Careteam

Overview

The solution

Careteam proposes a person-centred care collaboration platform which respects the person with multi-morbidities as a whole person, wrapping the team around them – including health and social care providers, and their support team (family/friends) – with a shared care plan and the tools to act on it.

The platform is built on three key principles:

  • A person’s integrated care plan is the result of many aspects of their health and care – the technology needs to provide an integrated view and coordination, while also supporting focus.
  • Careteam is built on a flexible user framework, allowing the person to decide who to invite to their team and assign their roles.
  • Careteam is a platform, integrating best-in-class technologies for a unified user experience.

The platform currently includes:

  • Onboarding: The ability to onboard users at scale through various mechanisms including through integration and self-signup, enabling early intervention.
  • Team: The ability to form the team around the person – including health, social, and personal support team.
  • Integrated Care Plans: The flexibility to have a single shared care plan, or multiple individual care plans that are integrated into a person-centred user experience. Care plans are made up of patient goals, instructions, educational content, activities, and referrals.
  • Assessment and monitoring: Mobile-oriented ‘check-ins’, full assessments, and manufacturer-agnostic device monitoring.
  • Messaging: The team can communicate 1:1 or in groups across organizations, and include the person and their personal support team.
  • Group Actions: The population can be filtered to select a defined group, and changes made to selected care plans, thus eliminating barriers to proactive care at scale.

Subject to input through CareMatrix, it is anticipated that areas of focus for R&D include further advancing the shared care plan functionality for cross-organization collaboration, and moving to dynamically updated algorithm-driven care plans that adjust as the person’s situation evolves.

Experience

The project will build on the existing Careteam platform, which has been in use for four years across a number of widely different populations, conditions and uses ranging from frail older adults to paediatrics, diabetes to palliative care, and ongoing chronic disease management to discharge/transitions.  The platform has proven the ability to facilitate multiple separate organizations, spanning health and social care from large tertiary hospitals to small community organizations, to collaborate around a truly multidisciplinary shared care plan for an individual, and engage the individual in their care.  The company was conceived by three founders whose experience spans clinical care (an emergency/family physician with background in occupational therapy), a health technology executive whose experience spans all aspects of health care and 100-800m EUR projects, and a seasoned tech entrepreneur with experience in both financial services and health care.  The founders have established an experienced team of staff including clinicians, designers, and developers who have delivered at least 10 R&D projects and overseen many deployments.  We have been working on leading-edge work with researchers who are members of the International Federation for Integrated Care (IFIC) in two projects: one related to goals-oriented patient engagement and another on cross-continuum multidisciplinary care collaboration.

Motivation and Goals

Careteam was established in 2018 specifically for the purpose of reducing fragmentation in care.  Our team had extensive experience in the areas of electronic medical records and health information exchange.  We recognized that while past records are important, they alone do not solve the problem.  We believe that empowering the person themselves, and enabling their team to form and support them, is transformational in a way that no previous digital health projects have been.

The founders recognized that to eliminate silos in care between different organizations, settings, roles, and conditions, the missing ingredient is the forward-facing plan of care, and support for the team to collaborate and ensure those things are accomplished.  Careteam is united behind the vision of Patient Success – recognizing that we can see the results when the stars align and things go well, so the opportunity is to ensure that occurs for everyone.  Clinicians can make the best medical decisions or perform flawless procedures, but outcomes have as much or more to do with follow-up care, transitions, what happens between visits, and how distributed and disparate teams work together.  These gaps are solvable, and we are determined to do so.

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