Shared Care Plan TrialsProgress to Date<br />Associate Professor Rob Doughty<br />ADHB<br />
Doctors are driven by science<br />
National Share Care Plan Programme<br />Requirement:<br /><ul><li>Collaborative approach for all care providers supporting...
Developing a person centered view of care
Enabling clinicians to be supported by common information sources
A comprehensive & coordinated care plan</li></li></ul><li>Current Situation<br />Patients<br />NHC Report 2007 – consumers...
Feel disempowered & frustrated by the system
Tired of repeating their story multiple times & repeated tests due to lack of timely info
Experience errors & fragmented care</li></li></ul><li>Current Situation<br />Health System <br /><ul><li>Inefficiencies  (...
Duplication of investigations & services
Reactive rather than offer proactive care
Increased presentations to emergency/secondary services
Reduced job satisfaction & retention</li></li></ul><li>What is a Shared Care Plan?<br />A structured plan:<br /><ul><li>De...
Integrated with the systems and portals that the providers, and the patient, are using as part of their daily activities</...
SCP - Anticipated Benefits<br />Increased patient involvement in managing their care<br />Increased safety & quality<br />...
Progress to Date<br />National Requirements<br />Project definition / governance / funding<br />EoI based selection of pre...
Proposed Pilots<br />Strategy<br />Build on current initiatives where services already have processes and relationships th...
Waitemata PHO locality based primary providers (GP practices and community based Allied Health providers and Community Pha...
Proposed PHOs Alliance Health+ and Procare – focus on Mangere GP practices and community based Allied Health providers and...
Procare PHO GP Practices with high follow up rates for Care Plus reviews and community based Allied Health providers and C...
Proof of Concept<br />Goals <br />implement Shared Care Management solution (CCMS) in limited setting to prove model and l...
Proof of Concept<br />GP/ PN access shared plan and record via PMS<br />Systems continuously synchronised<br />
Proof of Concept<br />Patient-centric Care plan - goals, actions, tasks, status<br />Based on Heart Foundation guidelines<...
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Shared Care Plan Trials - Progress to Date

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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
  • Shared Care Plan Trials - Progress to Date

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

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