Health and social care teams across Manchester have gone live with an integrated care record designed to help multi-disciplinary teams protect the city’s most vulnerable people and dramatically improve care outcomes.
The integrated care plan combines a shared care record with a care planning application. It gives authorised professionals immediate, on-the-spot access to the records of patients identified as being at risk of unscheduled or unplanned care.
Central Manchester, North Manchester, and South Manchester CCGs, together with Manchester City Council, are using Graphnet’s CareCentric software to integrate information from multiple health and social care provider systems, making detailed patient information available to multi-disciplinary care teams in a single care record. Use of this data in the care plans removes the need to enter information twice and means that the plan is kept up to date when new information is entered on local systems.
When a new plan is created, specific details such as patient management, crisis and risk planning, core team and specialist services, informal carer and next of kin details are combined with existing information such as medications, allergies and investigations from the shared care record. The care plans themselves are then kept up to date by users across the care community entering new information and by automatic feeds from the various linked systems. This avoids double entry and ensures that the plan is kept up to date.
At present, data is combined from three acute Trusts, 90 GP practices, and Manchester City Council’s social services department. Plans are in place to deliver records from Manchester Mental Health & Social Care Trust and North West Ambulance Service later in the year.
To date just under 6,000 care plans have been created by GPs in the city, with around 900 registered users of the system.
"This project is all about providing our multi-disciplinary teams timely access to the right information so they can provide more effective, rapid and joined-up care to our patients", said Ed Dyson, Project Sponsor & Assistant Chief Officer, Central Manchester NHS Clinical Commisioning Group .
"Our evaluation so far has shown that there has been a significant reduction in secondary care activity for people identified as being at high, or very high, risk of hospital admission."
All GP practices across the city have the ability to develop integrated care plans for patients. They are now being provided with Single Sign On access to CareCentric from within their EMIS Web software, which means they can access a patient’s integrated care record at a single key stroke from within that patient’s primary care record.
Live feeds of hospital patient activity from Central Manchester University Hospitals Foundation Trust, Pennine Acute Hospitals NHS Trust and University Hospitals of South Manchester Foundation Trust provide easily accessible summarised information on acute inpatient, outpatient and A&E attendances, and discharges, as well as future appointments and results from hospital pathology tests.
For GPs, care teams and hospital staff in Manchester, the shared information will help ensure that discharges from hospital are timely and that patients are supported successfully in the community, with keyworker-led alerts in place to try and reduce risks of re-admission.
The activity register could also be used to help identify and support patients for on-going practice and multi-disciplinary care reviews. Social care feeds from Manchester City Council provide details of current and recent social care interactions, any planned services and key team and personal relationship details.
Graphnet's director Markus Bolton commented: "There are large numbers of shared record systems now being purchased and rolled out across the UK. The Manchester initiative is particularly interesting because it builds on the shared data to support true multi-disciplinary working across organisational boundaries."
The Manchester deployment is a level 2 shared care record on Graphnet ‘s solution maturity model. Level 1 is a full shared record, combining records from multiple types of organisation within a care community eg acute, community, mental health, primary care, independent treatment centres and adults’ and children’s social care data.
Level 2 involves the integration of care planning support and management, where the shared record is integrated with the collection and update of community-wide assessment, workflow and care planning applications to support integrated patient-centric care.
Level 3 requires patient access to a personal health record, and Level 4 the full patient engagement associated with a population health management system.