Health Care for the Elderly, Plymouth
Plymouth’s Health Care for the Elderly (HCE) department has been using SystmOne to deliver a vertically-integrated health system, allowing patients to benefit from holistic care across their services. Using one shared IT solution, staff from GPs, community health services, and multidisciplinary teams (MDTs) on HCE hospital wards can develop a collective health plan for a patient based on their individual needs. The plan is sent to the patient and stored on the patient’s electronic health record, which is accessible to all clinicians involved including out of hours providers, meaning the entire team is working towards shared goals. This is fantastic news for staff and patients as care will be delivered more efficiently, meaning reduced waiting times for patients and a quicker turnover for HCE staff.
As part of this health system, staff across services in Plymouth have been able to work more collaboratively, sharing expertise and resources to meet each patient’s needs. For example, a community care team may have more insight into a patient’s home environment. Logging this information in SystmOne means that it is available to occupational therapists (OTs) who would not otherwise be aware of any issues. The OTs can begin working with the patient immediately, without the need for a referral or long waiting lists. Using a shared IT system makes it easier for clinicians to pool their expertise, improving the overall care that is delivered in hospital and at home.
“Having clinicians from GP practices, community services, and hospitals on the same page regarding patient care is crucial,” says Dr John Parry, former GP and Clinical Director at TPP. “As a GP, I would sometimes arrive for a home visit, having no idea that the same patient had been admitted to hospital the day before. Having the resources to deliver vertically-integrated care is a great step forward, and I am very pleased that we could facilitate this.”
The implications of this system for patients, particularly older patients living with a diagnosis of frailty, are enormous. The shared health plan put together by staff across services means that, when a patient is admitted to hospital, it is immediately apparent what care should be delivered. This increases efficiency on the ward, reducing the time the patient needs to stay in hospital. For older patients who are more vulnerable to picking up other illnesses during a hospital stay, this is vital. The results of these tests are made available on the patient’s electronic health record which can be accessed by all clinicians involved in delivering that patient’s care. This eliminates the need for tests to be repeated unnecessarily in different settings and therefore improves the patient’s experience.
Importantly, by following a dedicated care plan, staff can offer patients clear expectations as to what will happen while they are in hospital, and how long it will take. Irrespective of the friendliness and professionalism of the staff, hospital stays can be worrying for patients. Being given a clear plan for their stay and an idea of when they can return home can be a big help in reducing hospital-related anxiety. Additionally, as follow-up care is provided by members of the same cross-service care team, patients experience continuity across their healthcare regardless of the setting in which it is delivered.
“Being on a combined care record has totally transformed the healthcare landscape in the Plymouth Locality. The evidence is clear and robust; older people with frailty benefit from one key intervention, the Comprehensive Geriatric Assessment (CGA). The CGA needs an MDT and encompasses a suite of clinical activities, the output being a care and support plan, shared with the patient and other healthcare providers. Before the Combined Care Record, all providers were duplicating fragmented parts of this assessment and storing it in their own records,” says Dr David Attwood, GP Partner at Pathfields Medical Group and Clinical Lead for the Integrated Care of Older People in West Devon. “Now that we have a combined record, we have ‘Healthcare without Walls’ where the MDT can gather the information it needs from any provider organisation who is using TPP. This has allowed us to mass produce comprehensive geriatric assessments and all providers have access to the care plans. An evaluation is underway and early data is deeply encouraging – watch this space!”