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New-models-of-care

New models of care

New models of care

CareCentric is used by CCGs and service providers in many different ways to improve the quality of patient services and to support the redesign of care pathways and new models of care.

Our solutions use risk stratification or manual assignment to create patient registers and manage the patients on those registers.

Patients can be prescribed apps and wearable technology to feed regular data into the system. This is combined with standard shared care record data such as test results and visit outcomes to manage patients via dashboards, and can be used to assess and alert changes in condition. Care plans can then be set or amended accordingly.

Example groups include patients with epilepsy, heart failure, diabetes, frailty, COPD, obesity and mental health problems such as dementia and depression.

The background

The base building block is the shared record and the patient portal.

The myCareCentric range of condition-specific mobile apps enable patients and other service users to contribute information in a range of innovative ways, including:

  • Wearable technologies (e.g., Microsoft Band), automatically gathering personal data such as sleep patterns, exercise, heart rate and temperature
  • 250+ telehealth monitoring devices (e.g. blood pressure cuffs)
  • Other health and lifestyle Apps (20+)
  • Customised condition/problem specific assessments and forms, e.g., seizure diaries, questionnaires, mood assessments, dietary information and medication compliance

Benefits for patients

Our myCareCentric apps and patient portal engage patients as a pro-active partner in their own care process. They are able to participate in, and control, their care management to fit better with their own wishes and individual needs.

Key features:

  • Active and direct engagement in their own care e.g.:
    • Links to health education information that aims to encourage and assist them in maintaining compliance with their care pathway
    • Assessment against their personal targets
    • The ability to share their goals and successes with a chosen network of family and friends
    • Responsive care, provided when it is needed rather than according to a pre-arranged cycle of appointments and check-ups
    • Security and quality of life improvements associated with having mobile, real-time electronic clinical support

Benefits for care professionals

Allows the use of risk stratification to identify groups of patients with specified conditions, or existing registers can be loaded. Those patients can then be recruited onto revised programmes of care that combine information from wearables and other telehealth devices with data entered by the patient. This is added to information from various systems across the care community, and held in a single care record. The solution monitors patients remotely and alerts clinicians to changes in a patient’s condition using machine learning and clinical dashboards. Treatments and levels of intervention can be managed remotely and patients only called in for consultation when necessary.

Key features

  • Manage and monitor a patient’s condition and general health remotely (including information collected from wearables and telehealth devices such as weight, pulse, sleep patterns, exercise)
  • Reduced pressure on services – reduction in regular check-ups
  • More time released for care
  • Ability to respond immediately to any changes in condition and take preventive action (e.g. modify drug dosage)
  • Set alerts for pre-defined events – e.g. when a patient presents for an unscheduled admission
  • Pro-active, fast decisions could help ensure appropriate treatment, reduce length of stay, or avoid unnecessary admission
  • Communicate directly with the other care professionals e.g. call on the expertise specialist or acute-based teams, or plan care with community and social care workers
  • Involve patients actively in the management of their condition, in order to help keep them healthier longer or contribute to a successful recovery

For more information, visit www.graphnethealth.com.

EHI Awards - 2017 winner 225x315

myCareCentric Epilepsy

Winner, Best App for Patients & Carers Award, EHI Awards 2017

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The myCareCentric Epilepsy app at Poole Hospital