Planning for Automation of Care Pathway Management

1. Planning for Automation of Care Pathway Management Jason DaCosta - Warrington CCG Warrington CCG Population Health

2. AboutWarrington Warrington Population approx. 208,000 A process of clustering services around a geographically co-located population Eight ‘groups’ of GP practice with each group having population ranging around 20-35k Clinical time allocated to appointment ‘slots’ of 10 minutes provided to patients on an ‘as and when’ basis Demand on clinical time is greater than current capacity.

4. Management of patients is based on face-to-face consultations Some or all of these professionals may be involved in a single appointment • Inputs: • B/P recordings, weight and life style updates are recorded • Medications reviewed • Therapeutic decisions made or continued • Face-to-face consultations take place with: • Nurse specialists • Health Care Assistants • GPs

5. This periodic mode of management has 3 drawbacks • Blood pressure recordings impacted by: • Recent by activity (walking into the surgery) • The Iatrogenic effect • Recordings are a snap-shot • They record ‘now’ • May skew the clinical perception of the patient, interpretation of the patient’s B/P status • Appointments absorb clinical time • But may not result in a change in current management

6. How can patients be managed more effectively?

7. For patients with primary hypertensive, there is an option to manage care using elements of self-management • These technical solutions are offered by: • Cisco (Clinical portal and integration services) • Third Party Telemetry Devices • Using: • Self applied diagnostic equipment … • Recording data, transmitting telemetry … • Linked to secure internet services … • Storing data in an anonymised database … • Displayed within a clinical (web) portal … • Sharing data with GP systems

8. A pilot programme to test a technology enabled, remote monitoring hypertension surveillance service is proposed • Pilot Practice: Greenbank Surgery • Patients cohort characteristics: • Primary hypertension • Selected from hypertension register • Volunteer, consenting patients • Severity range: SI to SIII • Male-female mix • Across the adult age range • With internet access • Able and willing to record blood pressures, weight and activities over the internet

9. Our 300 …

10. Cisco Extended CareDriving Health and Wellness Cisco Extended Care is a personal health and wellness collaboration platform, enabling patient engagement and care team interactions at any time and from anywhere. The solution provides: • Enhanced and efficient care coordination • Secure messaging • Appointment calendar and scheduling • Questionnaires • Real time video collaboration • Anywhere access to care team consults • Personalized content sharing • Video platform to drive health and wellness awareness and education • Open APIs to embed into and enable 3rd party applications and environments

11. Cisco Extended Care CapabilitiesScheduled Video Consults • Anytime access to appointment information • Streamlined workflow for appointments – Single click Appointment initiation

12. Cisco Extended Care CapabilitiesProvider Scheduling • On Call Scheduler • Scheduled Appointments • Provider Group Schedules • Patient Type Grouping • Nurse Notes, Surveys

13. Cisco Extended Care CapabilitiesPre-appointment Questionnaire • Ability for users to take pre- appointment questionnaire • Saves total clinical time for an appointment

14. Cisco Extended Care CapabilitiesVideo Platform to Drive Health and Wellness Education • Empower the patient wellness by providing education information • Provide videos of how to use the system – reduces support cost and enhances patient satisfaction

15. Cisco Extended Care CapabilitiesMedical Device Readings • Ability for the patient to keep track of his or her wellness device readings • Visual trends display for ease of view

16. Cisco Extended Care CapabilitiesJabber Video Integration • Utilizes Cisco Jabber SDK technology for remote video consults • Removes the need for purchasing separate video endpoints

17. There are 11 perceived benefits from this approach * Patients managed via the technology have the potential to save, avoid 2 GP practice appointments per annum. At Greenbank Surgery, there are 300 patients with Hypertension only (no recorded comorbidity) on the Hypertension Register. A saving of 600 appointments equates to approx. 120 clinician hours pa, based on a mean 12 minutes per appointment

18. Next Steps • Integrate with a wider pool of telemetry devices • Build and share the care plans • Risk stratification to identify other patients who will benefit • Psychiatry liaison • Complex Care Management • Risk of readmission using LACE scores

19. Increasing clinical capacity & engagement

20. Thank You and Questions