8. Creating The Modern Outpatient
8.1 The Programme will use and adopt technologies which enable more community-based care, promote anticipatory care and support self-management.
8.2 Patient management algorithms and clinical decision support applications are important tools for supporting the extended community-based multidisciplinary team in the ongoing management of patients in the community. The Programme will continually review the types of clinical decision support required by the multidisciplinary teams ( MDTs) and support the rollout of any pilot work which has been evaluated well. Standardised and co-designed templates of clinical decision support systems would benefit Primary Care in their discussions with patients around the requirement for any referral to an outpatient service. Moreover, if this were interoperable with current Primary and Secondary care referral technology it would be auditable. This in turn could be used to standardise the quality of referrals, simplify the process of referral and help manage accountability for decisions relating to referrals.
Redesign in action: Clinical decision support
The National Dermatology Collaboration has developed 19 Condition Specific management pathways which were launched on the 22nd November 2016. Further to the launch, three regional educational support events are being held in December and will be streamed live to ensure maximum reach.
The programme is keen to harness the potential of digital and smart phone technologies by making sure the pathways are more readily accessible via Smart Phone App and web-based formats and hosted via a central facility.
Redesign in action: Using patient management plans to support Primary Care
NHS Tayside has been piloting an Intelligent Liver Function Test Primary Care Model in partnership with six GP practices. A baseline audit suggested that up to 50% of patients referred to consultant services with abnormal liver results could have been managed in primary care. Following initial and cascade blood testing, algorithmic patient manage ent plans are generated and sent electronically to the participating GPs practices. The pilot will be evaluated in March 2017. Postevaluation we will review the potential to spread this innovation across Scotland.
8.3 Offering consultation in the patient's own home or a setting close to their home will be key to developing a virtual model of care. The Programme will test, evaluate and roll out e-consultation, in collaboration with NHS24. The Attend Anywhere Video Call, is a web-based management software package which enables consultations to take place in the patient's own home. It will initially be tested in 50 clinic settings across a variety of specialties (see Annex 4). This will offer video call access to patients who would otherwise have to travel to appointments and will support services to work more 'virtually' as part of their day-to-day operations.
8.4 Home and mobile health monitoring ( HMHM) describes systems that use technology to support citizens to record and send clinically significant information about their health and wellbeing to an electronic storage system, where it can be accessed by themselves and healthcare professionals to support the management of their care (see Annex 5).
The Programme will look to extend the range of specialties who will benefit from the use of digital health technologies/wearable devices which enable the remote monitoring of care and supports patients on supported self-management pathways.
Redesign in action: Personalised care, education and remote monitoring
In collaboration with The CAN DO Forum, Highlands and Islands Enterprise and Innovate UK, the National Gastroenterology Collaboration will launch an SBRI Challenge for management of patients with inflammatory bowel disease ( IBD) in January 2017. The challenge is to personalise care, education and remote monitoring for people living with IBD to drive productive use of planned health and social care consultations and interventions (face to face or remote) in order to sustain homebased living and care.
Scotland's CAN DO Innovation Forum was announced in the Programme for Government and Scotland's Economic Strategy. Improving Scotland's innovation performance is a top priority; it will mean seeking to shift business perceptions of, and ambitions for, innovation, making best use of public sector levers and funding to drive change and developing a truly collaborative approach to tackling these issues.
8.5 Many of the traditional ways of working which have no basis in evidence of better outcomes, such as the 'routine follow-up appointment', are very wedded to a risk averse medical model. Some of these appointments are used as a means of 'keeping patients in the system' thus avoiding the need for re-referral from the GP. This is not appropriate or efficient. When moving from a basis of managing patients by routine to anticipatory-based care, we will ensure that patients can gain access to secondary care whenever their clinical need requires it.
Redesign in action: Patient initiated review
An Innovation Challenge will be launched in January 2017 in partnership with Civtech®, to ensure an accelerated process of concept/design to product availability and testing. The challenge is to develop patient self-scheduling tools/software which interfaces with existing systems and to provide patient iTriage assessment which allows the patient to access care when required and supports more effective triage to the right clinician or advice route.
From a patient's perspective this will mean that they will be able to initiate when they feel that their condition is deteriorating, and will avoid the need for routine appointments for some patients.
The CivTech® pilot is harnessing new technologies to drive innovation into the public sector. It brings together private sector innovation, public sector organisations and citizens to develop more efficient and effective products and services, which will translate to new, better, faster and easier experiences for everyone.
8.6 Maximising the roles of extended MDTs by developing training and e-learning opportunities are paramount in building fit for purpose community-based services and supporting specialist nurses and AHPs to work at the top of their licence.
Redesign in action: Maximising the role of clinicians with enhanced skills
NHS Ayrshire and Arran has Scotland's only Specialist Nurse Hysteroscopist who carries her own caseload, can diagnose and refer onwards for specialist treatment and can, when working to her full skill span, carry out minor procedures such as biopsies and polypectomies that would otherwise have to await a separate consultant appointment. Hysteroscopy is a critical tool in the early diagnosis of a range of female cancers so this service supports the Detect Cancer Early programme and delivery of our cancer waiting times guarantees.
Currently we see nearly 200,000 patents in gynaecology. It is anticipated that diverting 10% of this work to nurse clinics can be realised by the third year of the Programme.
Intra-vitreal injection is a procedure normally conducted by consultant ophthalmologists. A number of NHS Boards are now releasing nonmedical staff to undertake intra-vitreal injection training in the hospital setting via a competency framework shared between NHS Health Boards to ensure parity of training between all staff nurses.
Intra-vitreal injections have grown significantly over the last five to six years. In 2007/8 we undertook around 250 injections, now in 2016/17 we are undertaking just under 4,000. By utilising the extended skills of trained nurses we will able to keep abreast of this growth over the three years of the Programme.
The university course is accredited at masters level, sponsored by the National Ophthalmology Workstream to ensure that the knowledge base of non-medical staff continues to expand in this specialty.
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