Mobile technology and delegated work in specialist community services: the EnComPaSS Integration project

ObjectivesThe current UK healthcare workforce crisis is particularly severe in community services. A key limitation with traditional service-delivery models is the reliance on practitioners with levels of training and experience to enable them to operate independently. This paper describes a real-world evaluation of the implementation of digital health technology designed to provide remote, real-time support and task delegation in community palliative care services. It explores the ability of technology to support sustainable community workforce models and reports on key indicators of quality and efficiency.MethodsThe study was a mixed-methods, theory-driven evaluation, incorporating interviews, observations and analysis of routine data. The focus of this paper is the reporting of findings from pre–post implementation comparison and interrupted time series analysis. Data include community hospice service visits, hospital use by hospice patients and patient reported experiences.ResultsThe digital health intervention allowed the service to include a more junior workforce (p<0.001, Cramer’s V=0.241), requiring fewer joint visits (p<0.001, Cramer’s V=0.087). No negative changes in hospitalisation were observed and patient reported experiences improved (p=0.023). Changes in hospital non-emergency bed days were inconclusive. However, emergency department admissions reduced significantly (−76.9 /month at 17 months, p=0.001). The cost per hour for visits reduced from £16.71 to £16.23 and annual savings of £135 153 are estimated for reduced emergency admissions.ConclusionsThe evaluation demonstrates the value of digital innovation to support programmes of service redesign and begin to address the healthcare workforce crisis, while having a positive economic effect and indicating an improvement to patient experiences.

Rapid Evaluations of Innovations: A Scoping Review

BackgroundThere is increasing demand for more rapid evaluation of innovation in health and social care, to support timely decision-making about service redesign. These pressures have increased during the COVID-19 pandemic. Making evaluations more rapid raises challenges in terms of ensuring rigour and the effective use of resources, but assessment of rapid evaluation methodologies has been lacking. MethodsWe conducted a scoping review to map the developing field of methods of rapid evaluation of innovation in health and social care, to describe the existing literature, categorise different approaches to rapid evaluation, and identify knowledge gaps. We searched multiple databases and websites of key organisations. We prioritised studies with relevance to the context of the NHS in England. We extracted information to enable us to classify and map existing studies on key characteristics. We undertook a narrative synthesis to identify the evidence and the gaps; focussing on the different approaches to conducting rapid evaluation in primary research. ResultsWe identified 14069 records from our searches of which 352 explored rapid evaluations of innovations, methods for rapid evaluation or rapid evaluation of implementation. Our scoping review identified four main approaches used for rapid evaluation: (1) Use of a methodology designed specifically for rapid evaluation;(2) Increasing rapidity by doing less or using a less time-intensive methodology;(3) Use of alternative technologies and/or data to increase the speed of an existing evaluation method; (4) Adaptation of part of a non-rapid evaluation DiscussionThis scoping review identified a lack of clarity about ‘rapid evaluation’ but identified some useful preliminary categories. There is very little comparative research on the impact of using rapid rather than standard evaluation. There is a need for clarity and consistency in terms of what constitutes rapid evaluation, the development of specific methodologies for making evaluation more rapid, and assessment of the advantages and disadvantages of rapid methodology in terms of rigour, cost and impact.

Staff experience of rapid implementation of telemedicine: informing future service redesign

Background/Aims In response to the COVID-19 pandemic, many services in the NHS suspended face-to-face appointments and transitioned to remote consultations. Best practice advocates for evaluation of what was implemented, and the lessons learned, to guide future service redevelopment. This evaluation explored the experienced of physiotherapy staff, aiming to inform future service development and ensure that the staff perspective is taken into account. Methods A survey was distributed to all staff involved in the initial running of the integrated musculoskeletal physiotherapy service at Guy's and St Thomas' NHS Foundation Trust. Questions consisted of Likert scales, multiple choice questions, scales of 1–100 and open questions. Overall, 22 staff members from the new remote clinic and 10 from the follow-up clinic responded. Content analysis was performed to draw themes from responses. Results Overall, 75% of responses indicated a positive experience of the implementation of telemedicine. However, improvements in training and procedural matters were highlighted as fundamental to supporting staff in these clinics. There was considerable variation between staff in the new patient clinic and those in the follow-up clinic, with the former feeling less confident about running remote patient clinics. Conclusions Remote consultations are an accepted medium for staff to deliver physiotherapy consultations. However, future development of telemedicine services must be informed by this experience and take staff experiences into consideration.

Digital personal assistants are smart ways for assistive technology to aid the health and wellbeing of patients and carers

Background Digital health solutions such as assistive technologies create significant opportunities to optimise the effectiveness of both health and social care delivery. Assistive technologies include ‘low-tech’ items, such as memory aids and digital calendars or ‘high-tech’ items, like health tracking devices and wearables. Depending on the type of assistive devices, they can be used to improve quality of life, effect lifestyle improvements and increase levels of independence. Acceptance of technology among patients and carers depends on various factors such as perceived skills and competencies in using the device, expectations, trust and reliability. This service evaluation explored the impact of a pilot service redesign focused on improving health and wellbeing by the use of a voice-activated device ‘smart speaker’, Alexa Echo Show 8. Methods A service evaluation/market research was conducted for a pilot service redesign programme. Data were collected via a survey in person or telephone and from two focus groups of patients (n = 44) and informal carers (n = 7). The age of the study participants ranged from 50 to 90 years. Also, the participants belonged to two types of cohort: one specifically focused on diabetes and the other on a range of long-term health conditions such as multiple sclerosis, dementia, depression and others. Results The device had a positive impact on the health and social well-being of the users; many direct and indirect benefits were identified. Both patients and carers had positive attitudes towards using the device. Self-reported benefits included: reminders for medications and appointments improved adherence and disease control; increased independence and productivity; and for those living alone, the device helped combat their loneliness and low mood. Conclusion The findings from the study help to realise the potential of assistive technology for empowering supporting health/social care. Especially, the season of COVID-19 pandemic has highlighted the need for remote management of health, the use of assistive technology could have a pivotal role to play with the sustainability of health/social care provision by promoting shared care between the care provider and service user. Further evaluation can explore the key drivers and barriers for implementing assistive technologies, especially in people who are ageing and with long-term health conditions.

The needs and experiences of mothers while in prison and post-release: a rapid review and thematic synthesis

Background Women in prison are a vulnerable group, often with a history of abuse, out-of-home care, mental health problems and unemployment. Many are mothers when they become involved in the criminal justice system and their gender and parenting related needs are often not considered. The aim of this rapid review was to thematically synthesize the existing research on the needs and experiences of mothers while in, and following release from, prison in Australia. Methods We conducted a rapid systematic search of electronic databases, search engines, the websites of key agencies, and contacted key agencies and researchers. Results Twenty-two publications from 12 studies met the inclusion criteria and were thematically synthesized in relation to the mothers, their children, family and community, and systems and services which mothers had contact with. We found that mothers in prison have a history of disadvantage which is perpetuated by the trauma of imprisonment. Release from prison is a particularly challenging time for mothers. In relation to their children, the included studies showed that the imprisonment of mothers impacts their maternal identity and role and disrupts the mother-child relationship. Specific strategies are needed to maintain the mother-child relationship, and to ensure the needs and rights of the child are met. In relation to family and community, we found that although family and social support is an important need of women in prison, such support may not be available. Moreover, the stigma associated with having been in prison is a significant barrier to transitions into the community, including finding employment and housing. In relation to systems and services, although limited services exist to support women in prison and on release, these often do not consider the parenting role. Evaluations of parenting programs in prison found them to be acceptable and beneficial to participants but barriers to access limit the number of women who can participate. Conclusion Mothers have gender- and parenting-specific needs which should be considered in planning for corrective services in Australia. Any service redesign must place the woman and her children at the centre of the service.

Integrating patients with chronic respiratory disease and heart failure into a combined breathlessness rehabilitation programme: a service redesign and pilot evaluation

IntroductionThe successful integration of patients with chronic heart failure (CHF) into a traditional pulmonary rehabilitation (PR) programme has previously been reported. Our aim was to reconfigure both our cardiac rehabilitation (CR) and PR services to enable us to deliver a symptom-based programme—breathlessness rehabilitation (BR), for patients with a primary symptom of breathlessness irrespective of the index diagnosis, or comorbid disease.MethodsAfter a service redesign process, patients attended a two times per week, group-based, tailored exercise and education programme for 6 weeks, delivered by CR and PR staff. The classes included both aerobic and resistance exercises and an overarching generic education programme alongside disease-specific components. Home programmes were reviewed at each session to facilitate progress and influence changes in exercise behaviour beyond the supervised programme. Generic clinical outcome measures were performed pre and post BR.Staff focus groups were conducted to identify barriers and facilitators and explore staff perceptions.Results272 patients (n=193 chronic respiratory disease (CRD) and n=79 CHF) were assessed and enrolled into BR (153 men, mean (SD) age 68.8 (12.7) years, body mass index 28.8 (7.3), Medical Research Council 3 (IQR 2–4), New York Heart Association 2 (IQR 2–3)). 164 patients completed the programme. Statistically significant improvements were seen in both exercise capacity (incremental shuttle walking test: mean change 47.4 m; endurance shuttle walking test: mean change 310.7 s) and quadriceps strength (quadriceps maximal voluntary contraction: mean change 3.7 kg) (p≤0.0001) alongside a statistically significant reduction in dyspnoea (chronic respiratory questionnaire/chronic heart questionnaire - self reported - dyspnoea: mean change 0.4) and anxiety and depression scores (Hospital Anxiety and Depression Scale (HADS) - anxiety: −1.6; HADS - depression: −1.3) (p≤0.0001).Qualitative staff focus groups identified three subthemes: collaboration and integration, service quality and future challenges.DiscussionOverall the service redesign indicates the feasibility for staff and individuals with CRD and CHF to integrate into a breathlessness programme. Early data suggests clinical effectiveness. Given the significance of comorbid disease it is an approach that warrants further consideration.

Using institutional entrepreneurship to understand the role of innovation teams in healthcare: a longitudinal qualitative study

ObjectivesWe draw on institutional theory to explore the roles and actions of innovation teams and how this influences their behaviour and capabilities as ‘institutional entrepreneurs (IEs)’, in particular the extent to which they are both ‘willing’ and ‘able’ to facilitate transformational change in healthcare through service redesign.DesignA longitudinal qualitative study that applied a ‘researcher in residence’ as an ethnographic approach.SettingThe development and implementation of two innovation projects within a single public hospital setting in an Australian state jurisdiction.ParticipantsTwo innovation teams, with members including senior research fellows, PhD scholars and front-line clinicians (19 participants and 47 interviews).ResultsDespite being from the same hospital, the two innovation teams occupied contrasting subject positions with one facilitating transformational improvements in service delivery, while the other sought more conservative improvements. Cast as ‘IEs’ we show how one team took steps to build legitimacy for their interventions enabling spread and scale in improvements and how, in the other case, failure to build legitimacy resulted in unintended consequences which undermined the sustainability of the improvements achieved.ConclusionsAdopting an institutional approach provided insight into the ‘willingness’ and ‘ability’ to facilitate transformational change in healthcare through service redesign. The manner in which innovation teams operate from different subject positions influences the structural and normative legitimacy afforded to their activities. Specifically, we observed that those with the most power (organisational or professional) to bring about transformational change can be the least willing to do so in ways which challenge current practice. Those most willing to challenge the status quo (more peripheral organisation members or professionals) can be least able to deliver transformation. Better understanding of these insights can inform healthcare leaders in supporting innovation team efforts, considering their subject position.

Health economics for palliative care

Healthcare costs are escalating due to public demand for, and the increasing availability of, treatment. National frameworks that use economic evaluation as a basis for health technology assessment have been successful at constraining expenditure on low-value treatments primarily by explicitly considering the opportunity cost of new technology adoption or service redesign. At the end of life and in palliative contexts, such methods have not been widely applied and are underdeveloped despite evidence that healthcare costs typically increase with proximity to death. There may be a requirement for the adaptation of standard methods for healthcare resource allocation in this setting, where the goals of care may differ from a curative or preventative context. Health service and financing models may be complex and specific to this setting, with a greater consideration for third-sector provision and informal care. This chapter outlines the core concepts in health economics that are relevant in the planning of palliative services, with specific considerations in the developed and developing world contexts.

Co-designing a methodology for workforce development during the personalisation of allied health service funding for people with disability in Australia

Background Internationally, health and social services are undergoing creative and extensive redesign to meet population demands with rationed budgets. This has critical implications for the health workforces that serve such populations. Within the workforce literature, few approaches are described that enable workforce development for health professions in the service contexts that emerge from large scale service redesign in times of industry shift. We contribute an innovative and robust methodology for workforce development that was co-designed by stakeholders in allied health during the personalisation of disability funding in Australia (the introduction of the National Disability Insurance Scheme). Methods In the context of a broad action research project, we used program logic modelling to identify and enact opportunities for sustainable allied health education and workforce integration amidst the changed service provision context. We engaged with 49 industry stakeholders across 92 research engagements that included interviews (n = 43), a workshop explicitly for model development (n = 8) and a Project Advisory Group (n = 15). Data from these activities were inductively coded, analysed, and triangulated against each other. During the program logic modelling workshop, we worked with involved stakeholders to develop a conceptual model which could be used to guide trial and evaluation of allied health education which was fit-for-purpose to emerging workforce requirements. Results Stakeholder interviews showed that drivers of workforce design during industry shift were that (1) service provision was happening in turbulent times; (2) new concerns around skills and professional engagement were unfolding for AHP in the NDIS; and (3) impacts to AHP education were being experienced. The conceptual model we co-designed directly accounted for these contextual features by highlighting five underpinning principles that should inform methodologies for workforce development and AHP education in the transforming landscape: being (1) pedagogically sound; (2) person- or family-centred; (3) NDIS compliant; (4) informed by evidence and (5) having quality for all. We use a case study to illustrate how the co-designed conceptual model stimulated agility and flexibility in workforce and service redesign. Conclusions Proactive and situated education of the emerging workforce during policy shift is essential to realise future health workforces that can appropriately and effectively service populations under a variety of changing service and funding structures – as well as their transitions. We argue that collaborative program logic modelling in partnership with key stakeholders including existing workforce can be useful for broad purposes of workforce (re)design in diverse contexts.