Feature: Wound care goes mobile
The Latrobe Community Health Service's (LCHS) mobile wound care project has been running since April 2010 and in its first year, 12,775 assessments were performed on 824 clients presenting with 1227 wounds. It has enabled one specialist wound consultant to assess and give advice to community nurses across the Gippsland region of Victoria, which covers 42,538 square kilometres.
It has also enabled a large array of data to be captured, including clinical wound aetiologies, the cost of individual episodes of care and treatment per aetiology, and data on the cost of wound product consumables, healing time and healing rates.
So successful was the trial in its first year that a grant was provided by the Victorian Department of Health to continue it for another. One of the project partners, Monash University's Department of Rural and Indigenous Health, is evaluating the data and it is hoped that funding will be forthcoming for the project to continue for another year, by which time a great deal of quite significant trend data will be available.
Either way, the project is an excellent illustration of how technology can assist in finding ways to keep people out of hospital and aged care facilities and in their own homes. While some of patients involved in the trial had acute wounds, many were living with chronic wounds such as leg ulcers, pressure ulcers and skin tears that as often as not see sufferers repeatedly present for medical care at a general practice or a hospital, and others forced to move out of their homes and communities and into residential aged care.
The trial, a joint project between LCHS, the Department of Health, Monash and four different healthcare agencies in Gippsland, also includes software provider HSAGlobal and Fujitsu, which initially hosted the software and provides infrastructure-as-a-service (IaaS).
In the Latrobe project, a centralised clinical nurse consultant called Marianne Cullen acts as a regional wound consultant for community nurses throughout the region. Ms Cullen is based at LCHS's Traralgon site and has remote access to every patient file, so once the community nurse enters new data on the patient’s wound and needs some advice on the best way to proceed, Ms Cullen can view the file and the photographs and recommend the best treatment for the current situation.
Matt Hector-Taylor, CEO of Auckland-based HSAGlobal, which is providing its Mobile Wound Care (MWC) product for the trial, says the best part of the technology is the way it supports the model of care. Nurses are able to photograph and track wounds and deliver care at the point of care, which is in the home. “They can say they are a bit worried about the way a wound is tracking and ask for advice, and Marianne can remotely look into the wound and support the homecare nurse to manage the case,” he says. “There is literally a workforce in the community with the specialist support needed to keep the patient at home.
“What is important here is not just that there is a central wound consultant based in Latrobe but that all of the community and home providers of care in the Gippsland region are working in the same way and with the same information as she is. Her ability to make a difference across the whole region is significantly enhanced.”
As part of the research project, a good deal of baseline data was recorded about the types of wound, and the numbers, length of stay and cost per wound, divided into different types of wound. In the second year, the clinical leaders of the project – Ms Cullen and LCHS' executive director of ambulatory services Nicole Steers – have been systematically addressing opportunities to improve care and outcomes identified from the first year’s data, Mr Hector-Taylor says.
“After that second year of focused improvement initiatives such as standardised pathway introduction for specific wound-types, I believe they are seeing early signs that those initiatives are starting to bear fruit, in terms of both quality and cost,” he says.
LCHS is negotiating for funding to extend the research project for another year, and “it will be quite special if they are successful with keeping the research going, because at the end of year three there should be some great quantitative evidence supporting the introduction of new models of care supported by technology and the improvement process that follows”, he says.
The MWC product is available in both stand-alone and integrated options. Users can operate the application independent of any other, or it can be integrated into HSAGlobal's Collaborative Care Management Solution (CCMS).
HSAGlobal is using CCMS to work with three district health boards (DHBs) in Auckland, New Zealand, testing new ways of managing the care of people with chronic illness. The DHBs have launched three pilot projects involving selected GP clinics, community pharmacies and hospitals across Auckland, Counties Manukau and Waitemata, part of a National Shared Care Plan program sponsored by the NZ Ministry of Health’s National Health IT Board.
The pilots initially involved eight GP practices in greater Auckland, several hospital speciality services including heart failure, gout and acute intervention respiratory services (AIRS), pharmacists and community care services. Additional GP practices and secondary services, including renal, pulmonary rehab and diabetes have joined the project over time.
Patients taking part in the pilots have a shared care plan developed for them, which includes a summary of personal health information, their health goals and the treatment and follow-up care they receive. They can access the plan electronically, as can the doctors, nurses and other health professionals caring for them.
“What the three Auckland DHBs are looking to do is put a platform in place to enable shared care management and planning between primary, secondary and community care for patients with long-term conditions that would also involve the patient in their own care,” Mr Hector-Taylor says.
“Patients are selected from primary care who have a long-term condition like heart failure or COPD or diabetes or renal patients – patients who are heavy users of healthcare – are enrolled from primary care and then a kind of virtual team is created around the patient. A plan is prepared and there is proactive care across the continuum of healthcare.”
Similar to Precedence Health Care's cdmNet project under Australia's new Diabetes Care Plan, this project involves an electronic patient record coupled with a workflow management solution.
“One of the key differentiators here is that the National Shared Care Plan project is patient-centric rather than disease-centric,” Mr Hector-Taylor says. “The patient's record – their medications, their diagnosis, their measurements, their results – are brought to all of the parties wherever they are.
“But also you have a care plan and assessments and a variety of notification and communications mechanisms that mean the whole team is working with the person’s single integrated plan. CCMS integrates with the different practice management systems and those at hospitals and pharmacies so that people still work in their own systems but the data they are working with is also visible to the other members of the care team as well.”
The shared care plan involves bidirectional data that is kept in sync, he says. “It is a quite a complex challenge to provide the level of integration needed in a region where there are multiple providers and multiple district health boards and multiple primary care organisations. And now we are onto phase 2 and the program team is growing the number of GP practices and the number of patients and the number of other providers to come on board. The priority is using the technology to enable some of the strategic priorities across the region, including improved primary-based management of patients at risk of an acute admission.”
HSAGlobal's CCMS is a purpose-built shared care management product. It is web-based, highly configurable, designed to integrate and built using industry standards. It has been developed using standard Microsoft interfaces to provide rich functionality and a familiar look and feel for users.
CCMS is also being used as part of the collaborative care platform for Project Chain in Canterbury, an integrated primary, secondary, community care program that was given special impetus by last year's earthquake.
“Because of the earthquake the Canterbury region lost a number of acute care beds and residential aged care beds so they have a real shortage of capacity,” Mr Hector-Taylor says. “Project Chain is a group of targeted initiatives, all enabled by CCMS to help maintain the health of high needs patients in the community.
“The initiatives include CREST, a program of supported early discharge for selected over 65s; a medications management service for high needs patients with complex medications requirements, and a variety of other “frequent flier” type initiatives. Most importantly, Project Chain is looking to introduce long-term funding models to support integrated care, as well the technology enabler (CCMS) and new service delivery models.”
Project Chain and the National Shared Care Plan project are exciting whole of system initiatives that may well shape the direction of health service delivery over the coming years, particularly for patients with long-term conditions, he says.
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