IT contributing to improving community-based models of care
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Nurse Maude provides community health care services to over 14,000 patients per year in Canterbury, New Zealand. To improve coordinated care, Nurse Maude developed the Community Care Clinical Management System (CCMS) to share patient data across primary and secondary care providers. CCMS includes a clinical documentation system that uses standardized terminology and allows for mobile access. It aims to improve outcomes measurement, quality monitoring, and consumer access to health information. Nurse Maude also implemented a clinical documentation system on their Dynamics CRM platform to streamline charting for community nurses.
IT contributing to improving community-based models of care
- 1. Health IT Innovation In Practice The Canterbury Story 2013 HINZ Seminar Series IT contributing to improving community-based models of care Sheree East
- 2. Content • Nurse Maude • Collaborative IS developments in Canterbury • Health Information developments • Nurse Maude IS development
- 3. 115 years of community health care 14000 patients per annum 40% over 85 55% Multiple comorbidities700000 episodes of care
- 4. Nurse Maude Services (Canterbury) Avoid admission Enable early discharge Delay entry into residential care Supportive Community care Self care support Care Management High Complexity Care Management Specialist Nursing Acute Demand CREST District Nursing Home Care Total Care Long term care Palliative Care Continence Stoma Wound Diabetes Infusion NP Aged - Care School Health Liaison Case management Rest home at Home 40 bed hospital level aged care Support care Tertiary Hospice Community team Restorative Personal Care & Nursing Generalist nursing Dialysis Personal Care Domestic Assistance Education Equipment Meals Laundry
- 5. Collaborative health IT solutions working in primary and secondary care in Canterbury
- 8. Project CHAIN Collaborative care programme • electronic case management program to enable innovative workforce development and clinical delivery across Canterbury by sharing of care and clinical information, particularly for high needs patients, between multi-disciplinary teams.
- 9. CCMS - Single Source of Truth for Client Management Hospital Inpatient Outpatient/ Day Centre Multi-disc clinic Residential Facilities Community Nursing/ MHW + GP Clinic Associated to an Episode Referral management for relevant LTC Program(s), and Handoff of Care Assessment, Care Plan, Client Documentation Measurement and Results, Medication Management Info from other Clinical Systems eg Disch Summary, Lab Result, Rad Reports, Prescription Portal for Self Mgmt Patient Specific Info Family Health Info Home/ Workplace Report Builder: for Health Org or Enterprise wide reporting CCMS – Client information management platform SMS Outreach
- 10. A new era in consumer health information Point-of-care technology + improved PMS systems = better data Better outcome measurement (Big Data opportunities?) Improved quality monitoring Increased sharing of health information across boundaries Increased consumer access to health information “The expert patient” De-medicalisation of care
- 11. Why share community level data? Identified problems, interventions and outcomes at individual, family, and community level Change in these over time (improvement / decline). Dependency levels Community & clinical resource utilisation Accurate current information sourced from the persons living environment Immediate information about status for emergency services
- 12. Requirements for sharing community care information • System that allows interoperability • Shareable data • Defined clinical data set for sharing – Problems – Interventions – Visit schedules – Telemonitoring data • Solution for sending / receiving data
- 13. Nurse Maude Development • Enterprise wide – Managing the business (payroll, rostering, scheduling, billing, patient records etc.) • Clinical documentation • Mobile solution • Measurement of clinical outcomes • Consumer accessible*
- 14. Requirements • Use National and International data standards • Use community minimum data set • Interoperable with external systems • Flexible platform • Must follow the clinical work flow • Familiar and intuitive software • Patient record as the single source of truth
- 16. Nurse Maude Clinical Documentation • Developed COMMUNITY CARE CLINICAL DATA SET (CADI) • Architected system integrating SNOMED-CT and Nursing terminology • Implemented clinical documentation on Dynamics CRM in TotalCare service • Fast charting – ‘start and chart’ - Mobile devices • Described outcomes of care in standardised measurable terms • Uses plain language for patients
- 19. CCMS HSA Global HSA Care co- ordination CCCC Cardea NM Data Warehouse CADI SNOMED-CT Client Data CRISTA Scheduling Rosters Referral Management Contract Management Clinical Tools OMAHA System Care Plans Care Pathways Client Health Record Decision support GP CDHB short term ERMS e-referral IMS ABM Pay-global Interfacelayer Nurse Maude Referral Sources MOH ACC eSCRV / HCS CDHB long term InterRAI
- 20. References Butler M, Treacy M, Scott A, Hyde A, Mac Neela P, Irving K, Byrne A, Drennan J. 2006 Towards a nursing minimum data set for Ireland: making Irish nursing visible. J Adv Nurs. Aug;55(3):364-75. Monsen, K.A., Westra, B.L., Paitich, N., Ekstrom, D., Mehle, S.C., Kaeding, M., Abdo, S., Natarajan, G. , & Ruddarraju, U. (2012) Developing a shared personal health record for elders and providers: Technology and content. Journal of Gerontological Nursing. Jacobsen, M.S., Juste, F. (2010) Information Technology: Nursing in the era of meaningful use. Nursing Management 41, 1, pg. 11-13. www.omahasystemguidelines.org 20