GP Dashboard in HealthOne

Learning Objective: To understand what the GP Dashboard is, how to access it, and how you can use it in your practice.

What is the GP Dashboard?

The GP Dashboard in HealthOne allows practices to identify their current inpatients, recent ED presentations, and inpatient discharges. Outpatient appointment bookings and missed outpatient appointments can also be viewed. Where discharge summaries have been finalised these are displayed in patient context. The practice sets the number of days for which these events are displayed.  Patients can be identified at the individual practitioner level or at the practice level.

Why use the GP Dashboard?

The GP Dashboard is a useful tool for practices to make an informed decision regarding patient follow up post-discharge. Information in the GP Dashboard is live, providing a timely, single point of information on patient status. Where discharge summaries are available, the Dashboard can provide an efficient way of accessing the information needed for follow-up.

A follow-up post-discharge by a practice can help the patient understand what they need to do to stay well and therefore, in some cases, reduce the likelihood of re-admission. For the practice, a follow up post-discharge can be a good opportunity to re-engage patients - some of whom may be used to receiving hospital care - with their general practice and offer services such as CLIC to those patients who would benefit.

Who does what?

Measurements

To ensure the time and effort you are putting into following patients up post-discharge, here are some things which may be useful to measure:

• Total number of enrolled patients discharged from hospital

• Number of patients followed up by a healthcare professional

• Number of patients booked into a follow-up appointment at the practice

• Patient feedback about the follow-up

• Number of CLIC/Quick CLIC appointments created following a discharge conversation

• Number of inpatients presenting to ED within 14 days of discharge

• Number of patients readmitted within 28 days of discharge

Some of these measures are long term outcome measures.

Implementation

Ensure practice users can access the GP Dashboard via HealthOne. If not contact Sara.Ross@southerndhb.govt.nz

Develop a process to best use this information which suits your practice. This will be unique to your practice, however, here are some things to consider:

• If you have a huddle, one option is to have the list of discharges from the previous day discussed at the huddle and follow up actions coordinated. This will only be effective in smaller practices.

• A Health Care Assistant may be a good person to coordinate the use of the GP Dashboard.

• It is important to determine the scope of the post discharge follow up. A script may help guide the conversation and ensure all important topics of discussion are covered.

• Following up every discharge from hospital may be a time-consuming exercise. Parameters around who should be followed up may be important. For example, you may follow up all your Māori and Pacific patients, or maybe everyone with a long-term condition.

• Important to consider what the practice can offer the patients, especially if they have been un-engaged historically. For some patients offering a CHA – marketing it as an hour long free appointment with the Nurse – may be useful.

• Consider using Quick CLIC, as this service is perfect for patients who may need a little extra support to help them recover post-discharge.

• Think about the other funded WellSouth services which may be available to the patient and how they could be used as part of the post-discharge follow up.
  
  

Patients

Patients should be informed they may receive a follow up call from the practice if they attend secondary care. This could be used as a positive marketing opportunity by the practice as another service they offer to patients, free of charge.

How to measure success

The scope of success is different for each practice. Some practices may want to follow up all patients, while some may focus on certain conditions or demographics. How you measure success will depend upon how you implement following up patients. However, it is important to consider the number of calls you make and the outcomes of these calls. The number of follow-up appointments (of any kind) booked is the key metric of success. In the longer term there may be an impact on your practices secondary care utilisation, especially re-admission rates, however there will be a significant lag time in this measure of success.

Helpful Tips

The time-period for the GP Dashboard is initially set to update every three days. This can be changed to update on a timeframe you choose, we suggest daily.  See the SDHB GP Dashboard Document below.

A patient routinely missing outpatient appointments may be a trigger to utilise WellSouth Outreach service for this patient. Consider building this into your process.

Some follow up services may be available as part of WellSouth funding e.g., IV Antibiotics delivered through the POAC service. This is good for the practice financially and the patient, who can receive this care closer to home.

Sara Ross is responsible for HealthOne and HealthConnectSouth at SDHB. If you cannot access the dashboard following the instructions found in further resources (below), please contact Sara on Sara.Ross@southerndhb.govt.nz

As mentioned above it may be useful to create a script when following up with a patient post-discharge. Some things to consider for the script include patient education, medication use, appointment scheduling, and what level of support the patient has.

Determining who among the primary care team (e.g. nurse, GP, health coach, HIP, or pharmacist) is most appropriate to lead the post discharge follow-up for that patient could result in significant time savings for the practice.

A funded appointment following a hospital admission for COPD, with the aim of preventing a readmission, is available for patients. The hospital discharge coordinator may arrange this with the practice, however it would be useful to build confirming this appointment into your process.

A focus on chronic conditions, especially in the initial stages of implementation, may be worthwhile as these patients are more likely to be readmitted.