I have regularly talked about the need to better integrate health services in our community and while we have a good sense of what is happening across the Hospital, thanks to Middlemore Central, we need a similar system in our community so we have an overview of where our patients are and the care they require. This is what Community Central aims to do. To tell us more I’m joined by Penny Magud, General Manager Eastern Locality and Pam Hill, Service Development Manager Community Central.
If you have been on the receiving end of care, trying to navigate our complex health system can be confusing and frustrating. Take Sam for instance, Sam is a 66 year old man who was admitted to hospital with cellulitis. Following a short stay in hospital, Sam was discharged home with five seperate referrals to enable him and his family to manage his care at home.
Before Community Central each referral would have been triaged in isolation by the discipline it was sent to, at different times, allocating different priority levels which would result in five different appointments being made.
Community Central aims to help people like Sam, by providing a central place, where all referrals for community health services are received. These referrals are triaged by a skilled health professional, who works with the patient and their family to determine the best first response at a time and in a setting that best meets the patient’s need. If required a multi-disciplinary team of health professionals is consulted. This team works side by side and regularly share their skills and expertise.
The team’s focus is on the patient rather than the referral. They look at the whole person, not just the fact the person may have been referred for a certain piece of equipment – it’s asking the question, what else does this person need to make his or her journey a better one? The Triage process includes reviewing the patient’s clinical notes, e-shared care plan, liaising directly with the patients GP and Practice Nurses as well as other service providers such as Hospice and contacting the patient and/or their family directly to ask the all important question of “What matters to them?”
From an operational perspective Community Central will make it easier to plan care. Just like Middlemore Central, which has an overview of patients at Middlemore Hospital, Community Central will have an overview of patients in the community, what their needs are and the staff required to meet those needs. Community Central will enable us to have an overview for the first time of the acuity and complexity of patients being supported in the community.
For clinicians community central will provide them with a greater over-view of their patients, provide consistency of care across specialties, enable one request for service to be forwarded electronically no matter how complex a patients needs may be. Community clinician’s will have their work scheduled and allocated to them directly on their mobile devices. This provides greater work flexibility, more time spent with the patient with reduced travel time due to improved scheduling of routes.
The success of Community Central relies on recruiting staff with the right skills, building confidence and trust by health professionals that referrals are being triaged competently and correctly and providing the technology to enable health professionals to do their jobs, when and wherever they are.
In five years time we would like to see Community Central widely spread, with seamless integration between hospital and community care. To do this we need a mobile workforce, supported by technology to provide accessible and quality care. We realise it’s early days, however this innovative approach has real potential to be a game changer. Currently this is the first of its kind in NZ and while there are pockets of knowledge to learn from, we are really excited to see how far this can go to integrate whole of health and social care services to support our patients and their families in their communities.
If you would like to know more about Community Central contact Penny Magud via email: Penelope.Magud@middlemore.co.nz