Opinion: connected care means connected technology

The health system evolved to deal with the health problems of the day, but the needs of our population have changed dramatically in the last 40 years.

New models of person-centred, connected care are an emerging response to a health system struggling to cope with larger numbers of elderly and people with chronic illnesses.

The idea of 'connected care' aims to make it easier for all involved in a person’s health and social service support to act as a team. It’s about better decision-making and empowering greater self-care, built around a single, shared care plan.

Although intuitive, providing connected care presents a major change for many health ‘ecosystems’ and their funders, providers and patients. Technology plays a crucial enabling role but is only one element to be considered in the overall change management process.

At Canterbury District Health Board (DHB) in New Zealand, a whole of system approach to integrated care incorporates a shared care management platform to support a range of targeted initiatives, each dealing with a different set of specific but often overlapping patient needs.

These programs include a multidisciplinary community-based rehabilitative supported discharge program for elderly patients, a medicines management service for patients with high needs, an advance care plan, an acute plan to support the prevention of unnecessary acute admissions and ‘generic’ care coordination.

Since the patients in each program often overlap, having a common platform is invaluable. In this instance, Canterbury DHB is using HSAGlobal’s Collaborative Care Management Solution (CCMS).

The Community Rehabilitation Enablement Support Team (CREST) program uses a funding model based on an alliance arrangement between the care providers and the funder. Care is funded for a team delivering the service and health outcomes, not for individual outputs.

Each patient has a team of providers surrounding them, coordinating their care, and keeping them out of hospital. The coordinated approach minimises errors and improves communication when care plans change. Data from CCMS is used to support a quality improvement process across all care providers involved and is critical to improving patient outcomes.

CREST was introduced in April 2011 and more than 1700 patients were kept out of hospital in the first year of the program. Since then, over 4000 people have had their hospital length of stay reduced by management in the program without a subsequent increase in readmission rates.

Achieving this sort of joined up care and support within one health ‘economy’ requires multiple enabling information systems to play their part. In Canterbury, this includes Health Pathways, the electronic Shared Care Record View (eSCRV) portal designed by Orion Health and rolled out by Health Connect South, an electronic referral management system (ERMS) and CCMS. At the same time, ‘whole of system’ processes must be agreed for access, auditing and privacy.

Another large scale, connected care program linking health and social service providers is the 'At Risk Individuals' (ARI) program at Counties-Manukau DHB, which focuses on a stratified population of individuals at higher risk of hospitalisation.

ARI will support up to 30,000 at risk people with a CCMS-based care plan by the end of 2015 – one of the largest integrated care programs in the world. Once enrolled by their GP, a designated care coordinator will work with each person to co-develop a team-care plan and monitor progress and follow-up actions, working securely with other service providers within the single care plan.

A summary health record, available through Orion's Concerto patient record software, means key patient information is visible to everyone involved in their care even if they are not a regular member of the care team.

Again, delivering the vision for ARI requires integration of multiple hospital and primary care systems, including CCMS, Concerto and GP desktop systems such as Medtech and MyPractice, as well as systems connecting pharmacies, hospices and community providers.

At the ‘back-end’ delivery side of the solution, information standards like GP2GP are essential to guide integration, while licensing models that encourage sharing and prevent silos are also critical.

A population-based license is used for CCMS, removing any funding obstacles to the DHB adopting the care platform for as many programs and patients as possible with the goal of arriving at a ‘whole of patient’ view over time.

One way of effectively introducing connected care is to establish a simple starting point for a wide base of users and then layer more specialised programs on top for those that are ready. Connected care can be implemented incrementally, allowing funders and providers to start with small, simple improvements, taking advantage of new opportunities as experience and skills allow.

Different ‘flavours’ of shared care plans have emerged to reflect these different starting points, such as advance care plans, acute plans, meds adherence, service coordination and team-based plans.

Consumer engagement is critical throughout the design and delivery of connected care. Consumers are both contributors to and beneficiaries of joined up care. Each individual success story helps build confidence in new ways of delivering health and social services and contributes to the growing evidence that connected care works.

Significant lessons are also emerging about the role of funding – potentially a motivator or a barrier – in ensuring program sustainability. Contracting models are evolving as funders and providers build trust and experience.

Connecting care is a complex task with a number of dimensions to consider and manage. Experience in New Zealand does suggest though that sustainable change is possible and does deliver.

Matt Hector-Taylor is the managing director of HSAGlobal.

Posted in New Zealand eHealth

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