Caring for the Homebound: Technology and the Patient's Medical Home
e-Health ePoster Library. Condon A. Jun 6, 2017; 167108; EP07.02
Amanda Condon
Amanda Condon
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Purpose/Objectives: Increasingly, traditional models of in-office, appointment based care are being questioned as optimal to provide care for homebound and complex patients in our community. The pillars of a patient's medical home include timely access to care, coordination, team based approach to care and continuity of care for a population of patients. Achieving these goals can be difficult for patients who are homebound; use of various digital health technologies, interoperability of clinical systems and remote communication can optimize care delivery and experience of care for this population of patients and their caregivers. Further, use of data from exisiting electronic systems allows for measurement of patient outcomes and use of data for population identification. This presentation will describe a model of care that addresses the needs of this population, the role of technology in improving care and experience for these patients and where the gaps remain for seamless integration of electronic systems for home based primary care. Objectives: (1) Describe a model of care for complex and homebound patients, in keeping with the goals of the patient's medical home. (2) Identify opportunities for use of exisiting electronic systems for measurement of care delivery and improvements in clinical outcomes (3) Describe use of exisiting electronic systems for communication, care coordination and interprofessional team based care for homebound and complex patients. (4) Spark innovative thinking and problem solving to address existing barriers to communication and outcome measurement.

Methodology/Approach: Review of exisiting care model will be described and how various exisiting clinical systems (i.e. clinic electronic medical record, home care MDS and hospital EDIS) are used for data collection, patient identification and measurement of outcomes. Further, use of these systems for communication and information sharing amongst team members will be detailed. The role of the provincial electronic health record in care delivery for homebound and complex patients will be explored with examples given. Gaps within exisiting systems and opportunities for improvement will be described.

Finding/Results: Home based primary care, provided by an interprofessional team with intensive case management, to a population of high risk patients or patients who are high system users, has demonstrated a reduction in emergency room use and hospital bed days for this population.

Conclusion/Implication/Recommendations: Recognizing those in our community who are at high risk and in need of intensive primary care, requires us to look outside the walls of the clinic and change our approach to care delivery. Measurement of these innovative models of care is imperative to demonstrate success but also for appropriate identification of populations in need. Existing electronic systems can provide opportunites for communication, information sharing and data collection to improve care for this population. Ongoing barriers exisit to further optimization of care delivery for this population of patients and their care givers.

140 Character Summary: Care for homebound patients requires optimal and innovative use of exisiting electronic sytems to improve their health and healthcare experience.
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