PATIENT-CENTRED CARE. CLINICIAN-LEAD SUPPORT.

Transcription

1 -CENTRED CARE. CLINICIAN-LEAD SUPPORT.

2 Introducing WellNet WellNet is a comprehensive set of integrated care programs, powered by Sonic Clinical Services Pty Ltd (SCS) and the network of GPs working with its owned & partner medical centres. WellNet s integrated care programs provide timely, GP lead healthcare interventions designed to provide the patient with the best possible outcomes. WellNet s integrated care programs provide targeted healthcare interventions delivered through the patient s medical home and are designed to provide the patient with the best possible health outcomes. WellNet can be delivered through our network of over 250 medical centres, or through other GPs. Integrated Care Evidence-Based Stepped-Care Model Outcomes-Based Tailored for patients

3 Our philosophy WellNet has been designed to meet the needs of individuals, funders, clinicians and care-providers. WellNet utilises all parts of the health system and ensures that the patient is at the centre of the care continuum. Our goal is to deliver an integrated and collaborative solution providing the right care, at the right time and at the right place. Patient-Centred Integrated Medical Home The core principle behind WellNet: we use the patient s General Practice as their healthcare home. Outcomes-Based Program Philosophy We work with patients to establish a baseline measure of health, set clear goals and work with them to achieve these goals. Stepped-Care Model WellNet programs are carefully designed to offer the right amount of care with support being stepped up and down according to the needs of the patient. Data Analytics & Risk Stratification At WellNet, we understand that patients are not all the same; their care needs depend on personal, psychosocial and clinical factors. Therefore, we utilise a rich data analytics engine to stratify patients based on their individual needs. Evidence-Based Interventions All our programs are based on rigorous clinical evidence. Furthermore, because each program is scalable and based on individual patient needs, we can offer flexible support to suit each patient. Shared Electronic Health Records WellNet uses cdmnet as its Electronic Health Record and Care Coordination System, ensuring continuity of care by sharing information across primary, specialist and allied health professionals.

4 Patient-Centred Integrated Medical Home (PCIMH) WellNet is designed on the principles of the PCIMH model which puts the patient at the centre of all of our programs. This ensures the patient receives the right care at the right time and the right place. The GP lead care team works together with the patient to assess their needs, set goals and establishes a shared care plan accessible by care providers and the patients. Efficient coordination of services across primary, acute and allied settings makes access simple, streamlined and effective, making it easier for patients to get the care they need. Specialist Pharmacy CLINICAL GOVERNANCE EVIDENCE BASED GP Government SHARED HEALTH RECORDS RISK STRATIFICATION COOR DINAT CARE I ON NUR SE OUTCOMES BASED CLINICAL REPORTING Private Health Insurers Diagnostics

5 Hospital The PCIMH offers: Allied Health Targeted care: designed for patients at high risk of deteriorating morbidity and hospitalisation. Identifying these patients increases ROI for funders. And, because all patients can be considered, PCIMH doesn t only focus on patients with specific chronic diseases. Proactive and planned care: we use a multi-disciplinary care plan, developed/scheduled in collaboration with the patient. Team-based care: decentralisation of care from the GP to the patient s care team, with a clear (delineation) of roles and responsibilities, improving continuity of care and patient experience. Coordinated care: the care team agrees on a co-ordinated plan of action guided by the care plan. The aim is to provide access to the right care at the right time. Multi-channel: care delivered in primary care clinics, in the home, over the phone, and online / via the internet. Home Support Shared information: management of the patient by the care team is recorded centrally on one electronic health record accessible to the whole care team and the patient. Continuous quality improvement: successfully integrated care models use data to continuously improve service delivery, using formal review teams including the funders.

6 Our Process Our clinician-driven programs are designed to follow a comprehensive and rigorous process to ensure that patients receive the right care at the right time. GP REFERRED IDENTIFICATION ENROLMENT HOSPITAL REFERRED RECRUITMENT CONSENT GP letters PHI REFERRED In Practice Enrolment Outbound Phone Contact DATA ANALYTICS OTHER SOURCES Our Programs WellNet offers a set of cliniciandriven programs to help patients with a range of illnesses and comorbidities. Specifically designed for patients with 1 or 2 uncomplicated chronic diseases. These programs are designed to keep people well and ensure they have the right support to self-manage their conditions and remain healthy. A coordinated care program for patients with multiple chronic or complicated chronic diseases. This program aims to support some of the sickest people in the community that have not yet become frequent users in the hospital system and are currently being managed in general practice.

7 SHARED HEALTH RECORD (cdmnet) CLINICAL ASSESSMENT CARE PLANNING CARE COORDINATION MANAGEMENT SERVICE EVALUATION Scheduling Care Plan Development Team Care Arrangement GP (clinic, community & home) Patient Experience GP & CDM Nurse visit Service Development Service Referral Community & Home Nursing Clinical Indicators Needs Assessment Goal Setting Utilisation Management Community & Home Allied Health Economic Outcomes Social Service Access & Prioritisation (Telehealth, Web Based & Face to Face) Scheduled Follow up Medication Review & Management Change in Risk Profile Clinical Targeted Behavioural & Educational Interventions Ongoing Multi-Channel Targeted Intervention After Hours Medical Behavioural 24/7 Response Domestic & Personal Help Self Management Education Designed for patients with complex health needs, who are at a high risk of hospitalisation or re-hospitalisation. The care interventions are tailored to suit individuals complex needs and may include home care, educational and behavioural interventions. An extension of the FeelWell program, LiveWell targets patients who can have some or their entire care managed in the home. LiveWell improves quality of life (whilst reducing healthcare costs) by providing a team care approach and interventions that can be delivered in the patient s home or the community. Designed to support patients on their road to recovery from an illness or a health intervention. GetWell improves the patient s experience and shortens the length of hospital stays and assists in avoiding hospital primary admissions as well as re-admissions for situations that can be treated in the community.

8 WellNet: powered by Sonic Clinical Services Sonic Clinical Services (SCS) is the primary care division of Sonic Healthcare, bringing together a range of businesses that provide national healthcare services and solutions. The SCS network includes over 2,200 GPs, 250 medical centres and 3,000 healthcare staff offering a large range of health services including GP services, After Hours, Corporate Health, Disease Management Nursing Services, Data Analytics, Care Coordination and IT solutions. We have significant capability and experience in designing and implementing integrated care programs nationally. For more information please phone (02) or wellnet@sonicclinicalservices.com.au -CENTRED CARE. CLINICIAN-LEAD SUPPORT. Level 32, 60 Margaret Street, Sydney NSW 2000 GPO Box 7009, Sydney NSW 2001 Reception: (02) Fax: (02) ABN A subsidiary of Sonic Healthcare Ltd. ABN