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Personalised care plans are pivotal to realising Hospitals Without Walls

A quick look at the UK’s health statistics shows just how significantly patient demographics have changed in recent decades. One in three adults in England now live with a long-term health condition that requires long-term monitoring, while 18% of the UK population is over 65  – a figure that’s expected to rise to 24% by 2042.

It’s those suffering with long-term conditions that actually account for about 50 per cent of all GP appointments, 64 per cent of all outpatient appointments and over 70 per cent of all inpatient bed days. Yet, these are the people that can, and more importantly want to receive care outside of the hospital setting. Remaining healthy and well in their homes is a top priority but joined-up healthcare that’s tailored to them and their unique needs is critical to realising that.

Enabling more coordinated transfers of care for patients

It’s older patients and those with chronic conditions who are more likely to experience regular transfers of care, moving from hospital to GP to community care throughout their treatment. But, as I’m sure we’ve experienced at some stage, information doesn’t always follow people as they move through the health and care sectors, which can lead to a fragmented and frustrating experience for patients. It’s no surprise of course that improving transfers of care stood out as a priority in the NHS Long Term Plan and built on with the publication of the Health and Care Bill.

To achieve better transfers of care and improve the communication and coordination of teams across care settings, the entire care team must be empowered with accurate, real-time information about individuals wherever they are in their healthcare journey.

That’s why InterSystems has launched HealthShare Care Community. A solution designed to make providing personalised care across distributed healthcare systems easier for staff and more seamless for patients.

In building HealthShare Care Community, we spent many hours working with clinicians and care teams at the forefront of care delivery to understand their challenges and needs to create a solution that delivers for the entire team, inside and outside of the traditional hospital setting.

So now, everyone on the care team can see who is contributing to a patient’s care, their role, when they’re involved and their contact information – easily inputting detailed information and accessing the data inputted by others for a holistic view. And the great thing is, with patients inputting lifestyle and wellness goals into their plan, the whole care team can deliver more personalised and tailored care, specific to the patient’s objectives and needs.

That means the entire care team from patients and clinicians to care managers and community health workers, can easily build a highly detailed, accurate and continually updated picture of each patient’s condition and care preferences.

Good data keeps patients healthy and at home for longer

As well as making healthcare more coordinated and personalised, using a unified solution like HealthShare has the potential to transform the way the NHS delivers care in other ways.

It empowers Trusts to move from a less reactive, and more proactive way of delivering care. For example, HealthShare Care Community automatically notifies teams of events such as admissions, discharges, or transfers and enables person-to-person communication in the messaging centre so care can be coordinated more effectively as care transfers.

Plus, through integrated analytics and insights tools, high- and rising-risk populations can be more effectively identified, and care plans customised accordingly. With more comprehensive information available to them, clinicians can better detect when a change in care status is imminent and intervene earlier, preventing deterioration in a patient’s status that could require a transfer to hospital.

Reducing the need for precautionary hospital admissions in this way helps healthcare providers manage the number of patients who need expensive, high-dependency care. That not only alleviates the pressure on primary and secondary care providers, but also makes a difference to patients, who want to live and remain healthy in their own homes.

But, to really achieve the benefits of fully joined up health and care data, the NHS needs solutions that can talk with each other and easily share data, whether the staff using them are in a care home or an intensive-care ward. InterSystems HealthShare has proven interoperability in the NHS, and around the world, enabling patient information and care plans to be shared with various health and care providers for one single source of the truth.

With our unified care solutions further enhanced with personalised care capabilities, healthcare providers can truly transform how they deliver care beyond the hospital walls. With a joined-up system, care can be both more patient-centric and more preventative, keeping patients healthier and at home where possible. In our current environment, both our healthcare system and patients are facing more challenging circumstances than ever. We’re proud that our solutions can help play a part in supporting the NHS navigate these challenges.


Chris Norton

Managing Director, InterSystems, UK & Ireland Chris Norton joined the company in 2002 and is now managing director, running the business for the UK & Ireland. After obtaining an honours degree in environmental science in 1979, Norton worked initially as a graduate management trainee for the 600 Group, an engineering and metals company, where he rose through the ranks to become a regional manager. He went on to join the IT industry in 1987 with Nixdorf Computer which was acquired by Siemens in 1990 where he held several key positions until joining InterSystems. Chris is also a life-long Hockey player.
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