Each of the 1,070 children enrolled in Queensland’s Connected Care Program has complex health needs.
For a child to be referred onto the program he or she must have a complex or chronic medical condition, and require access to three or more medical specialties – for example paediatrics, orthopaedics and rehabilitation clinics.
Families often live in a rural or remote area, distant from medical and health facilities. A child could require a medical aid – a feeding tube, a ventilator or tracheostomy tube, for example.
Some children and their families face even more challenges.
For one child living in the Torres Strait, a recent specialist visit meant a 17 hour journey which involved travelling across a creek, catching a bus, getting on a plane and finally arriving at hospital in Brisbane.
The complexity of ensuring children and their families are supported through a series of co-ordinated appointments and procedures is something that Shirley Thompson, Nurse Manager for The Connected Care and Nurse Navigator Program – Children’s Health Queensland, understands only too well.
Based at Lady Cilento Children’s Hospital, Queensland’s dedicated quaternary hospital in South Brisbane, Thompson leads the program that supports children across Queensland, northern NSW, the Northern Territory and Torres Strait.
The program’s intent is to ensure effective, streamlined case management for each child and their family by improving communication and linkages between healthcare providers in acute, community and primary sectors.
To achieve this aim, Thompson works with Connected Care Co-ordinators based right across Queensland, stretching from the Gold Coast to Mount Isa. The care co-ordinators manage access to healthcare providers and support services, and act as a single point of contact for families providing support and assistance.
In tandem with Connected Care co-ordinators, Nurse Navigators, also based at The Lady Cilento Children’s Hospital work with families and hospital doctors to identify and monitor the healthcare requirements of children, develop tailored care plans and facilitate access to services.
In the past, the teams have relied heavily on Excel spreadsheets and Access databases. These however were ill-suited to the complex case management expectations of families and clinicians. Adding to the challenge is the fact that hospitals and medical specialists use different medical record systems which deliver a somewhat fragmented view of patients, particularly those with complex needs.
“It’s hard to have access to clinical real time information,” says Thompson.
To address the issue Connected Care, working with Microsoft partner Simient, elected to establish a single consolidated information system based on Microsoft Dynamics CRM that could be used to share information about the children enrolled in the program. The core information contained in that system can be accessed by co-ordinators and Nurse Navigators in Thompson’s team to ensure that the right care is delivered at the right time, ensuring that the child’s comprehensive care plan is accessible by anyone with the appropriate authority.
“If the child suddenly arrives at a hospital then staff can access the care plan that details the child’s healthcare needs,” Thompson explains. It has also allowed care to be streamlined across Queensland with the Connected Care team able to hand patient care from one area to another knowing that the critical information is always available through the platform. It has also allowed the Connected Care co-ordinators to work as a cohesive team regardless of their location.
Importantly also if a team member is absent for any reason, “Anybody can step in to the co-ordinator role and know where the family is up to and what care needs to be completed,” says Thompson.
The system is used from the time a child is first referred to and then enrolled in the program and assigned to a specific team. For example, a child living in the Darling Downs region would be assigned by the system to the Connected Care co-ordinator who would case manage the patient needs in Toowoomba, and would receive automated workflows associated with that child.
“They would see there was a new patient, do an intake and collect data about the child’s admissions, trips to outpatients, or emergency presentations in the last 12 months,” says Thompson.
The data is stored in Dynamics 365 and is used as a yardstick. It means that 12 months on the case manager is prompted to assess the difference that the Connected Care Program has made to the child’s life.
The case manager also makes contact with the family, the child’s GP and any other clinicians involved in their care, collects data for the CRM and ticks off on the workflow as steps are completed. Additional insights about the family and child – how the child is fed, if they are mobile, whether they attend school – can all be collected and better inform the care plan that is created for the child.
One of the key requirements for the platform was that it be intuitive.
“We are quite a dynamic and diverse team and have everyone from Gen Ys to Baby Boomers. Most took to the system very easily,” Thompson says, adding that was important because, “We are clinicians not IT people”.
Even remotely located co-ordinators quickly got on board with the system, recognising that the CRM delivered an efficient way to keep on top of caseloads.
Instead of complex and cumbersome spreadsheets, co-ordinators have clarity and support with workflows.
“This has added efficiency and stopped patients falling through the gaps – important things are getting done because of workflows flagging us to take action,” says Thompson.
“For example we now have notification of surgeries. The appointment is made and pops up on the dashboard 14 days before the procedure, so that preparation work can be carried out to ensure the patient is ready and prepared for admission to hospital.”
Information and insight
Besides providing a safety net for the children, Dynamics CRM means that Thompson and her team can generate reports quickly and efficiently. Checking that a patient care plan has been completed is done at the touch of a button – in the past it would have required hours of work poring over a spreadsheet.
The patient impact also extends beyond more streamlined care delivery.
In the last 12 months the Connected Care team has seen its case load double. Access to finer grained accurate information is leading to better informed discussions and decision making says Thompson.
“We can assess our effectiveness and the role we are playing in these families’ lives. It helps us decide how we are going to run a case because it identifies when things are going well. It has changed the way I access information – there are some things I could never get before –now I have a wealth of information I can access easily.”
Already Thompson says that the more comprehensive information available from the Dynamics CRM platform is helping to empower the broader healthcare and family community to care for children.
“We have a lot of children with cerebral palsy on the program. They are often fed through tubes, may be in a wheelchair, need orthopaedics and occupational therapy and three quarters of our children are across the State and not just in the vicinity of Lady Cilento.
“They live outside of the area and in some incredibly remote locations where there is no hospital anywhere near them. This is empowering the community to look after the children.”
Ultimately the information systems are being designed to transform the health care being delivered to children.
Thompson explains; “The more consolidated information you have, the easier it is to manage a family. Often one of the biggest frustrations they face is having to repeat their story over and over again”.
“If we can have a nurse in Townsville who is able to pull information from the system on the family or provide information that we need, we will minimise the family’s frustration and have access to up to date clinical information.”
Integration with clinical systems will deliver additional benefits. While families can tell co-ordinators what has happened, they may struggle with the detail. By integrating Dynamics CRM with clinical information systems the child’s health journey will be made more transparent.
Thompson also hopes that in time the CRM will be integrated with appointment booking systems to further streamline the care process.
Ultimately she believes the solution could streamline care across the State. We could share core information across the State to be a more cohesive service and improve the patient journey for children on our program”.
For the children enrolled in the Connected Care Program and their families this has been a welcome improvement in their journey through the healthcare system.