SCAMPI: Self-Care Advice, Monitoring, Planning and Intervention

In order to relieve pressure on an increasingly overstretched NHS, there is an ever-growing need to deliver more efficient, effective, patient-centric care in the community. New intelligent healthcare technologies have the potential to deliver this care relieve the pressure, in the form of simple-to-use digital technologies in people's home that support self-care and reduce the need for routine interventions from healthcare professionals.

Therefore, the SCAMPI consortium will develop a new form of computerised toolkit that will allow someone living in their own home with a chronic condition, together with their relatives, carers and healthcare professionals, to self-manage both their care of the condition and life with it. People will interact with the new toolkit through a new form of intelligent visual care plan, called VIZ-CARE. Any care plan is a documented agreement between a patient and healthcare professionals about the patient's care goals and qualities to maintain or work towards, and the desired services, medicines, and activities such as eating, exercising and socialising. SCAMPI's new form of care plan will be visual, natural and simple-to-use, enabling a person living at home with a chronic condition to customise their life and care according to their individual needs and preferences, with pro-active support for thinking about important care goals and qualities, as well as the means to achieve those goals and qualities. The person using VIZ-CARE will also be able to share the plan with named relatives, their carers and targeted healthcare professionals such as specialist nurses and their GPs, and make joint decisions about customising the care plan so that the person's needs can be met more effectively, even when these other people are elsewhere, using web technologies.

Moreover, the visual care plan will update regularly with care-specific feedback from discrete and cost-effective sensor devices placed around the person's home. Using the available data from these sensors as input to different artificial intelligence algorithms, a person's visual care plan in VIZ-CARE will indicate the degree to which the care goals and qualities of the person as specified in the plan are being achieved, and if needed, flag potential risk indicators along with care recommendations when a goal or quality is not being achieved. For example, to monitor planned daily activities such as a 20-minute local walk, VIZ-CARE will collect data not only about walking using a device such as a pedometer, but also about life and care qualities specific to the person and dependent on good hydration associated with walking about weight loss (from scales), movement in the home (to detect disorientation), kitchen temperature (to detect food consumption), loss of energy (from bed sensors) and water usage (from tap meters), and generate risks warnings if needed. This intelligence-led feedback is predicted to support self-care and reduce the need for routine interventions from healthcare professionals in the management of chronic conditions.

To develop and evaluate this new computerised toolkit, leading researchers in computer science, the health sciences and digital business at City University London have joined forces. The team will develop the first version of the toolkit to support with people with two conditions - dementia and Parkinson's disease. And to engage people with these conditions, their families, carers and disease experts in the co-design and evaluation of the toolkit, the researchers will work closely with the Alzheimer's Society and Parkinson's UK.

Moreover, to maximise impact from SCAMPI, the team will work with 6 London-based Care Commissioning Groups (CCGs) - Sutton CCG and the CWHHE Collaborative of 5 CCGs. Digital entrepreneurs Evalucom Consulting will seek to commercialise the research results so that the elements of the toolkit can be made quickly and widely available.

Computer science research will benefit from new scientific contributions to several of its sub-disciplines - to health informatics, a first computational model of care qualities that will be general rather than disease-specific; to requirements engineering, new uses and insights of advanced goal modelling representations and techniques; and to human-computer interaction, new visual languages for untrained users to interact with intelligent systems. To health service research, the computational model of care qualities will introduce new level of abstraction and precision with which to challenge and evolve existing care indicator frameworks developed in social care. Both the toolkit and standalone elements of it, such as the VIZ-CARE care planning tool, will provide health service researchers with more advanced technologies to evaluate in new clinical trials. It is also anticipated that new care practices, techniques and guidelines can be distilled from the toolkit, and introduced into care practices. Examples of these practices include visual care planning with digital drawing tools, improved care quality indicators framed in questionnaires, and more effective shared decision-making procedures. Business and management research can benefit with new business models to describe, explain and prescribe more effective digital innovation and diffusion, both in health care and social care and more widely. It can also benefit from validation of existing models and taxonomies in a new domain - integrated health and social care.

Future end-user communities can also benefit from the research. People with chronic health conditions such as dementia and Parkinson's disease who use the toolkit and its spin-offs will receive new capabilities to manage their care to their needs and preferences, to contribute to better quality of care received and happier lives. Improved self-care can reduce and/or delay hospital admissions that can be stressful and damaging to health - hospitalised people with Parkinson's have a prolonged stay, poor motor outcomes, infections, prescription errors and increased post-operative mortality, as well as are more likely to have repeat hospital admissions. Informal carers and the relatives of people with chronic health conditions can also benefit from the improved health to the wellbeing of people who are able to manage their own health at home. Their increased participation in shared decision-making about care will improve their understanding of a chronic condition and empathy of life with it.

Organisations that seek to improve the lives of people with chronic healthcare conditions, such as the Alzheimer's Society and Parkinson's UK, can also benefit through improved access to new thinking about dementia and Parkinson's. For example, the use of objective sensor data about daily life with a condition can be used to support others in similar circumstances to manage their own care. More generally, the strategic participation in co-design activities will offer new insights into what advanced digital technologies can offer to chronic care, and spawn new opportunities. Clinical Commissioning Groups that commission patient health and social care, such as the CWHHE, can refine their own care quality indicators and monitoring practices based on the new computational model. Furthermore, over time, these Clinical Commissioning Groups can mandate the use of new frameworks to improve patient safety and quality of services that patients receive from providers, thereby delivering better quality care. And as the CfP argues, the NHS can also benefit from reduction in the pressure of its services that can arise from the widespread uptake.

Digital innovators such as Evalucom Consulting will be able to build on SCAMPI's intelligent technologies, models and algorithms to disrupt the healthcare technologies market and deliver new products and services that will benefit it, similar SMEs and the UK's digital innovation sector.