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IT contributing to improving community-based models of care


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Presented by Sheree East
Nurse Maude

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IT contributing to improving community-based models of care

  1. 1. Health IT Innovation In PracticeThe Canterbury Story2013 HINZ Seminar SeriesIT contributing to improving community-basedmodels of careSheree East
  2. 2. Content• Nurse Maude• Collaborative IS developments in Canterbury• Health Information developments• Nurse Maude IS development
  3. 3. 115 years of community health care14000patients perannum40% over 8555% Multiplecomorbidities700000episodes ofcare
  4. 4. Nurse Maude Services (Canterbury)AvoidadmissionEnable earlydischargeDelay entryinto residentialcareSupportiveCommunitycareSelf care support Care ManagementHigh Complexity CareManagementSpecialistNursingAcuteDemandCREST DistrictNursingHomeCareTotal Care Longterm carePalliativeCareContinenceStomaWoundDiabetesInfusionNP Aged -CareSchoolHealthLiaison Case management Rest homeat Home40 bedhospitallevel agedcareSupportcareTertiaryHospiceCommunityteamRestorativePersonalCare &NursingGeneralistnursingDialysisPersonalCareDomesticAssistanceEducationEquipment Meals Laundry
  5. 5. Collaborative health IT solutions workingin primary and secondary care inCanterbury
  6. 6. CCMSCommunityProvidersPegasusHCSOPHSPOEGeneralPracticee-SCRV viewCareCoordinationPharmacyCanterbury’s Shared Views
  7. 7. Project CHAINCollaborative care programme• electronic case management program to enableinnovative workforce development and clinicaldelivery across Canterbury by sharing of careand clinical information, particularly for highneeds patients, between multi-disciplinaryteams.
  8. 8. CCMS - Single Source of Truth for Client ManagementHospitalInpatientOutpatient/ DayCentreMulti-discclinicResidentialFacilitiesCommunityNursing/MHW+GP ClinicAssociated to an EpisodeReferral management for relevant LTC Program(s), and Handoff of CareAssessment, Care Plan, Client DocumentationMeasurement and Results, Medication ManagementInfo from other Clinical Systems eg Disch Summary, Lab Result, Rad Reports, PrescriptionPortal forSelf MgmtPatientSpecific InfoFamily HealthInfoHome/WorkplaceReport Builder: for Health Org or Enterprise wide reportingCCMS – Client information managementplatformSMS Outreach
  9. 9. A new era in consumer health informationPoint-of-care technology + improved PMS systems = better data Better outcome measurement (Big Data opportunities?) Improved quality monitoring Increased sharing of health information across boundaries Increased consumer access to health information“The expert patient”De-medicalisation of care
  10. 10. Why share community level data?Identified problems, interventions and outcomes at individual,family, and community levelChange in these over time (improvement / decline).Dependency levelsCommunity & clinical resource utilisationAccurate current information sourced from the persons livingenvironmentImmediate information about status for emergency services
  11. 11. Requirements for sharing community careinformation• System that allows interoperability• Shareable data• Defined clinical data set for sharing– Problems– Interventions– Visit schedules– Telemonitoring data• Solution for sending / receiving data
  12. 12. Nurse Maude Development• Enterprise wide– Managing the business (payroll, rostering,scheduling, billing, patient records etc.)• Clinical documentation• Mobile solution• Measurement of clinical outcomes• Consumer accessible*
  13. 13. Requirements• Use National and International data standards• Use community minimum data set• Interoperable with external systems• Flexible platform• Must follow the clinical work flow• Familiar and intuitive software• Patient record as the single source of truth
  14. 14. Nurse Maude Clinical Documentation• Developed COMMUNITY CARE CLINICAL DATA SET(CADI)• Architected system integrating SNOMED-CT and Nursingterminology• Implemented clinical documentation on Dynamics CRMin TotalCare service• Fast charting – ‘start and chart’ - Mobile devices• Described outcomes of care in standardised measurableterms• Uses plain language for patients
  15. 15. CCMSHSAGlobalHSACare co-ordinationCCCCCardeaNM DataWarehouseCADISNOMED-CTClient DataCRISTASchedulingRostersReferral ManagementContract ManagementClinical ToolsOMAHA SystemCare PlansCare PathwaysClient Health RecordDecision supportGPCDHB shorttermERMS e-referralIMSABMPay-globalInterfacelayerNurse MaudeReferral SourcesMOHACCeSCRV / HCSCDHB longtermInterRAI
  16. 16. ReferencesButler M, Treacy M, Scott A, Hyde A, Mac Neela P, Irving K, Byrne A, Drennan J. 2006 Towards anursing minimum data set for Ireland: making Irish nursing visible. J Adv Nurs. Aug;55(3):364-75.Monsen, K.A., Westra, B.L., Paitich, N., Ekstrom, D., Mehle, S.C., Kaeding, M., Abdo, S., Natarajan, G., & Ruddarraju, U. (2012) Developing a shared personal health record for elders and providers:Technology and content. Journal of Gerontological Nursing.Jacobsen, M.S., Juste, F. (2010) Information Technology: Nursing in the era of meaningful use.Nursing Management 41, 1, pg. 11-13.www.omahasystemguidelines.org20
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