• identify patients who are the highest consumers of acute services
• register and track this cohort
• alert dedicated care teams every time these patients present in A & E

Alerting care teams to the admission of acute services patients is a key element in any strategy for dealing with the small population of patients who consume a disproportionate level of care resources.

Orion Health offers a reliable, configurable and technically flexible alerting module that lays the foundation for more comprehensive chronic care management.

The Business Case

People with chronic diseases (such as COPD, diabetes mellitus, CHF, and especially those with multiple co-morbidities) are frequent users of acute services, and better management of their condition will ensure more efficient use of limited resources. When the conditions of these patients are poorly managed, they tend to require more frequent hospitalisation

The ability to better monitor and regulate the care of such individuals will result in fewer instances of exacerbation of their disease, and fewer hospital admissions and a reduced demand on acute services.

The Solution

Patients who frequently present to the hospital A & E can be enrolled into a Recurrent Admission Patient (RAPA) Pathway. Enrollment means a dedicated team of chronic care clinicians are automatically alerted whenever a patient in this cohort registers at an A & E facility.

Orion Health's software solution is flexible and is designed to accommodate many of the complex factors causing frequent hospital admissions.

Features

Registering Patients as RAPA Patients
Authorised users (for example, community nurses) can register patients onto the RAPA pathway by filling out an electronic web-based form.

The registration form can prepopulate patient data from the hospital's PAS, including demographics and previous admission history, and authorised users can add additional notations as necessary.

The Form contains the following Data Items:

• A text area for the diagnosis/problem/reason for enrolment.
• A list that contains the group(s) of clinicians to be notified in the event of an ADT message.

The form can be expanded at a later date to contain additional Data Items, including structured and coded data items (eg. diagnosis codes).

Management of RAPA alert message groups
Programme administrators can add/delete users who should receive alerts.

Alert message groups are configurable and may be different based upon the patient's chronic condition (for example, the system could be set up to alert the Diabetes Team if the patient's primary chronic condition s is diabetes, and the Heart team if the patient suffers from CHF.)

Easy Viewing and Management of Patient Lists
A list of patients enrolled on the programme is displayed in a "whiteboard view" for easy tracking and management by dedicated ADM nurses and authorised programme officers.

Automated e-Mail alerts
When patients on the pathway present at A & E, an alert will automatically be generated and sent to all clinicians who have been included in the relevant user group(s). The alert is delivered in e-Mail format to the clinician's inbox or mobile device.

The e-Mail message will contain the patient's demographic details as well as details of the patient's diagnosis. The content of alerts is configurable depending on the data available in source systems and the hospital requirements.