Page created by Cindy Davidson

               Connected and
               Personalised service
               delivery for the elderly

October 2015
We are entering a new era of health – New Health

Health matters. It matters to each          closer to the citizen and manage
of us as individuals and to society         health collectively.
– it connects us all like no other. It
lies at the heart of our economic,          New entrants from outside
political, social and environmental         industries are already blazing a
prosperity and is one of the largest        trail, but preserving the health
industries in the world.                    of the populace will ultimately
                                            become a shared endeavour.
Two assumptions underpin the
traditional approach to healthcare:         This paper focuses on the need
that it’s about the treatment of            to shift our mind-set to reform
disease; and that it’s the domain           and create more innovative and
of a particular professional group.         effective ways to deliver services
We need a different approach to             in ageing societies. We believe
cope with the ageing curve and              those that quickly respond and
increasing incidence of chronic             make sense of the changing
conditions – an approach that               landscape will be the winners in
expands the focus from care and             the new paradigm.
cure to vitality and wellbeing,
and from episodic intervention              The transformation of health is
to personalised integrated                  upon us. A new era of healthcare is
services. We must also bring care           emerging. Will you be ready?

            Connected and coordinated: Personalised service delivery for the elderly | 2
Table of contents

The price of progress                                                                4

Why the current way of caring for the elderly is neither                             5
cost effective nor sustainable

A new service delivery model for the elderly                                         7

Addressing needs in a personalised way                                               8

Bringing everything together                                                       15

The road to a new care model                                                        16

A shared endeavour                                                                 24

           Connected and coordinated: Personalised service delivery for the elderly | 3
The price of progress

Two related – and remarkable –              Western Europeans now live alone. In                   more options and information about
changes have taken place in the last        Australia, if current trends continue,                 the care they receive, more input into
century. Thanks to sanitation, safe         there will be a 90% rise in 65+ single                 decisions about their care and higher
water, improved nutrition, modern           person households from 1996 to 2021.5                  standards of treatment.
medicine and better housing, we have        Solo living is also on the rise in many
triumphed over many of the maladies         emerging countries. Indeed, research                   Increasingly people want to receive
from which our ancestors died. And          firm Euromonitor International                         services in their own homes. One
the average human lifespan has more         predicts that there will be 288 million                Australian study found that almost 60%
than doubled. In 1900, infectious           single-person households by 2020 – up                  of Australians aged 70 years or over
diseases were the leading cause of          from 240 million in 2010.6                             would prefer to receive formal care at
death, even in developed countries like                                                            home in the event that they are unable
the United States. Today, the big killers   In addition, the quality of the care                   to care for themselves, compared to
are heart disease and cancer.1 Global       individuals of every generation seek is                28% who would prefer to receive
life expectancy at birth has soared         increasing. Widespread access to digital               residential care. The remainder would
from about 30 years to 70 years over        information due to new technology                      prefer to receive care from family.7
the same period.2                           and greater personal expenditure
                                            on healthcare (in the form of higher                   The question is: how can we deliver
Yet this huge improvement in human          insurance premiums, deductibles and                    this care? If the number of people aged
longevity carries a price. Whereas          prescription fees) have both raised                    65-plus swells by some 60% in the next
infectious diseases strike down             people’s expectations. So have their                   15 years, and the care they require
young and old alike, chronic diseases       experiences as consumers, where                        mounts with age, yet there are fewer
become more prevalent with age. So          having a voice, choice and convenience                 workers to support them, how can we
within current health systems, elderly      are the norm. As a result, people want                 look after them all?
people consume more healthcare. In
the United States, for example, older
                                            Figure 1: The ratio of retirees to workers is rising
citizens account for 14.7% of the
population but 33.9% of the healthcare      The number of people aged 65 or older per 100 people of working age (15–64)
bill.3 A similar pattern prevails in the
EU15, with per capita expenditure on                                                                                                        33.5
healthcare roughly doubling between                                                      31.2
the ages of 66 and 86.4                                                                             25.9
                                                                                  22.7                                               22.4
Moreover, declining fertility rates                                                                                           18.1
have created a demographic double-
whammy: as the number of older                                  11.0                                                   11.5
people is rising, so the number of            6.3 7.0
workers available to provide, and pay
for, their care is falling (see Figure                                           Australia &                       Latin America &   Northern
                                                Africa             Asia                               Europe
                                                                                New Zealand                         the Caribbean    America
1). And changing lifestyles mean that
fewer elderly individuals will be able to       2015             2030
rely on their relatives for help. Nearly
a quarter of all North Americans and        Source: United Nations, World Population Prospects: The 2012 Revision (2012).

                                                           Connected and coordinated: Personalised service delivery for the elderly | 4
Why the current way of caring for the elderly
is neither cost effective nor sustainable

               The current way of caring for the           what they need, he notes, their top
               elderly is economically unsustainable       three priorities are pain management,
               because it is based on a costly,            companionship and financial advice –
               hospital-centred health system. If we       in that order.9 So healthcare providers
               are to devise a better alternative, we      are focusing on the wrong thing:
               need to start by understanding the          what’s the matter with the patient, not
               real needs of the elderly and why we        what matters to the patient.
               currently spend so much on their care.
                                                           However, engrained clinical
               Culture is one key factor. Health is        assumptions are only one reason why
               usually defined in terms of ‘disease’,      caring for older people costs so much.
               and older people have more diseases         The other factors are structural. In
               than younger people do. Hence,              most countries, primary, secondary,
               seen from a clinical perspective, the       community and social care are
               elderly suffer more illness – and the       organised separately, with professionals
               solution is more healthcare. But older      who operate in an environment
               people themselves often view things         that encourages specialisation and
               differently. In one survey of 650           segregation. At best, this means
               elderly citizens in the Netherlands,        that those who need care have to
               for example, two-thirds of the              navigate a circuitous path through
               respondents – irrespective of age – said    the system. At worst, it causes friction
               their general state of health was good      between different care providers and
               or very good.8 In other words, they         unnecessary expenditure on duplicate
               enjoyed life, didn’t see themselves as      tests and services, as the elderly get
               sick and didn’t want to be medicalised.     shuffled from one department or
                                                           organisation to another. Faced with the
               Research by British gerontologist           difficulty of navigating a fragmented
               Ian Philp reinforces these findings.        system, the simplest option for many is
               When you actually ask older people          to go to the Emergency Department.

                           Connected and coordinated: Personalised service delivery for the elderly | 5
Similarly, in most countries, funding       helped to live independently end
is allocated to individual institutions     up in hospital, sometimes for quite
rather than networks of organisations       lengthy periods of time. Yet hospitals
with shared goals. Each institution is      were originally designed to isolate
a financial silo, with its own income       people with infectious diseases, not to
from central or local government,           care for those with protracted, non-
health insurers and patients or a           communicable conditions.
mixture of the four. Many of the
reimbursement mechanisms that are           In short, cultural biases, systemic
used also provide perverse incentives       flaws and historical precedent have
(see sidebar, Volume versus value).         all driven up healthcare spending on
And no one agency is responsible for        the elderly, creating a model that is
coordinating the care people receive        neither suitable nor sustainable.
or accountable for outcomes and
total costs.                                If we are to cope with the ageing curve,
                                            we must adopt a new approach: one in
The net effect is to direct expenditure     which health and wellbeing services
towards the costliest part of the           are seamlessly coordinated to meet the
healthcare system: the hospital.            needs of individual elderly citizens,
Many older people who could be              many of whom may have complex co-
treated within the community and            morbidities, effectively and efficiently.

Volume versus value
All the most common reimbursement models have drawbacks. The fee-for-
service approach rewards productivity but actively discourages efficiency,
while payment per day (where hospitals and nursing homes are paid an
agreed fee per bed-day) provides an incentive to treat patients for longer than
is really necessary.

Payment per case (where hospitals receive a single, standard payment for
every case, regardless of the actual cost of care) encourages the opposite
problem: early discharge and frequent readmission. And diagnosis-related
grouping (where hospitals receive a bundled payment covering a number of
treatments and services for a specific condition) is very difficult to administer.

Capitation (where healthcare providers receive a fixed amount of funding per
capita to cover the medical needs of a specific population for a specific period
of time) is probably the best model. But this must also be managed very
carefully to prevent skimping on care at the expense of outcomes.

            Connected and coordinated: Personalised service delivery for the elderly | 6
A new service delivery model for the elderly

A new service delivery model for             It should, furthermore, bring support         The new model should also reward
the elderly should possess several           services as close to the citizen as           outcomes – as defined by elderly
fundamental characteristics, as              possible. Companies like Apple, Google        people themselves – rather than
illustrated in Figure 2. It should be        and Amazon have upended retailing by          activities, since it is not the number of
far more holistic, with the emphasis         taking the store to the customer – and        interventions but their effectiveness
on vitality and inclusion as much as         the online experiences they offer are         that counts. But for many systems
on care, and focused on self-rated           shaping the expectations consumers            this will require a shift in how we
quality of life and wellbeing, instead       carry over to other industries, as many       measure results. If quality of life is the
of focussing on illness. It should also      of the companies now breaking into            goal, client experience surveys can
be organised around communities,             the healthcare business recognise.            add valuable insight on how we rate
not institutions, with clusters of care      These disruptive new players are              outcomes, for example.
providers sharing accountability             capitalising on wireless connectivity
for the budgets they manage and              and advanced mobile devices to erase          Lastly, it should be collaborative.
quality of the personalised services         traditional healthcare boundaries             Delivering individualised, integrated
they supply.                                 and deliver health and wellbeing              care entails dissolving ‘the classic
                                             services anywhere.10                          divide between family doctors and
                                                                                           hospitals, between physical and
                                                                                           mental health, between health and
 Figure 2: We need to adopt a more personalised and integrated approach to service
                                                                                           social care, between prevention and
 delivery for elderly in healthcare.
                                                                                           treatment’11 and between private and
                                                                                           public. Indeed, many of the factors
                                                                                           that influence wellbeing and quality of
                                   Puts the individual at the heart of
                                   the system
                                                                                           life – nutritious food, the right housing
                                                                                           stock, a reliable communications
                                                                                           infrastructure and the like – lie outside
                                   Brings service delivery as close to                     the control of healthcare and social
                                   the citizen as possible                                 care providers. Maintaining a healthy
      The core
                                                                                           population is not, therefore, just a
      features                     Measures and rewards outcomes,                          job for the doctor, nurse or social
      of a new                     not activities                                          worker; it’s a collective challenge and
     care model                                                                            opportunity for many organisations
                                                                                           in many different industries. With
                                   Treats health as a shared endeavour                     the powerful disruption of new
                                                                                           technologies and new entrants who
                                                                                           are entering healthcare from outside
                                   Focuses on wellness and prevention,                     industries, this collective approach
                                   not just care and cure                                  empowers the elderly to co-create the
                                                                                           health support system we all need, and
Source: PwC analysis                                                                       in a cost-effective way.

                                                           Connected and coordinated: Personalised service delivery for the elderly | 7
Addressing needs in a personalised way

Attending to the diverse needs of          #1. Helping older                           benefits, while (digital) befriending
an ageing society is a key challenge.                                                  schemes and group activities can
A more personalised model would
                                           people stay independent                     alleviate social isolation – which
allow providers flexibility to address     and healthy for as long                     doubles the risk of early death.13
population heterogeneity – to cope         as possible
with differences between genders,                                                      The right housing (in terms of size,
                                           “An ounce of prevention is better
socio-economic class, social network,                                                  location, layout and facilities in and
                                           than a pound of cure,” as the saying
cognition, mood, loneliness and frailty.                                               around homes) is equally important
                                           goes, and some of the main causes
                                                                                       in helping people stay at home as they
                                           of disease are avoidable. The first
So how does a new personalised                                                         age, so new housing stock should
                                           step is thus educating older people to
service delivery model operate in                                                      reflect the needs of more mature
                                           assume responsibility for their own
practice? We’ll touch briefly on the                                                   populations. Older housing stock
                                           wellbeing and providing them with the
core features.                                                                         can also be adapted with living aids,
                                           necessary support. Some measures –
                                                                                       ranging from door-entry intercoms
                                           such as dietary guidance and smoking
                                                                                       and stair rails to fully-fledged ‘smart
                                           cessation aids – fall squarely within
                                                                                       homes’ and mobile technology.
                                           the realm of healthcare. Others – such
                                                                                       In fact, technology can make a
                                           as smoking bans, tobacco taxes and
                                                                                       major contribution to helping older
                                           economic access to exercise facilities –
                                                                                       people maintain their health and
                                           may require political intervention.
                                                                                       independence, be it through living
                                                                                       aids, diet and exercise apps, gaming
                                           The next step is reducing the risks
                                                                                       and e-books for mental stimulation or
                                           to which the elderly are especially
                                                                                       social networking for companionship.
                                           vulnerable. Older people are, for
                                                                                       The elderly also need access to
                                           example, more susceptible to infection,
                                                                                       transportation to stay connected to
                                           more unstable on their feet and more
                                                                                       their community, friends and family.
                                           likely to be lonely. Various studies
                                                                                       The advent of driverless cars may be
                                           show that immunisation against flu,
                                                                                       a solution in the future, but in the
                                           pneumonia and shingles reduces
                                                                                       meantime the benefit of transportation
                                           the number of hospital admissions
                                                                                       services for the elderly should not
                                           and associated mortalities.12 Fall
                                                                                       be overlooked.
                                           prevention programmes have similar

                                                       Connected and coordinated: Personalised service delivery for the elderly | 8
#2. Helping older                          Effective intervention is likewise                        Technology, including telehealth,
                                           essential, and the key here is                            wearable devices, and sensor driven
people manage simple                       collaborative personalised planning                       detection software in homes, are
chronic conditions                         (see Figure 3). People with chronic                       increasingly helping older people
Much can be done to help older people      conditions spend relatively little time                   and their relatives to engage and
manage simple chronic conditions,          in contact with their professional care                   communicate with service providers
too. Early detection, supported by big     providers, relying more on their own                      on their own terms.
data analytics which provide insights      resources or peer-to-peer healthcare
and presights, is critical, but the jury   communities such as C3N, Connected                        The most progressive doctors, nurses
is still out on the value of annual        Living and PatientsLikeMe. Combining                      and social workers already recognise
health checks.14 Conversely, national      the perspectives and expertise of older                   this. They know that the best care
screening programmes have proved           people and their healthcare providers                     is shared care – where people make
very successful.15 Risk stratification     enables those with long-term diseases                     choices informed by the expertise of
also enables doctors to identify high-     to express their needs and preferences                    the professionals they consult, but
risk, high-cost patients and manage        for treatment. It also encourages them                    choices that are still theirs. Alloheim
their care more proactively.               to take better care of their own health                   is a fast growing elderly care provider
                                           and wellbeing.                                            in Germany with a strong client focus.

                                            Figure 3: Collaborative personalised planning lets the individual participate in
                                            the care process
                                            A new consultation approach

                                                            Listen to
                                                                                                  !                     Share professional
                                                                                            MIND THE GAP
                                                        personal life story                                                  insights

                                                                                       Information sharing

                                                                                                                            Agreed goal setting
                                                                                                                            and shared action
                                                                                                                            and care plan
                                                           Ask for state                   Each client &
                                                           of affairs first               family contact

                                                                                                                         Then deliver care and
                                                                                                                         upgrade care plan

                                           Source: Adapted from Angela Coulter et al., ‘Delivering better services for people with long-term conditions:
                                           Building the house of care’, The King’s Fund, (October 2013).

                                                           Connected and coordinated: Personalised service delivery for the elderly | 9
Alloheim’s mission “Wir dienen ihrer       Figure 4: Some care workers don’t listen to their clients as much as they claim
Lebensqualität” (We serve your quality
                                           Survey responses from nursing home staff and residents showing percentage that agree with
of life) is an example of a successful     each statement
company that proactively trains their
workers to be focused on the needs
and wishes of the elderly clients         The client always has a ‘voice’
to deliver a personalised service.           in the care he or she needs
However, not all care workers are so
enlightened. The multidimensional
benchmarking surveys conducted
from 2010 till 2015 by ActiZ, the           The provider is always open
                                                 to the client’s requests
Dutch association for healthcare                                                                                                         80.0%
entrepreneurs, show that those who
receive care are much less likely to                                                  Client           Employee
agree they have a ‘voice’ in their care
compared to the professionals who         Source: Aad Koster (CEO, ActiZ) and Robbert-Jan Poerstamper (Partner, PwC Netherlands) “Multidimensional
provide it (see Figure 4).                benchmarking in elderly care”, Presentation at IAHSA 10th International Conference (Shanghai, 18 November 2013).

                                          #3. Helping older people with complex
                                          co-morbidities remain independent
                                          Yet at some point in their lives, due                    Canadian geriatric hospital found that,
                                          to ageing, many older people will                        on average, they were each taking 15
                                          develop co-morbidities – no matter                       medications, with 8.9 drug-related
                                          how well they look after themselves                      problems apiece.17
                                          or how good the care they receive.16 In
                                          such instances, it’s crucial to perform                  The final element in helping older
                                          a multidimensional frailty assessment                    people with complex co-morbidities
                                          covering the elderly person’s physical                   stay out of hospital is round-the-clock
                                          and mental health, functional capacity,                  access to support services within the
                                          social circumstances and home                            community. Three components are
                                          environment. This should form the                        vital: multi-disciplinary community
                                          basis for a holistic treatment, support                  teams to meet people’s everyday
                                          and follow-up plan.                                      health and social care needs;
                                                                                                   ambulatory care clinics to provide
                                          Since older people with co-                              specialist advice; and out-of-hours
                                          morbidities often have to take multiple                  services to deliver urgent care. Current
                                          medications, it’s also important to                      hospital-centred health systems are
                                          review their regimens regularly to                       not designed to deliver care in a cost
                                          reduce inappropriate polypharmacy.                       effective way for older people who
                                          One study of people aged 80+ in a                        have multiple co-morbidities.

                                                        Connected and coordinated: Personalised service delivery for the elderly | 10
#4. Helping older                           experience less anxiety at home.19
                                                                                      Several proven techniques exist for
                                          people minimise the                         minimising the time the elderly have
                                          time they have to spend                     to spend in hospital. Many older
                                          in hospital                                 people are admitted with ‘non-specific’
                                                                                      problems that are dismissed as social
                                          Of course, proactive care doesn’t
                                                                                      or acopic. Conducting comprehensive
                                          preclude the need for good acute
                                                                                      geriatric assessments, including
                                          care in the event of an accident or
                                                                                      screening for malnutrition and
                                          emergency. But many older people
                                                                                      dehydration, makes it easier to identify
                                          don’t have to be admitted – and the
                                                                                      reversible medical problems and plan
                                          best way of helping those who do is
                                                                                      all the elements required to discharge
                                          to discharge them as soon as they
                                                                                      these patients safely. Specialist
                                          are well enough to complete their
                                                                                      elderly care units and wards can also
                                          recovery at home. This is not only
                                                                                      improve the quality of the care older
                                          more economical; it also produces
                                                                                      people receive and reduce the length
                                          better outcomes. Older people are
                                                                                      of hospital stays (see sidebar, Rapid
                                          more vulnerable to hospital-acquired
                                                                                      access delivers results).20
                                          infections, for example.18 And recent
                                          research shows that most patients
                                                                                      Other techniques include discharge-
                                                                                      to-assess and continuous discharge
                                                                                      planning. The former entails
                                                                                      stabilising patients and then referring
                                                                                      them to a community care team to
Rapid access delivers results                                                         complete the assessment and organise
                                                                                      support for them in their own homes
In June 2010, Poole Hospital in Dorset, England, set up a specialist acute            (see Figure 5). The latter involves
geriatric ward with a dedicated admissions system, rapid-access assessment            conducting discharge reviews every
clinic, ‘triage’ rounds every morning for patients who were thought to be             day. Many hospitals don’t discharge
well enough to discharge within 48 hours. There are daily multi-disciplinary          patients on a Saturday or Sunday,
meetings involving medical staff and social services representatives and close        partly because they have no senior
links with community care and intermediate care providers. The result? The            staff qualified to discharge patients
proportion of patients discharged within 48 hours rose from 20.8% to 36.5%;           working at weekends. But it’s far better
the mean length of stay fell by 14%; and average monthly occupied bed-days            to hold daily reviews, include patients
dropped by 22%.                                                                       and their relatives in the planning
                                                                                      process and discharge patients as soon
                                                                                      as they are ready.21

                                                     Connected and coordinated: Personalised service delivery for the elderly | 11
Figure 5: Discharge-to-assess models direct patients to the most appropriate sources of further care

                                                                           Coordination & crisis hub
     Multi-disciplinary           • Multi-disciplinary
           team                     teams
                                  • Family doctors/
     Multi-disciplinary             Out-of-hours                                       Signposting
           team                     doctors
                                  • Paramedics                       • Medical
                                                                                           Integrated     Integrated
     Multi-disciplinary           • Emergency                        • Nursing             area team      area team
           team                     telephone line
                                                                     • Mental health                                         A&E/
                                  • Social workers                                                                          Medical     Discharge
                                                                     • Social care                Integrated
   • District nurse               • Accident &                                                                            assessment    to assess
                                    Emergency (A&E)                  • Therapy                    area team                unit/Ward
   • Community matron
   • Social worker
   • Community mental
     health worker
                                                                            Risk stratification, care planning
   • Pharmacist
   • Family doctor

Source: PwC whole system elderly care design with client in the UK

                                                        If such strategies are to work, though,             nurses, 424,200 home health aides and
                                                        there must be adequate community                    312,200 nursing assistants by 2022.22
                                                        care facilities at all times – and this
                                                        is one of several areas in which                    To prepare for this shortage, municipal
                                                        many countries at the moment are                    governments can invest in ‘re-
                                                        experiencing huge shortages. The US                 ablement’ care in the home (including
                                                        Bureau of Labor Statistics estimates,               physical therapy and speech-language
                                                        for example, that if we don’t change                therapy) and other policies and
                                                        the current health system, the United               programs that encourage recovery
                                                        States would need another 580,800                   at home, which may save money and
                                                        personal care aides, 526,800 registered             improve quality.

                                                                        Connected and coordinated: Personalised service delivery for the elderly | 12
#5. Helping older people find the right residential
                                                          care, when they require it
                                                          Inevitably, some elderly people                 The quality of the care provided in
                                                          eventually reach the stage where they           some care homes needs to improve
                                                          can no longer look after themselves.            dramatically as well. A recent
                                                          Care in a residential home or nursing           inspection of nearly 1,000 care homes
                                                          home is more costly than care                   in England found “appalling” failings.
                                                          delivered in a patient’s own home.              Nearly one in ten residential homes
                                                          Even so, it is far less expensive than          did not provide adequate care and
                                                          hospital care. In the United States, for        welfare. The situation was even worse
                                                          example, the average cost of a semi-            in nursing homes for elderly people
                                                          private room in a nursing home was              with medical problems.25
                                                          US$222 per day in 201223 – nine times
                                                          less than the average inpatient day rate        Detailed individual care plans and
                                                          of US$2,090.24                                  accurate record keeping – with up-to-
                                                                                                          date information on every resident’s
                                                                                                          medical history, psychological and
                                                                                                          emotional profile, current medications,
                                                                                                          communication needs and preferences
                                                                                                          – would resolve some of these issues.
                                                                                                          Comprehensive staff training to ensure
                                                                                                          widespread understanding of clinical
                                                                                                          guidelines and best practice, including
                                                                                                          the importance of treating the elderly
                                                                                                          with respect, would alleviate others.

                                                                                                          Systematic sharing of information
                                                                                                          with other care providers is also vital.
                                                                                                          The best care homes maintain regular
                                                                                                          contact with local family doctors,
                                                                                                          community health teams, chiropodists,
                                                                                                          gerontologists and the like. They
                                                                                                          routinely monitor their residents
                                                                                                          to detect avoidable conditions and
                                                                                                          organise activities to provide mental
                                                                                                          and physical stimulation. And, where
                                                                                                          it’s feasible, they involve the residents
                                                                                                          in their own care.26

                                                                                                          Australia has implemented an Aged
                                                                                                          Care Gateway to help consumers
                                                                                                          navigate the system to get formalized
Photo credit: Vivium zorggroep
                                                                                                          access to care and find the most
                                                                                                          suitable provider. It will over time
The Hogeweyk village in the Netherlands provides an infrastructure which facilitates life as usual and
                                                                                                          also include performance and quality
wellbeing for people suffering with severe dementia.                                                      information about providers.27

                                                                         Connected and coordinated: Personalised service delivery for the elderly | 13
#6. Helping older people                       Figure 6: In many countries, most people die in hospital
to die as well as possible
with palliative care                                       Japan

By far the biggest share of per capita
healthcare spending typically occurs in                     Spain
the final phase of life. Various studies
show that most people would prefer
to die at home, yet most deaths still                    Canada
happen in hospital (see Figure 6). And                    France
the hospital is not just the place where
people least want to die; it’s also the       England & Wales
most expensive.                                         Australia

In the United Kingdom, for example, the                  Belgium
cost of a specialist palliative in-patient        United States
bed day in hospital is £425, compared to
                                                   New Zealand
just £145 for a day of community care at
the end of life.28 Similarly, in Australia,         Netherlands
the average cost of dying in hospital
(based on final admission) is A$ 19,000,          Deaths in hospital      Deaths in nursing homes        6.30
                                                                                                          Deaths in other locations, including own home

versus A$ 6,000 for community care in
the last three months of life.29              Sources: “Where do people die? An international comparison”, International Journal of Public Health, Vol. 58
                                              (2013), pp. 257-267; Centers for Disease Control and Prevention, Health, United States, 2010: With Special
                                              Feature on Death and Dying (2011)
Dying is an even more exorbitant
business in the United States. Eighty
percent of the 2.5 million Americans
who died in 2011 were Medicare
beneficiaries.30 The care they received       Again, several changes could make                        assess their physical, emotional and
in the last six months of life cost about     a big difference. One such measure                       spiritual needs, and allows them to
US$ 170 billion – or US$ 85,000 per           is early identification of people at                     draw up living wills that specify their
patient.31 Yet much of the money that         the end-of-life stage to facilitate                      wishes, thereby reducing the incidence
is spent on end-of-life care makes            advance care planning. Unlike                            of ‘futile care’.
the experience of dying worse, not            people who are diagnosed with a
better. Many people are subjected to          terminal illness, many elderly people                    More investment in palliative care
aggressive and unwanted treatments            don’t experience a single event that                     teams to provide pain management
rather than getting palliative care.          heralds their demise. So the UK Royal                    and emotional support at home
The humanitarian argument for                 College of General Practitioners                         would likewise allow many more
helping people end their lives well is as     has issued guidelines to help family                     people to die in their own beds,
relevant and powerful as the economic         doctors identify the estimated 1% of                     as would lending programmes for
one. How can we ethically balance             people on their registries who will                      specialist hospital equipment. And
the needs of the individual with those        die within 12 months.33 This makes                       all governments would do well to
of society? Should we concentrate on          it easier to ascertain peoples’ end-                     consider providing more financial
preserving life at all cost? Can we – as      of-life preferences and deliver more                     support for hospices, which are mainly
political philosopher Michael Sandel          coordinated care. It enables the doctor                  funded through charitable donations
asks – put a price tag on life?32             to initiate a conversation with them to                  and voluntary work.

                                                             Connected and coordinated: Personalised service delivery for the elderly | 14
Bringing everything together

               To sum up, this new care model isn’t        However, experience shows that it’s
               “rocket science”. On the contrary, many     possible to provide better, faster care
               of the changes it requires are simply       more economically by integrating
               common sense. But that doesn’t mean         the interfaces between primary,
               they will be easy to make or to connect.    secondary, community and social care
               Systemic reform is invariably more          (see sidebar The Canterbury Tale).34
               complex than piecemeal modification,        There’s much politicians, payers and
               and making the transition will entail       providers can learn from the path the
               managing two different systems in           pioneers have forged.
               parallel for some years.

               The Canterbury tale
               In 2007, the healthcare system in Canterbury, New Zealand, was in crisis. The
               population was rapidly ageing and admissions were rising, but the main hospital
               in Christchurch was already ‘gridlocked’ on a regular basis. The district health
               board estimated that Canterbury would need another hospital by 2020. It would
               also need many more general practitioners and nurses, as well as an extra 2,000
               residential care beds. This wasn’t feasible, given a deficit of nearly NZ$17 million
               on a turnover of just under $1.2 billion.

               So the district health board embarked on a major programme to introduce
               integrated care. Since then, Canterbury’s acute admissions rate has fallen. It also
               has the country’s third-lowest length of stay and acute readmission rates. The
               number of elective procedures performed has increased substantially, various
               conditions that once were treated purely or mainly in hospital are now provided
               in general practice and growing demand for residential care has flattened,
               thanks to better care in the community.

               The health board’s finances have also improved dramatically, although a big
               earthquake in September 2010 wiped out a projected $8 million surplus for that
               year. Even so, Canterbury’s health and social care system continues to improve,
               and the board projects that it will break even by 2014/15, despite incurring costs
               of $25 million as a result of the earthquake.

                          Connected and coordinated: Personalised service delivery for the elderly | 15
The road to a new care model

So what will it take to create a new      there will be five regional authorities,    ever comprehensive policy around
health system to support the quality of   each constituting a single-tier             elderly care. The so-called SPICE
life of older people? We’ve identified    administration for the delivery of care     program was developed by the Agency
eight key factors.                        in the area it covers.35                    for Integrated Care and will partner
                                                                                      and collaborate with numerous groups
                                          In 2011, the government of Singapore        to provide elderly day care centres
#1. Political vision                      responded to the needs of its “pioneer      in various regions of the island (see
and courage                               generation” and set in place the first-     sidebar SPICE from Singapore).36
Political vision – and the courage to
enact change – is crucial. Governments
alone have the mandate to formulate a
national care strategy. And the move to     SPICE from Singapore
personalised care for the elderly may
require such intervention, especially       The Singapore Programme for Integrated Care for the Elderly (SPICE) is a
in countries with market-oriented or        model of care developed by the Agency for Integrated Care (AIC) to provide
hybrid healthcare systems. Where            comprehensive, integrated centre- and home-based services to support caring
subsystems of competing payers exist,       of the frail elderly.
there is more fragmentation than in
systems with single payers.                 SPICE enables frail elderly who have high care needs and are eligible for
                                            admissions into nursing homes, to recover and age within the community.
Governments are likewise the only           Through SPICE Centres, a multi-disciplinary team comprising medical,
entities with the power to involve          nursing, allied health and ancillary professionals provides a suite of
stakeholders from other sectors.            patient-centric services such as primary and preventative care, nursing
Witness the imposition of legal             care, rehabilitation services, personal care and social and leisure activities.
requirements on the packaging of            These services are delivered both at the centre and at the patients’ homes,
cigarettes, despite fierce opposition       depending on their needs.
from the big tobacco manufacturers.
                                            AIC will partner Volunteer Welfare Organisations (VWOs) to operate SPICE
Many countries may also need new            centres in various regions of the island. The centres will collaborate with the
laws to establish an overarching,           Restructured Hospitals (RHs) and surrounding general practitioners (GPs)
coordinating body or harmonise              to form a seamless model of care, which will help lower the need for nursing
incompatible regimes. The Finnish           home admissions, decrease hospital admissions and visits to the emergency
government has already tackled the          department, reduce caregiver stress and increase patients’ and caregivers’
first of these challenges. In March         satisfaction with integrated care.
2014, it approved plans to unify the
provision of all social welfare and
healthcare. Under the new model,

                                                     Connected and coordinated: Personalised service delivery for the elderly | 16
#2. Embrace change   Driven by megatrends like                    telecoms operator Telus, teamed up
                     demographic shifts and technological         with Sanofi Canada, the Canadian
and cooperate with   breakthroughs, there is another, even        affiliate of pharmaceutical firm Sanofi,
new entrants         bigger change that care providers            to launch a web-based platform
                     everywhere must make: namely, in             that offers patients diabetes self-
                     the way they interact with companies         management and monitoring tools.40
                     from other industries and the elderly        A number of companies have also
                     individuals they serve. New entrants         developed high-tech home diagnostic
                     from retail, consumer products,              kits – and the X Prize Foundation’s
                     utilities, telecommunications and            contest to create a Star Trek-style
                     technology industries are expanding          ‘tricorder’ should yield even more
                     and reshaping the health sector.             sophisticated devices.41 Furthermore,
                                                                  home devices and wearables are
                     Some of these firms are tapping into         increasingly digital and internet
                     the growing market for wellness              connected. The internet of things will
                     and fitness products and services.           help the elderly and their families
                     US pharmacy chain Walgreens is               to manage medication, monitor
                     one such case; it recently acquired          diet and nutrition, or stimulate
                     Alliance Boots in a move to become           physical activity.
                     the first ‘global health and wellbeing
                     enterprise’ on the high street.37            Collectively, these ‘new kids on the
                                                                  block’ are revolutionising the way in
                     Other companies aim to help older            which care and support services are
                     people live more comfortably and             delivered and create a new experience.
                     safely in their own homes. So, for           They are importing the economic
                     instance, Norwegian energy and               discipline that characterises other
                     telecoms provider Lyse has piloted a         industries, where the customer is king
                     fire-alarm service in several homes          and revenues are based on results.
                     with direct alarm to the fire brigade,       They are also giving older people many
                     and that is integrated with different        of the tools they need to ‘co-produce’
                     home automation services like door           their care.42
                     locks, lights, ventilation and ovens or
                     coffee machines to make the service          That has two consequences for
                     safer and more preventive.38 Similarly,      traditional care payers and providers.
                     Deutsche Post has launched a new             First, it presents them with some
                     service called ‘Personal Post’ for elderly   critical decisions about whether to
                     citizens who live alone. Subscribers         compete or collaborate with their
                     pay a small monthly fee to have a            new rivals. Second, it alters the
                     postman ring the doorbell and speak          dynamics of the relationship with the
                     to them every Tuesday till Saturday.         elderly who need support services.
                     If something is wrong, the postman           As healthcare becomes decentralised
                     notifies the local help service, which       and democratised, older people will
                     immediately contacts a relative.39           expect a greater say in determining
                                                                  the care they receive. They will no
                     Yet other new players are capitalising       longer accept being defined in terms
                     on technological innovations to              of disease and told what they need;
                     ‘virtualise’ care. In 2012, for example,     they will insist that their opinions and
                     Telus Health, a division of Canadian         preferences be part of the dialogue.

                                Connected and coordinated: Personalised service delivery for the elderly | 17
#3. Reallocation of                              Figure 7: Many countries have too many hospital beds
resources from the                                   Canterbury,
secondary sector                                    New Zealand
                                                           Ireland            2.32

It will also be necessary to reallocate            United States                  2.82
resources from the secondary sector             United Kingdom                    2.89
to the primary, community and social
                                                             Spain                   3.08
care sectors. The most integrated
care networks operate with about                     Netherlands                     3.14
1.57 hospital beds per 1,000 people
                                                         Portugal                     3.30
without compromising the quality of
the service they provide.43 However, as                  Australia                       3.77
Figure 7 shows, most countries are far
                                                              Italy                         3.83
from this ideal.
                                                         Germany                                       5.96
Concentrating acute medical services                New Zealand                                        5.97
in fewer, bigger, more centralised units
reduces wasteful duplication of services                  Belgium                                        6.26
and enables staff to increase their skills by              France                                        6.30
treating more people. But converting or
closing hospitals is notoriously difficult,                 Japan                                                                      12.33
since it often engenders local opposition.
                                                                                       Number of hospital beds per 1,000 people
To build trust in society, governments in
                                                Source: Business Monitor International and Canterbury, New Zealand, case
this position need to offer access to an
alternative supply of services for elderly
care as they streamline infrastructure,         and the more complex forms of care                     sectors will also need extra funding,
whilst emerging market countries should         a consultant would previously have                     if they are to play a part in providing
leapfrog to new service delivery systems        supplied. This is driving up demand                    personalised integrated services for
for the elderly and avoid copying               for generalists and gerontologists. The                the different types of elderly people
the 20th century hospital-centred               American Geriatrics Society predicts,                  we identified in the beginning of this
infrastructure of western societies.            for example, that the United States will               report and managing the impact of
                                                need more than 30,000 geriatricians                    the demographic curve. To support
Redirecting resources to other areas            by 2030 – up from about 7,500 today.44                 this many home care and domiciliary
is imperative to close the ‘care gap’                                                                  workers will need professional training
that has emerged over the past few              However, the number of specialists                     focused on elderly people’s real needs
decades. Secondary care has become              is rising much more rapidly than the                   and capabilities. As an example of
increasingly specialised as a result of         number of generalists. Many countries                  taking the needs and abilities of the
scientific and technological advances.          will therefore drastically have to                     elderly into account, the Municipality
But though specialisation works well            improve the attractiveness of general                  of Copenhagen decided in 2010 to
with single diseases, it is much less           practice and alter their educational                   change home care for older citizens,
effective in treating medical conditions        systems, as well as exploring new                      from only providing passive help –
that span diseases, such as the co-             roles for other healthcare workers.                    where a home aid performs daily
morbidities that arise with age.                Incentives and redirecting resources                   tasks for the client – to also offer re-
                                                from the secondary care sector will                    ablement. Re-ablement is an approach
The primary care sector has been left           help to finance these changes.                         focused on helping older adults to
to pick up the slack. Family doctors                                                                   regain ability and maintain functional
now have to provide the generalist              The social, residential, home care and                 independence, thus allowing them to
care that has always been their remit           wellness services and palliative care                  stay longer in their own homes.45

                                                              Connected and coordinated: Personalised service delivery for the elderly | 18
#4. New payment models                      England’s Quality and Outcomes             Germany.47 Mexico is also working on
                                            Framework (QOF) for general                prevention and performance-based
                                            practitioners, which was introduced        incentive schemes around the most
Reallocating money from one part of the     in April 2004, is one such instance.       prevalent and costly diseases: diabetes,
care system to others won’t solve another   The QOF pays family doctors for            cardiopathies, oncology and neurology.
problem: funding schemes that reward        meeting certain quality targets,
activities rather than outcomes. New        more than half of which have to do         Other countries are testing alternative
financing incentives and mechanisms         with the management of common              approaches. The Dutch Ministry of
will be required to redress this issue,     chronic diseases.46                        Health has, for example, launched
and several innovative payment models                                                  a bundled payment scheme for
have emerged in those countries that        Performance-based incentives are also      treating people with diabetes, chronic
are in the vanguard of integrated care.     used in the Gesundes Kinzigtal             obstructive pulmonary disease and
                                            integrated care initiative, which          vascular disease.48 Similarly, Denmark
Some of these new models employ             serves the 31,000 members of two           is trialling an incentive scheme under
outcomes-based payment incentives.          sickness funds in Kinzigtal, southern      which family doctors receive an up-
                                                                                       front annual payment for every diabetic
                                                                                       patient on their registries in return for
                                                                                       providing them with integrated care.49
The Manises model
                                                                                       Meanwhile, the United States is
In 2009, Bupa-Sanitas contracted with the Government of Valencia to provide
                                                                                       experimenting with accountable
primary, specialised and long-term healthcare for the 200,000 residents
                                                                                       care organisations (ACOs), in which
of Manises on the outskirts of Valencia in eastern Spain. The agreement –
                                                                                       groups of doctors, hospitals and other
which runs for 15 years, with an option to extend for another five years – has
                                                                                       healthcare providers come together
several distinctive features. It uses a per-capita payment model, with a fixed
                                                                                       voluntarily to provide coordinated
fee per person irrespective of the number of treatments received, thereby
                                                                                       care. When an ACO succeeds both in
encouraging Bupa-Sanitas to maximise its efficiency and invest in disease
                                                                                       delivering high-quality care and in
prevention because a healthier population needs fewer treatments.
                                                                                       cutting costs it receives a share of the
The agreement also allows the residents of Manises to attend a hospital                savings, in the form of an advance fee
in another catchment area, if they want. When a resident goes elsewhere,               and monthly instalments based on the
Bupa-Sanitas pays the other hospital a standard fee set by the Government.             projected number of beneficiaries it
And when Bupa-Sanitas treats someone from outside its catchment area, it               will cover.50
receives 85% of the fee. This creates healthy competition between hospitals
                                                                                       The English National Health Service
and drives up the standard of care.
                                                                                       (NHS) is piloting an even bolder
The results speak for themselves. In 2013, more than 90% of patients                   version of population-based care
attended a primary care appointment within 48 hours, up from 76% in 2009.              delivery, with the devolution of
Meanwhile, waiting times for specialist consultations have fallen to about 16          control over all health and social
days, less than a third of the Spanish average of 53 days.                             care in Greater Manchester. The
                                                                                       region’s 10 councils and 15 clinical
Manises also scores highly on clinical quality and patient satisfaction                commissioning groups will control a
measures. In 2012, it ranked first out of Valencia’s 24 health districts for           budget of £6 billion, the goal being
improvements in maternal and palliative care, and second for improvements              to provide ‘better, more joined-up
in health outcomes. And, in 2013, the average patient satisfaction score               care’.51 But capitation payments to
was 8.17, out of a possible 10. Taxpayers have benefited, too; public-private          institutional networks rather than
partnerships have yielded savings of about 30-37% per capita, compared to              family doctors are still rare, despite the
the public-sector alternatives.                                                        advantages they offer (see sidebar, The
                                                                                       Manises model).52

                                                      Connected and coordinated: Personalised service delivery for the elderly | 19
#5. New contractual                             their integration. The advantage                 an agreement that specifies the
                                                of this model is that it gives the               principles to be used for allocating
structures                                      commissioning body a single point                tasks, costs and any savings that
                                                of contact. The downside is that it              are achieved. Each care provider
New contractual structures will also            restricts the commissioning body’s               maintains its own internal controls
be needed to align the interest of              ability to influence the behaviour of            but is judged on the performance
payers, providers, new entrants from            individual subcontractors                        of the entire alliance. And since
outside industries and citizens more                                                             each partner shares in the
                                            • In a joint venture, the
effectively. The simplest solution is to                                                         profits, they all suffer if any one
                                              commissioning body enters into a
merge all the providers in one single                                                            of the partners fails to fulfil its
                                              contract of contracts with various
integrated organisation, but that is not                                                         obligations. Alliances are especially
                                              third party providers. Joint
always feasible or likely to happen.                                                             suitable for complex projects where
                                              ventures are an effective way of
Another option is to borrow from the                                                             budgets and deadlines can run
                                              pooling expertise and increasing
various contract types used in the                                                               out of control. But they only work
                                              operating efficiencies. But they
private sector. These include the prime                                                          when there is a good pre-existing
                                              require a strong hand to overcome
contracting model, the joint venture                                                             relationship and the interests of
                                              different cultures and management
and the alliance. Each has its own                                                               each partner are aligned with the
                                              styles, and since everything is
strengths and weaknesses.                                                                        aims of the alliance. Moreover,
                                              agreed at the start, they may be
                                                                                                 the model has not yet been
• In the prime contracting                    unsuitable for managing projects
                                                                                                 thoroughly tested in the healthcare
  model, a commissioning body has             that evolve.
                                                                                                 arena, although experience in
  a contract with a prime contractor
                                            • In an alliance, multiple                           the commercial world shows
  for an agreed range of services.
                                              commissioning bodies join forces                   that when alliance contracting
  The prime contractor subcontracts
                                              with multiple care providers to                    works well, it promotes a more
  some of these services to third-
                                              deliver a range of services (see                   collaborative spirit.
  party providers and manages
                                              Figure 8). The parties enter into
                                                                                             The particular contractual form a
                                                                                             commissioning body chooses will
Figure 8: Alliances are ideal for handling complex projects but largely unproven
                                                                                             obviously depend on the services and
in the care space
                                                                                             outcomes it wants and the market
                                                                                             in which it operates. But, whichever
                                                                                             structure it selects, it should be
        Clinical                                                Social care                 prepared to enter into a long-term
        commissioning                                           commissioning              arrangement. At present, most
        body                                                     body
                                                                                             contracts only last between one and
                                  Care provider                                              three years, which is a deterrent to
                                                                                             serious investment. In an industry
   Care provider                                                      Care provider          facing change and disruption,
                                                                                             healthcare networks will need to
                                                                                             be agile and adaptive, supporting
                                                                                             care providers to partner with
                                                                                             commercial companies like Apple,
                             Alliance todeliver services
                                                                                             Google, Amazon, Facebook, energy
                                                                                             providers, telcos and many other
                                                                                             big and start up organisations from
                                                                                             different industries.

                                                            Connected and coordinated: Personalised service delivery for the elderly | 20
#6. Integrated                             Four general guidelines apply in            #7. Effective governance
                                           building an IT system that supports
information systems                        personalised service delivery:
                                                                                       and performance
and digitalisation                                                                     management
                                           • The needs of each of the
The ability to deliver integrated and        stakeholders must be identified.          Shared information is also, of
personalised services depends as much        Clinical safety should obviously be a     course, a prerequisite for effective
on integrated information systems            top priory, as should the security of     governance of any network – and this
as it does on the right financing and        the system itself. The information        is a much harder task than managing
contractual models, though. Care             stored in electronic care records is      a single organisation. The absence
services improve when doctors, social        highly sensitive, so privacy should       of a unified chain of command is one
workers, and family have immediate           be a key consideration for both           obvious distinction. But what is being
access to information. But integrated        ethical and regulatory reasons.           managed differs, too; orchestrating
information is not a challenge solely                                                  a network involves managing
for providers. Increasingly, the elderly   • The system must work horizontally         interactions rather than people.
and their caretakers will need to be         as well as vertically. Most health IT
proactive owners of their own health         systems are designed to perform a         Moreover, while the diversity of
data. New technology, including              specific set of functions in a specific   the participants in a network is one
devices and wearables connected to           department or organisation.               of its greatest strengths, it poses
the internet, collects more and more         But patients move from one                equally great challenges. Each
data (big data), increasingly outside        department to another and from            partner specialises in a particular
existing care providers. As such, the        one organisation to another, so it’s      form of care, so it must have
citizen becomes the central node in          vital to build a system that spans        sufficient freedom to do its job
the use of his or her own information,       the patient pathway.                      properly without compromising
and therefore involved in the seamless     • The information contained within          the performance of the network
delivery of the personalised services        the system must also be accurate          as a whole. And since the other
they need.                                   and instantaneously available.            partners lack its specific expertise,
                                             Users must thus be able to update         discerning where to draw the line can
The wave of digitalisation that              it wherever they are, which means         be difficult.
transformed industries like banking,         that mobile access is essential.
travel and entertainment is now                                                        Robust multidimensional
disrupting healthcare. This wave           • Lastly, the terminology and               performance management and
will merge consumer technology and           formats different care providers          measurement is critical in these
medtech and bring services closer to         and administrators use must be            circumstances – and numerous
the consumer.                                standardised to encourage more            measures of clinical performance
                                             effective utilisation of existing IT      have already been developed. But
Unfortunately, the IT systems and            assets and minimise the amount of         there are many other areas in which
software care providers use vary             additional investment that is required.   the indicators required to evaluate
widely. This creates numerous                                                          personalised integrated care are
problems, including errors as a            These guidelines will facilitate the        still missing: like the professional
result of duplicate data entry and         construction of a truly interoperable       involvement and capabilities to act as
difficulties in comparing data from        client centred IT network. That, in         a coach for elderly.
diverse sources. Furthermore, much         turn, will enable multi-disciplinary
of the software that is commercially       service delivery teams to manage the        They can be loosely divided into two
available can’t be easily adapted          elderly’s journey more effectively, let     categories. The first is organisational
to reflect the requirements of             people own and share their personal         – the extent to which processes are
individual organisations.                  records, and pave the way for other         integrated and the ease with which
                                           advances based on the insights and          people can be transferred from one
                                           presights ‘Big Data’ produces.

                                                      Connected and coordinated: Personalised service delivery for the elderly | 21
form of care to another. The second is          experience, more efficient use of            Figure 9 shows the conceptual design
the impact of personalised integrated           resources, cost savings and improved         and building blocks for an effective,
care and service delivery – the extent          outcomes at both the personal and            multi-dimensional performance
to which it produces a better client            population levels.                           measurement system.

 Figure 9: Evaluating personalised service delivery entails measuring three building blocks

            Input                                      Performance building blocks                                       Results

                                                                                                                       On 4 levels:

        Environment                                                                                                     Population
                                                     Client                  engagement
         Resources                                 experience                                                          Organisation
           History                                                                                                    Team or ward


                                            Strategic insights to improve quality & reduce costs

Source: PwC and ActiZ team analysis

                                                The indicators used to assess these          Effort Score (which measures the
                                                dimensions may vary from one care            effort it takes for a client to get things
                                                system to another, but they must all         done) give further insight into how
                                                be relevant, reliable and viable. They       satisfied people are with the service
                                                must also be amenable to change              they receive. In the Netherlands,
                                                in the short- or mid-term, since no          nationwide benchmark research shows
                                                country can afford to wait decades           that best practice organisations have
                                                to find out whether it’s pulling the         a balanced performance along the
                                                right levers. And they must provide          three building block dimensions: good
                                                information on which the stakeholders        client experiences driven by highly
                                                can act. Indicators like the Net             engaged professionals as a basis for
                                                Promotor Score (NPS) or the Customer         financial sustainability.

                                                            Connected and coordinated: Personalised service delivery for the elderly | 22
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