Western NSW Primary Health Network pilots integrated shared care planning platform


Inca is an integrated shared care planning platform that allows healthcare teams to manage patients with chronic disease in a collaborative manner, bringing multidisciplinary health teams together to help keep patients out of hospital.

Using Inca, GPs can create patient-centred, Medicare-compliant GP Management Plans (GPMPs) and Team Care Arrangements (TCAs) that can be securely shared with a patient’s health team, allowing for an integrated approach.

Inca is made available to general practices in Far West and Western NSW free of charge under the Care Partnership – Diabetes (CP-D) program. The CP-D program aims to improve health outcomes for more than 11,500 people living with type 2 diabetes (T2DM) in Western and Far West NSW. The CP-D Program is a collaboration between the Western NSW Local Health District, the Far West Local Health District, the Western NSW Primary Health Network and NSW Rural Doctors Network.

Molong HealthOne General Practice GP Dr Alexander Hoyle has been using Inca for the last 18 months to help manage his patients with chronic disease and has found the platform to be helpful in reducing administrative burden. One of the ways it does this is by syncing with all major practice software and automatically populating patients’ demographic and clinical information.

“Clinical outcomes get harvested from our practice software and are automatically uploaded, as do the medication lists so you know the people who you're referring to can get the latest measurements and parameters that are relevant to that patient,” Dr Hoyle said.

The portal clearly shows who is on the patient’s care team and the managing doctor can manage GPMP and TCA contributions and approvals with external care team providers such as allied health professionals, diabetes educators and specialists. Care teams can also easily communicate in real-time and share patient notes and reports.

Dr Hoyle said that creating care plans using Inca was much more streamlined than using traditional practice software.

“One of the big advantages for me is that … you've got the document that's relevant to the patient and you've got a document that's relevant to the clinicians.

“It shows two or three patient actions, their care team with their contact details … so the patient knows who's involved in their care and how to get a hold of them. For the patient, that's what's relevant.

“And for the clinicians, there is that full care plan that includes all of the details. We can get that detail needed for clinicians, without overwhelming the patient with unnecessary extra stuff.”

Inca’s patient-centred approach means that patients can actively participate in their care. By linking the Meditracker mobile app to Inca, patients can access their medical records in real-time and contact members of their care team. Patients can also add measurements via Bluetooth-enabled devices, such as weight, blood pressure, blood glucose, temperature, pulse rate and blood oxygen saturation levels.

Jacqui Arnold is an Exercise Physiologist and owner of Actify You who regularly sees patients referred to her by Dr Hoyle.

Her mobile business sees her travelling on average around 1,000 kilometres per week visiting communities in Central West NSW and helping patients to move more.

“I'm mobile so I go into small communities and I don’t always have good service,” Jacqui said.

“I can enter data straight into it, so I haven't then got to go into a separate letter or report later on that's required by Medicare. It's all covered in one.

“I can make notes in my program and quickly transfer the data, depending on where I am if I've got good service, and I can just log into the program or put it straight in and then send a quick report to Dr Hoyle and he’s already got most of the information.

“It's quite time-saving and I can see other people that are involved in the patient's care as well.”

Jacqui likes the collaborative approach to patient care and has found it helpful to be able to view the notes from the managing doctor.

Western NSW Primary Health Network (WNSW PHN) Senior Digital Health Officer Brenton Jones said that Molong HealthOne General Practice’s adoption of Inca has been invaluable in developing a deeper understanding about patient-centred shared care planning.

“Molong HealthOne’s clinical leadership and the time they’ve invested is proving that having a Medicare-compliant GPMP+TCA template and workflow tool like Inca can help teams be more effective in care coordination and building equity in continuity of care,” Mr Jones said.

“Perhaps the most valuable insight we’ve taken away is the importance of external allied health and specialist care provider management.

“Inca can help GPs establish effective, secure, safe and consistent electronic workflows with care team providers, but the trick is to make sure practices inform them of the change to Inca for TCA workflows before engaging them. Also, syncing a practice’s CIS address book with Inca’s Provider Directory, and setting up Preferred List of providers helps to speed up the care planning process.

“Inca can make engaging with a patient’s care team easier by giving everyone access to support the patient in a proper team care approach. GPs, nurses, practice managers and admin support staff can have user accounts to support care planning processes.” All general practices throughout Far West and Western NSW are invited to adopt Inca at no cost for the next two years.

To get started, contact Brenton Jones, Senior Digital Health Officer at WNSW PHN.


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