Gavin Young Technology Programme Manager Shared Care Planning at Canterbury Clinical Network Canterbury & West Coast, New Zealand Monday 30 July – 7:30am Transforming patient experience through shared care plans in Canterbury, NZ
Introduction • Canterbury had a fragmented health system • Need for a connected and integrated system centred around people • With the aim of improving the patient journey and to keep patients well in their own home
Alliances in a health context The Canterbury Clinical Network
In 2007 Canterbury’s health system was fragmented
Building a Platform – A Shared Vision
Shared Objective: Canterbury’s Strategic Goals People take greater responsibility for their own health. People stay well in their own homes and communities. People receive timely and appropriate complex care. One health system, one budget. It's about people. Focus on leadership. Take a 'whole of system' approach.
Canterbury Clinical Network Structure Reference Groups Enablers Funder
Where we fit in the Health System Canterbury Clinical Network (CCN) is a collective alliance of healthcare leaders, professionals and providers from across the Canterbury health system. Collaborative Care & Shared Care Technology are enablers of the alliance
Collaborative Care & Shared Care Planning Technology Collaborative Care supports people with complex health conditions to work together with a range of health providers to plan how their health care is delivered. Shared Care Planning Technology provides a central IT solution to enable Collaborative Care.
How we do it Communication Change Management Create & maintain strong relationships Understand the patient and the services providing care Securely share electronic information to support people with complex health conditions
Benefits our people & their whanau/family Care planning supports people to stay well in their own homes and communities Plans are part of a wider suite of enablers that enhance patients self management ‘puts the person and their whanau/family at the centre of their own care’
Benefits to providers & the system Increases the coordination of service delivery across providers Improves workflow and communication across the system Increases the efficiency of our health system.
Shared Care Plans – Acute Plan An Acute Plan is for patients with complex health conditions and those who are at moderate to high risk of attending acute services over the next 12 months. Can be contributed to or viewed by any clinician across Canterbury Created when the patient is well and details how to best manage the patient during an exacerbation Documents normal observations for that patient Specific information for the ambulance crew
How are we doing? 250 Acute Plans Published 200 150 100 50 0 Jan-Mar 2016 Apr-Jun2016 Jul-Sep 2016 Oct-Dec 2016 Jan-Mar 2017 Apr-Jun 2017 Jul-Sep 2017 Oct-Dec 2017
Steve has Chronic Pancreatitis and suffers from chronic pain syndrome which he often needs support to manage. An Acute Plan was developed by his hospital specialist, Steve can now be fast-tracked to the Surgical Assessment and Review Area (SARA) for his severe pain, which results in less time being spent in ED. According to Steve “ As a result, I suffer less and my family feel involved in the process and are less stressed about my admissions”
Shared Care Plans – Personalised Care Plan • A Personalised Care Plan (PCP) documents person-centred issues, goals and actions for people who have moderate to high complexity health needs and receive services from primary, community and secondary care. It contains information from the person about what is most important to them at present. • The Personalised Care Plan provides the care team with a view of what is being done to assist the patient in managing their conditions & achieving their goals.
The Personalised Care Plan
The Personalised Care Plan – How are we going? • 520 PCPs created across the health system since go live, 14 Feb 2018 • 59 PCPs created by General Practice since go live • 3250 contributions to existing plans
Shared Care Plans – Advance Care Plan • The Advance Care Plan is a process of discussion & shared planning for future health care. It involves an individual, family/whanau & health care professionals. • The Advance Care Plan gives people the opportunity to develop and express their preferences for future care based on: – Their values, beliefs, concerns, hopes & goals – A better understanding of their current & likely future health – The treatment & care options available
Advance Care Plan
How are we doing - Uptake 1634 ACPs published 450 400 Number of ACPs 350 published 300 250 200 150 100 50 0 July - Dec Jan - June July - Dec Jan - June July - Dec Jan - June July - Dec Jan - June 2013 2014 2014 2015 2015 2016 2016 2017
How are we doing - Outcomes • 80% GP Practices have supported patients to create an ACP • 60% Patients with an ACP died in there preferred place of death • 82% Patients with an ACP died in a community setting
Shared Care Plans - Accessibility
Community Rehabilitation Pathway
Medications Management Service
Canterbury Health System – Shared Care Planning
Shared Care Planning - Canterbury Health • Benefits – Improved collaboration across care teams • Contribute to share care plans regardless of location • 2.6 million new pieces of data every month – Improved patient journey and efficiency • 1,600 ACPs completed, majority of patients able to die in their place of preference (only 18% in hospital) • Reduction of 864 average hospital bed days per year – @ $1,500 per day ~ $1,296,000 * • MedMan provides dispensed medication information – Over 100 Medication Use Reviews per month since initiation
Conclusion There is now a connected and integrated technology solution that spans the entire Canterbury health system Improving the usability of the technology for clinicians Improving the patient journey Providing increased efficiency and cost savings
Where to next? • Older Persons Health & Rehabilitation Teams Community Team Pathways • Brain Injury Rehabilitation Service • Communicable Diseases (Community & Public Health) • Child Health • Palliative Care • Endocrinology • Respiratory Services
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