Evolution of Care Co-ordination Opens Up New Possibilities in Pop Health Mgmt

The evolution of care co-ordination opens up new possibilities in population health management

Back in the “good old, bad old days,” household shopping consisted of a series of visits to high street shops.

We bought vegetables from the greengrocer, went to the butcher for meat, the grocery store for eggs, sugar and jam. The newsagent sold papers and magazines, the florist sold flowers. Then came supermarkets, with all products under one roof, paid for at a single checkout. The supermarkets started to collect data about our buying habits and used this to create more customer-intimate approaches to shopping, alongside much better business planning.

In the latest retail iteration, we have seen the rise of the platform with a wide range of products purchased online and delivered within a short timescale. Platform players have a relationship with the customer and have such a solid core business that they can innovate with new services. They can use platforms to drive advanced analytic approaches.

So why take a trip down memory lane? Simply put, the high street shopping model of days gone by represents a metaphor for the way in which health and social services work with respect to records and health data. We use a range of health and social care providers, each of whom documents our attendance, but there is a risk that essential information from one setting may not be available in another. The greengrocer, not realising we just bought eggs, throws the potatoes into our bag on top of them!

Even where there have been linkages between systems to create an integrated record view, the visible record lacks any overall system-wide care plan. We are moving slowly towards a supermarket position, but the world is expecting the health and social care version of Amazon.

Working with Trafford Clinical Commissioning Group, DXC Technology has established the Trafford Coordination Centre (TCC). This centre uses data feeds from GP, hospital and social care records to create an integrated health and social care record for patients -- along with an integrated dataset that can be analysed. Whilst there is a range of potential service offerings that can use this integrated data, DXC has focussed on delivering a care coordination service provided by a team of nurses and administrators based in a clinical call centre.

The TCC makes use of a customer relationship management system (CRM), Microsoft Dynamics. This offers multichannel communication with customers and a platform that supports consistent, well-informed interactions and analytics. In Trafford, this has been specially configured to prompt, document and inform interactions with people whose care we are coordinating. These are, in the main, people identified as having a high risk of admission to hospital. This approach is already demonstrating potential admission-preventing interventions.

The use of the CRM in Trafford was a “first of type” approach to underpin better coordination of care. DXC is so convinced of its potential benefits based upon our experience in Trafford that we acquired Tribridge, a US company with a formidable Microsoft Dynamics practice and a CRM product called Health360. The evolution of Health360, including lessons learned from Trafford, will enable the creation of truly integrated and actionable health and social care plans at a system level.

This approach means that health and social care professionals can continue to use their preferred “systems of record” designed and refined for use within their workplaces and including mobile solutions for work in the community. They will, however, be able to ensure that relevant granular information is available within a system-wide care plan.

Implementation of the Trafford model has had its challenges, mainly concerning stakeholder engagement and information governance rather than technical aspects. Working closely with the CCG, DXC has overcome these challenges and has the necessary expertise to support customers with respect to working with stakeholders, developing the required information governance and supporting the development of technology links.

We are now seeing the availability of analysable, integrated data opening up new possibilities in population health management. An example of this would be an approach to diabetes that spans a continuum from prevention at a population level to management of multi-morbidity in which diabetes is a component. It has the potential to facilitate planning of education and leisure, improve primary care management, support people with high risk of developing the condition and offering intensive support to those who already have diabetes to minimise complications.

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