People with advanced serious illness often fall into the gaps between services when accessing care to meet their needs. They are also high users of emergency, hospital and primary care services. One of the major challenges facing patients, their families and care providers is the difficulty they experience navigating complex care systems.

Calvary along with the Local Health District, Primary Health Network and Ambulance partners in the Hunter region identified that there was an opportunity to work collaboratively to better coordinate care across service providers to deliver better outcomes for patients, families and communities. Co-designed with patients, families and clinicians a real time, secure digital clinical handover tool was implemented within the greater Newcastle community in New South Wales.

The care model known as MyNetCare is a bespoke cloud-based digital clinical handover tool developed in partnership with Vitro Software. The project attracted support and funding through the NSW Ministry of Health Program of Innovation Funding. The MyNetCare program has been operational in the Hunter region for more than 12 months. More than 200 patients have been referred into the MyNetCare program.

Patient Centred and Patient Controlled

MyNetCare is a patient authorised clinical handover tool. It establishes a ‘virtual’ team of clinicians and services identified by the patient and provides them and the patient and family with an electronic tool to enable real time, meaningful communication and clinical handover. Vital to the success of the program MyNetCare employs Care Navigators who support patients and their families to ensure that the information required to deliver integrated care is available at all system touch-points. Care Navigators also support clinicians and clinical services to take up the patient’s invitation to participate. MyNetCare has the capacity to upload and store advance care plans, advance care directives, goals of care and ambulance care plans. MyNetCare also provides clinicians with a shared platform to document current clinical problems, treatment plans, and handover information. Patients can, through the patient portal, enter Patient Reported Outcome Measures and Patient Experience Measures which can be viewed by clinicians whenever patients access care.

“Understanding how patients with advanced serious illness use hospital, primary care and social care systems can help use better design care to meet patient and family needs. Putting people in the centre and reorganising care systems around them can help us improve their outcomes and experience and improve efficiency”. MyNetCare is a program that helps us work together to achieve these aims.", Ms Sue Hanson, National Director Clinical Services at Calvary Health Care.

Real Time Clinical Handover

The MyNetCare record provides real time clinical handover between clinicians supporting patients, as they move between services and systems and aims to:

• Improve the experience of patients, their families and care givers;
• Reduce the need for repeated hospitalisations;
• Prevent unnecessary emergency department visits; and
• Reduce Ambulance calls and avoidable transfers.

Benefits for Clinicians

Importantly, MyNetCare makes it possible for clinicians across the health sector to access and contribute to the sharing of clear, concise and relevant clinical handover information about patients with advancing illness, including:

• A summary of relevant medical history and diagnoses;
• Copies of advance care plans;
• Patient documented goals of care;
• Details of the patients nominated Person Responsible (substitute decision maker); and
• Real time information on the patient’s self-rated level of health and wellbeing.

There are a number of referral pathways for identifying patients for enrolment in the program which were developed by the MyNetCare team in consultation with acute, community and primary healthcare sectors:

• Attending regular rounds within the inpatient setting;
• Regular contact with inpatient Nursing Managers;
• Sitting in on multi-disciplinary team meetings;
• Utilising the Palliative Care Outreach List;
• Contacting identified patients via post with follow up phone calls; and
• NSW Ambulance patients who are high service utilisers.

Integration for MyNetCare Pilot

Mr Todd Tobin, Integrated Care Program Manager at Calvary said: “We worked very closely with acute, community and primary health care sectors along with the Vitro Software project team to identify and co-design the integration pathways that would best support the pilot including patient identification, general practice and the acute care sector”. Following successful deployment there are further opportunities to deepen the integration with the electronic information systems of clinical services.

MyNetCare is a cloud based application. Five key points of integration were developed for the MyNetCare pilot program, which include:

• Individual Healthcare Identifiers (IHIs), a Commonwealth patient identification number;
• Medical Objects, a secure messaging program;
• Best Practice and Medical Director, GP clinical desktop systems via the Oridashi general practice purpose built widget.

Access to current information about patient and clinical care goals is critical to prevent avoidable admission and emergency department presentations. Over the course of the pilot, the MyNetCare team developed a particularly close working relationship with a number of ambulance stations within the MyNetCare catchment area. A medical caution note was placed in the Ambulance system to alert end users the patient is enrolled in MyNetCare, allowing the Ambulance officers to view the MyNetCare Record on route or at the patient’s home.

The Bottom Line

Of the 208 referrals received to date 111 patients were enrolled in the MyNetCare program. For enrolled patients the following health touch points were identified over a twelve month period:

• 687 general practice visits;
• 147 emergency department visits;
• 282 outpatient attendances; and
• 206 inpatient admissions.

MyNetCare provides services with a mechanism to understand patterns of health service utilisation and patient experience so that care pathways can be better designed and, care can be more fully integrated around the patient and family needs.

Advances in medical research, rising living standards and the improved diagnosis of rare and ultra-rare diseases are seeing populations in most western countries living longer lives, often with two or more chronic diseases. Which means demand for technologies like MyNetCare will continue to grow in line with the increasing numbers of patients with advanced illness.

Calvary is responsible for 15 Public and Private Hospitals, 17 Retirement and Aged Care Facilities and a national network of Community Care Centres.