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Mobile Assistance for Groups Individuals within the Community - STROKE REHABILITATION

Periodic Reporting for period 1 - MAGIC (Mobile Assistance for Groups Individuals within the Community - STROKE REHABILITATION)

Reporting period: 2016-01-01 to 2016-08-31

• What is the problem/issue being addressed?
During Phase Zero of the MAGIC-PCP the primary objective was to clarify and agree the ‘problem to be solved’ within the care of people post stroke and the following overarching project requirement was finalised. The key narrative was as follows:
“The MAGIC pre-commercial procurement (PCP) challenge is being conducted, on behalf of the Buyers Group, by the Regional Business Services Organisation (BSO), Northern Ireland.

The main goal of the MAGIC PCP challenge is to develop new, innovative technology based solutions that improve physical function and thus personal independence, within the first six months following the onset of stroke. These solutions are not yet on the market, but can be developed and tested within the MAGIC PCP period of 2-4 years. It is specifically designed to address current deficits in care for people following a stroke to empower them to maximise their recovery potential through rehabilitation in the home environment, without the need for additional staff resources.

Tenderers should aim to a market introduction of their new solution a maximum of 2-years after the end of the PCP. By 2020 the new solutions should make it possible to improve individual levels of autonomy at six months of the onset of stroke, determined through the application of the an internationally recognised metric, the Barthel index, which is a sensitive tool which measures activities of daily living and the Modified Rankin Score.”

In July 2016 a detailed report was submitted and accepted in October 2016 which explained in detail the stakeholder events and additional effort undertaken to refine the call and understanding of the problem to be solved. However, the stakeholder events articulated not only the wider societal needs but also the difficulties faced by individuals post stroke.

• Why is it important for society?
Stroke is a condition caused by obstructed blood flow to the brain. And it is the one of the largest causes of adult disability in the world. Every year it is estimated that approximately 15 million people world-wide suffer a stroke; of these, 5 million die and another 5 million are left permanently disabled, placing a burden on families and communities. Around 20% of stroke survivors are under the age of 65 and hence can be considered to be of working age.

Major risk factors for stroke are similar to those for coronary heart disease; with high blood pressure and tobacco use the most significant modifiable risks.

In Europe stroke is listed as the cause of death in 10% of men and 15% of Women According to the WHO (2002), statistics indicate that stroke is responsible for the loss of 7% of the total European population disability adjusted life years (DALYS) and thus presents a significant burden in respect of population morbidity and not just mortality. The demographic changes are such that health and social care systems are failing to keep pace with demand and are not fit for purpose. MAGIC Buyers Group contracting authorities have recognised a significant gap in the care associated with the recovery of patients during the first six months of the onset of stroke and the need for a new cost-effective way of meeting these needs.

Rehabilitation is one of the most important aspects of the care of patients following a stroke, and is proven to affect the eventually level of recovery and independence achieved. Community stroke services exist in Italy and in Northern Ireland that provide rehabilitation, support, lifestyle advice and risk factor reduction. Charitable organisations often provide a range of valued support services for stroke survivors and their carers’ in the community. When patients leave hospital very quickly after stroke to receive intensive rehabilitation in the environment of their own home it is called ‘Early Supported Discharge’ (ESD). This is usually for people who have milder disability after stroke and are able to move about unaided or with help of one person. All stroke survivors in Northern Ireland will receive a comprehensive review at six months after the stroke onset which includes the Barthel Index, which is score of functional independence.

There is strong evidence that the quality of care for patients who have sustained a stroke is sub-optimal within the MAGIC buyers group regions. There is evidence that the amount of therapy patients received is often sub-optimal in the community services. Often when additional therapy is needed after 12 weeks or after the standard six month review, it is difficult for patients to access this service. Community Stroke services are not widely available at the weekends this creates a deficit in the provision of intensive therapy.
The reason for this deficit in provision of care is primarily a lack of professional clinical staff and physical resources. For example, UK service standards indicate that patients referred to community stroke teams should be reviewed between one and three days after hospital discharge. However, the 2015 Post- acute Stroke National Audit found that patients in Northern Ireland may wait up to 5 days after discharge before contact is made by a community stroke team this situation is replicated across the Buyers Group regions. The rising costs of care, rehabilitation and fiscal constraint creates a real risk of a continuing shortfall in therapy provision, thus failing to optimise personal independence for stroke survivors. If personal independence is not optimised for stroke patients there is both detriment to the individual and to society through the economic cost of providing long-term care and support. As a consequence the MAGIC PCP is of critical importance to health economies by testing alternative and potentially cost effective methods of optimising the individuals’ recovery.

UK based research has shown that 49% of stroke survivors have unmet needs, including: mobility problems, falls, incontinence, pain, fatigue, emotional problems, reduced concentration, memory, sight, reading and speech difficulties. In NI audits performed against the UK service standards have identified the following areas where improvement is needed:
• Setting goals for rehabilitation in partnership with the patient
• Intensity of stroke rehabilitation which should be tailored to the patient’s needs
• Assessment of cognitive functioning
• Assessment of emotional functioning
• Swallowing therapy for survivors with dysphagia
• Return to work; work assessment, impairments to work performance,
• Long-term health and social support.
In Italy a lack of equipment to boost functional recovery or compensate for motor and communication impairment is a known deficit. When this background is linked to the increasing number of older people with co-morbid chronic disease suffering stroke the outlook is set to deteriorate from both socio-economic and human well-being perspectives if there is not a radical rethink of the system.

Timely access to rehabilitation is a key factor in the recovery for people who have survived a stroke. Therapy-based rehabilitation appears to improve independence in personal activities of daily living according to evidence based guidelines. The use of self-management approaches to help patients and carers better manage the life-changing impacts of stroke presents an opportunity to improve patient care in a cost effective way. It is important for potential solutions to be cost-effective in order to ensure they are accessible to the greatest possible number of service providers. However, there is no technological solution ready to deploy that will adequately address this problem. It is the combined analysis of the Magic buyers group that only an innovative use of technology can enable providers of stroke services to realistically meet the growing demands upon their services and provide optimal outcomes for stroke in Europe. .For these reasons there is clearly potential benefit within MAGIC regions to be achieved by enhancing the cost-effective provision of rehabilitation for this patient group through this innovation.
It is only through working in novel ways and by reengineering care delivery systems with new innovative technology solutions that we begin to think differently about our approach to stoke rehabilitation and thus improve the well-being of stroke patients across Europe. The MAGIC group seeks to achieve this specifically by optimising the recovery of physical function and personal independence in order to reduce the overall socioeconomic burden of this disease.

• What are the overall objectives?
The specific objectives of the MAGIC-PCP were directly shaped by the service users. Consultation with a range of stakeholders (clinicians, therapists, patients and families/ carers) about potential innovative solutions that might improve physical function and personal independence, in the first six months of stroke onset, has highlighted that they envisioned technology could provide a range of adjunct to the care processes.
• Provide rehabilitation and therapy in the environment of patients’ own home, to enable increased intensity and duration, within limited and existing staff resources.
• Offer individualised programmes that are tailored to the patient’s needs, focusing upon stroke recovery and prevention.
• Track patient progress, which can be shared with health care professionals and provide direct feedback to patient to encourage, motivate and reward progress and self-management.
• Complement and enhance existing services, enabling therapists to reach a larger number of patients and/or focus their time on those patients with greater needs.
• Be easy to use and adapt to patients’ changing needs and progress.
• Schedule reminders and prompts
• The following secondary benefits would also be welcomed by the buyers group.
• Reduced feelings of isolation and fostering of peer support
• Provision of support to informal carers
• Improvement in communication between health care professionals
• Improved access to information and support regarding stroke.
Through the Call for Tender documentation specific measurable objectives and milestones of the suppliers and of course, the Buyers Group have objectives to deliver project objectives, deliverables and milestones. To date all requirements have been delivered and required amendments submitted and approved. Over the next quarter, three deliverables and one required amendment are due for submission and delivered on time.
The MAGIC-PCP started work on the 01:01:17 with the ‘Kick-off’ event being held in Chieti, Italy during the week of 11:01:16. The inaugural meeting for each of the ‘project’s formal committees were undertaken; the Terms of References for each being agreed. In addition, the Project Execution Plan was agreed along with the clarification of roles and responsibilities, agreed deliverables, time line and the H2020 funded project MAGIC-PCP was shared with the local dignitaries and interested practitioners as Università degli Studi “Gabriele D’Annunzio” di Chieti-Pescara - Department of physical medicine and rehabilitation (UDA) hosted a large conference.
The project also had a clear schedule of deliverables to be achieved by month 8, albeit this timeline had to be compressed given our request to issue the PCP Call for Tender during month 8/ 9. All deliverables and milestones were achieved.
Within the context of all deliverables and milestones the most notable achievements are as follows:-
• The creation of the Project Execution Plan, establishment of project structure, constitution and governance of formal committees with associated Terms of Reference documents.
• The creation of a communication, engagement and dissemination plan along with the establishment of the Website
• The comprehensive engagement with service users, carers and clinicians to understand in detail the needs to be addressed by potential R&D suppliers.
• Updated the State of the Art including early engagement with industry through group & face-to-face meetings and an on-line survey monkey questionnaire accessed through the project website.
• Agreed, as a buyers group the Brief for the MAGIC-PCP; the real shared need to be addressed was articulated.
• Issued a Prior information Notice (PIN) for a 2-month period (April and May) alerting the market to the start of an Open Market Consultation (OMC) which was planned to be delivered over a 2-month period (June and July)
• In line with documents produced by the Commission the Framework Agreement for the PCP and the entire suite of PCP documents were written and approval given by the Commission.
• Call for Tender has been issued with the close scheduled for 09:12:16
• All questions submitted by potential tenderers have been answered both individually and published for all and there is under two weeks to close of tender (3pm GMT 09:12:16).
• All 60 clinical assessors have been briefed and should be given access to the submissions that have passed through the eligibility and compliance checks by the 16:12:16 in order to keep the project on track. The Assessors will score the bids and the ranked bids compiled in order for the Buyers group to ratify the award of tender on 16:01:17.
In summary, the project management within the MAGIC-PCP has been very tight and the team is delighted to report that although there have been some hurdles to overcome on the way, the project remains on track with well over 130 downloads of the call for tender (CfT) taken by potential bidders. Ergo, our communication and dissemination plan has also worked as the response has been unprecedented and the MAGIC team are hopeful of a successful outcome to the CfT.
State of the Art Review and Industrial Engagement
In order to fully understand the range of technologies that are currently available or in development, the MAGIC consortium carried out industrial engagement events in March & April 2016 in preparation for the MAGIC PCP; 4 face-to-face events were held in Italy and Northern Ireland with more than 100 participants from supplier and academic institutions involved. In addition, an online survey was undertaken to complement the face-to-face consultation, receiving 113 responses from 6 countries. The outcomes from the industrial engagements have been used to inform the development of the scope for the MAGIC PCP. These were to extend the State of the Art knowledge and help formulate the thinking within the Buyers Group with regard to opportunities to find a solution to the shared problems associated with post stroke rehabilitation.

A pie chart illustrating the range of solutions suggested can be reviewed within the PCP Call for Tender which demonstrates of the 113 organisations responded to the ‘Survey Monkey’ on-line Questionnaire. 97 participants replied to the question ‘What new or innovative techniques could be applied to address the MAGIC Project challenge?’ with 80 organisations suggesting possible solutions. These suggestions were then classified into overarching technology types. The technologies suggested were classified within the following groups:- Telemedicine, Hardware Devices, Hospital information Systems, Telerehabilitation, Biomechanical Assessment, Bid Data Analysis, Virtual Reality, Wearable Detectors, Sensors, Apps, Gamification, Robotics and Video Technology.

The industrial engagement did not form part of the Open Market Consultation (OMC) or part of the tender process and organisational identifiers were not shared with consortium members.

Of these, many technologies have potential to provide a solution either by a single application or by combining technologies in novel ways. Although the MAGIC Consortium is particularly interested in virtual reality, augmented reality, apps, remote connection between therapist, patient & carer, technologies to empower patients within the rehabilitation process through self-care, gamification, remote vital sign monitoring (beyond standard tele-care and telehealth) & robotics, other technologies will be considered if these meet the challenge outlined within this PCP. In addition, Consortium bids would also be welcomed to enable the novel combination of innovative technologies.