Western Sydney Wellness Trust
The Western Sydney Wellness Trust provides community health care and social care services to a population of 2,000,000 people living in the Western Sydney Area of Australia. The Trust was formed five years ago from the merger of the then separate Community Health Care Trust and Social Services Department.
The Community Health Care Trust employed staff with medical training from a variety of disciplines such as District Nurses and Physiotherapists. They visited patients in their homes and provide care to them there. The Social Services Department employed staff with non-‐medical care skills, also from a wide variety of disciplines such as Adult Carers and Child Protection Officers, who also visited clients in their own homes and provided social care.
The objective of both organisations was to enable people to go on living in their own homes for as long as possible, thus delaying their move to Trust-‐funded Nursing homes.
This merger was the result of a new central government policy being piloted in the region in which Western Sydney falls. There are nine other Community Trusts within the region, none of which are as progressive in their thinking as the Western Sydney Health and Social Care Trust. The objectives of the government policy are to improve the care provided and reduce the overall cost of providing that care. The new combined Trust was given a large degree of organisational and financial autonomy within the framework of overall management by the local region, and an energetic, forward thinking Chief Executive, Jim James, previously the Director of Social Services, was appointed to lead the new combined Trust. Jim James immediately appointed the hardworking Operations Director of the Community Health Care Trust, DrNorthy to the position of Business Development Director – effectively his deputy.
The Trust is headquartered in an old Victorian-‐style Mental Health Hospital facility in Parramatta with 50 other offices, clinics and care homes scattered over the geographical area served by the Trust. Very few of these offices have been purpose-‐built.
The Trust now employs 3000 staff split into a relatively small Head Office team including Finance, Personnel and Business Development and the professional care staff who are divided into 3 Directorates as follows:
- Adult Care
- Mental Health Care
- Child Care
Child Care Services
Each Directorate is in turn divided into 24 professional care disciplines such as District Nursing, Physiotherapy and Child Immunisation. Each professional care discipline is, in turn, divided into up to 5 teams spread over the area covered by Western Sydney Health and Social Care Trust. There are in total 84 such teams, each containing only specialists in the team’s particular discipline.
Figure 1: Organisation Structure of Western Sydney Health andSocial Care Trust
The Care Delivery Process
The Trust is one of only a few separate organisations which deliver care to the geographic area of Western Sydney. The other organisations are:
- Separate NSW Government-‐managed Hospitals who provide Accident & Emergency services, maternity services and a full range of clinical services toperform operations on patients as required
- Doctor Practices (Clinics) that are all contracted independently to the National Health Service and run effectively as individual small businesses, paid by Medicare depending on how many patients are served by them
People in need of care are referred to the Trust from a range of sources, for exampleCentrelink, doctors, the hospitals, police, schools, neighbours and next of kin.
Referrals contain wide disparities in the quality and quantity of their information. They are normally directed to a local Trust office which mayor may not house the professional care team capable of dealing with the particular problem, so the referral is then forwarded on within the Trust, finally reaching the correct team who take action. Referrals are received on a 24-‐hour basis 7 days a week and are actioned immediately if they are deemed to be urgent.
The key actions following receipt of the referral are typically:
- A visit to the referred person in need of care by a senior care professional from the most relevant care team, who carries out an assessment of the patient and may generate referrals to other teams within the Trust for their follow-‐up
- Creation of a handwritten care plan. Some care plans are very complicated and some very simple. For example, the Child Protection teams draw up very complex plans to solve the domestic problems leading to abuse of the child whereas the Podiatry teams are only concerned with scheduling visits to cut elderlypatients’ toenails
- Signoff of the costs of delivering the care by the Team Manager,or adjustment if too expensive
- Delivery of the care services, which vary in duration from one hour to everals years depending on the discipline and type of care
- Review of progress and revision of the care plan as necessary
Each professional care discipline has developed its own style of assessment form and care plan to record information about the patient, and each uses its own medical and care jargon to describe the same condition. Although a patient may receive care services from several teams in parallel, each of which is delivering its own speciality– for example district nurses dressing leg ulcers or occupational therapists modifying the home environment – no attempt is made to coordinate the care delivery or exchange care plans between the teams so they may well turn up at the same patient’s house on the same day and at the same time and one will then have to reschedule their visit.
The teams are traditionally suspicious of sharing patient related information in casethey make patient diagnosis mistakes, and the mental health and child protection teams are particularly concerned about security of information for their patients and clients.
The IT Systems
The main IT software systems used in the Trust are not integrated with each other and comprise:
- The legacy Social Care system, which is primarily concerned with providing a basis for analysing the type and source of referrals received by the individual social care teams and recording the type of care and cost of care delivered in response to the referral. No attempt is made to record the outcome of the care delivered and all notes made by the social workers are handwritten and filed locally
- The legacy Health Care system which is primarily concerned with collecting details of the activities carried out by the health care workers so that mandatory statistical analyses can be forwarded to the Ministry of Health in federal government
- An effective email system linking all of the offices together
- A financial management and payroll system
The legacy systems are old and very user unfriendly in look and feel, and staff activity data is entered by clerks located in the scattered offices and then used for statisticalreport generation by the central IT Department. None of the health and social care professionals ever make use of the information in these systems.
The network linking all of the offices together is the responsibility of the IT Team in the Regional Office. They have wider and deeper IT infrastructure skills than the Trust.
Having merged the administration of the two Community Health and Social Care organisations into one central team, Jim James has decided that he now wants to make advances in the provision of more effective care to his client base.
He has enthusiastically led the Trust in active participation in several federal government-‐ organised and funded R & D projects exploring the benefits of multidisciplinary care teams based on patient-‐centred IT systems with composite care plans.
He now wishes to implement this strategy right across the Trust and has motivated many staff within the Trust with his vision of the future, comprising teams of staff drawn from several disciplines developing an integrated care plan around the needs of their patient/client and working in an information sharing environment to achieve better coordination of care delivery and thereby hopefully faster recovery of the patient or at least a more comfortable supported existence at home. As always in healthcare, all staff within the Trust are already working to the limits of their available time. This project involves further changes to the organisation, ways of working and the provision of a comprehensive integrated IT system.
One of the Directorates has previously done some promising R & D workon a pilot project within the Trust. Now the Trust is very keen to develop this pilot into a software package for a much wider health and social care market and see this leading edge projectand see this as an excellent opportunity to bypass existing Healthcare and Social Care software suppliers and establish a market lead.
Requirements Specification written jointly by staff from the Trust and the Regional Office
The Trust’s team involved in the Requirements Specification comprised the Trust’s IT Manager and IT Systems Manager and four managers seconded from District Nursing, Occupational Therapy, Child Protection and Mental Social Work teams respectively. They were chosen on the basis of their reputation for being innovative in their thinking and supportive of the overall multidisciplinary team concept. The Requirements Specification Team Leader was a senior Systems Consultant, James Saunders, who was seconded from the Regional IT team for the project. The Requirements Specification comprised an overall vision of the future written byJim James and up to two pages of bullet points for each Care Discipline identifying their particular process and information needs. An extract from the Requirements Specification is provided at the end of this document.
All of the Trust’s Directors are in agreement withJim James’ vision of the future but have targets to meet in the short term and huge organisations to run. No plans currently exist for how the care staff will be reorganised into the multidisciplinary teams.
If the project is successful, the Region intends to implement the same reorganisation everywhere and the Minister of Health will take the same approach right across the country. Both the Region and the Ministry want to monitor progress.
Dr. Northy has been made responsible for driving the whole project and has recruited you as a Project Manager reporting to her, to take day-‐to-‐day responsibility. The goals have been set byJim
James, the Regional Director and the Minister of Health. The project should commence on 1st July 2017 and full implementation of the systems is required by 30th June 2019 (2 years).
The following table is an extract of the requirements identified that should be applied across all Care disciplines.
|3||Production of Treatment/Care Plans|
|3.1||Access to Assessment information||The software will provide easy access to|
|Assessment information and Assessment|
|summaries both for individual staff members|
|and, where appropriate, other members of the|
|3.2||Mobile Access||The software will include a mobile app (for both|
|Android and iOS) which will allow access froma|
|3.3||Link to Episode of Care||The software will automatically link the|
|Treatment/Care plan to the appropriate|
|Episode of Care|
|3.4||Alerts||The system will create alerts that highlight|
|imminent and late reviews. This will include|
|push notification to mobile devices.|
|3.5||Library of Standardised Plans||The software will contain a library of|
|standardised Treatment/Care Service Plans|
|which can be tailored to individual needs.|
|Administrators will have access to add new|
|plans to the library and edit existing standard|
|3.6||Linking goals to outcomes||The software will record goals and objectives|
|and also record outcomes so that over time the|
|success (or otherwise) of the Treatment/Care|
|Plan can be analysed.|
|3.7||Knowledge Base||The software will contain a knowledge base|
|that allows easy access to the results of the|
|analysis (from 3.6) so that future allocation of|
|plans can improve over time.|
|3.8||Access to history||The software will provide access to historic|
|Assessments and Treatment/Care Plans.|
|3.9||Access to all records||The software will allow access to all records|
|regardless of the discipline.|