2. 2
âOne of the great challenges in
healthcare technology is that
medicine is at once an enormous
business and an exquisitely human
endeavour; it requires the ruthless
efficiency of the modern plant and the
gentle hand holding of the parish
priest; it is about science, but also
about art; it is eminently quantifiable
and yet stubbornly notâ
Robert Wachter, The Digital Doctor
4. 4
A picture of the challenges
Deman
d
Changing in
nature
Access
Removin
g
barriers
Equity
Social
determinants
Between now and
2050 the number of
older people (65 to
84 years) is
expected to double
Most
chronic
diseases
are
preventable
Intersection of
health &
communicatio
ns
5. 5
PHN Framework: Identifying
opportunities for health system
improvement in western
Sydney
Western
Sydney PHN â
Health system
Improvement
opportunities
Whole-of-system (Macro level):
Enhanced structural integration
across the various health services
serving the population of western
Sydney and covering both private
and public health sectors.
Care/population groups (Meso level):
Enhanced service integration for
targeted health initiatives including
local and national priority focus areas
and/or sub-populations that have
been identified as a result of PHN
population needs analyses.
Patient-centric integrated and
coordinated care (Micro level):
Improved delivery of patient-centric
health services to individuals and
their carers through a coordinated
set of care interventions that ensure
the right care is provided in the right
place at the right time.
Advocac
y
Commissionin
g
Integration
Western Sydney
PHN â Health
system
Improvement
opportunities
6. 6
The building blocks of a
successful integrated care
system
Support with Enablers
Payment Governance Information Leadership Support
âQuadruple Aimâ
Organise Delivery
Protocols
Care
plans
Performance
review
Care
coordination
and delivery
Understand Needs
Low risk
Moderate
risk
High risk
Very low
risk
Very high
risk
7. 7
⢠Adoption of an evidence based
approach to achieving good
quality primary care for the
community
⢠Engaging and investing in
leadership at all levels â
especially GP Leaders
⢠Linking the model to:
- What we do and can do
more of
- What changes are needed
and how we can make
them
- A platform for integrated
care
⢠Promoting networks of
practices
⢠Sustaining the effort
Building Blocks for High-
Performing Primary Care *
*Wllard & Bodenheimer 2012
8. 8
The information challenge â
some observations
⢠Understanding general practice/primary care data
- Creating reliable and accurate sources
⢠Sharing across organisational boundaries
- Even greater complexity when associated with
care coordination
⢠Integrating, not just collating
⢠Associating information collection with best
practice care pathways
- Living documents to achieve the quadruple aim
⢠Up to date infrastructure
⢠âMy integration is your fragmentationâ
10. 10
A shared care plan is a structured,
comprehensive plan developed jointly
by the patient and their family/carer
and health professional(s). It may
include a summary of personal health
information, a personâs health goals,
and the treatment and follow up care
they receive.
National Health IT Board NZ
13. 13
Our vision of Primary Care for
the future
âPrimary care will have at its heart
active collaboration between
healthcare professionals and the
people they care for. This patient-
focused approach will require
collaboration between professionals
and strong team working, both within
and across organisational boundaries.â
Source: Primary Care Workforce Commission UK - 2015
14. 14
Shared care plans and teams
⢠Direct service provision verses care coordination
- Aligning payments systems to integrated care
strategies
⢠Primary care/general practice clinical leadership
⢠Role definition among professionals, generalists,
specialists and sub specialists
- New roles such as nurse practitioners and
physician assistants
⢠Engaging and activating consumers through
better information transparency
⢠Shared care planning platforms
- eHealth/EMRs aligning to clinical pathways
16. 16
LinkedEHR â a shared care
planning tool
⢠Itâs development was led by GP leaders who at time felt
existing products did not meet needs
- Commissioned Ocean Informatics to develop for
WSydney
⢠Ability for simultaneous viewing/updating by team caring
for the person
- Uses Clinical Management System and TopBar
⢠Can be accessed by browser, in the GPs âneighbourhoodâ
- Sending eRederrals, to be accessed through hospital
systems
⢠Same security and privacy as the national MyHR
⢠Can read a patientâs MyHR.
- Will soon be sending Shared Health Summaries to MyHR
⢠Captures lost revenue by closing the loop for various PIPs
18. 18
Additional Features
A comprehensive clinical decision support
system (HealthPathways) embedded
By June of 2016, LinkedEHR will be
integrated with the Telstra Health Gateway
collecting consumer entered data and
delivering an accessible SCP
A Risk Stratification feature to assesses the
risk of hospitalisation being developed
21. 21
Building capacity and capability
There is a need for general
practice to adapt rapidly so that
it operates at a scale that can
provide a platform for integrated
care.
(Kings Fund 2011)
Finding ways to build leadership amongst primary health
care providers and working with early adopters
22. 22
Practice Capability: steps on the
journeyPen
Licences
186
Practices
Pat Cat
âActiveâ
120
Installed
Integrate
d Care
Contracts
52
Signed
LinkedEH
R
Registere
d
218 GP
158
AHP
45
Nurse
Total
421
PCMH
Engaged
15
transformin
g
15 more
engagin
g
Health
Pathways
4,000 new and
returning users
23. 23
Western Sydney
Integrated Care
Program
Mar 2016 update
GP
Practices
51 (38%)
GPs 175
Enrolments â GP Practice:
January
GP Practices Total Number
Enrolled YTD
Target
(Total)
Number of GPs
Enrolled YTD
Total 52 135 135
Level 1 28 30 100
Level 2 24 45 35
28. 28
As the Western Sydney Primary Health Network,
WentWest is focused on addressing both regional
and national health challenges. Together with
health professionals, partners from both the
health and hospital sector, consumers and the
broader community, WentWest seeks to identify
gaps and commission solutions for better health
outcomes.