Transforming Care at Home: Experience of the Belfast Health and Social Care Trust. Colm Donaghy Chief Executive December 2013
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1 Transforming Care at Home: Experience of the Belfast Health and Social Care Trust Colm Donaghy Chief Executive December 2013
2 Transforming Your Care Choice Empowerment Right information TeleHealth/Telemonitoring Right Place Right Time GP systems Mobile Access Integration and Access Portals (ECR) Community system Hospital based systems
3 Building Blocks Technical solutions/devices for accessing and recording Portals for ease of access and data collaboration Interfaces with primary care and private sector Good quality Hospital and Community data
4 BHSCT Case Studies 1. Older People & Phy Dis Services (NISAT & PARIS) 2. Community Podiatry 3. Home Dialysis 4. Early Innovator- Paediatric Cardiology 5. ICD(Implantable Cardiac Device) Tele-monitoring
5 Case Study 1: Older People & Physical Disability Referral Sources GP Hosp. Self Internal External External Onward Referral Single Point of Access One off support Signposting Crisis Response & Referral Rapid equipment access Governed by Service agreed protocols Discharge Internal Onward Referral Reablement Up to 6 weeks support to re-learn skills (includes Hospital Discharge support) Temporary Support in Crisis Assessment,Commissioning & Integrated Care Teams Review of Long Term Care Needs Short-term uni-disciplinary clinical & social work interventions/treatments End of life pathway MDT assessment, co-ordination, commissioning & review of longer-term maintenance care options Discharge Assessment & provision of equipment/home adaptations Intermediate Care Services Rapid access services to expedite hospital discharge Up to 6 week therapy driven rehabilitation programme within home/facility based locations Assessment,Commissioning & Physical Disability Services Social work assessment/ interventions Review of Long Term Care Needs Assessment, co-ordination, commissioning & review of long-term maintenance care options Discharge Older People s Mental Health & Old Age Psychiatry Services MDT assessment & short-term interventions for community clients with mild conditions Underpinned by Electronic NISAT Assessment Discharge Discharge Onward referral for service provision Discharge Service Menu Examples Independent -Nursing Home -Residential - Domiciliary Voluntary Agencies -VSB -Engage with Age Statutory -Residential - Home care - Day Centres - Supported Housing Specialist Services -Palliative Care -COPD -CHF -Diabetes -Continence -Tissue Viability -Care & Protection -Physiotherapy -Speech & Language -Support to Nursing Home Team - Carers Support
6 6 Before PARIS BP
7 After PARIS.AP Paris Functionality Reporting Letters Home care models Family and child care modules Referral Assess Diary Waiting List Discharge Treat Mental Health Order /Inpatients Social Care Health Mental Health
8 Paris Journey Benefits Shared Clinical Record across all disciplines determined by security levels Business Process Reengineering within Services Holistic view of patient Reduction in duplication Shared Assessments between disciplines Shared Alerts and Notifications Mobilisation/Integration Started North and West (app 2000 staff) Complete by 2014 South and East Belfast (app 2000 staff ) Started 2002
9 Team (ICT) Structure The Integrated Care Teams bring together staff x 8 Teams Care Managers and Assistant Care Managers District Nurses 24 hours a day Occupational Therapists Social Workers and Social Care Co-coordinators Reablement teams TM TM TM TM Bradbury Knockbreda ICT Beechall Shankill ICT Arches Dundonald ICT Grove Carlisle ICT Population focused & GP Aligned
10 Challenges: Addressing Challenges by Exploiting Technology Increased work load to community Preventing hospital admissions. Timely assessments Appropriate use of resources Faster hospital discharges Home is the hub! Exploitation of Technology: PARIS hospital/community interface Implementation of enisat across all disciplines Handheld mobile technology Performance Management Systems based budgets established for each team PARIS reports/dashboards Reablement pathway established Use of Assistive Technologies Telecare & Telehealth.
11 CASE STUDY 2 Community Podiatry Podiatry in Health & Well being centres with complex case Access Paris on Motion device Using Lync call Senior Hospital based Podiatrist for advice. Prevents Hospital Referrals
12 Case Study 3 Self Care Haemodialysis- The Knockbreda project Patients dialysing three times a week are not maximising dialysis Sometimes home care is not an option Self care in a purpose built centre is an option Design to open- 5 months 5 patients trained- 2 more training
13 Self Care Haemodialysis More frequent dialysis When it suits the patient Currently available Monday to Friday but plans to extend to 24/7 Reduced costs when compared to in centre dialysis
14 Remote monitoring Belfast HSCT supports patients undergoing Home Haemodialysis in all areas of Northern Ireland Patients must be reviewed on a monthly basis Trouble shooting is difficult via a phone call Travel time can be more than 3 hours What is the solution?
15 Remote video monitoring Initial projects with CCH and BHSCT IT department Aim to be able to connect via video to all remote patients Trials of various packages on going First Video review successful Aim to be connected wherever we are
16 Case Study 4 Paediatric Cardiology Telemedicine as discharge support for families of children with major congenital heart disease when: Bringing home a child with major congenital heart disease (CHD) is difficult Anxiety levels are often high As a regional service, patients may be distant from specialist help if problems arise
17 Paediatric Cardiology Home monitoring of children with major congenital heart disease via videoconferencing: Provides reassurance to families Decreases parental anxiety Uses team resources more effectively
18 Case Study 5 Implantable Cardiac Devices (ICD) implant rates in UK First ICD implants performed 1990 Over 1,400 ICD patients are currently under review at the BHSCT per million population Year ccad.org.uk/devicesurvey
19 Patient s Home CRM Device ICD System overview Remote review patient management system remotely monitors Implantable cardiac devices Health Following Physician Objectives Device Battery Management Patient s Weight Management Compliance with Guidelines Device Managing Physician Objectives Device management Arrhythmia management
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