Data-Led Digital Discharge - Support, Enable, Empower, to Prevent Re-entry (encourage self caring rather than Council reliant services)

Full Application: Not funded at this stage

This solution has been chosen from our discovery outcomes due to the disparity digital / IoT deployments across Newham, Havering, Brent & LBBD already with digital technologies across:

  • Older Adult Extra Care Schemes
  • Learning Disability Schemes
  • Independent Living
  • Post Hospital Discharge
  • Adult & LD Living Independently in the community

It now makes sense for us to coherently combine the offer and target specifically post hospital discharge given the enormous impacts facing Local Gov and Health budgets as the over 65 population increases its trajectory.

To that end we propose to aim to reduce hospital admissions and prevent re-admissions through providing a citizen with tech enabled digital discharge support.

These digital discharge packs offer remote technology-enabled monitoring through an IoT ecosystem , therefore reducing the demand on local care providers and the NHS.

For the project we propose a Phase 1 – the design stage for which the Alpha money will be spent – this will provide all necessary preparation for a large implementation, and a Phase 2 for large rollout. This will be a high impact project through the use of standards to support health and adult social care system interoperability.

This will mean a mini deployment in each of our core councils to unpick the pathways and on a small scale test the proof of concept for each.

During Phase 2 (Beta) we will support 250 older adults being discharged from hospitals in the named partners boroughs.

As part of the project a research piece for each authority will be carried out assessing the direct impact from a macro perspective on the demographic time bomb facing each authority.

Previous work carried out has resulted in considerable cost savings and lives saved and better service delivery. Please see case study collateral from our partner: for a summary of the work delivered across Newham and Havering to date.

A VERY COMMON PROBLEM – “Many governments across the OECD have cut or frozen welfare spending since the global financial crisis began in 2007, populations are ageing, and as technology advances, the cost of health care continues to rise.” ( Adult social care services are in crisis with nearly £5bn cuts in last 5 years and 150 allegations of abuse a day (Andrea Sutcliffe, Chief Inspector of Adult Social Care, Care Quality Commission). This is an opportunity – both for solutions that create efficiencies for public-funded care providers, and those that encourage self-care and take up by self-funders or personal budget holders. Currently, on entry to the system, a social worker conducts an assessment, which most often results in prescription of a number of home visits a day, and in some instances some “telecare” support. The care package created is then not reviewed again until at least a year later, unless there is an extremely costly unplanned review, usually after some crisis event or significant deterioration in condition. Care packages quickly become outdated, uncorrelated to any near-time evidence of need, and unlikely to include any enablement services which may reduce future need. STATE OF THE ART – The existing pull cord and pendant alarm “telecare” approach does not create savings because it is reactive and does not reduce carer workload. Neither is it desirable nor particularly useful for the self-funder.

WIDER MOTIVATIONS – NHS and social care services have reached crisis point with the increased demand caused by an ageing population… “Care home closures set to bite as funding crisis hits” The Guardian, 11/1/17. “Red Cross steps in to help alleviate ‘humanitarian crisis’ at UK hospitals.” The Independent, 7/1/17. A data-driven service can create economic returns by deferring entry to residential care; and reduce pressure on the NHS by reducing hosptial re/admissions (30% of older adults currently readmitted within 30 days). Social impact is considerable as families are better empowered to care for loved ones (also reducing GDP and taxes lost to carers taking early retirement or going part time); quality of life is improved for older adults, their families and paid carers; social isolation is reduced by increasing connectedness with informal and formal care networks.

Previous work carried out has resulted in considerable cost savings and lives saved and better service delivery. Please see case study collateral from our partner: for a summary of the work delivered across Newham and Havering to date.

The wider implications of a digital post hospital discharge service for the Adult Social Care sector will show economic savings by maximising a client’s independence and helping them live longer in their own homes rather than incurring costs to pay for a residential home placement (£40k per annum per resident).

Regular interaction with health professionals remotely can lead to living well for longer and independently and can reduce hospital admissions from falls and hip fractures. Social workers and carers will be able to replace some of their visits such as prompts and reminders with video calls which can be up to 40% more cost effective (£2000 per user per annum) . Family/Carers/Staff will be able to monitor the client’s home and be more involved in the client’s lives, reducing the need for costly state interventions.

The 5 key financial benefits are:

  • Provide a solution for new/devolved purchasing power – personalised budgets & direct payments, self-funders / ‘grown-up children’ who currently rely mostly on Council’s to fund equipment for their loved ones coming out of hospital
  • Deliver an affordable basic solution which can be added to as required
  • Reducing barriers to entry by limiting unmanageable upfront spend
  • Replacing outdated telecare services with our digital sensors/video /pendant to raise an alert with your 24 hour response and properly data led approach without just sending out an ambulance as the first port of call in reaction to an incident.
  • Driving a shift towards ‘preventative’ interventions rather than ‘reactive’ care and health support and maintenance of buildings. Private spend will be directed to drive the delivery of a smarter service to reduce the costs of those that fall within means-tested provision.

We plan to estimate the costs and benefits of a potential beta by deploying a benefits tracker cost calculator from first day of the project, something that will allow us to keep track of the savings as and when they are made (in the main we predict from those going onto self caring and also those being prevented from getting worse due to our early intervention model using the AI, sensors and video carephones.

PROJECT MANAGEMENT: We will adopt a strong project structure with clear accountabilities for project direction, management, delivery and reporting at the same time as being highly reactive to the agile nature of the project. Project progress controlled through monthly project board meetings and quarterly external partner reporting. At these strategic decisions will be made, objectives and performance reviewed, and delivery validated. Members will provide the necessary leadership, commitment and motivation to manage the project to deliver stated outcomes, and continue to mobilise the commercial proposition and beyond. Collaboration and project management tools like Asana, an intuitive task management system for teams needing real time interaction. Subcontractors will be closely managed with regular gateway reviews put in place to ensure delivery.

GOVERNANCE STRUCTURES The project sponsor has overall responsibility for the project outcomes and the project manager will direct all members of the project team and other project members from each Council in turn, reporting to the PM.

PROJECT PLAN & PID –compiled as part of the kick off meeting will be adhered to so that there is a natural progression through the project, with engagement needed from each party as we get near deployment and completion or near completion of the former a prerequisite for commencement of the next one.

The progress of the project will be monitored by the monthly project board,  chaired by the lead authority project sponsor.

This has not become apparent yet as part of this process. Perhaps we would like support from some digital / data experts such as the NICE lab in Manchester University.