care close to home A rural and Metro partnership model Debra - - PowerPoint PPT Presentation

Access for Older People’s complex care close to home A rural and Metro partnership model

Debra Tooley - District Manager Aged Care Services John Cullen - Geriatrician

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Where are we? Western NSW… Population: 277,353

18% Aged

• ver 65 yrs

Our Services…

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Why Telehealth Enhanced Model?

Data Analysis Project Design Implement & Test

Increased demand Pt complexity No Geriatrician Increased waiting times Increased travel for services No funding for Geriatric Medicine services

Collaborative solution design Technology Funding source Leadership Clinical – pt selection Patient engagement Role clarity Quality & Audit process Staff Education Honorary medical contracts Service Agreement Purchase of Telehealth devices Development of protocols Data collection – activity & cost Rostering of staff Communication strategy

Person Centred, directed and empowered Primary care based Targeted Continuously improved Collectively accountable and mutually beneficial Shared information

Principles

Enablers

Engagement Partnerships Governance Funding Leadership Capability Culture Technology Information

Telehealth Model – a component of a comprehensive geriatric model of care

Clinics

Scheduling Equipment, Patients and Geriatrician Booking Transcription service

Workforce Metro: Geriatrician Local: Clinician Liaison with GP

Patients Clinical assessment & reports collated Mgt plans Technology Booking Equipment testing Education Health Record Shared clinical notes Audit process Governance & Funding Clinical gov. Local leadership

Evaluation Quadruple Aim Continual improvement

• Well accepted by patients and carers
• Family patient education and care

planning discussions

• Cognitive Assessments and diagnosis
• Capacity Assessments
• Comorbidities / Chronic disease

assessment ( and management)

• Medication reviews
• Driving assessments
• General healthy ageing advice
• Advanced care planning discussions
• Gait, Falls and Bones evaluation

What Works Well

• Telehealth is not “instead of” face to

face clinics

• complimentary
• The Medicare model rather than ABF

funding model

• The enterprise has had the support
• f both CEs of both LHDs
• The network has been reliable and

the equipment continues to improve

• Patient characteristics

– severe deafness

• Non-cooperation – extremely rare
• Assessments requiring hands on

physical examination

• (undertaken at face to face clinics)

What Doesn’t Work

Measuring Success

Improved experiences for people, families and carers Improved experiences for clinicians and service providers Improved health

• utcomes for the

population Improved Health Systems QUADRUPLE AIM

Measuring Success

“Great service in our own town” “No different to a face to face appt” “Great not having to travel to Sydney (6-10 hours)” “Felt like I had specialists’ full attention the whole time” “Perfect for country people” “Excellent team work – felt supported” “Technology easy to use” “Very organised clinic” “Feel connected to the patients and carers” “I can do clinics from my own

• ffice”

Decreased waiting time for patients – less stress

Improved Patient & Carer Experience Improved Clinician Experience

5 14 22 40 55 76 56 85 36 52 55 140 150 132 110 138 160 50 100 150 200 250 300 2010 2011 2012 2013 2014 2015 2016 2017 2018

WNSWLHD Geriatric Medicine Program

Consults FTF Consults via Telehealth 20 40 60 80 100 120 140 160 180 2010 2011 2012 2013 2014 2015 2016 2017 2018

Consults via Telehealth

Consults via Telehealth

Measuring Success & Sustainability

Outcomes

People, families and carers

• I can access specialist services in my own town
• I don’t have to re-tell my story
• I know that there are a team of skilled staff that assist with my health and social

care needs Service Providers and clinicians

• I can access all relevant information about the patient so I can provide high

quality care (comprehensive assessment, restorative care, GP collaboration)

• I work in an efficient system that supports me to provide high quality care
• I collaborate and communicate effectively with other providers to deliver the best

care possible Population

• Care addresses the social determinants of health
• Care for people with long term conditions is improved

Health Care System

• The system is efficient and results in timely and appropriate management
• Health care service in NSW connected with social care
• IT systems and processes are integrated across the health system
• Financially viable

• WebRTC – using the web to connect to patients and

carers on their own devices in locations that are convenient to them (including RACFs)

• Use of wearable devices
• Embedded into clothing
• In home monitoring
• Linking outside the health network e.g. with AMSs

Where to from Here?

Quote for John Cullen ‘The Geriatric Medicine Service

is one of the more worthwhile and satisfying things I do as a clinician and a service manager’

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Thank you!

Where to from here?

Debra Tooley - District Manager Aged Care Services email: Debra.Tooley@health.nsw.gov.au