USING TECHNOLOGY TO DELIVER BETTER CHRONIC DISEASE MANAGEMENT Dr - - PowerPoint PPT Presentation

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using technology to deliver better chronic disease
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USING TECHNOLOGY TO DELIVER BETTER CHRONIC DISEASE MANAGEMENT Dr - - PowerPoint PPT Presentation

Aug 24, 2023 18 likes •189 views

USING TECHNOLOGY TO DELIVER BETTER CHRONIC DISEASE MANAGEMENT Dr Eleanor Chew Dr Amit Vohra Clinical Lead Integrated Care Executive General Manager Sonic Clinical Services Sonic Clinical Services Complex target group High care

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USING TECHNOLOGY TO DELIVER BETTER CHRONIC DISEASE MANAGEMENT

Dr Eleanor Chew Clinical Lead Integrated Care Sonic Clinical Services Dr Amit Vohra Executive General Manager Sonic Clinical Services

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‘Complex’ target group

  • High care needs
  • High risk of re-admissions
  • High level clinical care coordination

‘Multi-morbid’ target group

  • Complications of chronic disease
  • At risk of hospitalisation
  • Targeted care coordination

‘Uncomplicated’ target group

  • Controlled or low risk of

complications

  • Low risk of hospitalisation
  • Supported self-care

Smoking 13%

‘At risk’ target group

  • Personalised patient

education

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Home care & individualised care High level care coordination Tailored interventions Care coordination Personalised CDM care plan Shared e-health record (cdmNet) Preventive Care Smart phone app (MediTracker) Patient education (GoShare)

Patient Centred Medical Home

Stepped care approach

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Technology supporting CDM

  • Risk stratification
  • Shared electronic

medical records

  • Mobile app
  • Digitally enabled

education

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Patients over 45 years Chronic Disease Diagnosis

Smoker FHx Diabetes 1 Dx 2 Dx 3 Dx

Microalbuminuria >20mcg/ml eGFR <60 ml/min

BP >160/100

TC > 7.5mmol/L

HbA1c >7.5

NO YES NO YES

Ineligible for WellNet

LiveWell StayWell FeelWell

YES NO FGB >7.0mmol/L

BMI > 40

TC > 7.5mmol/L

BeWell

NO YES

Patient Identification Selection & Stratification

OR OR OR OR OR OR OR OR

BP >160/100

Chronic disease identified? >38 10 - 38

OR

Assess HARP Perform in clinic health assessment <10

Risk Stratification

  • Data extraction tool
  • Risk factors/diagnoses
  • Patient identification
  • Health assessment
  • Stratification
  • Selection
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Shared electronic health records

  • Web based e-record shared & used by

whole of care team including AHP

  • Digital care plans – guidelines based
  • Care coordination - assigns tasks &

responsibilities to care team members

  • Tracking – team members contribute

to care plan on completion of tasks

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Patient mobile app

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Digitally enabled education

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WellNet Trial Locations

Current Locations Size & Mix Target Cohort

North Sydney Trial

  • 3 IPN & 3 non-IPN Practices.
  • LHD, PHN, BUPA, HCF, nib, Teachers &

DoH on Steering Committee.

  • Expanding to another 6 practices in

2019

  • 1050 Tier 2 and Tier 3 Patients.
  • 600 in evaluation cohort
  • Public & Private Patients
  • PHN confirmed expansion of trial to

new practices in 2019-20 AHSA Victoria Trial

  • 10-15 IPN & non-IPN Practices.
  • AHSA, AU, GMHBA, Defence Health,

People Care on Steering Committee.

  • Target 400-600 Private Patients.

SEMPHN Victoria Trial

  • 6-8 non-IPN practices
  • Target 800 Public patients
  • Separate cohort of 40-50 Frequent

Flyers Hunter PHN & nib Trial

  • 5-6 IPN and non-IPN practices
  • Target 800-1000 patients
  • Greater focus on obesity related

chronic disease

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Learnings – Risk stratification

5 chronic disease categories:

  • Cardiovascular
  • Respiratory
  • Diabetes
  • Major joint disease
  • Mental health

Additional chronic diseases:

  • Osteoporosis
  • Low back pain
  • Cancers
  • Kidney failure
  • Liver disease
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Learnings - cdmNet

  • Enables shared care planning and

coordination

  • Can be confusing for GPs not familiar

with it

  • Requires dedicated training
  • Sits outside other record systems
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Learnings - MediTracker

  • Available to all WellNet patients
  • ‘Tech savvy’ more likely to

download app

  • Check results and appointments
  • Access to medical record overseas
  • 60% continued to access app after

completing WellNet program

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Learnings - GoShare

Not hitting the mark…

  • 35% viewed items
  • Older age cohort
  • Too much e-traffic
  • Contact too frequent
  • GPs not familiar with it
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Evaluation findings - CMCRC

Statistically significant improvement in: Clinical Outcomes

  • Systolic & diastolic BP
  • Body Mass Index
  • Waist circumference
  • Hba1c
  • Lipids inc TC, HDL, LDL, TG

Self-reported Health Assessments

  • HARP score
  • Patient Activation Measure (PAM)
  • Quality of Life score (EQ-5D-5L)
  • Cardiovascular Disease Risk score
  • Psychological scores (K10 & DASS21)
  • Diabetes Risk Assessment (AusDRisk)
  • COPD Assessment Test (CAT)
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“many silent or unattended to issues are uncovered and dealt with”.

CLINICIAN FEEDBACK

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PATIENT FEEDBACK

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Thank you

Questions?