The power of integration, to improve health outcomes for patients

Abstract

Gnosall Surgery has used the innovative software solution "Health Fabric" to improve care coordination, communication and quality of care for patients with dementia. Health Fabric is an application available on PC, tablet or mobile phone that supports the following 1. A shared record between health and social care accessible to nominated carers and family 2. Workflow management 3. Personalised care planning 4. Integration of tele-healthcare 5. Access to medical record by patients including prescriptions, appointments, letters, results, ability to set goals and share aspects of care. 6. It will also support PHB spend and tracking ( future development) 7. Personalised external information linkage relating to condition ( NHS Choices, Pharma advice) 8. Near real time Patient Satisfaction measurement questionnaires and scoring 9. Integration based on ITK Standards 10. Personal Healthcare Measurement Dashboards 11. Condition Management sharing functionality via Social Media. It is built on the ethos of personalised care planning (digitalisation of the West Midlands developed PCP booklet) and self management that involves carers and family, the overall aim is to increase quality and productivity, keeping people out of hospital whilst giving control to those that are able to better manage their own LTCs. It has a patient facing "app" and a staff facing "app" that communicate using the ITK framework, so giving a seamless integrated solution. There are several partners working with Health Fabric to ensure integration including EMIS, SIMPLE TELEHEALTH, telehealth devices companies and risk stratification to ensure a whole system approach. The software is being used for people with dementia in Staffordshire,and is showing significant benefits to patients and organisations. It supports a cultural shift and transformational change of how we interact with patients and their families and uses the NHS Change model as the basis for its large scale change management approach. [ABSTRACT FROM AUTHOR]