Gavin Young

Technology Programme Manager

Shared Care Planning at Canterbury Clinical Network

Canterbury & West Coast, New Zealand

Monday 30 July – 7:30am

Transforming patient experience through

shared care plans in Canterbury, NZ

Introduction

• Canterbury had a fragmented health system

• Need for a connected and integrated system

centred around people

• With the aim of improving the patient journey

and to keep patients well in their own home

Alliances in a health context

The Canterbury Clinical Network

In 2007 Canterbury’s health system was fragmented

Building a Platform – A Shared Vision

Shared Objective: Canterbury’s Strategic Goals

People take greater responsibility for their own health.

People stay well in their own homes and communities.

People receive timely and appropriate complex care.

One health system, one budget.

It's about people.

Focus on leadership.

Take a 'whole of system' approach.

Canterbury Clinical Network Structure

Reference Groups

Enablers

Funder

Where we fit in the Health System

Canterbury Clinical Network

(CCN) is a collective alliance of

healthcare leaders, professionals

and providers from across the

Canterbury health system.

Collaborative Care & Shared Care

Technology are enablers of

the alliance

Collaborative Care & Shared Care Planning Technology

Collaborative Care supports people with complex health

conditions to work together with a range of health

providers to plan how their health care is delivered.

Shared Care Planning Technology provides a central IT

solution to enable Collaborative Care.

How we do it

Communication

Change Management

Create & maintain strong

relationships

Understand the patient and

the services providing care

Securely share electronic

information to support people

with complex health conditions

Benefits our people & their whanau/family

Care planning supports people to stay well in

their own homes and communities

Plans are part of a wider suite of enablers that

enhance patients self management

‘puts the person and their whanau/family at the

centre of their own care’

Benefits to providers & the system

Increases the coordination of

service delivery across

providers

Improves workflow and

communication across the

system

Increases the efficiency of our

health system.

Shared Care Plans – Acute Plan

An Acute Plan is for patients with complex health conditions and

those who are at moderate to high risk of attending acute services

over the next 12 months.

Can be contributed to or viewed by any clinician across Canterbury

Created when the patient is well and details how to best manage

the patient during an exacerbation

Documents normal observations for that patient

Specific information for the ambulance crew

How are we doing?

0

50

100

150

200

250

Jan-Mar 2016 Apr-Jun2016 Jul-Sep 2016 Oct-Dec 2016 Jan-Mar 2017 Apr-Jun 2017 Jul-Sep 2017 Oct-Dec 2017

Acute Plans Published

Steve has Chronic Pancreatitis and suffers from

chronic pain syndrome which he often needs support

to manage.

An Acute Plan was developed by his hospital specialist,

Steve can now be fast-tracked to the Surgical

Assessment and Review Area (SARA) for his severe

pain, which results in less time being spent in ED.

According to Steve

“As a result, I suffer less and my family feel

involved in the process and are less stressed about

my admissions”

Shared Care Plans – Personalised Care Plan

• A Personalised Care Plan (PCP) documents person-centred

issues, goals and actions for people who have moderate to high

complexity health needs and receive services from primary,

community and secondary care. It contains information from the

person about what is most important to them at present.

• The Personalised Care Plan provides the care team with a view of

what is being done to assist the patient in managing their

conditions & achieving their goals.

The Personalised Care Plan

The Personalised Care Plan – How are we going?

• 520 PCPs created across the health system since

go live, 14 Feb 2018

• 59 PCPs created by General Practice since go live

• 3250 contributions to existing plans

Shared Care Plans – Advance Care Plan

• The Advance Care Plan is a process of discussion & shared

planning for future health care. It involves an individual,

family/whanau & health care professionals.

• The Advance Care Plan gives people the opportunity to develop

and express their preferences for future care based on:

– Their values, beliefs, concerns, hopes & goals

– A better understanding of their current & likely future health

– The treatment & care options available

Advance Care Plan

How are we doing - Uptake

0

50

100

150

200

250

300

350

400

450

July - Dec2013

Jan - June2014

July - Dec2014

Jan - June2015

July - Dec2015

Jan - June2016

July - Dec2016

Jan - June2017

1634 ACPs published

Number of ACPspublished

How are we doing - Outcomes

• 80% GP Practices have

supported patients to create

an ACP

• 60% Patients with an ACP

died in there preferred place

of death

• 82% Patients with an ACP

died in a community setting

Shared Care Plans - Accessibility

Community Rehabilitation Pathway

Medications Management Service

Canterbury Health System – Shared Care Planning

Shared Care Planning - Canterbury Health

• Benefits

– Improved collaboration across care teams

• Contribute to share care plans regardless of location

• 2.6 million new pieces of data every month

– Improved patient journey and efficiency

• 1,600 ACPs completed, majority of patients able to die in their place

of preference (only 18% in hospital)

• Reduction of 864 average hospital bed days per year

– @ $1,500 per day ~ $1,296,000 *

• MedMan provides dispensed medication information

– Over 100 Medication Use Reviews per month since initiation

Conclusion

There is now a connected and integrated technology

solution that spans the entire Canterbury health system

Improving the usability of the technology for clinicians

Improving the patient journey

Providing increased efficiency and cost savings

Where to next?

• Older Persons Health & Rehabilitation

Teams Community Team Pathways

• Brain Injury Rehabilitation Service

• Communicable Diseases (Community &

Public Health)

• Child Health

• Palliative Care

• Endocrinology

• Respiratory Services