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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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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>