Technology for Change

You may have noticed that the Living Well care pathway leans into technology. To stay in touch with modern care delivery practices and to future-proof our systems, we are embracing a number of technologies to improve the management of at-home and in-community support for people living with COPD and CHF. And we are already seeing some great results.

Some of the technologies we are using so for are:

Virtual Rehabilitation clinics

Our physiotherapists have been working with patients via virtual rehab classes for a while now, with our second cohort part-way through their eight-week program. Designed to provide access to those living in communities where there may not be a face-to-face class running or where access is difficult, the group sessions run twice a week, working virtually with individuals in their own home, using their own equipment – which in some cases may even be cans of food serving as a weights. Our physios are finding these classes are building a great sense of community with patients and are effective in committing individuals to sessions in addition to face-time with their support workers.

Patient Flow Portal

This portal allows our care team to review emergency department admissions to identify people that are currently managing COPD and CHF episodes with the hope of capturing them early in their health journey. Through a built-in rating system assessing the likelihood of hospitalisation, the care team can prioritise support for individuals, reconnecting with those who we already know to offer additional support during an exacerbation and introducing those not yet in our programs to available services to help them manage their health better as assist in preventing future readmission. 

CareMonitor app

We’re thrilled to now be very close to trialling the CareMonitor app across the district. CareMonitor is a real-time remote health monitoring and management app designed to link patients with their health care team and drive self-monitoring of their conditions. With the app, individuals can track their vital signs like oxygen level and blood pressure and see a trend in their results. From there, they can make a decision about their best course of action and organise a check-in with the most appropriate clinician. Clinicians and GPs will be able to log into the system and discuss the trend with the patient and further plan the course of action. We look forward to the trial being well supported and are keen to see the app rolled out in 2023.

HOPE tool – outcomes and patient evaluation 

In another move in the digital space, a web-based platform capturing patient-reported healthcare experiences and outcomes is being adopted across the MLHD, with a number of services jumping in early to use the system, known as Health Outcomes and Patient Experience, or HOPE. 

Co-designed with consumers, clinicians and managers across NSW in partnership with peak health bodies, HOPE will help healthcare providers and services understand what matters to patients and support shared decision making about their care, treatment and interventions. 

Effective use of HOPE relies on involvement across the entire health system but especially from patients and clinicians. Patients are required to report on their healthcare experience across 25 patient measures based on the internationally recognised seven social determinants of health (SDOH) through an online portal, ideally at the point of care. Carers and clinicians can add in information about their condition, treatments, care plan, relevant services and desired outcomes, and HOPE is integrated with clinical systems such as the NSW Health electronic Medical Record (eMR), Patient Administration System (PAS) clinical systems, and general practice desktop systems. 

The secure web-based database then serves as a central repository of information for patients and their multidisciplinary teams to access, review and act upon in real-time and is a great step toward realising the Living Well vision for joined-up healthcare. Summary data collected via HOPE allows us to establish and respond to trends across COPD and CHF patients in the district, and the summary of patient experience feedback allows providers to identify ways to improve their delivery of care.