Quality Improvement for Primary Health Networks (PHNs)

pencs.com.au

Quality Improvement for Primary Health Networks (PHNs)Quality Improvement with CAT PlusCAT Plus Eco SystemPLAN: Analytics and Data InsightsACTION: Data-driven Quality Improvement WorkflowMONITOR: PAT ProgramsQuality Improvement Data Flow Diagrams

Objective 1 - Monitor and Evaluate QI ProgramsObjective 2 - Recall Patients matched to QI ProgramObjective 3 - Prompt Doctors when eligible Patients are in Consultation

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Contents

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Pen CS delivers population to patient management healthcare technology solutions. Our software is deployed Australia-wide for Research, Consent Management, Population Health Management, General Practice Quality Improvement, Indigenous Health and Clinical Trials. This booklet focuses on Pen CS’ role in delivering data-driven quality improvement for population health management by Primary Health Networks.

Constraints on care resources, coupled with an ageing population and the concurrent increased demand for services, are placing existing health services under increasing strain and calling for a new model of care. There is a strong need to plan for outcome based healthcare, mobile workforces, data portability and consumer oriented healthcare.

Data-driven actionable insights and workforce enablement are some of the ways Pen CS is empowering your employees with tools to maximize their effectiveness. Here we demonstrate how to utilise the CAT Plus Eco System that includes Topbar clinical decision support, CAT4 clinical audit tool, PAT CAT population aggregation tool and the Consent Management Portal to monitor and advance clinical practice.

A healthy Australia that prioritises prevention and outcomes-based healthcare.

To empower medical practitioners to deliver better patient care and consumers to optimise their health, through data-driven technology solutions that anticipate the needs of Australia’s population.

Collaboration, Adaptation, Innovation, Respect and Acknowledgement.

Pen CS follows the quadruple aims, plus one:• Affordable care• Improved population health• Enhanced provider satisfaction• Better patient outcomes• Engaging technology solutions

Priority Areas• Disease Prevention• Chronic Disease Potentially Preventable Hospitalisation• Prevention of rehospitalisation• Workforce enablement• Data-driven improvement

Quality Improvement for Primary Health Networks (PHNs)

Vision

Purpose

Values

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Quality Improvement may be implemented using the CAT Plus eco system which enables you to efficiently support your practices in the following ways:

Standardise Quality Improvement Programs

• Compatible with many clinical information systems, to successfully monitor and evaluate practice QI

• Use population health findings based on de-identified data to provide clinicians with patients matched to QI programs

• Standardise patient inclusion criteria across practices

Drive Workforce Efficiencies for Quality Improvement

• Empower your Practice Support Team so they can spend their time focusing on the needs of the practice and patient cohorts

• Improved operational efficiency• Automated administrative and QI processes• Easier collaboration with practices (subject to digital maturity of practice)• Better patient outcomes• Reduced costs

Match Practices and their Patient Cohorts to Quality Improvement Programs

• Enrol and invite practices• Provide participating practices with ‘ready-to-action’ patient lists – make it easy for

practices to action QI programs aligned with PHN needs.• Easily update patient lists at regular intervals• No extra work for the Practice and reduces administrative burden

QI Program Monitoring and Evaluation

• Set up QI Program, patient eligibility criteria and invite practices• Action notifications for clinicians• Action targeted Recall, as appropriate• Track patient health outcomes• Track practice engagement and population health outcomes• Report on progress and outcomes for QI Programs

Quality Improvement (QI) with CAT Plus

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CAT Plus Eco System

• Quality improvement and analytics software that supports data-driven patient to

population health management.

• Acknowledges the contribution made by medical practitioners, Australia-wide and

their role in driving data-driven improvement.

• Responsive to health providers’ work flow and patient needs.

a c t i o n• PAT2CAT Filters• PAT Prompts

m o n i t o re va l u at e + r e p o rt

p l a n

PAT CAT

Programs

PAT BI

PAT CAT

PAT BI

Voicemail & SMS

4Voicemail & SMSCAT

Recall

CAT4

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PLAN: Analytics and Data Insights

Pen CS facilitates data sharing, data linkage, data analytics and data mobility to support

effortless and seamless data-driven improvement for population health management.

Actionable data insights derived using the CAT Plus Eco System may inform planning and

resource allocation for commissioning healthcare services.

The Practice Aggregation Tool (PAT CAT) is an easy-to-use web-based interface that

aggregates de-identified General Practice data for population health management and

research programs.

PAT Business Intelligence (PAT BI) is a purpose built granular patient level database

compatible with data visualisation tools e.g. Power BI, QLIK that may be mined for

meaningful evaluation and impact.

For further information, please get in touch with your Account Manager.

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ACTION: Data-driven Quality Improvement Workflow

PHN to practice high impact intervention

Objective 1: Monitor and Evaluate QI ProgramsSoftware: PAT ProgramsActivity: Enrol and track patient participationOutcomes: Monitor and evaluate patient outcomes Opportunistic Patient Engagement

Objective 2: Recall Patients matched to QI ProgramSoftware: PAT2CAT Filters and Recall CAT (in CAT4)Activity: Create actionable patient lists matched to QI ProgramOutcomes: Targeted Patient Engagement including:

• book an Appointment e.g. Flu shot• send patient health education e.g. health videos OR URL link• receive SMS text and/or voice message from Doctor

Objective 3: Prompt Doctors when eligible Patients are in ConsultationSoftware: PAT PromptsActivity: Set Up Clinician Notifications matched to QI Program for eligible patientsOutcomes: Opportunistic Clinician Engagement

Clinician may action QI program recommendations including:• book a Health Assessment • refer to a program e.g. My Health for Life in QLD• healthPathway recommendation• send patient health education e.g. health videos OR URL link

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QI Program Work Flow

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INVITE PRACTICES SET PATIENT INCLUSION CRITERIA

PHN PRACTICE

PRACTICE PARTICIPATESACCEPT INVITATION

PRACTICE RE-IDENTIFIES MATCHING PATIENTS

CLINICIAN NOTIFICATION

PATIENT HEALTH MANAGEMENT

REPORT AND EVALUATE

PRACTICE INFORMS PATIENTSSMS Text/Voice

4Voicemail & SMSCAT

Recall

CAT4

CAT4

PAT CAT

PAT CAT PAT BI

MONITOR: PAT Programs

Quality improvement requires five essential elements for success*: • fostering and sustaining a culture of change and safety• developing and clarifying an understanding of the problem• involving key stakeholders• testing change strategies• continuous monitoring of performance and reporting of findings to sustain the

change

PAT Programs delivers continuous monitoring of performance.

*Source: Tools and Strategies for Quality Improvement and Patient Safety, Ronda G. Hughes

https://www.ncbi.nlm.nih.gov/books/NBK2682/

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the practice the PHN

Create a PAT Program

PAT Programs Example: HealthPathways App in Topbar

• Nominate patient cohorts• Create automated prompt in PAT CAT • Insert HealthPathway URL•

Clinician notification automatically appearswhile in consultation with presenting patient

• No extra work for the doctor

CISPatient Record

Patient is eligible and enrolled Opportunity for targeted patient interaction.

Practice/Patient Enrolment

Track Outcomes

Information to Patient

John SmithProg. App

Education LinksHealth PathwaysSMSEmail

• Link health education materials for thedoctor and/or patient

• Information may be emailed

or sent via SMS to patients while in consultation

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Programs

Objective 1 - Monitor and Evaluate QI Programs

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Recall Patients

the practice the PHN

Create patient inclusion criteria in PAT CAT

PAT2CAT FiltersPatient Matching

Patient Match

Filter for practice patient matching

Track Outcomes

Report of filtered patients at risk from PAT CAT.

4Voicemail & SMSCAT

Recall

PAT CAT

Objective 2 - Recall Patients matched to QI Program

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Objective 3 - Prompt Doctors when eligible Patients are in Consultation

the practice the PHN

Clinician Notification

Select patient inclusion criteria

Prompts clinicianwhen eligible patient is in consultation

Create Notification in PAT CAT

PAT CAT to Topbar (PAT Prompts)

PAT CAT

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Pen CS’ CAT Plus supports reporting at various levels including:• Regulatory Reports• Quality Improvement Program Evaluation• Feedback to General Practice to motivate behaviour change• Continuous reporting of findings to sustain the change

Business Intelligence Reports & ServicesThis year Pen CS is offering BI services matched to Quality Improvement objectives. If you have a QI Program that needs a report, speak to your Account Manager to learn more.

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Quality Improvement for Primary Health Networks (PHNs)

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