmes working on service selection. An average of 32% in Scope and Ambition indicators,
such as approach, tools and participant involvement. An average of 121% in Utilisation and Coverage indicators, such as
of patients can be done by population-based distributed services according to patients´ coverage, frequency of usage and professional number
health risk assessment, by individual patient needs. The perfect scenario would be to have
identification, or by a mixed method. individualised care plans that changes ac-
Selection of patients can be the result of the cording to patient´s evolution (ageing, disease The key success factor of the programmes was the combination of the Service
population based identification or the result status, patient conditions etc.). Selection driver and the collaborative methodology to support and monitor
of a specific clinical assessment. improvement. Programmes having extra focus on service selection, expanded in
scope and ambition and increased utilisation and coverage. Programmes that had
population based approach in 2016, have added an individual approach to their
3. On-boarding the required stratification method, and used both simultaneously.
professionals and services Population Patient
Service Service Recommendations
Collaboration among professionals of different
Selection Selection • Apply the Service Selection Evaluation Framework in combination with the
22 healthcare levels and integration between Collaborative Methodology to help assist in service selection and improve 23
healthcare and social support services. The Population Individual scaling-up programmes
coordination and integration of professionals Risk Clinical Risk • Use the combination of qualitative and quantitative indicators to monitor
Handbook
Satisfaction Assessment
and services has a high impact not only on service selection changes on a yearly base.
patients´ health outcomes but also on health • Increase staff’s skills and awareness about Service selection components
care system´s effectiveness and efficiency. (case identification, case evaluation, case selection and, care plan formulation
Target Individual and follow-up) to improve quality and efficiency of patient care.
Population Care Plan
ProgrammeSustainability and Sustainability Capacity
Average domain score
Business Models Stakeholder
& Change
Management
Service Survey 1: Environmental Support
Selection
1st wave programmes
completed in Q1 2017
One of the main challenges for large adoption of integrated care is to find a sus- and 2nd wave pro- Strategic Planning Funding Stability
tainable financial model. Public and private healthcare systems use a varietyOutcomes
of grammes completed
in Q1 2018
reimbursement methods and business models. Common improvement actions for
Process
sustainability are the evaluation of barriers, information on health outcomes, and
Structure Survey 2:
1st and 2nd wave
costs/care utilisation. In the three years of ACT@Scale, the programmes partici-
programmes both Communications Partnerships
pating in the sustainability driver published different economic evaluations. completed in Q3-4
Sustainability&
Business Models 2018
Citizen
Empowerment
All over Europe, there is a large diversity in the type of economic evaluation performed
by programmes, depending on the local funding system and the same applied in the
case of ACT@Scale. For instance, programmes supported by government budgets Programme Adaptation Organisational Capacity
proved to get more value out of budget impact analyses whereas those funded by
reimbursement rely more on cost-effectiveness and cost-utility analyses. Most of our Programme Evaluation
programmes reported positive outcomes related to economic evaluation, except for
one. These evaluations now serve as input for redesign of the services or in developing
alternative business models.
The experience of two regions that had go/no-go decisions after long duration of
Programme Year Method of
published Authors Comparator analysis
economic evaluation reinforced the importance of continuous measurements accom-
panied by iterative redesign. Continuous monitoring and economic evaluation over
Embrace 2018 Cost-utility
NNL Uittenbroek Care-as-usual analysis/
time provides crucial information for programme managers, decision makers and
et al. Cost-effective- payers (insurer or government) and should be integrated in the life cycle of the service.
ness analysis
In order to tackle the challenges of scaling-up, programme managers should focus
Effective 2013 on an integrated approach across multiple domains. Programme managers should be
Cardio Veenstra Baseline Observational
NNL et al. Measurement before-after study
provided with tools for self-assessment, stakeholder management, risk stratification,
business modelling, and economic evaluation.
Complex 2018
Case Ma- Hernandez Baseline Observational For programmes that do not have an integrated payment model in place, raising suf-
nagement et al. Measurement study
Catalonia
ficient funding is more difficult but technically possible. Scaling-up in a health system
with fragmented budgets requires a bottom-up approach with long-term commitment
24 2018 25
Physical Barberan- Matched Randomised
and perseverance, in a partnership with all stakeholders. Comparable issues have been
Activity Garcia et al. Control Group Controlled Trial raised in another EU project (SELFIE).
Catalonia
Handbook
2017 Propensity Synthetic quasi- Recommendations
Gesundes Gröne et al. Scored Mat- experimental
Kinzigtal ched Control study, patient
• Make integrate collection of economic data into the programme management
Southwest Group experience study routine. This provides an opportunity to be adaptive and refine the
Germany
business model.
• Provide payers with clear information for a more continuous financial decision-
In ACT@Scale, the SUSTAIN tool was used to assess sustainability capacity. While im- making. They require information to be packaged in an accessible manner. Write a
pacts in this area are difficult to achieve within 3 years, improvements in two specific business case in which all relevant information for the payers is high-lighted.
elements of sustainability were found: funding stability and partnerships. • Focus on the added value of the programme.6 Good Practices Maturity Level
Advancing
ACT@Scale developed, tested and consolidated “best practices” in Care Deployment
Coordination and Telehealth to ensure that the experiences of all participating Early
healthcare regions could be leveraged by others regions aiming to deploy Deployment
large scale integrated care services.
ACT@Scale has targeted integrated care in the Basque Country, Catalonia, Northern
Netherlands, Southern Denmark, Northern Ireland, Southern Germany, and Scotland.
All these regions were and are continuously implementing novel and innovative
care coordination and telehealth processes at scale. The target groups were Full
populations with chronic conditions and elderly with special needs including social Deployment
services, frailty and psychiatric morbidities. The programmes are presented ac-
cording to their level of deployment in the scaling process:
Redesign &
Improvement
Early deployment is considered the Advancing deployment is considered
initial phase of the programme de- the phase were not all aspects have
End
ployment. In this phase, the case for been fully defined yet. The programmes
change is established, all aspects for are in a transition between early and
the programme are defined (interven- full deployment.
tion, scope, timeframe, resources, etc.),
and support for the programme is
progressing. The programmes have been deployed in two waves
The programmes of the Basque Country, Catalonia, and Northern Netherlands were
first wave deployment sites as they followed the deployment and scaling process
from the beginning of ACT@Scale completing two cycles of improvements and
assessments according to the collaborative methdology. Southern Denmark and
26 Full deployment is considered the final Redesign & improvement is the point Northern Ireland were originally in the first wave deployment programmes. Northern 27
implementation of the programme. where the programme is implemented, Ireland encountered political changes and withdrew as a deployment region but con-
In this phase, organisations apply outcomes are assessed, and extensive tinued as a supporting partner to the Citizen Empowerment driver. The telepsychiatry
Handbook
structural changes and the programme adaptations may occur to improve the programme from Southern Denmark encountered difficulties in aligning the upscaling
is part of routine care. Continuous im- performance. As part of the programme activities on local level and on European level and withdrew the programme. The
provements may occur. review, decisions of no-continuation lessons learned from the programmes are still to be found in the first sections of this
may occur. handbook. Kinzigtal, Scotland, and Video Consultation programme from Southern
Denmark were the second wave deployment programmes and entered the project to
replace the programmes of Northern Ireland, and have followed one cycle of im-
provements and assessments according to the collaborative methodology.Intervention
Objective: To advise and coordinate Results
health care services to provide the right Even though pharmacies and stakehol-
care at the right time. ders were informed and equipped with
information material, the number of
Implementation actions participants did not rise significantly.
GK cooperates with pharmacies that GK will examine further possible in-
provide information about the pro- centives to motivate stakeholders to
gramme and refer patients to My scale-up the programme.
Health in order to increase the number
of participants. Meetings (Quality Cir- Enablers /Barriers
Scaling cles)of physicians were used to inform The programme can be promoted by
29 > 38 stakeholders about the programme and different stakeholder groups such as
to get feedback for potential adapta- physicians, pharmacies, non-medical
tions to be applied to specific patients. staff, social care institutions, and
The Quality Circles have been organised health insurance companies. However,
by Gesundes Kinzigtal every quarter the efforts did not fulfil the expectations
My Health where physicians exchanged their views of increasing the number of participants.
Region of Kinzigtal, Southern Germany and experiences on topics related to The high fluctuation rate of My Health
prevention or treatment of chronic staff members was a barrier in the
Target group: Citizens of the Kinzigtal region who are enrolled in the conditions. Every stakeholder who were implementation success of the pro-
integrated care model “Gesundes Kinzigtal” equipped with information material gramme. The new staff competences
about My Health, were invited to work- and engagement and associated extra
shops and face-to-face meetings. efforts and expenses made it difficult to
realise the scaling within the project’s
Gesundes Kinzigtal’s (GK) is a population individual needs. timeframe.
service that covers up to 40,000 users Due to the different components patients
in the south of Germany. My Health is are able to develop their individual
health counselling service for people health care plan together with the staff
who are enrolled in the GK initiative. of My Health. The programme is about Lessons learned
28 Specially trained staff supports patients patient empowerment and vertical and 29
by advising and coordinating health horizontal integration of the healthcare ➢1 In order to scale-up the programme, stakeholders must be convinced
care services to provide the right care services. of the added value of the programme. Without the support of all
Handbook
at the right time. stakeholders it limits the ability to achieve sustainability.
In ACT@Scale, GK focused on stake-
holder and change management. This ➢2 As the coordination of different health care components is accompa-
programme successfully modified fixed nied by extra efforts and expenses more time is required to make the
health care processes into different programme work.
health care components that can be
compiled and adapted to the patient´sIntervention
Objective: To allow private podiatrists Results
to conduct foot screenings through the The training video has been viewed 27
MDMW Service. times and 7 podiatrists operating pri-
vate services have completed nationally
Implementation actions agreed FRAME training course (http://
The programme designed and built a www.diabetesframe.org/) to ensure
foot screening tool into the records that the process is completed using the
access section of the My Diabetes My agreed methodology. 7 private podia-
Way site. It is designed to be accessed trists have completed the course and
by patients and their private podiatrist registered to use the service with their
Scaling during a consultation to ensure data patients.
Programme
recorded is assigned to the correct pa-
started in
2019 tient record. This tool is now available Barriers/Enablers
to private podiatrists across Scotland to Barriers: Finding and contacting private
allow them to conduct a standardised podiatrists to raise awareness of the
foot screening when otherwise any data foot screening tool. Recruiting private
My Diabetes Foot Screening recorded would be lost to the wider podiatrists to use the system as many
University of Dundee, Scotland podiatry and diabetes services. A sup- were unaware that this was available.
port and training video was created to Enablers: Presenting at the national
Target group Citizens with diabetes who attend private podiatry explain the process and the importance Diabetes Foot Conference and support
of standardised foot screening. from the national Diabetes Foot Action
Group provided validation and support
for the use of the service.
My Diabetes My Way (MDMW) is an screenings using the same standardised
online self-management platform for process, and for the results recorded
people with diabetes that has been in private podiatry to be automatically
running in NHS Scotland since 2008. shared with the public health service
MDMW allows citizens with diabetes to team. This avoids duplication of effort Lessons learned
access their medical records online to and allows data to be shared more
30 allow them to manage their diabetes effectively. 1 Support from key national stakeholder groups is highly effective in 31
more effectively. To ensure that citizens are able to engaging the target population of busy healthcare professionals.
Through ACT@Scale, MDMW has handle their diabetes more effectively,
Handbook
scaled-out an online foot screening the MDMW programme has focused on 2 Standardised foot screening is deliverable in a consistent manner
tool that allows private podiatrists in the area of citizen empowerment in across public and private healthcare.
Scotland to record their standardised ACT@Scale. The recruitment of podia-
assessment for diabetes patients on a trists started in 2018. 3 Data sharing is possible between public and private healthcare pro-
nationally approved tool. viders and information systems.
This allows public and private health-
care organisations to conduct footIntervention
Objective: To expand the WOT programme Results
by developing different scaling-up and Scaling-up: The mandatory appoint-
scaling-out concepts. ment allocations resulted in better
customer control, reduced waiting
Implementation actions times and guaranteed individual support.
To scale-up the programme, mandatory Scaling-out: Outdoor classes increases
appointment allocations were established socialisation promoting both an incen-
to handle the increasing number of tive to attend and loyalty of users. By
participants, reduce waiting times and organising group courses for specific
to guarantee individual support of the conditions, patients will be able to ex-
participants. change views and experiences.
Scaling One of the scaling-out concepts is the
implementation of the outdoor classes. Enablers /Barriers
381 > 496 Scaling-up: Staff member’s own satis-
For that, a new staff member has to be
hired and new devices, such as Nordic faction with better coordination with
Walking sticks have to be purchased. participants was an enabler. A barrier
Two payment models were calculated was the unclaimed capacity utilisation
World of Training as part of developing a sustainable
business model.
when appointments are cancelled.
Scaling-out: Those already enrolled
Region of Kinzigtal, Southern Germany Furthermore, WOT is adapting the ser- in WOT will be easier to attract to the
vices to the needs of older aged people, outdoor classes. The existing coope-
Target group Citizens of the Kinzigtal region by providing either a new location or ration between WOT and the physician
a separate training area with focus on network also enables the programme
elderly people’s needs. Trainers are to reach older people. For people living
Gesundes Kinzigtal’s (GK) is a population sustainable business models. Even though developing age friendly training plans in an ambulatory supervised flat-sharing,
service that covers up to 40,000 users in the World of Training unit may not be including massages, cardio workout, the costs of physical training services
strength, and coordination training. For were covered by the German care
the south of Germany. World of Training profitable, the increase in levels of health
people with limited mobility, transport insurance. One barrier was the training
(WOT) is a specific programme fostering and independence of its users led to a
will be organised to take them to the capacity of WOT, which was almost
physical activity to promote, maintain, reduction in health care utilisation and
WOT facilities. exhausted and currently, there is no
and restore health. WOT targets all thus in expenditure. Due to the shared- possibility to expand the training area.
citizens of the Kinzigtal region but is savings contract with two statutory
32 primarily offered to those, who are health insurance companies, the savings 33
members of the german insurance can be used to cross-subsidise the unit.
companies AOK and SVLFG and enrolled To expand the programme, not only Lessons learned
Handbook
in the Gesundes Kinigtal initiative at the scaling-up strategies but also scaling-out
same time. WOT provides equipment strategies were considered. WOT developed 1 A programme may not be efficient by itself but can still demonstrate
such as cross trainers, treadmills, and leg two different approaches: an outdoor trai- efficiency in a system and long-term effects.
presses, and owns further devices to train ning approach which addresses the same
strength, endurance, and flexability. The target population and an indoor training 2 In order to expand the programme not only scaling-up but also
excercise is supervised by trainers who approach that targets the people aged 80 scaling-out strategies need to be considered.
operate as personal coaches. In ACT@ years and older.
Scale, GK focused on the development ofIntervention
Objective: To conduct ward rounds with Results
relatives present through video (VC), and During the implementation phase, the
to make this a feature of daily practice patients and relatives were successfully
for health care staff. offered the VC ward rounds. The re-
search assistants were present for five
Implementation actions weeks, during which time they engaged
During the implementation process, the all the team members and patients
staff asked the patients if they wanted or relatives. Based on interviews with
their relative to participate in the ward focus groups and participant observa-
Scaling round using VC. Each morning over tions, the multidisciplinary team were
600 > 800 period of three weeks, a multidiscipli- able to implement the changes, and
nary team involved all relevant sta- found it important to listen to the staff
keholders and discussed the changes, when implementing changes into daily
proposed ideas for facing the changes, routines.
and debated how to integrate them in
Video Consultation for Relatives daily routines. To facilitate and re- Barriers/Enablers
ceive expert advice as well as to keep One barrier was that the healthcare
Odense University Hospital, Region of Southern Denmark
the momentum of the implementation professionals needed to be present at
process, two innovation consultants a specific time for the VC. Furthermo-
Target group Citizens with hematologic diseases and their relatives
and two research assistants supported re, when the consultants ended the
the initial implementation. They provi- structured support, the implementa-
Video Consultations have been imple- that the relatives can attend consul- ded individual training to the staff, and tion slowed down. The enablers were
mented in several areas in the Region tations even if they are not able to offered practical advice regarding the the positive feedback and engagement
of Southern Denmark and this type of attend in person. use of the technology for the rounds. from patients and relatives who percei-
service is crucial to health care delivery In the scaling process, RSD focused on ved the initiative to be a success. The
and communication in the region for empowering patients and their relati- patients felt more empowered and the
citizens, relatives and care professionals. ves using video consulted ward rounds. relatives felt that they could support
Therefore, scaling is considered a Through increased information and their relative even though they were
34 necessary requirement as video consul- support, the relatives felt included not physically present. 35
tations have been proven to be a good in the patient’s course of treatment.
solution in many different clinical areas. Another focus area was stakeholder Lessons learned
Handbook
This service has scaled from 8,000 to and change management to make sure
20,000 patients. that the department is ready for the 1 Structured implementation is key even for well-known technology.
In ACT@Scale, RSD has focused on implementation.
scaling video consultations in the re- 2 The flexibility of the PDSA methodology enabled efficient change
gion with a specific focus on relatives management.
of haematology patients at Odense
University Hospital (OUH) to ensureYou can also read
