Updated on 13 September 2013
In Singapore, HSAGlobal is working with the Singapore Agency for Integrated Care (AIC) on several Advance Care Plan projects using its Collaborative Care Management Solution (CCMS) as a common IT platform. Individuals, their healthcare providers and their family will be able to together create a plan for future health care, which can be viewed by all when needed. In Canterbury, New Zealand, the loss of 741 beds after a number of significant earthquakes accelerated the need for the Canterbury District Health Board to reduce hospital admissions, as those beds physically no longer existed. Rather than a generic programme for all patients, several initiatives for specific patient groups with long-term or complex needs were introduced. These well-targeted programs allowed for close reporting, specific change management resourcing and even changes to the funding model to incentivize all healthcare providers to engage.
CREST is a community-based rehabilitative supported discharge and admission avoidance service for older people in Christchurch. HSAGlobal's CCMS platform enables staff from Older Persons Health Specialist Services, community based care providers, general practitioners and allied health professionals to collaborate in caring for patients at home for up to six weeks.
The CCMS platform has recently been extended to include Acute Plans for patients who use acute services frequently or are at risk of sudden deterioration of their health problems. These plans can be updated by any clinician involved in the patient's care and provide valuable information when the patient presents at the emergency department or after-hours clinic. Patients with chronic obstructive pulmonary disease and heart failure, another high usage group, also have a program. In Australia, CCMS has been used in a different care setting - early childhood and parenting support. The Tweddle and Queen Elizabeth Early Parenting Centres in Melbourne manage residential and community-based support service programs for vulnerable families. The ability for a number of care providers to share a patient record, collaborate on a plan and communicate with each other has significantly improved the level of care and led to cost savings.
Shared care in action
New Zealand's National Shared Care Pilot provides a useful case study of how each health professional engages with Connected Care. As is common in many countries, in New Zealand people with long-term health conditions consume a major proportion of healthcare funds. The National Health IT Board has piloted new approaches to shared care management for people with long-term conditions with a select group of health professionals in the Auckland region for over a year. The objective is to improve the journey for people living with long-term conditions through patient participation, effective teamwork between the many services delivering their health care, and support for people to manage their conditions at home.
One patient enrolled in the pilot, Mr Mani Kant, has long standing and untreated hypertension which damaged his heart and he suffers from heart failure. His regular doctor, Dr Neil Hefford at the Grey Lynn Family Medical Centre, enrolled selected Mr Mani into the shared care system directly from his existing Practice Management System. During an initial consult Dr Hefford and Mr Mani worked together to identify his main health concerns and create a plan for managing these. The plan includes goals, actions and self-management activities that the patient and practice team undertake to help manage his condition.