1.Introduction
The Internet of Things(IoT) plays a vital role on medicine today; studies show that, 40% of IoT-related technologies will be assigned to the health domain in 2020. This new ICT reshape the possibilities to accomplish integrated care, among all stakeholders. The aim is to demonstrate the level of new ICT-integration and models for integrating the personal health, quality of life and self-care into conventional health care processes.
2.Method
The study is based on a case study of an codesign process with a group of 6 elderly and 5-7 different health care professionals and 6 technical developers/researchers. During five focus group meetings the group discussed the need for support of new ICT solutions and care processes when focusing on designing new processes for preventing fall accidents. The study is based on integrated care theories and models.
3.Results and discussion
The necessary technical requirements will be shifting in different stages of a natural ageing process, the older person can go from being totally independent to more and more dependent on effective health care services. Three different personas were developed by the group, and all these stages need different types of integration of IoT and use of big data analytics.
* Active Alice, the main ICT-challenge is to support the elderly to stay in this stage for as long as possible, using IoT for inspiring them to take actions for health promotion, preventing accidents and upholding a good quality of life. The gathered data can also be viewed by health care professionals on regular care and follow up meetings.
* Vital Hubert, the older adult is still living independently at home but faces a number of health issues, including chronic conditions. It is essential to uphold and rehabilitate the elderly to stay as independent as possible and get the best possible care at the time it is needed. By using innovative technologies to share clinical- and health-related information among the different experts, the service will with less efforts, than today, produce an individualised and integrated horizontal care to prevent more severe conditions.
* Life fighter Lee, the older person is dependent on care and in this stage and the use the IoT-technology will be as a tool to plan and coordinate a seamless care around the patient – going with the help of innovative technologies from a plan-based-care to a need-based-care that are integrated both horizontal (experts) and vertical (primary, secondary etc.).
4.Conclusions
New ICT sloutions like IoT and big data analytics will be important to get an effective vertical and horisontal integrated care that focuses on the patients empowerment.
5. Lessons learned
Using the co-design approach for defining new models for integrated care are beneficial and takes all stakeholders into account.
6. Limitations and future studies
The health and wellbeing sectors are very diverse across Europe and the world, where each person has their own specific needs, preferences and interests when it comes to using ICTs for living independently at home. Thus, there is a need to study it further.

Introduction:
Telemonitoring of patients with chronic diseases shows potential for improved quality of community based care resulting in fewer hospital admissions. Questions remain about how best to employ the technology, staff roles and how to integrate the intervention into existing healthcare practice and community based care. A previous retrospective analysis of telemonitoring study within South Western Sydney indicated the need to understand in more detail how the program was being implemented

Theory/Methods:
The aim of the study is to identify the challenges and lessons of the telemonitoring implementation in the District, and identify strategies to inform the future implementation of telemonitoring initiatives. A program logic model was developed in order to develop an array of themes for interviews. Semi-structured interviews were carried out with a purposive diverse sample. It consisted of managers, administrators and clinicians involved in implementing telemonitoring, as well as those from the private telemonitoring services provider. Interviews were recorded, transcribed verbatim and thematic analysed.

Results:
Sixteen semi-structured interviews were conducted (response rate-55%). Analysis of the transcripts identified 5 core themes linking different aspects of the implementation of the telemonitoring program: 1) Impact of telemonitoring (in community and health systems); 2) Implementation and management lessons; 3) Program risks; 4) Program main changes from beginning; and, 5) Future strategies and recommendations. The challenges from implementation were also included.

The participants viewed telemonitoring as a “Positive” initiative that had contributed in providing self-management capability for the patients, as they had increased ownership of their health and confidence in managing their own care. Stakeholders reported that telemonitoring was embraced enthusiastically by many patients and staff, and that it had a positive impact. They reported that patients credited it as a tool that provided support and increased their confidence in managing their own disease at home. The identified main challenges in implementing the telemonitoring model of care are: connectivity/network issues, up-to-date technology and software, limited resources (i.e. consumables, staff, number of devices), and potential for dependency on equipment.

Future strategies to improve such initiative could be managing such programs in house, organizing more human resources, more promotion and education around available programs at community level and within the hospital systems, making it better structured, engaging culturally and linguistically diverse (CALD) communities, and incorporating research and evaluation component.

 

Discussions and conclusion:
This study provides guidance for the future development and escalation of telemonitoring across NSW. It highlights the importance of partnerships between the District Health, PHN, service providers (private/non-private) and local general practitioners. The results of this study will contribute to the understanding of practical considerations as well as barriers and facilitators of implementation telemonitoring beyond this region.

Lessons learned:
Selection of right cohort for the intervention and a better communication between the patients, staff and the GPs.

Limitations:
Only one service provider.

Suggestions for future research:
To explore the feasibility related to self-management aspects of telemonitoring in a cohort of patients with early stages of chronic diseases and primary health professionals views on acceptability and perceived usefulness of telemonitoring in care provision.

Introduction: Wollondilly LGA is a peri-urban region in south-west Sydney with a population of approximately 48,000. A health needs assessment of the area identified Chronic Obstructive Pulmonary Disease (COPD) was the main chronic disease for frequent Emergency Department (ED) presentations and hospital admissions. In addition, there were limited health specialists, no local hospital and no after-hours health services; and a GP:patient ratio of 1:2,723 (national benchmark 1:1,100).

Practice change: Telemonitoring was identified as a strategy to address the needs assessment concerns. An individualised telemonitoring care plan is co-designed with the patient’s GP. At home, patients/carers monitor vital signs and health conditions via peripheral devices and individualised health interviews. All management decisions are made in partnership with their GP for clinical governance.

Aim: The telemonitoring program aims to facilitate coordinated care delivery through closer collaboration between the patient/carer, treating GP, LHD community services and disease-specific specialist/team. As well as improve support and rapid access to care in the community, manage multi-morbidities, encourage self-management, increase health literacy—disease signs and symptoms—and improve clinical outcomes.

Population: The original cohort for the telemonitoring project in Wollondilly were advanced stage COPD patients.

Timeline: Established in 2015 and sustained since.

Highlights:
• Improved patients’ understanding of their condition
Patients involved in their own care and over time have better identified their risk status. Patients are able to better recognise symptoms of their condition and know what to do to self-manage. With confidence that patients can self-manage at home, the program has reduced carer burden, enabling them to undertake activities outside the home (e.g. shopping).
• Patients’ needs are identified, assessed and managed in a caring, effective manner meeting patients’ needs
This is the first telemonitoring program in NSW that has implemented patient reported experience measures (PREMs). PREMs outcomes demonstrate that the program improved quality of life, increased patient confidence to self-manage their chronic condition, and enabled timely, easy to understand information or advice from health professionals.
• Reduced hospital admissions and length of stay (LOS)
Chronic disease-related hospital admissions have decreased by 35% and LOS for chronic disease have decreased by 34% based on a year-to-date comparison to June 2019.

Sustainability/Transferability: The telemonitoring model of care has been successfully expanded to other LGAs in South Western Sydney. It now also includes other chronic conditions, such as heart failure and diabetes.

Telemonitoring transitioned as part of the Primary and Community Health suite of care delivery through the Integrated Care for Patients with Chronic Conditions program.

Discussion/Lessons:
• Need for greater communication between client/patient, carer, Telemonitoring Clinical Coordinator and GP
• Increased GP engagement between a patient and their usual GP
• Role of the Telemonitoring Clinical Coordinator as essential to enable appropriate referrals to the program and ongoing care support.
• Suitability of cohort (to include patients at earlier stages of chronic conditions) for a sustainable initiative.

Conclusion: This model of telemonitoring provides a patient-focused approach with the GP as key stakeholder and integration across different sectors of the health system.

Introduction:
CSIRO has undertaken numerous investigations into the efficacy of new, technology supported, integrated care models for chronic disease management. Aims of these trials have been to make care personalised, flexible, objective, accurate and timely; for cardiovascular disease, diabetes, chronic obstructive pulmonary disease and chronic kidney disease. Feasibility and proof of concept studies, to comprehensive trials, have been conducted to gather evidence for new care models. Some have been scaled-up for implementation in business-as-usual settings to evaluate its effectiveness in practice. This abstract outlines the learnings, highlighting aspects that are mandatory for success when transitioning from controlled conditions to routine care, and the impact of funding policy that facilitate collaborative care.

Methods: Selected studies
a) A range of m-Health care models utilising smartphone apps and web-based clinician access, to remotely record and share patient health measurements, and to deliver motivational and educational multi-media materials to patients. Patient data is regularly accessed by carers to monitor progress, set goals and provide guidance.
b) Telemonitoring Trial designed to demonstrate how home-telemonitoring can be deployed nationally. The intervention was the provision of telemonitoring equipment for monitoring and sharing vital signs, and the administration of questionnaires.
c) Pilot program by the Victorian Department of Health and Human Services (DHHS) called HealthLinks Chronic Care, a new funding policy designed to provide capitation funding to hospitals, enabling collaborative integrated care.
The objective of this abstract is to highlight areas for improvement and enablers for technology supported, integrated models of care.

Results:

Enablers: high clinician/service provider acceptance, efficient service delivery, leadership support, communication and branding, holistic approach to patient care, adequate skills and training.

Areas for improvement: not having dedicated, allocated and trained staff, technology setbacks, ineffective incentive models, inability to provide assurance of patient privacy and security measures, lack interoperability with clinical systems, and change management.

Discussions & future research:
In almost all the mentioned studies/trials, the technology was well accepted by patients. The technology was also well accepted by the service providers where we had motivated clinicians and/or mentors/care coordinators. However, from an implementation and scale-up perspective, the key areas for improvement were at the service provider level. Important success factors to consider for future programs are timely resolution of issues, strong leadership, extensive training programs aligned with workplace culture and decision support tools to identify patient deterioration.

Conclusions & lessons learned:
Implementing successful technology supported, integrated care models into routine practice requires a pragmatic and learning culture. Where organisations are willing to try, change and adopt evidence-based care models into routine care. However, when implementing these care models, it is important to priorities patient safety and staff wellbeing during scale-up. Furthermore, an incremental scale-up plan underpinned by a thoroughly designed Evaluation Framework enables a ‘Learning Health System’ and the ability to significantly re-align, train, develop, promote and reinforce new behaviours in uptake of evidence-based practices into routine care. This encourage ownership by frontline staff, ability to manage funding sustainably, maintain expectations and increase successes.

Under the NSW Integrated Care Strategy, the NSW Government has committed $180 million over six years to implementing innovative and locally led models of integrated care in NSW[1], with wide variation in care models and target populations across 17 sites spanning the state. The challenge is to identify successful programs at each site, and scale them up across the state, with information provided to different Local Health Districts to help them choose the right program to meet the needs of their local population.

Methods
The study comprised all IC sites for which at least 18 months of post enrolment data was available (13,000 patients across 12 sites). Using an interrupted time series design, we evaluated year-on-year differences in (1) the number of ED visits, and (2) length of stay for hospital admissions, for each patient, across a 6 year period – 4 years before and 2 years after (pro rata adjusted) the enrolment date as point of reference. Year-on-year differences, as a self-referential metric for individual patients afford a more direct measure of efficacy in a heterogeneous cohort setting.

For inferential confidence, we used propensity score matching to establish an equivalent comparison group for each of the program cohorts using Admitted Patient and Emergency Department Datasets, the Registry of Births and Deaths , as well as socioeconomic and geographic information provided by the Australian Bureau of Statistics for the population of NSW.

Results
We were able to identify successful programs where patients had a significant reduction in ED presentations and / or Hospital stays measured relative to their comparison group. In each case we quantified the reduction in service utilisation.

For successful programs, we have produced algorithms which can separate those patients who will benefit from the program and those who will not, to support clinical decision making for future patient selection and enrolment.

Finally we have used these algorithms to show in advance the patient populations across NSW, who are likely to benefit from each of the programs earmarked for scale-up. We have built an R/Shiny software based dashboard to help communicate this information to partners and stakeholders.

Conclusion
We have created an evidence based, state wide approach to implement IC which takes proven programs, scales them up, and enables each locality to choose those which best meet needs of their population.

[1]http://www.health.nsw.gov.au/integratedcare/Pages/default.aspx