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Accountable and Collaborative Care: Lessons Learned from Across the Globe


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Accountable and Collaborative Care: Lessons Learned from Across the Globe.

Alan spoke about how important it is to have Collaborative Care; especially in chronic conditions, such as diabetes and COPD. Collaborative Care is facilitated by multi-specialty facilities which makes it more convenient for the patients to get tests results; for example, to make less visits to the doctors office. This can give patient care continuity, since everyone is working for the same cause: You, the patient.

Also bundled payments give physicians the incentive to be more efficient with how they treat their patients.

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Accountable and Collaborative Care: Lessons Learned from Across the Globe

  1. 1.  Introduction to AxSys Health Introduction to Accountable and Collaborative Care Solutions Across the Globe Ontario, Canada – Diabetes Chronic Disease Management East Elmbridge & Mid Surrey Primary Care Trust -England COPD Remote Monitoring Services National Clinical Network for Cleft Services - Scotland Managed Clinical Network for Cancer- Scotland National Sexual Health System (NaSH) - Scotland Total Knee Replacement Golden Jubilee Hospital - Scotland
  2. 2.  AxSys Health is the North American division of AxSys Technology Ltd Founded by physicians in the UK. Started operations in 2000 Approximately 250 employees across offices in UK, India and the US. AxSys has produced a unique Collaborative and Coordinated Care platform called Excelicare The Excelicare solution has delivered more than 30 discrete specialized clinical applications across more than 120 clients across the United States, Canada, Scotland, England, Ireland, and India
  3. 3.  Most of the rest of the world has a single payer model – typically the government – with a single payer model the focus has been on the clinical side of care as opposed to the clinical and the payment of care Managed Clinical Networks (MCN), a pre-cursor to ACOs are an important component in the support of better patient access and treatment through a coordinated care approach. The MCN concept was created in Scotland in 1999 by the Scottish Department of Health ◦ Their definition of MCNs is defined as “linked groups of health professionals and organizations from primary, secondary and tertiary care, working in a coordinated manner, unconstrained by existing professional and Health Board boundaries, to ensure equitable provision of high quality clinically effective services throughout Scotland.” ◦ Like a fine wine, this definition has aged well and seems to translate into the current goals of ACOs. Some features of a MCN include: ◦ The application integrates primary, secondary and tertiary care services ◦ A care plan is established which will serve all network stakeholders ◦ The care plan has the capability to incorporate evidence-based medical practices ◦ All participating members of the multi-disciplinary care team will have equality of access to the care plan (access rights can be granted, partly or whole) ◦ Multi-disciplinary team meetings are facilitated through the telemedicine and teleconferencing. Experts at remote sites are able to discuss the patient review patient notes simultaneously ◦ Automated generation of referral letters, summary documents and discharge letters ◦ Educational and patient advice leaflets can be accessed and distributed
  4. 4. Description: Chronic Disease Management System (CDMS) started in 2010 for Diabetes and other chronic conditions – Connecting 100,000 providers, 15 Million patients and 1 Million patients with DiabetesObjectives: The creation of the CDMS-Diabetes reflects the number of Ontarians with diabetes; there are now more than one million - a total which has doubled over the last 10 years. The aim is to manage diabetes treatment and care effectively and economically, and to prevent the heart attacks, blindness and amputations.
  5. 5. Project Success Metrics – Benefits Realization The CDMS-Diabetes is an interactive, real-time information tool to develop care plans and monitor clinical results to improve treatment. The system is building on eHealth Ontarios provincial identification and access systems infrastructure to ensure the secure identification of patients, providers and relevant diabetes healthcare services, based on common informatics standards and access technology. Providers will be able to manage the care of patients with diabetes according to recommended guidelines, securely receive, produce reminders, alerts and reports to help improve the quality and safety of patient care. The development of Ontarios CDMS will enable significant improvements to be achieved in the quality of services and real benefits to be delivered to patients. As the first system of its kind in Canada, the CDMS solution will result in faster diagnoses, more effective treatment and improved management for Ontarians living with diabetes. Providing alerts to physicians will help them better care for their patients.
  6. 6. Patient Claims Radiology Laboratory Access Consent Security and Access Control Enterprise Master Patient Index Patient and Provider DemographicsProviders Connecting 100,000 providers, 15 Million patients and 1 Million patients with Diabetes
  7. 7. Description: A COPD Community Service was initiated by East Elmbridge and Mid Surrey Primary Care Trust in 2004 in England to provide high quality personalized care to patients in the home setting to reduce inpatient care and focus on preventative rather than reactive acute careObjectives: Monitor severe COPD patients at home, patients and their caregivers were to be fully informed about their disease and options, and patients and caregivers were to be taught to recognize changes in condition
  8. 8. Project Success Metrics – Benefits Realization Improved Patient Involvement- The platform empowered patients to become more actively involved in their own care Reduction in patient cost and time – lower costs and time incurred for patients travel to clinics for assessment and treatment Move from Crisis management to Preventative collaboration - published results demonstrated the change on emphasis from ‘crisis management’ to a proactive ‘preventative partnership’ Reduced severity of exacerbations - 44% reduction with improved maintenance of lung function and quality of life Reduced hospitalization – 40% reduction in admission for patients seen at home Reduced LOS– reduced to 5.9 days a 26% reduction in bed days Increased service deliver -80% of services delivered via phone or email, more patient involvement with same staff levels Reduced duplication of effort - Care can be delivered anywhere and referrals made by email
  9. 9. Description: Project established in 2000 to deliver interdisciplinary care between health professionals providing care for cleft lip and palate patients between the ages 0 and 20 yearsObjectives: Provide a single record for a patient, accommodate clinical imaging, generate email and letter alerts to remind clinicians of their particular responsibility at specific times, and support and facilitate audit and outcome assessment
  10. 10. Project Success Metrics – Benefits Realization Improved communication – sharing of information across care providers Improved standards of care- a single source of patient information to monitor and analyze outcomes Improved coordinated care - Interdisciplinary treatment planning and care has improved due to use of the platform Improved efficiencies - more effective use of clinicians’ time as well as the patients, their parents and caregivers Improved data access – minimized risk of data fragmentation over multiple sites, reduced cost, time and effort incurred by offline data entry and replication Better patient satisfaction – through improvement in the organization of clinics and coordination among specialties Improved reporting – Reports and analysis on a national basis
  11. 11. Care Plan from Birth to 20 Year Old
  12. 12. Description: Managed Clinical Network (MCN) project established in 1999 to integrate all cancer settings across the West of Scotland, to have the patient at the core of the system, to implement care pathway protocols in conjunction with National datasets, and to incorporate multidisciplinary team (MDT) meetings within the care pathway. Covers 50% of the population of Scotland – 2.5 Million people. Connecting 5 regions and 10 hospitalsObjectives: Establish clinical meetings using video conferencing, provide a secure clinical information system to record the patient history and store clinical information and medical images. Provide means of informing primary, secondary and tertiary care teams of ongoing cancer care
  13. 13. Project Success Metrics – Benefits Realization Reduced travel and delays – The MDT discuss individual cases without extensive travel patients are referred and seen without delay Equitable access to care- Patients are guaranteed that they will receive specialist review regardless of geography and that all clinicians involved in their care participate in establishing and reviewing their care plans Improved care delivery- the speed of delivery of the treatment plan has improved as all relevant information such as laboratory reports and pathology is recorded and collated through one central system Improved education – Clinicians have benefited from the sharing of knowledge through the cross specialty discussions and the meetings also provide an excellent training ground for junior doctors and other clinical staff who attend Improved data quality – through a central repository with better audit trail and introduction of standardization and accountability
  14. 14. Forth Valley HB SCI-Store PMI / LABS / RIS Falkirk iSoft EXPRESS PAS (x3) iSoft TELEPATH Clinisys Hospital LABS CHEMOCARE WS (SOAP) Stirling Varian VARIS RT Royal EP Infirmary Slave Server FTP ODBC ODBC MSMQ ODBC Argylle & Clyde HB SCI-Store Inverclyde PMI / LABS Exceliport Integration Hospital Slave Server WS (SOAP) MSMQ EP Lanarkshire HB MSMQ Slave Server EP Slave SIEMENS DICOM3 Server PACS DICOM3 Hairmyres Hospital Wishaw Hospital Ayrshire & Arran HB EP TELNET Slave COMPAS MSMQ, Server ODBC PAS DICOM REVIVE DICOM 3 LABS/RIS GE CT GE MRI Crosshouse Glasgow Southern Beatson HospitalStobhill Royal General OncologyHospital Infirmary Hospital Centre
  15. 15. Description: Managed Clinical Network (MCN) and integrated Sexual Health Enterprise Patient Record System (EPR) for Sexual Health project established in 2007 to integrate all Sexual Health clinics settings across all of Scotland.Objectives: The NaSH system is a key component of the National Sexual Health Strategy - ‘Respect and Responsibility: A Strategy and Action Plan for Improving Sexual Health’, launched in 2005. This strategy set out a framework for improving sexual health in Scotland by enhancing access to information and services whilst enabling flexibility for local services to respond to local requirements. It also highlighted the need to be able to review existing data and develop a data collection framework to provide a more accurate picture of sexual health and wellbeing in Scotland, in terms of both sexual ill health and behaviours and attitudes.
  16. 16. Project Success Metrics – Benefits Realization Improved Clinical Care with patient focused processes and modern communication tools. Streamlining of services enabling improved throughput and availability. More effective use of staff resources and more efficient clinical staff training Increased ability to share patient data across services. Removal of multiple manual record keeping systems. Ability to address some clinical governance issues more effectively. Improved service security. Reduction in resource required to complete coding. Improved ability to access and share patient clinical information. Reduced requirement for duplicate entry of patient data and better quality of data. Increased use of national data standards. Reduction in number of potential diverse clinical systems. More efficient and increased integration of systems. Improved resilience and support for clinical systems. Get more value from strategic infrastructure products. Increased clinical buy-in and usage of IM&T. Better public health information.
  17. 17.  ACOs, Patient Centered Medical Homes, and Bundled Payment methodologies are Collaborative Care Solutions that have their precursors both in the US and abroad Need to analyze what worked in a single payer model there and what will work in a multi-payer model here Focus on cooperation while being cognizant of the competitive realities in the U.S.