Over the last two years a pilot project has been underway in east London, creating a specialist new ‘Complex Care Practice’. This pilot practice aims to align the care of patients with four or more long term conditions. Throughout this project digital innovation has been key to joining up health and social care services.
One aspect of the project, the use of digital technology to provide remote access to patient records, serves as a useful example of where technology currently stands within the NHS landscape, and highlights areas of care that are still yearning for rapid development.
The pilot was based on a model of integrated care, delivered by a unique, multi-disciplinary team including dual-skilled (administrative and clinical) ‘keyworkers’, Occupational Therapists and GPs, supported by a Social Worker, Practice Nurse, Practice Manager and Consultant Geriatrician.
Patients were identified using anonymised disease registers, and those with at least four out of eight pre-defined long-term conditions were invited by their current GPs to re-register at the Complex Care Practice. The practice population was drawn from across three large east London boroughs, with the central base nested within a District General Hospital site.
Due to their co-morbidities, many of the patients required care at home. Ordinarily, health and social care professionals conducting home visits can only see print outs of a patient’s medical record. These contain limited detail, and the process of printing and later disposing of these records is time consuming, duplicates work, wastes paper, and can put confidential medical information at risk.