Planning for Automation of Care Pathway Management

Warrington CCG Population Health

Jason DaCosta - Warrington CCG

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About Warrington

• Warrington Population approx. 208,000

• A process of clustering services around a geographically co-located population

• Eight ‘groups’ of GP practice with each group having population ranging around 20-35k

• Clinical time allocated to appointment ‘slots’ of 10 minutes provided to patients on an ‘as and when’ basis

• Demand on clinical time is greater than current capacity.

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Management of patients is based on face-to-face consultations

• Inputs:

B/P recordings, weight and life style updates are recorded

Medications reviewed

Therapeutic decisions made or continued

• Face-to-face consultations take place with:

Nurse specialists

Health Care Assistants

GPs

Some or all of these professionals may be involved in a single appointment

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This periodic mode of management has 3 drawbacks

1. Blood pressure recordings impacted by:

Recent by activity (walking into the surgery)

The Iatrogenic effect

2. Recordings are a snap-shot

They record ‘now’

May skew the clinical perception of the patient, interpretation of the patient’s B/P status

3. Appointments absorb clinical time

But may not result in a change in current management

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How can patients be managed more effectively?

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For patients with primary hypertensive, there is an option to manage care using elements of self-management

• Using:

Self applied diagnostic equipment …

Recording data, transmitting telemetry …

Linked to secure internet services …

Storing data in an anonymised database …

Displayed within a clinical (web) portal …

Sharing data with GP systems

• These technical solutions are offered by:• Cisco (Clinical portal and integration services)• Third Party Telemetry Devices

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A pilot programme to test a technology enabled, remote monitoring hypertension surveillance service is proposed

• Pilot Practice: Greenbank Surgery

• Patients cohort characteristics:

Primary hypertension

Selected from hypertension register

Volunteer, consenting patients

Severity range: SI to SIII

Male-female mix

Across the adult age range

With internet access

Able and willing to record blood pressures, weight and activities over the internet

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Our 300 …

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Cisco Extended Care is a personal health and wellness collaboration platform, enabling patient engagement and care team interactions at any time and from anywhere.

The solution provides:• Enhanced and efficient care coordination• Secure messaging• Appointment calendar and scheduling• Questionnaires• Real time video collaboration• Anywhere access to care team consults• Personalized content sharing• Video platform to drive health and wellness

awareness and education• Open APIs to embed into and enable 3rd party

applications and environments

Cisco Extended CareDriving Health and Wellness

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Anytime access to appointment information

Streamlined workflow for appointments – Single click Appointment initiation

Cisco Extended Care Capabilities Scheduled Video Consults

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• On Call Scheduler

• Scheduled Appointments

• Provider Group Schedules

• Patient Type Grouping

• Nurse Notes, Surveys

Cisco Extended Care Capabilities Provider Scheduling

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Ability for users to take pre- appointment questionnaire

Saves total clinical time for an appointment

Cisco Extended Care Capabilities Pre-appointment Questionnaire

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Empower the patient wellness by providing education information

Provide videos of how to use the system – reduces support cost and enhances patient satisfaction

Cisco Extended Care Capabilities Video Platform to Drive Health and Wellness Education

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Ability for the patient to keep track of his or her wellness device readings

Visual trends display for ease of view

Cisco Extended Care CapabilitiesMedical Device Readings

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Utilizes Cisco Jabber SDK technology for remote video consults

Removes the need for purchasing separate video endpoints

Cisco Extended Care Capabilities Jabber Video Integration

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There are 11 perceived benefits from this approach

GP & GP Practice Focused Benefits

Patient-Focused Benefits Overarching Outcome

1. Increased clinical efficiency – GPs only intervening with Hypertension patients that need an intervention

5. Time saving for the patient* – fewer or no attendances, appointments at the Practice

   

Enables enhanced management and control of patients with Hypertension

Increases capacity in Primary Care - up to c600 appointments from our 300 patients – or 120 clinical hours

2. Releases time, provides capacity for clinical staff to manage ill and more complex patients (Links to above)

6. Provides for a high level of patient autonomy and self-management

3. Simplifies and informs medication reviews

7. Increases patient’s understanding of hypertension, factors and therapies, activities impacting blood pressure

4. Increases potential for practice to meet Hypertension QOF targets

8. Potential for increased medication concordance

9. Improved control – seeing Blood Pressure readings has potential to influence patient behaviour (links to self-management above)

  10. Potentially fewer hypertension, hypertension therapy related incidents

* Patients managed via the technology have the potential to save, avoid 2 GP practice appointments per annum. At Greenbank Surgery, there are 300 patients with Hypertension only (no recorded comorbidity) on the Hypertension Register. A saving of 600 appointments equates to approx. 120 clinician hours pa, based on a mean 12 minutes per appointment

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Next Steps

• Integrate with a wider pool of telemetry devices

• Build and share the care plans

• Risk stratification to identify other patients who will benefit

- Psychiatry liaison- Complex Care Management- Risk of readmission using LACE scores

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Increasing clinical capacity & engagement

Thank You and Questions