CCMS to be rolled out for at-risk patients in Counties-Manukau

Counties-Manukau District Health Board will roll out HSAGlobal's CCMS connected care platform to all general practices in the district by June next year to allow them to provide a care plan to up to 30,000 patients with long-term conditions.

Counties-Manukau DHB's At Risk Individuals program (ARI) is aimed at providing earlier intervention and patient-centred care by allowing primary carers to identify at-risk patients and better coordinate their services.

The DHB will enrol people in ARI who have one or more long-term conditions, such as diabetes or heart disease, as well as other risk factors like inadequate housing or low health literacy. It will support ill support up to 30,000 at-risk people with a CCMS-based care plan by the end of 2015.

CCMS is used throughout New Zealand for care coordination and forms the technological basis of Auckland's shared care program. It is also used by Canterbury DHB and has a small but growing footprint in Australia.

Once enrolled by their GP, every person will have a designated care coordinator responsible for developing individual care plans in CCMS and monitoring progress in consultation with other providers of health and social services.

Care team members including community nurses can secure message each other and the patient through the shared care record. A summary health record will be available to healthcare teams through their existing Concerto patient record software so that key information relating to the patient is visible to everyone involved in their care.

Counties-Manukau has an existing program using CCMS that targets 3000 intensive healthcare users at high risk of readmission to hospital. The DHB uses CCMS under a licence covering the Northern region DHBs.

CCMS is licensed on a population basis, so DHBs can use the care platform for as many programs as possible.

HSAGlobal managing director Matt Hector-Taylor said the ARI program would allow the DHB to respond to demands on the health system from long-term conditions.

"It demonstrates new thinking applied in New Zealand in designing and managing large scale, whole of system connected care models to ensure improved and more accurate delivery of health and social services,” Mr Hector-Taylor said.

Benedict Hefford, director of primary health and community services with Counties DHB said that rather than reacting after people needed hospital care, health services will be supporting them to manage their health problems so they can stay well and at home.

Posted in New Zealand eHealth

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