Canterbury & West Coast, New Zealand Monday 30 July 7:30am - - PowerPoint PPT Presentation

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

• ver 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?

50 100 150 200 250 Jan-Mar 2016 Apr-Jun2016 Jul-Sep 2016 Oct-Dec 2016 Jan-Mar 2017 Apr-Jun 2017 Jul-Sep 2017 Oct-Dec 2017

Acute Plans Published

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

50 100 150 200 250 300 350 400 450 July - Dec 2013 Jan - June 2014 July - Dec 2014 Jan - June 2015 July - Dec 2015 Jan - June 2016 July - Dec 2016 Jan - June 2017

1634 ACPs published

Number of ACPs published

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

• f 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
• f 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