Transcript Planning for Automation of Hypertension Care Pathway

Warrington CCG Population Health
Jason DaCosta - Warrington CCG
• 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.
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• 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
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Some or all of these
professionals may be
involved in a single
appointment
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1.
Blood pressure recordings impacted by:
Recent by activity (walking into the surgery)
The Iatrogenic effect
2.
Recordings are a snap-shot
They record ‘now’
May skew the clinical perception of the patient, interpretation of the
patient’s B/P status
3.
Appointments absorb clinical time
But may not result in a change in current management
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• 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
• These technical solutions are offered by:
• Cisco (Clinical portal and integration services)
• Third Party Telemetry Devices
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• 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
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Cisco Extended Care
Driving 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
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Cisco
Scheduled Video Consults
 Anytime access
to appointment
information
 Streamlined
workflow for
appointments –
Single click
Appointment
initiation
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Cisco
Provider Scheduling
• On Call
Scheduler
• Scheduled
Appointments
• Provider Group
Schedules
• Patient Type
Grouping
• Nurse Notes,
Surveys
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Cisco
Pre-appointment Questionnaire
 Ability for users
to take preappointment
questionnaire
 Saves total
clinical time for
an appointment
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Cisco
Video 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
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Cisco
Medical Device Readings
 Ability for the
patient to keep
track of his or her
wellness device
readings
 Visual trends
display for ease
of view
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Cisco
Jabber Video Integration
 Utilizes Cisco
Jabber SDK
technology for
remote video
consults
 Removes the
need for
purchasing
separate video
endpoints
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GP & GP Practice Focused
Benefits
Patient-Focused Benefits
1. Increased clinical efficiency
– GPs only intervening with
Hypertension patients that
need an intervention
2. Releases time, provides
capacity for clinical staff to
manage ill and more complex
patients (Links to above)
3. Simplifies and informs
medication reviews
5. Time saving for the patient* –
fewer or no attendances,
appointments at the Practice
4. Increases potential for
practice to meet Hypertension
QOF targets
6. Provides for a high level of
patient autonomy and selfmanagement
Overarching Outcome
Enables enhanced
management and control
of patients with
Hypertension
7. Increases patient’s
understanding of hypertension,
factors and therapies, activities
impacting blood pressure
8. Potential for increased
medication concordance
9. Improved control – seeing Blood
Pressure readings has potential to
influence patient behaviour (links
to self-management above)
10. Potentially fewer hypertension,
hypertension therapy related
incidents
Increases capacity in
Primary Care - up to c600
appointments from our
300 patients – or 120
clinical hours
* 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
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• 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
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Thank You and Questions