Jason DaCosta, Director of IT at the CCG and Warrington & Halton NHS Foundation Trust explained: "Warrington CCG's Long Term Conditions (LTC) and Frail Elderly Improvement Programmes aim to improve services for patients and their carers by shifting from a reactive, hospital-based system of unplanned care to a preventive, anticipatory, whole-person approach. The net result of developing this kind of fully integrated sustainable model of patient care is to significantly reduce the financial impact of these patients on overall health and social care spend in the area, while allowing us to maintain or improve outcomes and patient experiences.
"Working with HCS and Net.Orange on this project allows us to take advantage of a significant amount of expertise and resource that will help us respond to the joint vision of the CCG, the hospital Trust, community-based clinicians and primary care, and successfully deliver our components of the Programme alongside all organisations within the wider health economy."
During the project, the HCS Care Coordination service will:
- Provide support for multi-disciplinary teams developing and deploying evidence-based care pathways
- Provide decision support technology for protocol-driven care across acute and community settings, in order to reduce the demand on urgent care
- Provide mobile care applications to deploy checklist-driven, evidence-based care plans
- Stratify the population by risk for community-based case-finding
- Develop and promote patient self-management to support optimal self-care and reduce exacerbations
- Shift the focus of care for clinical teams from 'disease-based' to integrated co-ordination of care for an individual, regardless of how many or which LTCs they are living with.
The objectives will be achieved by implementing two HCS Care Coordination service modules, Readmission Manager and MobileCare. These modules are enabled by Net.Orange's clinical operating system (cOS), a real-time cloud-based big data platform, which forms part of the HCS Care Coordination solution.
The first module, Readmission Manager, will allow Warrington and Halton NHS Foundation Trust to significantly reduce preventable hospital readmissions by identifying high-risk patients, enhancing the management of discharge planning, and supporting more effective transitions of these patients to non-acute care settings.
The second module, MobileCare, will support pro-active management of patients across boundaries in all care settings - primary, acute and community – through applications running on handheld devices that can be used by clinicians, practitioners and members of multi-disciplinary teams both within the acute setting and when visiting patients at home.
Warrington and Halton NHS Foundation Trust expects to benefit from improved compliance with protocol-driven care pathways throughout the patient journey and a significant reduction in the number of patients transitioning to higher severity levels for their long-term conditions. “The Warrington health economy has been a leader in addressing the population health needs of the community, and the CCG's contract with HCS to improve outcomes and reduce costs associated with the frail elderly is another example of this commitment,” said Dr. Rob Beardall, Chief Medical Officer for Net.Orange. "We are grateful for the opportunity to work with all the stakeholders to enable them to provide more cost-effective, high-quality health services to the community."
It also hopes to achieve some of the other typical benefits that can result from implementing the two HCS Care Coordination modules together. These include a reduction of more than 30% in readmissions, a reduction of over 20% in overall hospital admissions, and a reduction of more than 30% in the costs resulting from hospital admissions from the same patient cohort.
Martin Walsh, director of HCS, said: "Delivering integrated services across the health economy is widely recognised as a means to reduce urgent care demand. We are excited about helping to enable protocol-driven care, which provides a big opportunity for local health economies to improve the quality of services and reduce the cost of provision. Our work with the Warrington and Halton health economy aims to improve the delivery of care to those patients in most need of its services, while at the same time providing the support to release urgent care capacity."
About Warrington CCG
The clinical commissioning group works for the people of Warrington buying the services Warrington people need. There are 26 GP practices in Warrington, which are all members of the clinical commissioning group.
Warrington Clinical Commissioning Group works with all providers to make sure services meet the needs of local people. There are lots of providers of services, but for Warrington the main providers are Warrington and Halton Hospitals NHS Foundation Trust, 5 Boroughs Partnership NHS Foundation Trust, Bridgewater Community NHS Health Care Trust, and the local council.
Although we focus on Warrington, when something affects more than one area, we may work with other clinical commissioning groups, for example, Warrington may work with Halton on things that affect both areas.
About Warrington and Halton Hospitals NHS Foundation Trust
Warrington and Halton Hospitals NHS Foundation Trust manages Warrington Hospital and Halton General Hospital in the North West of England. The Trust's vision is "High Quality, Safe Healthcare", and the Trust's 4100 staff work together to provide high quality, safe health care services to more than 500,000 people across the towns of Warrington, Runcorn (where Halton General Hospital is based), Widnes and the surrounding areas. The Trust is responsible for a budget of around £200 million each year.
About HFMA
HFMA is the professional financial voice of healthcare in the UK. HFMA's aim is to maintain and develop the financial management contribution to healthcare in the UK. Supported by a strong branch network, it promotes the highest professional standards in financial management and governance in healthcare. The organisation furthers personal and professional development by providing access to tailored education and training, offering a professional network for members and a greater contribution to national policy.
About Net.Orange
The Net.Orange solution, which forms part of the HCS Care Coordination service, enables the rapid deployment of virtually integrated care delivery models that include role-based workflows for all stakeholders including physician practices, specialty networks, hospitals, community providers, commissioners and payers, employers and patients. The patented clinical operating system (cOS™) leverages existing legacy systems, and prepares the stakeholders to thrive in a value-driven accountable healthcare environment, regardless of the payment model.