Integrated Case Management Service for Chronic Disease, National Clinical Programmes

Tender description

This project centres on an integrated virtual case management of patients with multimorbid chronic disease in the community. It is a joint initiative between Enhanced Community Care programme together with specialist chronic disease ambulatory hubs partnering with Caredoc, through the use of virtual case management by trained triage nurses combined with remote patient monitoring, to support patients with multimorbidity to live more independently and reduce their episodes of deterioration. This project will focus on the integration and expansion of the established SMILE 1 service with the ambulatory care hubs so that the learnings and support from SMILE 1 can be utilised and maximised to further strengthen patient outcomes. I Lot 1: This project centres on an integrated virtual case management of patients with multimorbid chronic disease in the community. It is a joint initiative between Enhanced Community Care programme together with specialist chronic disease ambulatory hubs partnering with Caredoc, through the use of virtual case management by trained triage nurses combined with remote patient monitoring, to support patients with multimorbidity to live more independently and reduce their episodes of deterioration. This project will focus on the integration and expansion of the established SMILE 1 service with the ambulatory care hubs so that the learnings and support from SMILE 1 can be utilised and maximised to further strengthen patient outcomes. International research shows that virtual case management services are best integrated with the clinical service structure, and not created as a standalone service. Hence to build on the SMILE 1 project success and scale up the service integration with chronic disease ambulatory care hubs is now necessary. The project now being proposed would be an integrated project between Enhanced Community Care chronic disease ambulatory hubs and Caredoc, to use the expertise gained in the SMILE 1 project to expand the service to an additional 300 patients and transition the current SMILE 1 cohort to the new service. The appropriate high need patients would be identified through chronic disease ambulatory care hubs and GPs. The experienced Caredoc triage nurses would work in partnership with the newly recruited chronic diease hub Clinical Nurse Specialists to identify and stratify patients from the population that would need this more intense case management support and to provide it in an efficient way through virtual enablement. The system utilised by Caredoc in their delivery of the SMILE 1 project will be extended to the chronic disease hub specialist staff, thereby giving visibility of all patients that have been enrolled and their ongoing health dat This project will focus on the integration and expansion of the established SMILE 1 service with the ambulatory care hubs so that the learnings and support from SMILE 1 can be utilised and maximised to further strengthen patient outcomes.