care close to home a rural and metro partnership model · telehealth model –a component of a...
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Access for Older People’s complex care close to home
A rural and Metro partnership model
Debra Tooley - District Manager Aged Care Services
John Cullen - Geriatrician
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Where are
we?
Western NSW…
Population: 277,353
18% Aged over 65 yrs
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Our Services…
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Why Telehealth Enhanced Model?
Data Analysis Project Design Implement & Test
Increased demand
Pt complexity
No Geriatrician
Increased waiting times
Increased travel for services
No funding for Geriatric Medicine services
Collaborative solution design
Technology
Funding source
Leadership
Clinical – pt selection
Patient engagement
Role clarity
Quality & Audit process
Staff Education
Honorary medical contracts
Service Agreement
Purchase of Telehealth devices
Development of protocols
Data collection –activity & cost
Rostering of staff
Communication strategy
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Person Centred, directed and empowered
Primary care based
Targeted
Continuously improved
Collectively accountable and
mutually beneficial
Shared information
Principles
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Enablers
Engagement Partnerships Governance
Funding Leadership Capability
Culture Technology Information
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Telehealth Model – a component of a
comprehensive geriatric model of careClinics
Scheduling
Equipment, Patients and Geriatrician
Booking
Transcription service
Workforce
Metro: Geriatrician
Local: Clinician
Liaison with GP
Patients
Clinical assessment
& reports collated
Mgt plans
Technology
Booking
Equipment testing
Education
Health Record
Shared clinical notes
Audit process
Governance & Funding
Clinical gov.
Local leadership
Evaluation
Quadruple Aim
Continual improvement
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• Well accepted by patients and carers
• Family patient education and care
planning discussions
• Cognitive Assessments and diagnosis
• Capacity Assessments
• Comorbidities / Chronic disease
assessment ( and management)
• Medication reviews
• Driving assessments
• General healthy ageing advice
• Advanced care planning discussions
• Gait, Falls and Bones evaluation
What Works Well
• Telehealth is not “instead of” face to
face clinics
- complimentary
• The Medicare model rather than ABF
funding model
• The enterprise has had the support
of both CEs of both LHDs
• The network has been reliable and
the equipment continues to improve
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• Patient characteristics
– severe deafness
• Non-cooperation – extremely rare
• Assessments requiring hands on
physical examination
- (undertaken at face to face clinics)
What Doesn’t Work
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Measuring Success
Improved experiences for people, families and
carers
Improved experiences for clinicians and service
providers
Improved health outcomes for the
population
Improved Health Systems
QUADRUPLE AIM
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Measuring Success
“Great service in our own town”
“No different to a face to face appt”
“Great not having to travel to Sydney (6-10 hours)”
“Felt like I had specialists’ full attention the whole time”
“Perfect for country people”
“Excellent team work – felt supported”
“Technology easy to use”
“Very organised clinic”
“Feel connected to the patients and carers”
“I can do clinics from my own office”
Decreased waiting time for patients – less stress
Improved Patient &
Carer ExperienceImproved Clinician
Experience
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0 5 14 2240
5576
56
85
3652
55
140
150132
110138
160
0
50
100
150
200
250
300
2010 2011 2012 2013 2014 2015 2016 2017 2018
WNSWLHDGeriatric Medicine Program
Consults FTF Consults via Telehealth
0
20
40
60
80
100
120
140
160
180
2010 2011 2012 2013 2014 2015 2016 2017 2018
Consults via Telehealth
Consults via Telehealth
Measuring Success & Sustainability
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Outcomes
People, families and carers
• I can access specialist services in my own town
• I don’t have to re-tell my story
• I know that there are a team of skilled staff that assist with my health and social care needs
Service Providers and clinicians
• I can access all relevant information about the patient so I can provide high quality care (comprehensive assessment, restorative care, GP collaboration)
• I work in an efficient system that supports me to provide high quality care
• I collaborate and communicate effectively with other providers to deliver the best care possible
Population
• Care addresses the social determinants of health
• Care for people with long term conditions is improved
Health Care System
• The system is efficient and results in timely and appropriate management
• Health care service in NSW connected with social care
• IT systems and processes are integrated across the health system
• Financially viable
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• WebRTC – using the web to connect to patients and
carers on their own devices in locations that are
convenient to them
(including RACFs)
• Use of wearable devices
- Embedded into clothing
• In home monitoring
• Linking outside the health network e.g. with AMSs
Where to from Here?
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Quote for John Cullen
‘The Geriatric Medicine Service
is one of the more worthwhile
and satisfying things I do as a
clinician and a service manager’
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Thank you!
Where to
from here?
Debra Tooley - District Manager Aged Care Services
email: [email protected]