In the run-up to another winter, all eyes will again be focused on the challenge of preventing unnecessary hospital admissions to relieve pressure on inpatient beds.
Caring for people more effectively in their own homes is part of the answer. But this relies on the effective working of community-based multi-disciplinary teams (MDTs).
Made up of different clinicians who work together as one cohesive unit, these teams aim to ensure that all the patient’s needs are looked after in a holistic way.
As any health professional knows, accounting for every part of a patient’s history is a huge hurdle to overcome. But I know from personal experience that it becomes exponentially more complicated when there are multiple agencies and staff involved in delivering this care.
We are seeing more and more patients living with co-morbidities. According to NHS England, one in four of us have two or more long-term conditions with this rising to two-thirds of people aged 65 and over.
Care for people with co-morbidities is complicated because different agencies and healthcare professionals can be responsible for treating each individual condition. As a result, care can often be fragmented and may not consider the combined impact of the conditions and their treatments on a person’s quality of life.
However, there is one way we can simplify this for everyone - with technology.
Shared electronic records are essential
How can technology help? Let’s start with the corner stone - information.
Clinicians in any MDT need instant, electronic access to a shared care record – whether they are in a clinical room, in the patient’s home or in the car. This helps them make more informed and safer decisions, have more effective conversations with their colleagues and provide patients with the best experience possible.
As well as containing all the information they need, it’s important the shared record can be updated at any location. So, when a nurse visits a patient in their home or needs to consult a colleague on a decision, all the clinical activity is up to date and recorded in one place.
Clear accountabilities and actions
As well as ensuring everyone is working with up-do-date information, this shared way of working can define who is responsible when it comes to care planning and delivery. Each action can be assigned to a person who has responsibility for it and can ensure it is completed.
If healthcare professionals within an MDT can track exactly what others have done, what stage a patient is at with their care and what needs to be done next, it’s much easier for them to provide holistic care that is vital to so many.
Making connected care more effective
Joined-up technology can also help make MDTs more effective by improving their processes. For example, it can enable electronic referrals to be sent within a team. Each relevant clinician can then triage it and either accept or reject it from within their own clinical software system. Straightaway, you have gone from a few different referrals to one, which can be picked up by the relevant person immediately.
This is already making a real-world impact. The Liverpool Diabetes Partnership (LDP) was founded to improve the prevention and management of diabetes and is made up of healthcare professionals from different disciplines. By enabling everyone to have access to the same patient record, the service is now providing more care in the community and working with secondary care to pick up inappropriate referrals. It’s better for patients as they are receiving care in their own homes while inappropriate, diabetes-related, hospital referrals in Liverpool have been reduced by 50%.
Nurses themselves are also becoming more efficient by using technology. They no longer have to chase patient information which enables them to spend more time having more meaningful discussions with their peers in multi-disciplinary meetings.
A better experience for everyone
Asking patients to continually retell their story to different people is tedious. There is, quite rightly, an expectation that as healthcare professionals, we should know what is going on.
During an appointment where time is of the essence, removing the need to ask for this information is better for everyone. It allows the clinician to use the time more effectively and ask questions directly related to the reason the patient has presented. This can only be done by sharing electronic records.
Improving prevention and early intervention
With technology, we can begin to identify which patients are at risk of developing illnesses and shift care to a more proactive model, rather than a reactive one.
With different healthcare professionals feeding into one record, there is a much richer database which can be analysed to start pinpointing where care should be directed. At-risk patients could be cared for more efficiently in their own homes by MDT members rather than waiting for a serious condition to develop and a hospital admission.
Many of us use fitness trackers and other wearable technology. But what happens to the data they collect? If nurses have access to this information, they can help educate and empower patients to understand what steps they can take to improve their health for the better. In effect, the patient becomes a virtual member of the MDT.
As with shared electronic records, this technology is available now and can be used by MDTs in the community. So, let’s make sure that we are ready to use new technology; let’s make sure that we take every opportunity possible to create a case to have the best technology available to us; let’s make sure that as individuals and collectively, we are able to use technology. As nurses, we’re great at establishing relationships with our patients, but imagine how much more powerful and beneficial these could be with the use of the right technology; we could really start to make even more of a difference.