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healthAlliance Care Connect - A National Health Shared Care Plan Program
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healthAlliance Care Connect - A National Health Shared Care Plan Program

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Sarah Tibby

Sarah Tibby
Programme Manager
healthAlliance
(Thursday, 1.00pm, Opus International Room)

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  • Care is collaborative, starts with the patient/whanau’s issues and leads to truly patient/whanau centred care Care is optimally integrated and coordinated across general practice, hospital, specialist and community services and teams Shared decision-making occurs regularly with increased transparency & accountability to patients An understanding of health literacy underpins all communication to ensure it is truly two way, clear, timely and in ways patient can understand. Same-page care - 12 month planned, proactive care plan anticipatory & responsive to differing needs over time all healthcare team members use the same plan!
  • it is important to note that it is unlikely that any one programme alone will provide the maximum potential benefit unless there is seamless integration within our healthcare system in New Zealand. Shared care is one mechanism by which to provide this integration.
  • Everyday activities like digging the garden, growing his own vegetables and walking around the block have given 72-year-old Tomoavao Wichman a new lease on life. The turning point came when Tom and Mangere Family Doctors practice nurse Donna Snell created a shared care plan for all his long-term conditions. "I've got diabetes, I've got cancer, and you name it I've got it. When you've got these conditions the light in the tunnel goes off. But when I talked to Donna and made a plan the light started coming back on, it was fantastic. If you just sit back and say 'that's it for me, I'm a goner,' well you will be. But if you plan to get up and go for a walk next week, well then you will, your mind will be ready,” says Tom. Tom also appreciates not having to repeat his story, not having unnecessary tests and not being the ’go-between’. "Donna is more like a coordinator. We talked about my medications, the different clinics I go to and the specialists and I told her I was worried about all the different drugs reacting together. She checked this out with the chemist and put in all in my record."
  • Figure 1 demonstrates the user growth and uptake trend across all participating healthcare organisations over time. The blue bars only count those active provider users who have logged in the system on at least three days, including the general practices’ PMS account counted as one user. The red bars count those who logged in the system once or twice so far. And the green bars count patient users logging. Comparing the number of login days on which any provider activities are correlated to a patient (e.g., creating or viewing patient records) with the total number of days since the patient was enrolled onto CCMS, the average active days over enrolled days is 12%.
  • Between Feb 2011 and 30th September 2012, 468 tasks have been created in CCMS by 61 provider users regarding 169 patients; 337 (72%) of these tasks have been modified by 56 providers (not excluding the task creators themselves) and 4 patients. There is a skew in the Task creation activities as one general practice nurse created 133 tasks (28%) in the system. The top five task creators (all general practice nurses) have created more than half of all tasks by 30 th September 2012.
  • On 30 th September 2012, 137 patients (49%) have care plans recorded in CCMS. (This only counts meaningful care plans, i.e. not the leftovers from templates.) These care plans were initiated by 30 individual healthcare providers from 21 organisations, including 15 general practices (18 practice nurses and five GP), five DHB services (three secondary nurses, two district nurses, and one physiotherapist) and one pharmacy (one pharmacist). Figure 2 further breaks down the care plan creation activities by month, which appears to not have surged along with the increase of new patient enrolment numbers each month. The care plan creation activity peaked in October 2011 with 17 plans initiated in the month, at which point eight general practices, four DHB services and three community pharmacies had started participating in the pilot. The care plan creation activity does not seem to have exceeded this level in the next twelve months, despite the involvement of another fourteen general practices, one PHO, fourteen DHB services, and five pharmacies.
  • From August 2011, DHB hospital providers are able to access SCP enrolled patients’ summary record page within Concerto. This summary page has patient’s basic information such as diagnosis, medication, allergy and primary care plan. The CCMS Audit log has 245 entries regarding access to 56 patients’ summary record page by 73 distinctive login UserIDs who are all affiliated with DHBs. Figure 4 examines the monthly Summary Record viewing by DHB providers. Note that the first month recorded possibly testing activities as they have not identified relevant NHI.
  • Shared care is complex and multi-faceted; it requires significant efforts to implement Evaluation findings to date, have highlighted The creation of clear governance framework is essential to ensure sustainability and ongoing buy-in Understanding and informing the medico-legal processes as SCP progresses An iterative approach to review and monitoring processes for privacy & security is needed as SCP challenges traditional models Understanding different funding models to support sustainability and maximise value proposition
  • Evaluation findings to date, have highlighted that there is a need to have clear direction for Mapping and understanding current clinical workflows to see where the touch points for change are Determining a shared model of care from multi perspectives Identifying the commonality's of care planning across the health sector Determining the value proposition for health and consumers Key steps to maximising the work flow of shared care against current work processes Understanding expectations of communication, coordination across multi organisational teams Understanding expectations of accountability
  • The need for an on-going iterative approach and review of the technology that reflects learning's Understand value of Patient Portal Explore the patient role and establish broader experiences with patients Understand the links to patient contribution to the shared care record through online input into the Patient Portal and wellbeing Value of the Patient Portal in clinical Undertake a usability study Software Focus is essential Confirm utility and outcomes from Intra-team communication Link in with existing activities to maximise efforts for common areas e.g. Medication lists How SCP and software enhances the SC paradigm vs referral paradigm

healthAlliance Care Connect - A National Health Shared Care Plan Program healthAlliance Care Connect - A National Health Shared Care Plan Program Presentation Transcript

  • healthAlliance Care ConnectTo deliver outstanding shared services that enable healthcareexcellence for the Northern Region’s population.
  • PurposeThe New Zealand National Shared Care PlanningProgramme (NSCPP) is an clinically led IT-enabledapproach to address the growing problems of•ageing population,•more chronic conditions•fragmented general and specialist care. To deliver outstanding shared services that enable healthcare excellence for the Northern Region’s population.
  • 3 Concepts to improvingHealth Outcomes• Shared access to common information by care providers• Integrated care planning and communication across multidisciplinary teams• Using technology as an enabler To deliver outstanding shared services that enable healthcare excellence for the Northern Region’s population.
  • What does Technologyprovide?The technology provides a shared care record andcoordination capability, including careplans, messagingand task assignment, for multidisciplinary care teams.•Integration with general practitioner’s (GP’s) PracticeManagement System (PMS) and browser access toshared record for community-based providers, hospitalproviders and patients. To deliver outstanding shared services that enable healthcare excellence for the Northern Region’s population.
  • GoalEnable a patient-centred approach to care irrespectiveof the current care provider. To deliver outstanding shared services that enable healthcare excellence for the Northern Region’s population.
  • Shared Care - Overview• Enables sharing of summary health information and improved communication between shared care team members across Primary, Secondary and Community health providers• Patients with LTC benefit from a patient centred care plan developed in partnership with their care team, improving co-ordination of care and communication• Patient access to own record To deliver outstanding shared services that enable healthcare excellence for the Northern Region’s population.
  • Key Principles of Shared Care• Patient/whanau centred• Collaborative, integrated• Partnership based shared decision-making• Self-management support• Incorporates behaviour change methodologies• Interdisciplinary teamwork• Same-page careTo deliver outstanding shared services that enable healthcareexcellence for the Northern Region’s population.
  • Expected Benefits• Reduced delay in treatment decisions – info 24/7• Improved safety, quality of care, communication, coordination & interdisciplinary teamwork• Reduction in readmissions• Patients - increased independence and sense of control• Increase in virtual consults, case-review & follow-up• Improved crisis management, reduced ED visits• Potential to reduce medication errors & improve quality of care and safety To deliver outstanding shared services that enable healthcare excellence for the Northern Region’s population.
  • Key Components• Generic care planning approach that enables care coordination & case management• Clinically-led• Change management specialists• Quality improvement framework• Patient portal• IT platform that integrates information across system to enable new models of care To deliver outstanding shared services that enable healthcare excellence for the Northern Region’s population.
  • Shared Care - Progress• >400 patients enrolled• >40 patients using the patient portal• Additional secondary and allied health teams• Increasing general practice numbers to encompass both urban and rural shared care• Linking patient identification to various initiatives – 20,000 unplanned hospital admissions – Patients at Risk of Readmissions – Pharmacy services agreement – Localities To deliver outstanding shared services that enable healthcare excellence for the Northern Region’s population.
  • Our Stories – Botany ClusterPrimary Driver = 20,000 Bed Days•Using Shared Care as the tool to link: – 4 EastHealth GP practices – 4 pharmacies – Howick Home Health Care team – VHIU & PARR CMDHB patients – Secondary teams: Renal, Rheumatology, Diabetes, NASC, Community geriatrics To deliver outstanding shared services that enable healthcare excellence for the Northern Region’s population.
  • Our Stories – Grey LynnPrimary Driver = PARR•Using Shared Care as the tool to link: – Heart Failure service – Grey Lynn GP practice – Grey Lynn pharmacies x 2 – 38 patients enrolled To deliver outstanding shared services that enable healthcare excellence for the Northern Region’s population.
  • Our Stories – Coast to CoastPrimary Driver – Rurality, Primary Secondaryintegration and communication•Using Shared Care as a tool to link: – 6 rural practices and pharmacies – LTC WDHB patients – Secondary NSH diabetes with satellite clinics – Virtual consults through secure communications To deliver outstanding shared services that enable healthcare excellence for the Northern Region’s population.
  • Our Stories - TomTo deliver outstanding shared services that enable healthcareexcellence for the Northern Region’s population.
  • Overview ScreenTo deliver outstanding shared services that enable healthcareexcellence for the Northern Region’s population.
  • Summary Data in ConcertoTo deliver outstanding shared services that enable healthcareexcellence for the Northern Region’s population.
  • Patient PortalTo deliver outstanding shared services that enable healthcareexcellence for the Northern Region’s population.
  • NIHI Evaluation LogicTo deliver outstanding shared services that enable healthcareexcellence for the Northern Region’s population.
  • Findings in BriefTechnology: User growth pattern To deliver outstanding shared services that enable healthcare excellence for the Northern Region’s population.
  • Social: Tasks assigned by roleTo deliver outstanding shared services that enable healthcareexcellence for the Northern Region’s population.
  • Outcome: Care Plan DevelopmentTo deliver outstanding shared services that enable healthcareexcellence for the Northern Region’s population.
  • Technology: Summary page viewing To deliver outstanding shared services that enable healthcare excellence for the Northern Region’s population.
  • NIHI Recommendations:PolicyShared care is complex and multi-faceted; it requiressignificant efforts to implementEvaluation findings to date, have highlighted – The creation of clear governance framework is essential to ensure sustainability and ongoing buy-in – Understanding different funding models to support sustainability and maximise value proposition – Understanding and informing the medico-legal processes as SCP progresses – An iterative approach to review and monitoring processes for privacy & security is needed To deliver outstanding shared services that enable healthcare excellence for the Northern Region’s population.
  • NIHI Recommendations: Implementation• Evaluation findings to date, have highlighted that there is a need to have clear direction for – Mapping and understanding current clinical workflows to see where the touch points for change are – Determining a shared model of care from multi perspectives – Identifying the commonalities of care planning across the health sector – Key steps to maximising the work flow of shared care against current work processes – Understanding expectations of communication, coordination across multi organisational teams – Understanding expectations of accountability To deliver outstanding shared services that enable healthcare excellence for the Northern Region’s population.
  • NIHI Recommendations:Technology• The need for an on-going iterative approach and review of the technology that reflects learnings• Understand value of Patient Portal – Explore the patient role and establish broader experiences with patients – Understand the links to patient contribution to the shared care record through online input into the Patient Portal and wellbeing• Software Focus is essential – Confirm outcomes from Intra-team communication – Link in with existing activities to maximise efforts for common areas e.g. Medication lists To deliver outstanding shared services that enable healthcare excellence for the Northern Region’s population.
  • Current Focus• Care Planning • Keep refining tools and process• Patient Portal • Interaction with their Care Plans, resource library available, and messaging between patients and care team members.• Pharmacy Engagement • Increase the engagement and activity for pharmacist and test the feasibility of program to enable Medicines Management Plans• Loading stratified patients in Shared Care
  • Transition to June 2013• A tool that enables the community pharmacy services agreement• Enhance clinical integration with members of Multidisciplinary teams in localities• Enable current DAP deliverables with reference to National Health Targets, clinical integration and Northern Region Heath Services Plan Clinical Networks• Continued technology refinement• Continue to reflect on evaluation findings to shape direction To deliver outstanding shared services that enable healthcare excellence for the Northern Region’s population.
  • Contact• eMail: info@sharedcare.co.nz• Website: www.sharedcareplan.co.nz• Programme Manager: Sarah Tibby• Evaluation: GaylH@adhb.govt.nzAcknowledgments• The evaluation study was funded by the New Zealand National IT Health Board. We extend our thanks to all the users, patient participants and their families, project team members, software vendor team, steering group members and all the stakeholders interviewed to date for accommodating our study. We extend our thanks to the metro Auckland DHBs & NHITB for funding this project over the last 2 years