MyNetCare: An Integrated Care Model to support people in the last year of life

Join Sue Hanson, National Director, Clinical Governance, Calvary Care who will showcase the MyNetCare project at HIC 2018 during the Industry session chaired by Phil Robinson. From 11.20am on Tuesday July 31st at Level 2, Pyrmont Theatre.

People in the last year of life access services ten times more than they did in their second last year of life. In a study of patterns of health service utilisation in NSW in 2011/12 people in the last year of their life were found to have spent more than 1.4 million days in a public hospital during that year – care that cost more than $1 Billion. This is despite the fact that the majority (70%) would prefer to be cared for and remain at home. Multiple clinicians and services are involved in providing care during this time – hospitals, general practitioners, ambulance services, emergency departments and community services - leading to the risk of significant gaps in continuity of care. Patients too are not only strained by the constant need to recall clinical information, but also by the need to share personal information, for example advance care plans with multiple providers.

MyNetCare was developed through a robust co-design project funded by the NSW Program of Innovation that included patients and their families, an alliance of service providers and clinicians in the Hunter Region of NSW (Calvary, the Hunter New England Local Health District and the Hunter Central Coast PHN, NSW Ambulance Services, Hunter Primary Care) and a software vendor (Vitro Software). The MyNetCare Model has been piloted by Calvary in the Hunter region and is currently in operation with over 150 patients enrolled.

MyNetCare is an integrated care service model that creates cross-boundary ‘virtual’ teams of clinicians and services around individual patients using an innovative cloud-based technology solution to ensure seamless, real time clinical handover as patients move between services. The innovative technology at its centre provides a patient authorised and controlled web based clinical handover tool that enables access to relevant patient information across different organisations, services and practices working within the Hunter region of NSW. MyNetCare also connects patients and their families and collects patient reported measures.

MyNetCare is a patient-centric model of care with a technology enabler that empowers patients and their carers to actively participate in their care as they access their personal record online:

• Patients decide who has access to their record,
• Patients and carers are able to read clinical information entered by their healthcare providers,
• Patients and Carers are able to report on patients’ outcomes and experience,
• Patients can share information on advance care plans.

At its heart are three key design principles – integration, interoperability and flexible design. The flexible technology provided by Vitro Software catered to the needs of the varied end users from patients accessing their record in their homes, ambulance officers accessing patient records prior to transporting patients or GP’s accessing the system directly through their practice software.

As with all socio-technical innovations MyNetCare experienced common implementation challenges – clinician engagement, time taken to build necessary infrastructure and integration platforms and, just as importantly, changes to the existing models of care and practice norms.

A formative evaluation of the Program for Innovation funded projects undertaken for NSW Health by Deloitte Access Economics rated MyNetCare highest for integrated model of care and the program was awarded the Catholic Health Australia Outreach Health Care Award in 2017.

This case-study presentation will share some of the challenges and benefits experienced through the design, development and implementation of the MyNetCare project. The discussion will cover both the social and technological changes that are required to bring about transformative change that will positively impact patient outcomes and experiences.