Nurse Maude provides community health care services to over 14,000 patients per year in Canterbury, New Zealand. To improve coordinated care, Nurse Maude developed the Community Care Clinical Management System (CCMS) to share patient data across primary and secondary care providers. CCMS includes a clinical documentation system that uses standardized terminology and allows for mobile access. It aims to improve outcomes measurement, quality monitoring, and consumer access to health information. Nurse Maude also implemented a clinical documentation system on their Dynamics CRM platform to streamline charting for community nurses.
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IT Innovation Improves Community Care in Canterbury
1. Health IT Innovation In Practice
The Canterbury Story
2013 HINZ Seminar Series
IT contributing to improving community-based
models of care
Sheree East
2. Content
• Nurse Maude
• Collaborative IS developments in Canterbury
• Health Information developments
• Nurse Maude IS development
3. 115 years of community health care
14000
patients per
annum
40% over 85
55% Multiple
comorbidities700000
episodes of
care
4. Nurse Maude Services (Canterbury)
Avoid
admission
Enable early
discharge
Delay entry
into residential
care
Supportive
Community
care
Self care support Care Management
High Complexity Care
Management
Specialist
Nursing
Acute
Demand
CREST District
Nursing
Home
Care
Total Care Long
term care
Palliative
Care
Continence
Stoma
Wound
Diabetes
Infusion
NP Aged -
Care
School
Health
Liaison Case management Rest home
at Home
40 bed
hospital
level aged
care
Support
care
Tertiary
Hospice
Community
team
Restorative
Personal
Care &
Nursing
Generalist
nursing
Dialysis
Personal
Care
Domestic
Assistance
Education
Equipment Meals Laundry
8. Project CHAIN
Collaborative care programme
• electronic case management program to enable
innovative workforce development and clinical
delivery across Canterbury by sharing of care
and clinical information, particularly for high
needs patients, between multi-disciplinary
teams.
9. CCMS - Single Source of Truth for Client Management
Hospital
Inpatient
Outpatient/ Day
Centre
Multi-disc
clinic
Residential
Facilities
Community
Nursing/
MHW
+
GP Clinic
Associated to an Episode
Referral management for relevant LTC Program(s), and Handoff of Care
Assessment, Care Plan, Client Documentation
Measurement and Results, Medication Management
Info from other Clinical Systems eg Disch Summary, Lab Result, Rad Reports, Prescription
Portal for
Self Mgmt
Patient
Specific Info
Family Health
Info
Home/
Workplace
Report Builder: for Health Org or Enterprise wide reporting
CCMS – Client information management
platform
SMS Outreach
10. A new era in consumer health information
Point-of-care technology + improved PMS systems = better data
Better outcome measurement (Big Data opportunities?)
Improved quality monitoring
Increased sharing of health information across boundaries
Increased consumer access to health information
“The expert patient”
De-medicalisation of care
11. Why share community level data?
Identified problems, interventions and outcomes at individual,
family, and community level
Change in these over time (improvement / decline).
Dependency levels
Community & clinical resource utilisation
Accurate current information sourced from the persons living
environment
Immediate information about status for emergency services
12. Requirements for sharing community care
information
• System that allows interoperability
• Shareable data
• Defined clinical data set for sharing
– Problems
– Interventions
– Visit schedules
– Telemonitoring data
• Solution for sending / receiving data
13. Nurse Maude Development
• Enterprise wide
– Managing the business (payroll, rostering,
scheduling, billing, patient records etc.)
• Clinical documentation
• Mobile solution
• Measurement of clinical outcomes
• Consumer accessible*
14. Requirements
• Use National and International data standards
• Use community minimum data set
• Interoperable with external systems
• Flexible platform
• Must follow the clinical work flow
• Familiar and intuitive software
• Patient record as the single source of truth
15.
16. Nurse Maude Clinical Documentation
• Developed COMMUNITY CARE CLINICAL DATA SET
(CADI)
• Architected system integrating SNOMED-CT and Nursing
terminology
• Implemented clinical documentation on Dynamics CRM
in TotalCare service
• Fast charting – ‘start and chart’ - Mobile devices
• Described outcomes of care in standardised measurable
terms
• Uses plain language for patients
17.
18.
19. CCMS
HSA
Global
HSA
Care co-
ordination
CCCC
Cardea
NM Data
Warehouse
CADI
SNOMED-CT
Client Data
CRISTA
Scheduling
Rosters
Referral Management
Contract Management
Clinical Tools
OMAHA System
Care Plans
Care Pathways
Client Health Record
Decision support
GP
CDHB short
term
ERMS e-referral
IMS
ABM
Pay-global
Interfacelayer
Nurse Maude
Referral Sources
MOH
ACC
eSCRV / HCS
CDHB long
term
InterRAI
20. References
Butler M, Treacy M, Scott A, Hyde A, Mac Neela P, Irving K, Byrne A, Drennan J. 2006 Towards a
nursing minimum data set for Ireland: making Irish nursing visible. J Adv Nurs. Aug;55(3):364-75.
Monsen, K.A., Westra, B.L., Paitich, N., Ekstrom, D., Mehle, S.C., Kaeding, M., Abdo, S., Natarajan, G.
, & Ruddarraju, U. (2012) Developing a shared personal health record for elders and providers:
Technology and content. Journal of Gerontological Nursing.
Jacobsen, M.S., Juste, F. (2010) Information Technology: Nursing in the era of meaningful use.
Nursing Management 41, 1, pg. 11-13.
www.omahasystemguidelines.org
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