An Integrated Information Environment Supporting Community Based Care
Authors: A. Maeder, G. Morgan M. Karunanithi, and J. Boyle
Date: November 2006
Abstract:
It is well established that there are severe current pressures on our health systems caused by diverse factors such as ageing population, burden of chronic diseases, shortage of resources, diminished health workforce. Changes in healthcare delivery mechanisms by adopting new workforce models and workplace practices have been widely advocated to ease these pressures. Recent trends toward making such changes include patient-centric care models incorporating extended carer teams and detailed care plans, and place-based care initiatives which permit care delivery to be conducted in community-based settings away from hospitals.
These approaches present a number of challenges on the human front. They require learning of new skills and protocols involving coordination of a large and diverse group of participants, only some of whom will have team skills and health systems domain knowledge. They also require substantial amounts of health information on the patient to be gathered and monitored, to ensure that care is proceeding beneficially, and allowing adjustments to be made to the care plan on an individual patient level. In addition, they need to respond to an expectation that comprehensive, updated and reliable information on all aspects of the patient’s care progress should be available in future episodes involving clinicians and facilities outside of the normal care circle.
All of the above human issues can be addressed in part by use of platform software technology that provides an integrated environment which combines the particular patient/disease characteristics, representation of the care plan, various health assessments performed at different timepoints, capture of relevant dynamic information from patient and carers, monitoring of patient progress against care plan, and any additional details of care plan revisions or additional episodes. These aspects demand far more powerful computational tools than simple electronic record systems, including a need for embedded procedural guidelines, care decision support, and provision for alerts triggered by changes in patient conditions.
Our design for such a platform is currently being deployed for clinical trial on COPD and CVD sufferers in a Brisbane community-based care setting. The platform will be applied to three different cohorts: a "currently well" who are "at risk" of these diseases and who will adopt preventative strategies, an "initial onset" cohort who are engaged in self-managed care with intermittent external advice from various healthcare professionals to prevent rapid advance of the disease, and a "chronic sufferer" cohort who are managed by a multi-person care team. The trial will establish the effectiveness of the platform and as a subsidiary benefit will enable the training of carers in a multi-party care team based on an active learning approach.
© 2006 CSIRO
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