USING TECHNOLOGY TO DELIVER BETTER CHRONIC DISEASE MANAGEMENT Dr - PowerPoint PPT Presentation

USING TECHNOLOGY TO DELIVER BETTER CHRONIC DISEASE MANAGEMENT Dr Eleanor Chew Dr Amit Vohra Clinical Lead Integrated Care Executive General Manager Sonic Clinical Services Sonic Clinical Services

‘Complex’ target group • High care needs • High risk of re-admissions • High level clinical care coordination ‘Multi - morbid’ target group • Complications of chronic disease • At risk of hospitalisation • Targeted care coordination ‘Uncomplicated’ target group • Controlled or low risk of complications • Low risk of hospitalisation • Supported self-care ‘At risk’ target group • Personalised patient education Smoking 13%

Stepped care approach Home care & individualised care High level care coordination Tailored interventions Care coordination Personalised CDM care plan Shared e-health record (cdmNet) Preventive Care Smart phone app (MediTracker) Patient education (GoShare) Patient Centred Medical Home

Technology supporting CDM • Risk stratification • Shared electronic medical records • Mobile app • Digitally enabled education

Patients over 45 years Risk Stratification NO Chronic Disease Diagnosis YES Smoker NO YES 1 Dx 2 Dx 3 Dx • Data extraction tool OR BP >160/100 OR • Risk factors/diagnoses Microalbuminuria NO YES Identification >20mcg/ml FGB >7.0mmol/L OR Patient OR eGFR <60 ml/min • Patient identification BMI > 40 OR OR BP >160/100 TC > 7.5mmol/L OR • Health assessment OR TC > 7.5mmol/L FHx Diabetes OR HbA1c >7.5 • Stratification Ineligible for WellNet • Selection Perform in clinic health assessment YES Assess HARP Chronic disease Stratification Selection & identified? <10 10 - 38 >38 NO FeelWell LiveWell StayWell BeWell

Shared electronic health records • Web based e-record shared & used by whole of care team including AHP • Digital care plans – guidelines based • Care coordination - assigns tasks & responsibilities to care team members • Tracking – team members contribute to care plan on completion of tasks

Patient mobile app

Digitally enabled education

WellNet Trial Locations Current Locations Size & Mix Target Cohort • 3 IPN & 3 non-IPN Practices. • 1050 Tier 2 and Tier 3 Patients. North Sydney Trial • LHD, PHN, BUPA, HCF, nib, Teachers & • 600 in evaluation cohort • Public & Private Patients DoH on Steering Committee. • Expanding to another 6 practices in • PHN confirmed expansion of trial to 2019 new practices in 2019-20 • 10-15 IPN & non-IPN Practices. • Target 400-600 Private Patients. AHSA Victoria Trial • AHSA, AU, GMHBA, Defence Health, People Care on Steering Committee. • 6-8 non-IPN practices • Target 800 Public patients SEMPHN Victoria Trial • Separate cohort of 40-50 Frequent Flyers • 5-6 IPN and non-IPN practices • Target 800-1000 patients Hunter PHN & nib Trial • Greater focus on obesity related chronic disease

Learnings – Risk stratification 5 chronic disease categories: Additional chronic diseases: • Cardiovascular • Osteoporosis • Respiratory • Low back pain • Diabetes • Cancers • Major joint disease • Kidney failure • Mental health • Liver disease

Learnings - cdmNet • Enables shared care planning and coordination • Can be confusing for GPs not familiar with it • Requires dedicated training • Sits outside other record systems

Learnings - MediTracker • Available to all WellNet patients • ‘Tech savvy’ more likely to download app • Check results and appointments • Access to medical record overseas • 60% continued to access app after completing WellNet program

Learnings - GoShare Not hitting the mark … • 35% viewed items • Older age cohort • Too much e-traffic • Contact too frequent • GPs not familiar with it

Evaluation findings - CMCRC Statistically significant improvement in: Self-reported Health Assessments Clinical Outcomes • HARP score • Systolic & diastolic BP • Patient Activation Measure (PAM) • Body Mass Index • Quality of Life score (EQ-5D-5L) • Waist circumference • Cardiovascular Disease Risk score • Hba1c • Psychological scores (K10 & DASS21) • Lipids inc TC, HDL, LDL, TG • Diabetes Risk Assessment (AusDRisk) • COPD Assessment Test (CAT)

CLINICIAN FEEDBACK “many silent or unattended to issues are uncovered and dealt with”.

PATIENT FEEDBACK

Thank you Questions?