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

1. Shared Care Plan TrialsProgress to Date Associate Professor Rob Doughty ADHB

2. Doctors are driven by science

4. Developing a person centered view of care

5. Enabling clinicians to be supported by common information sources

7. Feel disempowered & frustrated by the system

8. Tired of repeating their story multiple times & repeated tests due to lack of timely info

10. Duplication of investigations & services

11. Reactive rather than offer proactive care

12. Increased presentations to emergency/secondary services

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

31. SocialHealth professionalsPatients & family / carer

32. TechnologyArchitectureFit with clinical practiceIntegrationPerformance

34. Over time, information that is recorded against the care plan becomes part of the electronic health record