The Shift to Coordinated Care Part Three

July 9, 2018 Dealla Smith

The healthcare system needs to provide a more holistic approach to care and move out of the hospital and into the community. This blog series looks at the factors that influenced this change in approach and how an integrated technology platform can help transform patient care delivery and health outcomes.

Part One and Two of this series looked at why an integrated model of care is important to 
coordinate services across multiple organizations, providers, community and social services so they can collaborate, proactively manage care and take preventative action for patients they are responsible for.

Now, we will examine the role of a centralized technology platform in achieving integrated care coordination. The journey has six key elements, known as the 6 As: 

  1. Acquisition: Acquiring data from disparate information systems and care locations
  2. Aggregation: Secure storage of structured, normalized and identified data
  3. Analytics: Tools for risk identification, management and quality improvement
  4. Access: Fast, easy and convenient access to information for the patient’s circle of care
  5. Action: Turning information and insights into activities and outcomes
  6. Adoption: User engagement and adoption of technology

Once the 6As have been addressed, the centralized technology platform allows
everyone involved in a patient’s ‘circle of care’ to see and update the electronic medical record. This ‘circle of care’ connects members of multidisciplinary clinical care teams, community providers, case managers, the patient and the patient’s support network through a secure cloud-based platform. In short, it supports people to stay healthy at home and remain in their communities. There is an increasing body of research that shows how patient empowerment can facilitate improved health outcomes. 

The ‘circle of care’ is pivotal to care coordination and care management of existing illnesses because it facilitates the identification and sharing of information about the network of people and organizations that play a role in the care and support of a patient. Often chronically ill patients will need the services of multiple care organizations and the collaboration tools and pre-defined care pathways that are built into the system guide practitioners and community support staff along a predetermined and optimized pathway of care programs and support. Subscription by health and community providers to electronic notifications enables real-time messaging of critical information, ensuring they are informed and kept up to date with a patient’s progress. 

Another benefit of a collaborative and centralized technology platform is the way it can be used to monitor and manage chronic illness within at-risk populations. Analytics can identify vulnerable population groups, and help community providers to set prevention objectives for them, then monitor the success of the healthcare and wellness pathways that have been implemented. By integrating social determinants of health, genomic, environmental and lifestyle factors into the patient record, the care management team can identify trends at a population group level and reveal opportunities to improve health at the patient level. 

For example, they can identify a group of Type 2 diabetic patients that haven’t been seen regularly and contact them for referrals to appropriate care groups. Providers can reduce the need for acute hospital admissions, with stratification of patients who are most likely to require hospital-level care, through early intervention of appropriate and targeted healthcare coordination. Or, even more, cost-effective for the healthcare system, they can identify pre-chronic individuals and promote wellness strategies such as smoking cessation and weight loss, avoiding the need for healthcare intervention in the first place. 

Being able to view a secure shared care record is critical to not only allow timely, safe and informed decision-making to occur in a medical setting but also out in the community. A study from Canterbury District Health Board (DHB) outlines its journey to provide an integrated, person-centered health system that crosses the boundaries between primary, community and hospital-based care. Canterbury DHB’s vision is to create an integrated health system that keeps people healthy and well in their own homes by providing the right care and support, to the right person, at the right time and in the right place. 

To achieve this, Canterbury DHB is pursuing a number of projects of its own and is also a member of the South Island Health Alliance, a partnership between the five South Island DHBs to support clinically and financially sustainable health services, including a shared patient information system called Health Connect South. This revolutionary web-based EMR portal connects the entire South Island of New Zealand, which covers a large geographical area and over one million people. Canterbury has also developed the Shared Care Planning Program, which is a consolidation of multiple technologies that enable the delivery of patient care closer to the patient’s home. It is designed to meet the needs of all people who would otherwise be referred to hospital but who can safely be managed in the community. It is currently focused on children, older people and people with respiratory or cardiology-related conditions and provides a good example of why providers such as Community Pharmacists should be included in the electronic health record.

This more holistic, multidisciplinary approach to healthcare will enable the fundamental shift in emphasis from acute in-hospital care to more cost-effective coordinated care across the community. The focus can then shift from reactive to preventative care – identifying signs of chronic conditions well before they develop and putting in place plans for prevention within a community setting. This preventative approach will allow healthcare organizations and governments to meet the health demands of their growing and often aging populations. To achieve this level of population health management, a robust technology platform that supports integrated care across all care coordination situations is imperative. 

To learn more, download our White Paper here.

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