Sheffield City Region – Perfect Patient Pathway Test Bed
One of the initiatives of Care2050 is the development of the ‘Perfect Patient Pathway’ NHS Test Bed site, which was recently announced for the Sheffield City Region (read news update here)
People with long term conditions (LTCs) are intensive users of health and social care services, including primary care, community services, social care and acute services. In total, around 70% of the total health and care spend in England is attributed to caring for people with long term conditions. This means that 30% of the population account for 70% of the spend.
There is a strong link between physical long term conditions and psychological disorders. Compared with the general population, people with diabetes, hypertension and coronary artery disease have double the rate of mental health problems, and those with chronic obstructive pulmonary disease, cardiovascular disease and other chronic conditions have triple the rate. People with two or more long term conditions are seven times more likely to suffer from depression. Addressing concurrently physical and psychological needs can improve outcome s and reduce health care consumption.
Although NICE guidelines recommend the use of psychological interventions for people with LTCs, there are many difficulties in offering an effective personalised health and care service that completely satisfies their needs. This reduces quality of life for people with LTCs, increases inequalities and decreases the cost savings to the NHS.
The Test Bed
Our Test Bed will address these challenges by creating the ‘perfect patient pathway,’ based on the combination and integration of innovative technologies and pioneering service designs that will support direct holistic care with a patient-centric approach. The Test Bed will provide evidence of the clinical, social and economic impact of this model and the technologies involved and will analyse the results of scaling the model at the national level.
Facilitated by the second largest trust in England, Sheffield Teaching Hospitals NHS Foundation Trust, this Test Bed is actively involved NHS, academic, public, manufacturing, charitable and commercial organisations. The co-design of the proposal ensures the strategic engagement of key stakeholders and the long-term vision of a model that should become the standard for tomorrow’s healthcare.
Creating the Perfect Patient Pathway
In the SCR Perfect Patient Pathway Test Bed, the optimal patient pathway will be created increasing the support at three levels: patient empowerment, service offer integration and strategic decision support.
- Patient empowerment: Major involvement of the patient in the health and care plans will be achieved through solutions that support patients to understand their condition and increase their confidence for self-management, including access to group support to interact with people with similar conditions. Discrete, effective and remote physiological monitoring systems will support independent daily living, providing data directly to the patient as well as their service providers. Alerts to the patient, their family and carers, or health and care professionals will activate interventions when needed.
- Service offer integration: The integration of service provision across primary, secondary, social care and mental health will be promoted to create a coordinated, effective and efficient service acting as one single team for the patient. This will include the capture and share of health data and information among multiple care providers, applying Information Governance (IG) standards to ensure safe storage and secure transport/access of patient records. A virtual central data repository will facilitate the interconnectivity and integration of the different systems, including those used by the patient for self-management, providing an aggregated view of patient needs and offering combined clinical decision support.
- Strategic decision support: A central command centre will supervise, in real-time, the key health and care indicators for the region, the organisations and the individuals. This will allow rapid tactical and strategic decisions to be made, increasing efficiency and effectiveness of the services. the aggregated data will be used for trend analytics and risk prediction for population needs, services delivered and cost. The early identification of at-risk individuals and subpopulations will be linked to the alert system that will coordinate interventions.
The combined improvements with patient empowerment, service offer integration and strategic decision support will shift the paradigm, promoting a proactive and coordinated system for people with co-morbidities, beyond the organisational boundaries of social, primary, community, secondary care and mental health.
Patient Centric Model – Sheffield City Region Perfect Patient Pathway