A ‘Simple’ Way to Support General Practice to Improve Health Outcomes

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Presented by Jo de Lisle
Practice Solution Lead, Midlands Health Network

This presentation is accompanied by six video clips:
GPs giving feedback on Patient Prompts, Common Form, and Best Practice Intelligence





Nursing Liaison giving feedback on Patient Prompts and Common Form:

Published in: Health & Medicine, Business
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A ‘Simple’ Way to Support General Practice to Improve Health Outcomes

  1. 1. A ‘simple’ way to support general practice to improve health outcomes
  2. 2. Timeline Who are we ? 2009 Feb 2010 Aug 2012 Feb 2012 April 2012 Aug Midlands Health Network Midlands Health Network - a primary health care innovator and development company working on behalf of Pinnacle Incorporated. Midlands Health Network is owned by Pinnacle Incorporated, a network of nearly a hundred general practices across four DHBs. We are not-for-profit . Offices in Hamilton, New Plymouth, Gisborne and Taupo. 2012 Sept Jul 2012 Jul 2012 Jul 2012 2013 Oct BPAC Inc bestpractice is a decision support system for health professionals. bestpractice is owned and developed by Best Practice Advocacy Centre Inc (BPAC Inc) its an Incorporated Society and is a not for profit organisation with charitable status. BPAC Inc was formed in 1997 and is a joint venture between: University of Otago (Schools of Medicine and Pharmacy), and South Link Health (Health Management Service Organisation).
  3. 3. Timeline 2009 Feb 2010 Aug Approach The challenge was creating a toolset which would support the healthcare value cycle: 2012 Feb 2012 April 2012 Aug 2012 Sept 2009 Jul 2012 Jul 2012 Jul 2012 2013 Oct Support practices:  To provide the best possible care to their patient Use best practice standards To meet health targets Improve patient outcomes Integrated with the practice’s current systems and work flow: Support the PHO in monitoring achievement against health targets
  4. 4. Timeline 2009 Feb 2010 Aug 2012 Feb 2012 April 2012 Aug 2012 Sept Jul 2012 Jul 2012 Jul 2012 2013 Oct Lessons learnt Lesson 1: Don’t deliver too many new tools at once! Lesson 2: Combining systematic, structured and repeatable processes for delivery with a lean, efficient approach Lesson 3: Successful IT-enabled change is not just about teaching people how to use the tools Lesson 4: Every general practice is different!
  5. 5. Timeline eReferral Pilot 2009 Feb Waikato generic eReferral 2010 Aug 2012 Feb 2012 April 2009 – February Supports the electronic transfer of patient care from the general practice to other health providers 2012 Aug 2012 Sept Jul 2012 Jul 2012 Jul 2012 2013 Oct 2009
  6. 6. Timeline 2009 Feb 2010 Aug 2012 Feb eReferral rollout Waikato Train the Trainer Team Portal 2010 – August 2012 April 2012 Aug 2012 Sept Jul 2012 Jul 2012 Jul 2012 2013 Oct Enhancements eReferral to Waikato Hospital ED and Radiology with referral criteria and template reply functionality Waikato 2012 – February
  7. 7. Timeline eReferral roll out 2009 Feb Tairawhiti 2010 Aug 2012 - February 2012 Feb 2012 April eReferral roll out 2012 Aug 2012 Sept 2009 BOP DHB 2012 - April Jul 2012 Jul 2012 Jul 2012 2013 Oct eReferral to Emergency Department Tairawhiti DHB 2012 - April
  8. 8. Timeline eReferral User Group Created 2009 Feb All Midland DHBs Clinical and IS representatives 2010 Aug 2012 - July 2012 Feb 2012 April 2012 Aug 2012 Sept Jul 2012 Jul 2012 Jul 2012 2013 Oct eReferral roll out Lakes DHB 2009 2012 - August High Suspicion of Cancer Urgency introduced BOP DHB Tairawhiti DHB 2012 - August
  9. 9. Timeline 2009 Feb 2010 Aug eReferral to Mental Health Services and NGO’s Community: Podiatry, Pharmacy, Social work, Dietetics 2012 Feb Waikato DHB 2012 April 2012 - September 2012 Aug 2012 Sept Jul 2012 Jul 2012 Jul 2012 2013 Oct eReferral roll out Taranaki DHB Including Radiology – public and private 2012 - September
  10. 10. Timeline 2009 Feb 2010 Aug 2012 Feb 2012 April 2012 Aug 2012 Sept Jul 2012 Jul 2012 Jul 2012 2013 Oct eReferral uptake
  11. 11. Timeline 2009 Feb 2010 Aug 2012 Feb 2012 April 2012 Aug 2012 Sept Jul 2012 Jul 2012 Jul 2012 2013 Oct eReferral uptake
  12. 12. Timeline Patient Prompt - the need 2009 Feb 2010 Aug 2012 Feb 2012 April 2012 Aug 2012 Sept Jul 2012 Jul 2012 Jul 2012 2013 Oct Three of New Zealand Health targets are about prevention:  Increased immunisation  Better help for smokers to quit  More heart and diabetes checks The impact they make can be measured to see how they are improving health for all New Zealanders. 2009 The Patient Prompt was designed to assist busy health professionals to remind them of things that need to be completed when they have contact with the patient. The Patient Prompt module analyses the patient record at the time of consultation, providing notification of any areas where action may be required.
  13. 13. Timeline 2009 Feb 2010 Aug 2012 Feb 2012 April 2012 Aug 2012 Sept Jul 2012 Jul 2012 Jul 2012 2013 Oct Patient Prompt- 4 key areas Clinical reviews that are due or imminent CVD and diabetes Clinical data that is missing height, weight, blood pressure Clinical/lifestyle recommendations diet/exercise advice Clinical indicating action elevated HbA1c, not on insulin
  14. 14. Timeline 2009 Feb 2010 Aug 2012 Feb 2012 April 2012 Aug 2012 Sept Jul 2012 Jul 2012 Jul 2012 2013 Oct Patient Prompt- the impact Increased Immunisation All areas met the 85% national goal Lakes have improved 4% on March coverage Better Help for Smokers to Quit All areas have improved coverage since March Waikato have had the largest improvement since March (11%) More Health and Diabetes Checks All Midlands network areas are in the top half of NZ Lakes and Waikato met the target of 75% coverage by June 2013 Tairawhiti have had the largest increase in coverage since March (11%)
  15. 15. Timeline bestpractice intelligence (BPI) - the need 2009 Feb 2010 Aug 2012 Feb A business intelligence tool with up-to-date information on performance against NZ health targets and specific PHO targets. 2012 April 2012 Aug 2012 Sept BPI reports on progress against quality and health targets, allows visibility of achievement and enables practices to plan workloads. Jul 2012 Jul 2012 Jul 2012 2013 Oct It also helps to identify those patients that may otherwise fall through the cracks.
  16. 16. Timeline bestpractice intelligence- the need 2009 Feb 2010 Aug 2012 Feb 2012 April 2012 Aug 2012 Sept 2009 Jul 2012 Jul 2012 Jul 2012 2013 Oct Best Practice Intelligence (BPI) - provides practices with up-to-date and actionable information on performance against health quality targets
  17. 17. Timeline 2009 Feb 2010 Aug 2012 Feb 2012 April 2012 Aug 2012 Sept Jul 2012 Jul 2012 Jul 2012 2013 Oct bestpractice intelligence- the impact Increased Immunisation All areas met the 85% national goal Lakes have improved 4% on March coverage Better Help for Smokers to Quit All areas have improved coverage since March Waikato have had the largest improvement since 2009 March (11%) More Health and Diabetes Checks All Midlands network areas are in the top half of NZ Lakes and Waikato met the target of 75% coverage by June 2013 Tairawhiti have had the largest increase in coverage since March (11%)
  18. 18. Timeline Common Form - the need 2009 Feb 2010 Aug 2012 Feb 2012 April To support the Long Term Conditions Management Programme, The Common Form has been developed by bestpractice in association with Midlands Health Network. 2012 Aug 2012 Sept Jul 2012 Jul 2012 Jul 2012 2013 Oct This2009 module combines features from the Diabetes and CVD Management modules in a new design that emphasises speed and ease of use. It is a standards-based tool to assist clinical review, disease monitoring and clinical management
  19. 19. Timeline Common Form 2009 Feb 2010 Aug 2012 Feb 2012 April 2012 Aug 2012 Sept Jul 2012 Jul 2012 Jul 2012 2013 Oct 2009
  20. 20. Timeline Common form-the impact 2009 Feb 2010 Aug 2012 Feb 2012 April More CVRA and DARs in MHN practices average 10% increase in checks done in Q3 2012-13 relative to 2011-12 figures. 2012 Aug 2012 Sept Jul 2012 Jul 2012 Jul 2012 2013 Oct 2009
  21. 21. Timeline 2009 Feb 2010 Aug 2012 Feb 2012 April 2012 Aug 2012 Sept Jul 2012 Jul 2012 Jul 2012 2013 Oct Personal health planning tool – the need Care plans for patients with long term conditions: A means of improving patient’s health outcomes through better engaging patient in their care and understanding what they can do to help themselves. Screening questions to identify the patient’s broader health needs and preferences for care. These support clinician’s decision on whether to refer, plus discussion with patient on health goals for care plan. Shared assessment and health plan information between providers helps the care team to ensure that they are not duplicating activities.
  22. 22. Timeline Current work PHAP 2009 Feb 2010 Aug 2012 Feb 2012 April 2012 Aug 2012 Sept Jul 2012 Jul 2012 Jul 2012 2013 Oct 2009
  23. 23. Timeline 2009 Feb 2010 Aug 2012 Feb 2012 April 2012 Aug 2012 Sept Jul 2012 Jul 2012 Jul 2012 2013 Oct Lessons learnt implemented - PHAP Integrated with rest of BPAC toolset:  eReferral tool, accessible from PHAP, provides means for engaging other care providers in the patient’s care. They can view assessment findings, edit care plan and reply to eRef.  Common Form assessment findings displayed in tool as reference for clinician as he/she creates care plan.  Existing assessments including PHQ9 and audit Fit with practice workflow, and educational:  Tool’s design recognises the time pressures facing practices – use selected part or whole tool as part of extended consultation.  Houses validated screening tools, plus help resources relevant to the patient’s condition and circumstances.
  24. 24. Timeline 2009 Feb 2010 Aug 2012 Feb 2012 April 2012 Aug 2012 Sept Jul 2012 Jul 2012 Jul 2012 2013 Oct Lessons learnt implemented – PHAP Implementation approach:  Significant change management effort is being enveloped around the introduction of the tool.  Initial pilot to 10 practices over a 3 month period. This will identify ‘champions’ of 2009 the tool and define cases studies illustrating use in practice.  Training, with key speakers in the are of care planning, will explore the benefits of care planning and its fit into the practice workflow.  Train the trainer approach for tool roll-out.

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