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Shared Care Plan Trials - Progress to Date
Shared Care Plan Trials - Progress to Date
Shared Care Plan Trials - Progress to Date
Shared Care Plan Trials - Progress to Date
Shared Care Plan Trials - Progress to Date
Shared Care Plan Trials - Progress to Date
Shared Care Plan Trials - Progress to Date
Shared Care Plan Trials - Progress to Date
Shared Care Plan Trials - Progress to Date
Shared Care Plan Trials - Progress to Date
Shared Care Plan Trials - Progress to Date
Shared Care Plan Trials - Progress to Date
Shared Care Plan Trials - Progress to Date
Shared Care Plan Trials - Progress to Date
Shared Care Plan Trials - Progress to Date
Shared Care Plan Trials - Progress to Date
Shared Care Plan Trials - Progress to Date
Shared Care Plan Trials - Progress to Date
Shared Care Plan Trials - Progress to Date
Shared Care Plan Trials - Progress to Date
Shared Care Plan Trials - Progress to Date
Shared Care Plan Trials - Progress to Date
Shared Care Plan Trials - Progress to Date
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Shared Care Plan Trials - Progress to Date

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Associate Professor Rob Doughty …

Associate Professor Rob Doughty
Auckland DHB
National Health Shared Care Plan Programme

Published in: Health & Medicine
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  • focus on patients active in self-management and involved in other long term care initiatives
  • GP accesses shared plan and record through PMS
  • Transcript

    • 1. Shared Care Plan TrialsProgress to Date
      Associate Professor Rob Doughty
      ADHB
    • 2. Doctors are driven by science
    • 3. National Share Care Plan Programme
      Requirement:
      • Collaborative approach for all care providers supporting people with Long Term Conditions
      • 4. Developing a person centered view of care
      • 5. Enabling clinicians to be supported by common information sources
      • 6. A comprehensive & coordinated care plan
    • Current Situation
      Patients
      NHC Report 2007 – consumers experience:
      • Poor coordination / communication
      • 7. Feel disempowered & frustrated by the system
      • 8. Tired of repeating their story multiple times & repeated tests due to lack of timely info
      • 9. Experience errors & fragmented care
    • Current Situation
      Health System
      • Inefficiencies (clinicians 1-2 hrs/day chasing info)
      • 10. Duplication of investigations & services
      • 11. Reactive rather than offer proactive care
      • 12. Increased presentations to emergency/secondary services
      • 13. Reduced job satisfaction & retention
    • What is a Shared Care Plan?
      A structured plan:
      • Defining mutually agreed problems, goals, actions, timeframes and accountabilities for all involved
      Promoting personal responsibility, increasing patients’ confidence and active participation in their care
      • Enabling a multidisciplinary health care team to access a common set of clinical information.
      • 14. Integrated with the systems and portals that the providers, and the patient, are using as part of their daily activities
    • SCP Programme Objectives
      To learn about how to do it, measure the benefits and understand the barriers
      To identify a candidate solution(s) and core components of a care plan for regional and national consideration
    • 15. SCP - Anticipated Benefits
      Increased patient involvement in managing their care
      Increased safety & quality
      Improved visibility of care
      Improved efficiency, with better use of health resources
      Improved relationships & satisfaction
      Improved communication & workflow
      Improved health benefits to the individual
    • 16. Progress to Date
      National Requirements
      Project definition / governance / funding
      EoI based selection of preferred supplier: HSAGlobal
      Implementation Planning Study
      Steering Group Endorsement
      3 Pilot projects proposed
      Finalising details prior to kick off pilots end Feb
      Proof of Concept live 21 Feb
    • 17. Proposed Pilots
      Strategy
      Build on current initiatives where services already have processes and relationships that are orientated towards shared care
      Local ownership involving hospital and non hospital based care providers and patients
    • 18. Waitemata PHO locality based primary providers (GP practices and community based Allied Health providers and Community Pharmacy) – location being determined
      Primary care entry are patients that meet the CarePlus criteria
      ED and hospital based care teams engaged initially for those patients with respiratory diagnosis who attend the AIRS service
    • 19. Proposed PHOs Alliance Health+ and Procare – focus on Mangere GP practices and community based Allied Health providers and Community Pharmacy
      Primary care entry are patients that meet the CarePlus criteria
      ED and hospital based care teams engaged initially for those patients with Metabolic Syndrome
    • 20. Procare PHO GP Practices with high follow up rates for Care Plus reviews and community based Allied Health providers and Community Pharmacy
      Primary care entry are patients that meet the CarePlus criteria
      Hospital based care teams engaged
      – Pilot starts with Proof of Concept (21 Feb go-live)
    • 21. Proof of Concept
      Goals
      implement Shared Care Management solution (CCMS) in limited setting to prove model and learn
      Scope
      5-10 patients with diagnosis of Heart Failure in 1 GP practice – Grey Lynn Family Medicine Practice
      interacting with ADHB Heart Failure Service
      potentially extending to 1-2x Community Pharmacy for 3-4 months
      Integration
      2-way data exchange between GP PMS (MyPractice) and CCMS
      Workflow
      selection, enrolment, review and assess, plan care, deliver care, review
      Plan
      electronic and dynamic for clinical team, paper for patient initially
    • 22. Proof of Concept
      GP/ PN access shared plan and record via PMS
      Systems continuously synchronised
    • 23. Proof of Concept
      Patient-centric Care plan - goals, actions, tasks, status
      Based on Heart Foundation guidelines
    • 24. Proof of Concept
      Secondary care team access common information to inform plan and decisions (meds, diagnosis, notes, tasks, alerts etc)
      Stand-alone for POC, then through Concerto for pilots
    • 25. Proof of Concept
      Full ad hoc reporting capability – eg primary-secondary activity
    • 26. Proof of ConceptExpected Benefits
      Patient involvement in planning and common plan with all providers
      Communication improved within team (includes patient):
      Know who is doing what, when
      Common meds list, action list, problems
      “virtual consult” request and fulfillment e.g. request for meds change, request for secondary consult
      Team can be mobile/ distributed and still share
      Full reporting of “shared” care delivery
    • 27. Programme Governance
      Programme Steering
      Group
      Programme Team
      DHB
      Reference
      Forum
      DHB
      Reference
      Forum
      Pilot Project
      Team 1
      Pilot Project
      Team 3
      Pilot Project
      Team 2
      DHB
      Reference
      Forum
      Clinical/ Consumer ‘consistency’ Panel – Wider Programme Team
    • 28. Risks
      Technical
      Can it work technically
      Social
      Will it work in the real world; impact on Clinical Workflow
      Workforce
      Will changes be required in the workforce (e.g primary care Nurse Practitioner)
      Economic
      What business models are needed to enable uptake (quality target incentives)
    • 29. Programme evaluation
      National Institute for Health Innovation contracted by NHITB
      Interim Report Exploratory Phase
      Report at end of Phase 1
      Final Report end of Phase 2
    • 30. Evaluation Report
      4 domains
      • OutcomesOrganisationalPartnershipsEquityQuality & safetySystems
      • 31. SocialHealth professionalsPatients & family / carer
      • 32. TechnologyArchitectureFit with clinical practiceIntegrationPerformance
      • 33. EconomicSuitable for NZ environmentScalableROI
    • It is nota Shared Electronic Health Record
      An Electronic Health Record is a longitudinal record of past health activity
      • A Care Plan is an active multi-disciplinary dynamic plan to manage the patient’s current condition(s)
      • 34. Over time, information that is recorded against the care plan becomes part of the electronic health record

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