There is significant potential for the transformation of health and social care through better widespread use of digital technologies. This includes a growing role for technology in supporting people to monitor and manage their own health and wellbeing and also enhancing people’s experience of accessing services.

Access to own care record and care plan

To truly be empowered, people will require access to their own care record and care plan, containing a summary of their care information from their care coordinator and the providers they have come in contact with. The individuals themselves might also contribute to their care record and care plan by adding information.

Self-management

Digital health provides the ability to offer a personalised approach to self-management via digital tools that support people to live well in their communities and enable access to the right support and services tailored to the individual’s needs. Teams supporting people can also interact with patients through the same digital service, allowing them to deliver new care pathways and better meet people’s needs.

Communication and engagement with professionals

To help individuals take more ownership in their care and rely less on in person interactions with care professionals it is useful to send them reminders and updates via e mail, text message or mail at appropriate times. It is also helpful for users to have an effective way to communicate remotely with care professionals, particularly their Care Coordinator. While such interactions could happen via
telephone, more sophisticated online approaches need to be considered.

Access to information online

People might need to get information on topics such as information and advice, services available and activities and events.

New and more integrated ways of providing care will require local health and care professionals to act and behave in different ways. This will include working with local people, carers and their families so they are more empowered to set their own care goals and manage their own wellbeing, being part of a multi disciplinary team and delivering more responsive and proactive care.

Population analytics

To be as effective as possible in their role, health and care professionals require a thorough understanding of the needs and activity of their population as well as the costs associated with it.

Population segmentation

A core part of having a good understanding of the population is to have an effective approach to group the population, to support care for specific groups. We will therefore ensure health and care professionals are able to segment the Lincolnshire population and understand health, care and wellbeing needs, activity, outcomes and costs for each group defined.

Performance analytics

We will establish approaches to enable health and care professionals to monitor the performance of the local health, care and wellbeing providers (and associated networks, collaborations and alliances) that care for the local population in an integrated way, in particular monitoring the outcomes delivered as well as other agreed indicators and parameters.

Service user identification

Local care teams will be required to support specific population groups and we will support them to employ a granular approach, such as risk stratification, to identify specific service users that they will need to focus more attention on.

Service user registry

To support an effective and truly integrated delivery of care, we will make sure local care teams have access to an accurate summary of information for each individual in their care, with input from all providers of health and care services, as well as service users themselves.

Care planning

We will make sure local Care Coordinators have the ability to create a care plan and review progress and results. This care plan will shape the integrated care that the individual will receive, ensuring its appropriateness and timeliness. As part of the care planning process, access to a library of care protocols will be made available to support decision-making and ensure that the care plan being created is in line with relevant guidelines and best practices.

Intervention management capability

We will ensure local care teams are alerted to relevant events so they can respond to the specific needs of individuals in a timely fashion. This could include alerts issued when an individual requires an intervention (e.g. vaccination reminders), based on recent events (e.g. discharge from hospital) or on a “care gap analysis”.

Delivery analytics

We will make sure local care teams are able to regularly monitor and review the care they are delivering multiple times a week so the progress and impact of the care delivered to specific individuals and groups is fully understood. These types of reviews will need to be informed by ad hoc analytics that track metrics tied to specific care plans and models and are therefore different from the higher
level outcome and service standard indicators determined by commissioners or the provider organisation.

Remote monitoring capability

In line with our objectives to support user empowerment and the ability of individuals to receive appropriate care in their home and, where appropriate, to self-manage, we will ensure local care teams have the ability to monitor certain service users remotely.