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Key objectives
To provide patients with a digital eRehabilitation Prescriptions following discharge from hospital after a serious injury.
The eRehabilitation Prescription is part of a 3-step discharge process, helping trauma patients leaving hospital to better manage their aftercare better.
It includes:
eRehabilitation Prescription – a tailored care plan informing patients about what has happened to them and signposting support services to give advice advise about commonly confronted problems.
Discharge consultation – a detailed consultation conducted in collaboration with patients and their specialist healthcare professional (i.e. trauma practitioner and pharmacist) before leaving hospital.
Two-week follow-up phone call / ongoing access and online consultation via Patients Know Best – to reinforce the contents of the eRehabilitation Prescription and move forward using online consultations and remote monitoring.
Outcome measures
To register a patient on PKB and pre-populate the demographics and appointments in PKB.
To use a standards-based approach to enable the solution to be reused with other PHRs.
Share care plan via third-party systems using PKB's API's.
Current Baselines
Patients left the acute hospital with no care plan, no documentation of their stay or treatments and primary care wasn't alwaysinformation of the acute hospital admission.
“Our feedback told us that patients, and sometimes their families or carers, felt like they’d been ‘forgotten’ once they left the hospital and there really was no sort of care plan in place to help with that.”
Workflow
Patient: Claim their PKB record
Team: Add carer to the record
Carer: Claims PKB record and views patients record
Team: Adds care plan and diary entry to the patients PKB record
Carer: Views patients PKB record
Team: Discharges patient with complete history in their PKB record
Team: Share Rehab prescription care plan with third party system via PKBs APIs
Patient: Views history of stay and rehab care plan
Third party systems: Views patients care plan and data in the PKB record
Rehab Prescription Care Plan Template
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“If you have a patient that comes in with a head injury and they have short-term memory loss, they can’t always retain the information they’re being told. By using Patients Know Best, it means that when going home or to a local hospital, the information is there and can be reiterated and utilised when needed.”
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