Care Team Connect

Care Team Connect is new functionality to provide workflow, scheduling and communication support to Multi-disciplinary Patient Care Teams

As an Australian software development initiative motivated by requirements of Commonwealth Government Healthcare Home program Connected Health set about creating our Care Team Connect functionality. The name reflect the purpose and objectives of this module, which is to provide software driven co-ordination of care interventions, events and activities delivered by a Multi-disciplinary Care Team associated with a Patient’s defined care plan. Although initially designed to meet Healthcare Home requirements we quickly realised that the functionality has far wider applicability and is relevant to any care setting where there is an on-going program of care. The COVID-19 pandemic makes Care Team Connect even more relevant as it also assist care delivery to eliminate unnecessary face to face interactions; changes we feel sure will continue to be adopted in post COVID-19 care delivery.

Development of the Care Team Connect concept has been a participative process with involvement and feedback from a GP Practice participating in Healthcare Home trials, a second GP Practice not involved with Healthcare Home initiative, and a Diabetes Specialist who have assisted in specification, prototype development and testing activity. The software has progressed to pre-production release status and will be added to Connected Health production released products once our beta-site testing program has been successfully completed.

We are currently looking for more beta-site partners to help take the software to production release status so please get in touch if you are interested in taking part in beta-site testing.

The drivers behind Care Team Connect mean it has primarily been designed for use in non-Acute care settings and is typically (but not exclusively) expected to be utilised for a Patient with Chronic Disease ailments but can be equally valuable in any situation where the Patient requires on-going treatment such as outpatient care post hospital discharge. The Patient may of course be living at home or in a residential care facility.

Central to the Care Team Connect concept is Active Care Manager which automates the workflow management and scheduling role on behalf of the Care Delivery Team to ensure planned tasks are automatically initiated when required and without dependence on Patient, a specific Care Provider or any other Care Team member. A Care Team will have a designated lead Member who has responsibility for the Patient Care Plan, including initial creation and ongoing amendment and update as required. Other Team Members is anticipated to include all essential clinical and ancillary care providers, the Patient, and any family members who are involved in the Patient’s care.

Whilst the Care Team Lead or their delegate has overall responsibility for Active Care Plan content, including making amendments where required or requested by other Care Team members, the concept expects the content of any Active Care Plan has been agreed and signed off by all participants including the Patient. In this way there is far greater potential that a Patient and associated family members (if relevant) will take responsibility for their own care and comply with actions they have agreed are beneficial to their future health.

Activities controlled and automated by Active Care Manager are not restricted to clinical interventions such as periodic blood tests, regular face to face or Tele-Health consultations but can include many other once off or repeated activities, such as:

  • electronic provision of educational information at the appropriate time in a program of Care Delivery to the Patient or a family member who is part of the Patient Care Team.
  • information sharing between Care Team members including alerts, which becomes particularly relevant when all Care Providers are not co-located with the Care Team lead.
  • automatic initiation of a (PROMS) survey such as for periodic health status at appropriate intervals (be that weekly, monthly, quarterly or annually) to provide information on how this is progressing over time. This would call on the survey engine functionality incorporated in Patient Connect and in many instances can be configured by 4th user without programming intervention. Others will require programmed add-ins that can be delivered as an enhancement.
  • initiation of Patient Experience (PREMS) surveys which are both valuable from a Patient Satisfaction perspective and essential input to Quality Accreditation. These are easily set-up to meet defined requirements such as for RACGP or State mandated surveys.
  • alerts that vaccinations have become available e.g. at the start of the flu season every year.

Importantly our Care Team Connect workflow and communication capabilities do not aspire to replace, but to complement and integrate to installed Patient Management and Clinical systems. For example Care Team Connect functionality includes the ability to import an existing Care Plan from a Practice Management system and automate intervention, activities and events documented in that Care Plan..

Care Team Connect therefore adds value by providing essential administrative support to ensure planned activities and interventions occur when needed, and without significant change to current clinical practice. The aim is to provide for easy adoption and fast delivery of benefits to Care Team efficiency and effectiveness which transforms into improved Patient outcomes.

Further new functionality in the pipeline as a scheduled enhancement includes integration to Video Conferencing to facilitate regular Care Team meetings, or Care Team to Patient interactions built into the Patient Care Plan..

Care Team Connect seamlessly builds upon and utilises functionality already available in Patient Connect and Staff Connect to provide many incremental benefits that can be seen by looking at Patient Connect and Staff Connect.