Updated on 13 September 2013
Cardiologists at the Auckland Hospital Heart Failure Service, a community Heart Failure Nurse Practitioner and his local community pharmacist are also part of Mr Mani's care team. In future, other health care professionals, such as a dietician, may be involved. Everyone involved in Mr Mani's care can access his record, view his 12-month care plan, request advice or services from other care team members, record notes, assessments and measurements and review and update his medications. Any changes or updates are shared with the whole care team. Members of the team can use the system to manage referrals, undertake virtual consultations, discuss Mr Mani's care with each other or allocate tasks to other team members. Mr Mani himself can also access it and reports being much more engaged with his own health status.
Janet Callender, a Practice Nurse at Grey Lynn Medical Centre, views this immediate sharing of information as vital in providing better care to her patients. As well as the time savings that are made by not having to repeat patient information, redo tests or search for historical data, the shared care system improves productivity through electronic 'service requests' between the various members of the care team. It also allows for virtual consults to take place with a wider care team and the care plan to be amended quickly. Referrals to the Heart Failure Service may not be necessary to gain their input into the plan.
The proactive approach focuses on the health of the person over time, not just on the problem they present with at ER. If a patient that is part of the Shared Care Pilot ends up in hospital with an acute episode, hospital staff can access their care plan. This means that they can confidently treat the patient in the acute setting knowing their goals and care plan, baseline measurements, current medications and care team details. Information about the hospital visit is also shared automatically with the care team so that the care plan can be adapted if necessary.
Helen McGrinder, the community Heart Failure Nurse Practitioner reports that when patients with a shared care plan do end up in hospital, it is often for a much shorter time as their condition is being better managed overall. To date Mr Mani has not had an acute presentation at hospital, and the goal is for him to be able to continue living an active lifestyle, enjoying time with his grandchildren and in his garden.
In all of these cases, the CCMS solution is an enabling platform for care collaboration across organization and physical boundaries. Connected care is a significant transformative step for many health systems, particularly when compared to the traditional approach where highly specialized providers operate in their own 'silos'. In order for change to be implemented effectively, each health provider along the continuum of care - as well as the patient - must experience benefits. Otherwise costs and workloads are merely being moved from one part of the health system to another.
One theme emerging from these various implementations is that the technology is only a part of what is required to be successful. Change management, service redesign, rethinking roles and responsibilities, and even structural and funding system changes are critical to successful implementations. However, as these examples demonstrate connected care is not only possible but effective. Small projects provide big lessons and signpost the path towards more mainstream adoption.