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Integrated Care Plans

CareCentric Pathways solutions have been designed to support pathways of care and workflow management across multi-disciplinary teams and care settings, as well as supporting clinical correspondence if required. Used as part of the CareCentric solution as a whole, the system supports clinicians and care professionals in their decision making by giving them access to a wealth of integrated care data, presented in meaningful views applicable to their role, complemented by an easy and intuitive e-form capability, which allows for true multi-disciplinary working in real-time.

CareCentric solutions have been designed to be user friendly, making use of consistent screen layouts and unambiguous, familiar navigation tools to simplify system use and engage users. Clinical and care professional involvement has been key to developing our user interfaces and ensuring clinical relevance and safety. The aim is to help care services provide more effective and timely care, and to keep patients healthy and out of hospital.

CareCentric Pathways is tailored to suit a wide range of requirements, including condition management, end of life preferences, assessments, correspondence, for example, our End of Life (EPaCCS) solution makes use of data integrated from primary care systems with CareCentric and automatically pulls this through to the End of Life plans, including demographics, medications, allergies and alerts ie. adverse drug reactions. Any changes and new information feed through to update the record and the forms.

The integrated care plan gives authorised professionals immediate, on-the-spot access to the records of patients identified as being at risk of unscheduled or unplanned care. The plan is updated in real time, and so provides a single up-to-date record which can be shared across a whole health community.

The use of integrated care plans (ICPs) brings tangible benefits, particularly in terms of efficiency and cost-effectiveness. ICPs help health and social care teams work together to provide responsive, integrated services. However, ICPs can also help the patient feel independent, in control of their lives and able to plan to prevent further deterioration in their health and social care. They encourage a ‘whole person’ view of the individual, whatever the complexity of their needs.

Key product features:

  • Care forms: Care forms and proformas are used to collect, validate and present information. They support data of many types including numbers, text, dates and pop-up options. Features include data validation and conditional data entry. The forms are central to many of the speciality solutions that are used within CareCentric.
  • Assessments: CareCentric Pathways uses care proformas to support the definition and completion of assessments. CareCentric Pathways assessments support data entry, conditional form logic, baton passing, assessment scoring and assessment summary.
  • Immediate discharge summaries: A discharge planning workflow that collects information at each step of the care pathway and creates a discharge summary for electronic transmission and upload to the GP system.
  • The system can embed third party applications and uses this feature to provide solutions such as: Electronic Document Management, Integrated clinical information and electronic document management systems to deliver healthcare without paper notes.
  • Order communications: CareCentric Pathways supports order communications by embedding third party products and calling them with single sign on and within patient context.

CareCentric Pathways caters for a number of clinical and practitioner requirements, for example, assessments for specific problems, health issues or conditions such as Diabetes or individuals with other complex long-term conditions.

The solution has been designed to support pathways of care and workflow management across multi-disciplinary teams and care settings, for example, providing enablement and support for a diabetes care pathway, as follows:

Diagnosis stage:

  • Ensuring all appropriate care professionals are aware of the diabetes diagnosis via the shared care record, particularly important for an Out of Hours’ service and A&E users who may not otherwise have this information readily available to them.
  • Creation of and/or access to relevant referrals to supporting dietician, educational, lifestyle and other services.
  • Creation and sharing of regular diabetic assessments

Treatment management stage:

  • Creation and sharing of regular assessments, for example lifestyle changes, medication compliance, including inputs from the patient themselves if the optional myCareCentric Personal Health Record / myCareCentric Diabetes App are in place. The latter can also be used to provide health and lifestyle guidance and links to patients to promote self-management.
  • Displaying medication information which is comprehensive and up-to-date in the integrated care record for authorised care professionals to view and act upon
  • Prompts for regular actions required, e.g., screening via email notifications or via the optional Careflow alerting and notification module

Complication / Risk management:

  • Highlighting risk data within the integrated care record, whether made available from source systems or recorded in CareCentric Pathways e-forms, such as hypertension and so on.

Maintenance phase:

  • On-going creation and sharing of regular diabetic assessments, plans and reviews