Enabling continuity of care

As patients move across the system of care-from their family physician's office to community services to specialist offices into hospital and out again-the information required to support decision-making is seldom accessible. For patients with multiple chronic diseases, this information gap can result in poor health outcomes. For healthcare authorities, it can mean increased reliance on the healthcare system implying repeated hospital admissions and longer hospital stays.

Timely access to clinical information is particularly important for patients with multiple chronic conditions, complex care needs and who have several healthcare providers involved in planning and delivering their care. 'Point-of-care' access to longitudinal health information such as patient encounters, medical history, recent test results, diagnostic reports, medication profiles and consultation and discharge summaries can significantly impact treatment decisions and plans of care.

Patients express dissatisfaction at the current fragmentation in the healthcare system, especially at transition points from one healthcare service provider to another. While many patients articulate a belief that 'each provider will do its best' to provide high quality care, the coordination across multiple providers remains unsatisfactory.

Effective patient care across the healthcare continuum can be significantly improved when healthcare professionals share relevant information and work together to support a 'shared care' approach. 'Shared' or 'collaborative care' models place the client or patient at the centre, ensuring that the care is driven by best evidence guidelines and patient health goals. Facilitating improved patient self management is another hallmark of successful shared care models. Electronic Health Records (EHRs) enable a 'shared care' approach by providing clinicians access to relevant clinical data as well as a 'shared care' plan that clearly sets out patient health goals, guideline based intervention plans and progress against that plan.

A shared care model for Chronic Disease Management (CDM) has a number of key attributes:

• • A strong self management focus
• • A coach, facilitator and navigator role working with the patient to help them achieve their health goals
• • Care planning based on approved clinical guidelines
• • Development of individual patient care plans with input from providers involved in their care
• • Enabling technology tools, such as electronic health records, to support clinical collaboration and provide clinicians with access to patient care plans and health records when / where required.
   

The Chronic Disease Management (CDM) Care Connectivity Project, Vancouver Coastal Health (VCH) in British Columbia (BC), Canada is the largest regional health authority in BC serving a population of more than one million people.

Driven by a commitment to improve the coordination of care through effective population-based strategies and reduce unnecessary utilisation of acute services, VCH launched the CDM Care Connectivity project in September 2007. Focussing on the patients living with two or more chronic diseases, The VCH CDM Care Connectivity Project links patients to the services and supports them with what they need to achieve optimum health. It provides coaching and support to help patients manage their own health more effectively. This shared care model involves a number of roles and depends upon an EHR to facilitate collaboration and provide authorised access to clinical information to support improved decision-making. The model includes:

Chronic Disease Nurse

The Chronic Disease Nurse (CDN) is at the centre of the healthcare team and works directly with the patient, family physician and other clinicians as required to develop, implement and manage the patient's individualised care plan. The CDN is often the first point of contact for patients and supports them to manage their own health better. This includes monitoring patient progress and coordinating with other health service providers as required.

Family Physician / Nurse Practitioner

As the key decision-maker, the family physician and / or nurse practitioner identify the patients who meet the programme criteria and could benefit from 'shared care' approach. As the most responsible physician, the family doctor guides the development and implementation of individual care plans and consults with specialists as required.

Specialists

As a consultant to the family physician, the specialist provides advice and input to the patients' shared care plan as needed, and is available to discuss changes, concerns, or to accept patient referrals.

TeleNurse

Specially trained to support patients with chronic diseases, TeleNurses are available on phone 24x7 to assist patients as needed. These healthcare professionals have access to individual patient shared care plans and other information via the EHR, so that they are able to provide timely and relevant advice to patient based on the individual's condition.

Enabling Technology

Patient's access to timely, quality care depends on access to the 'right provider' 'right data' at the 'right time'. Providers share access to a comprehensive care planning tool and the Electronic Health Record to support -

• • Care plan development and sharing - What are the past, current and planned interventions for this client?
• • Multi- provider task management - Who is responsible for specific interventions and when are those interventions scheduled?
• • Progress Tracking and reporting - How is the patient progressing with the plan? What changes are required?
   

Innovative Approach

Combining a 'shared care' model with an EHR is an innovative approach to effectively support improved health outcomes for patients living with chronic disease. It shifts the focus of chronic disease care from a reactive response to a proactive, patient-centric approach using technology to connect clinicians to the information they need and positioning patients at the hub of a coordinated system of care.

One of the biggest challenges faced by clinicians when caring for patients with a complex condition is incomplete patient information and inadequate resources to support them proactively. A shared care model, enabled by a robust EHR, addresses these challenges by facilitating collaboration among clinicians and linking them to the information they need at the required time.

Beyond the EHR - Lessons learned

The introduction of 'shared' or 'collaborative care' models, multi-provider care planning processes and new, albeit enabling technology is challenging and is not meant for the faint- hearted. Great technology is not enough to support transformational changes in care delivery models.

Beyond the widely known 'best practices' for shared care success, some less 'famous' critical success factors include -

• • Clear articulation of the future vision in the terms of the value proposition for each stakeholder facilitates stakeholder buy in to the transition. Focussing on shared outcomes provides a foundation for effective consensus based decision-making for the multi-disciplinary team as new processes and technology enablers are developed and implemented.
• • Addressing policy and process barriers to facilitate optimised workflows and information sharing requires significant support from privacy, legal and policy champions. It is advisable to engage these key team members early during the planning phase of the transformation.
• • Recognise that the 'shared' or 'collaborative care' model requires the providers to be willing to embrace changes in their traditional roles and responsibilities. The new model calls for an enhanced level of trust and accountability between providers. It requires expert providers to move from their 'my practice' comfort zone to adopt new behaviours, new shared work processes and to learn new technologies. Ensuring that effective stakeholder engagement and change support processes are active and involving the stakeholder in the definition, design, implementation and evaluation of changes is a critical success factor in optimising the benefits of a shared care model.
• • Ensuring that technology solutions and access to them supports and enhances provider workflow can make the difference between an enabling and a disruptive technology.
   

Through its supporting role in collaborative care, the patient centric EHRs can dramatically improve chronic disease management outcomes by providing comprehensive clinical decision support information at the point-of-care, across the continuum of healthcare services.