Patient Journey - Vision & Mission

Vision

To enable the provision of appropriate support for high and medium risk chronic-care patients in their home.

Mission

An online system to ‘watch over’ the health, health care and social support of persons who are at risk of hospitalisation. ​

To enable regular or as needed outbound phone calls to consenting patients​

To identify any signs of deterioration and worsening in a person’s condition that would require attention that day, tomorrow or soon.​

To provide output from calls to the patient’s care team in a timely and intelligible fashion so that they address the patients’ needs​

To monitor the health, wellbeing and support capacity of patient caregivers.​

To enable patients to better self-manage their health conditions through regular conversations and feedback​

To filter the high risk from other levels of risk to assist with the workload management of the clinicians​

To provide a journey record so that we can understand and assist individuals and groups more effectively​

To provide a journey record so that we can analyze and predict deteriorations more accurately ​

Aspirations

Patient Journeys will provide phone outreach to elderly GP patients who risk unstable health journeys between formal contacts. Following consent, a Community Navigator (CN) will make Patient Journeys enabled phone calls (supervised by the practice nurse/GP). Patient Journeys uses a web browser for online reporting of structured summary of the medical, medication, support and service needs and risk of hospitalisation as reported by the patient. The practice nurse/GP will triage and assess what actions to take. It may include – more GP, pharmacist, social care and other services. Community health navigators extend the role of the primary care team, with timely personal journey risk prediction. Patient Journeys has been operating in Community Health settings in Victoria since 2018, but not in general practice which provides the majority of healthcare for elderly populations.