The At Risk Individuals' programme (ARI) at Counties-Manukau District Health Board is being enabled by HSAGlobal's connected care platform, CCMS.
The ARI, which will be one of the world's largest connected care programmes, provides earlier intervention by allowing primary carers to identify at risk patients and better co-ordinate their services.
Progressively rolled out to all general practices in Counties-Manukau DHB between now and June next year, ARI will support up to 30,000 at risk people with a CCMS-based care plan by the end of 2015.
Counties-Manukau DHB will enrol people in ARI who have one or more long-term conditions, such as diabetes or heart disease, as well as other risk factors like inadequate housing or low health literacy. People in this group are at a greater risk of poor health outcomes, including unplanned hospitalisation, and they use a disproportionate amount of healthcare services.
Once enrolled by their GP, every person will have a designated care coordinator responsible for developing individual care plans (based on a patient's goals) in CCMS and monitoring progress in consultation with other providers of health and social services. Care team members including community nurses can secure message each other and the patient through the shared care record. A summary health record will be available to healthcare teams through their existing Concerto patient record software so that key information relating to the patient is visible to everyone involved in their care.
"Rather than reacting after people require hospital care, we will be proactively supporting them to manage their health problems so that they can stay well and at home," says Benedict Hefford, director of primary health and community services. "To achieve this we require a flexible and secure software platform designed to enable care coordination and planning."
ARI builds on an earlier Counties-Manukau programme, also built on the CCMS platform, targeting 3,000 intensive healthcare users at high risk of readmission to hospital. Counties already uses CCMS under a licence covering the Northern region DHBs. CCMS is licenced on a population basis, so DHBs can use the care platform for as many programmes as possible.