By Gary Mooney, clinical solution executive at InterSystems
- Margaret is 84, she lives alone with frailty and heart failure. She is admitted to her local hospital by ambulance after a fall for the third time this year. Her district nurse had noted weight gain, her GP had changed a diuretic, and a therapist had flagged a falls risk. Each record sat in a silo of disconnected digital and paper records. The warning signs were all recorded, just never in one place, by one co-ordinated team, or in time.
The hospital-centric model of care is failing to meet the needs and expectations of modern societies around the world. Demand is growing faster than acute care capacity can respond. In the UK, we see the direct impact of this imbalance with concepts such as “corridor care” and “carpark triage” becoming all too commonplace in our Emergency Departments. Common pressures are forcing nations to re-think their models of care to meet the demands of modern societies.
Choosing two nations as examples of national care services attempting to respond to these challenges, England’s National Health Service (NHS) and Ireland’s Health Service Executive (HSE) have set out national strategies for new models of care:
- Fit for the Future: the UK Government’s 10-year plan for the NHS in England to seize the opportunities provided by new technologies, medicines, and innovations to deliver better care for all patients – wherever they live and whatever they earn
- Sláintecare: Ireland’s ten-year cross-party strategy to replace the traditional two-tier healthcare system with a single-tier universal health service based on medical need rather than ability to pay
Both strategies explicitly place community services at the centre of their planned care reforms. From a digital perspective, the paradox is that care is shifting into the community setting, which is typically the least digitally mature estate.
Policy is shifting to orientate towards integrated models of care. However, you cannot shift care to a place you cannot see:
- Community records are often paper-based, fragmented across services, or held in systems that do not share data with acute and primary care
- National visibility of community activity and outcomes is weak compared with acute
- Multidisciplinary teams cannot coordinate around a single view of the person
The Challenge: How do healthcare systems move from sharing information between silos to delivering one integrated model of care closer to home, safely, at scale, and measurably?
The trap for this challenge relates to having the same care silos with more information. For example, a Shared Care Record solution can provide many benefits for the sharing of information but on its own, gives every silo more information and leaves the patient journey unchanged.
Data sharing is the first step, not the destination, and it is why the policy and structural shifts outlined by the English and Irish ten-year plans are critical. Integrated models of care change how care is organised across four key dimensions, illustrated by the figure below.
Figure: Shared Data vs Integrated Care
The Response: redesign the model of care, then enable it digitally
First, redesign the model of care across settings: shared pathways, shared workflows, pooled resourcing and joined-up communications. Second, enable that model with four digital capabilities that are mutually exclusive and collectively exhaustive: connect, see, act and prove.
The HSE Community Care Record
Ireland’s Community Care Record (CCR) illustrates the approach this article argues for: a national, person-centred record for community services, introduced through redesigned processes rather than as a data feed. The HSE describes it as “a single shared digital record for community services” and a step towards the national One Health Record (HSE).
The problem it addresses. Community services in Ireland have run on paper and local systems, which cause delays, duplication, and difficulty sharing information. At the CCR launch, the panel put it plainly: “fragmented information is one of the greatest risks in community care today” (HSE).
The HSE CCR delivers against the strategic intent of Sláintecare to deliver a digitally enabled new model of integrated care. The CCR will provide a single national digital platform supporting community services, CAMHS, and Specialist Palliative Care across the nation’s six regions.
Figure: HSE National Community Care Record
The CCR programme offers key reusable learning, agnostic to the digital platform, relating to:
- Pathways: Starts with a Single Point of Access (SPOA) for community services: one standardised route for referral, triage, and waiting-list management, with one record per person used across all community services
- Workflows: Regional Service Process Mapping workshops have staff map current practice, local variation, and dependencies, and agree what to stop, start, or continue, before the system is configured (HSE) and informed by over 10k data points expressed in service activity and outcomes, not functions and features
- Resourcing: Replaces multiple ageing local systems with one national solution, giving visibility of referrals, caseloads and waiting lists across services and regions, and for the first time, the ability to gain real-time and on-demand service insights at national, regional, service, and team perspectives
- Communications: Community appointments appear in the HSE Health App, so the person sees their care in one place; role-based, audited access supports safe sharing between teams
- Process first, then technology: In the HSE’s words, “successful adoption depends not only on the technology, but also on how people use it to support their day-to-day work”.
- Staff-led design and change: It is built from workshops, mapped clinical workflows, and prototypes. A Change Network of more than 1,600 staff supports it, and about 1,500 attended the launch webinar (HSE)
- Phased by readiness: Services start with service-management functions. CAMHS and Specialist Palliative Care, which already have national standards, start with fuller clinical functionality, including medication management
Enablers and Barriers
Technology is necessary but alone, it is not sufficient. The move, however, to national scale digitally-enabled models of integrated care represents a significant challenge for all healthcare services. Common barriers and enablers relate to:
People
- Barrier: Community workforce shortages; variable digital confidence
- Enabler: Clinically led design; digital champions; time released through mobile working
Money
- Barrier: Funding has historically prioritised hospital activity, not community outcomes
- Enabler: Ring-fenced community digital investment; outcome-based allocation
Governance
- Barrier: Information governance and consent hold back data sharing
- Enabler: National frameworks for direct care sharing; clear secondary-use rules
Standards
- Barrier: Proprietary data models and point solutions
- Enabler: Mandated open standards (FHIR, SNOMED CT); national interoperability specifications
Care Closer to Home
Margaret is 84 and lives alone with frailty and heart failure. Six months ago, her neighbourhood team’s population health review flagged her as high risk: a heart failure diagnosis, two falls in a year and nobody at home. She was enrolled on the local frailty pathway, given a named care coordinator, and agreed one shared care plan with her daughter, her GP, the community nursing and therapy team, the heart failure nurse, and social care.
On Monday, her district nurse records a weight gain of 2kg in three days, a recognised warning sign in heart failure. Because every team works from one record and one pathway, the entry creates a task for the heart failure nurse, who reviews it that afternoon and, with her GP, adjusts Margaret’s diuretic. The change is visible at once to the district nurse, the community pharmacist, and the therapist.
The therapist had already flagged a falls risk. Seeing the new diuretic, she knows Margaret may now be rushing to the bathroom at night, so she brings her home visit forward: a bedside commode, a grab rail and a pendant alarm. Margaret is stepped up to the virtual ward for a week, with a connected scale, and a daily call. Her daughter sees every appointment in the app. At Thursday’s multidisciplinary huddle, the team reviews her together; by the following week her weight is back to normal, and she steps down to routine care.
No ambulance is called, and there is no fourth admission. The pathway dashboard records a hospital admission avoided, and that evidence helps the region justify funding the team that made it possible.
The warning signs were recorded once, seen by everyone who needed them, and acted on by one co-ordinated team, in time.
This scenario is entirely achievable with the technologies available today, they are not the rate-limiting step. The 10-year plans are encouraging, and the HSE appears to be ahead of the curve in delivering a new model of digitally enabled integrated care at a national scale.
The shift to the community, however, will be won or lost not on whether data is shared, but on whether care is truly integrated.
