Webinar Summary: Improving Continuity of Care Through Integrated Care Planning
13 November 2024
In late October, Graphnet welcomed Saif Ahmed, Clinical Digital Lead for Transformation at Health Innovation Manchester, to present at the latest event in our webinar series, Improving Continuity of Care Through Integrated Care Planning.
Saif Ahmed, a GP by background, has spent the last 2.5 years largely focused on the Greater Manchester Care Record (GMCR), developing care plans and spreading their use across Greater Manchester. His work involves enhancing digital functionality across the system and ensuring the integration of care plans within the shared care record.
In addition to his work at Health Innovation Manchester (HIM), Saif holds the position of Associate Medical Director for Digital at Tameside Trust, where he supports the trust in digital transformation initiatives. He also advises the Greater Manchester Integrated Care Board (GM ICB) on frailty, providing expert guidance on how best to manage and support frail patients across the system.
The webinar explored how integrated care planning, supported by digital tools like shared care records, can improve continuity of care within the NHS. The session, led by Saif, focused on the use of technology to coordinate care across primary, secondary, and community services. David Grigsby, from Graphnet Health, introduced the session by discussing the growing pressures facing the NHS and the crucial role of integrated care in addressing these challenges.
Introduction by David Grigsby
Graphnet’s David Grigsby began by emphasising the immense pressure currently facing the NHS. The population is projected to rise by 4% over the next 15 years, but the number of people aged 85+ is expected to increase by 55%. Meanwhile, urgent cancer referrals have surged by 30% in the last four years, and the number of people in the UK suffering from conditions linked to high blood pressure and obesity has risen by 50% since 2000.
David pointed out that to address these challenges, the NHS needs to focus on better managing these high-risk conditions. He highlighted that population health data could be a gamechanger in targeting cohorts who need focused support. By using data from shared care records, healthcare teams can develop tailored care plans, such as frailty plans, that are accessible to all professionals involved in a patient’s care.
The use of shared care records allows information to be added and updated continuously, facilitating better coordination and communication across agencies. David also discussed how remote monitoring, and patient apps could empower individuals to manage their conditions more effectively, with the results of these interventions feeding back into the system to measure effectiveness.
Key Webinar Themes and Insights
- Integration of Care through Shared Care Records: Saif Ahmed explained that moving towards integrated care planning within shared care records (SCR) was essential for improving the continuity of care. By providing a centralised platform where all patient data is accessible to multiple care providers, healthcare teams can have a clearer, real-time view of a patient's history, treatments, and ongoing needs. This is particularly important in managing complex conditions like heart failure, dementia, and end-of-life care.
- Patient-Centred Care: One of the core themes of the webinar was the shift towards patient-centred care. Saif emphasised the importance of involving patients in their care plans from the start. The heart failure and dementia care plans were designed not only to be accessible to clinicians but also to allow patients to contribute their personal information and preferences. This approach moves away from traditional, top-down care models and empowers patients to have a voice in their treatment and care journey.
- Key Care Plans Developed:
o Heart Failure Care Plan: The heart failure care plan integrates real-time data from primary and secondary care, ensuring that clinicians have up-to-date information about their patients. It also includes self-reported data from patients, such as weight, blood pressure, and mood, which is automatically updated in the care plan.
o Dementia Well-Being Plan: Developed with input from Dementia United and local patient groups, this care plan digitises and standardises the dementia well-being form, which is used across multiple care settings. By incorporating both medical and social care teams, the care plan ensures a holistic approach to managing dementia, including referrals to social care and other community services.
o End-of-Life Care Plan: This plan aims to provide clear communication and coordination between healthcare providers, patients, and their families. It ensures that end-of-life care is patient-centred and aligns with the individual's wishes, including their preferred place of death. The plan is now being rolled out across Greater Manchester, with training provided to clinicians and care teams to ensure adoption.
- The My GM Care App: A key innovation discussed in the webinar was the My GM Care app, which allows patients to actively engage with their care plans. The app enables patients to input their personal details, such as emergency contacts, preferred places of care, and health metrics like weight and blood pressure. They can also access and contribute to their care plans, making them a more active participant in managing their health. This digital tool is expected to play a major role in shifting the focus of care planning from clinicians alone to a collaborative, patient-centred approach.
- Improved Communication and Data Sharing: A significant benefit of using shared care records and digital tools is the enhanced communication between healthcare providers. Saif emphasised that having up-to-date, integrated patient data reduces errors and ensures better coordination between different services. This is particularly important in managing complex or long-term conditions, where continuity of care is essential to improve outcomes.
- Outcomes and Results: Saif shared some early success stories and data points that demonstrate the positive impact of these integrated care plans:
o Dementia Care: The digitisation of the dementia well-being plan has led to increased face-to-face assessments and a greater focus on social prescribing, ensuring patients receive coordinated care across both health and social sectors.
o End-of-Life Care: The end-of-life care plan is already showing promising results with significant increases in care plans being created across Greater Manchester month on month. This rapid uptake highlights the growing acceptance of digital tools in end-of-life care planning and the positive impact on communication between healthcare providers.
o Impact on Hospital Admissions: One of the goals of the end-of-life care plan is to reduce unnecessary hospital admissions for patients at the end of life. Saif emphasised that improving care in the community can reduce inpatient bed usage, which has significant cost-saving potential for the NHS.
- Looking Forward: Saif concluded by outlining the next steps in the rollout of integrated care plans across Greater Manchester. The My GM Care app and shared care records will be expanded to include more localities, with ongoing training and support to ensure widespread adoption. This will enable healthcare providers to offer more personalised, patient-centred care while also improving the efficiency and sustainability of the healthcare system.
Conclusion
The webinar underscored the critical role that integrated care planning, supported by digital tools like shared care records and the My GM Care app, will play in improving continuity of care in the NHS. By shifting towards a more coordinated, patient-centred approach, NHS teams can better manage long-term and complex conditions, improving outcomes for patients while also reducing the strain on the healthcare system. As Saif Ahmed and David Grigsby highlighted, this model has the potential to transform the way care is delivered, ensuring that patients receive the right care at the right time, wherever they are in the system.
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