From Pulse+IT, Australia, 18 Mar 2015 (full article)
Western Sydney is trialling a new model of care for patients with chronic illnesses involving GP-led shared care planning, hospital-based rapid access and stabilisation clinics and nurse-led care facilitation, all powered by a web-based, dynamically updated, shared care plan.
The trial is part of the four-year, $120 million Integrated Care in NSW strategy announced by state Health Minister in March 2014.
GPs will create and manage a shared care plan, hospital specialists will update it with action plans, and nurses will facilitate the plan by working with patients, GPs and speciality services to ensure its recommendations and goals are carried through.
At the heart of the project is the LinkedEHR shared care planning system first developed by the Western Sydney Medicare Local (WentWest) in association with Ocean Informatics, which went live in early 2014.
As part of the integrated care demonstrator site, LinkedEHR is being used as the IT centrepiece of a new model of care that will see quite a radical change in the normal divide between primary and acute care.
WSICP clinical lead Michael Crampton said the wider strategy was to deliver more timely and appropriate health services to complex patients across the spectrum of care settings, with the intention of improving the integration of their care.
Dr Crampton, the 2014 RACGP GP of the Year and a well-known advocate for using eHealth to better care for patients, said the project will focus on people with four specific chronic diseases: diabetes, chronic heart failure, ischaemic heart disease and chronic obstructive pulmonary disease.
LinkedEHR has been provided for free to GPs and allied health professionals in WentWest’s catchment for some time, and access will now be extended to the hospitals as well. Western Sydney LHD has agreed to extend the electronic medical record system in outpatients so specialists can write action plans for the patient that will be sent back to the GP electronically.
“The patient can also have a view of the care plan. If the patient wants to carry it around on their tablet or their smartphone, then they can also call up their own care plan and show it to anyone that they want to.”