1. Catch & Match

2. © Western Cape Government 2012 | Catch & Match: model of care Integrated client-centred model of community-based care PHC re-engineering Healthcare 2030 Provincial Strategic Goal 3: Increasing wellness and safety and reducing social ills 1 st 1000 Days C+M model Door-to-door health promotion and support services 3 pilot sites: Nyanga, Delft, Site C 10 CHWs & 1 coordinator per site 150-250 households per CHW Assigned area/CHW

3. © Western Cape Government 2012 | Catch & Match community-based model of care HIA: Household Screening/ Community Surveillance PICH/PSG-3: Transversal Screening & Referral Service providers: MDHS, CoCT Health, DSD, Environmental Health, SASSA, NPOs, Home Affairs CBS: PHC re-engineering/ Healthcare 2030 Vision IM & Data Centre: Electronic linkage to care

4. Screen No RISK Follow up Refer II. CATCH III. MATCH CHW house-to- house visits Electronic and paper-based referrals Service provided? Monitoring & Evaluation RISK Low High Urgent Electronic and paper-based screening D. Referrals: Health (Province & City) Environmental Health Social Development Home Affairs, SASSA Relevant NPO’s A. Household Screening B.1. Pregnancy B.2. Postnatal (<28d) B.3. Child (<5y) B.4. Adherence Support/ Wellness Promotion B.5. Home Based Intermediate Care Integrated CBS activities I. CBS Encounters Mentor Mothers Model C. Screening

5. mHealth

6. II. CATCH III. MATCH I. CBS Encounters Household AssessmentMaternal/caregiver formChild form Data components: mHealth intelligence * Conceptual model: other CBS encounters/stationary can be added in future, e.g. Adherence Support/Wellness Promotion & Home Based Care

7. II. CATCH III. MATCH I. CBS Encounters Household AssessmentMaternal/caregiver formChild form Child Risk Factors Maternal/Caregiver Risk Factors All children All pregnant women ± Caregivers All household members General Risk Factors General Referrals Mat/CG Referrals Child Referrals Data components: mHealth intelligence * Conceptual model: other CBS encounters/stationary can be added in future, e.g. Adherence Support/Wellness Promotion & Home Based Care

8. II. CATCH III. MATCH I. CBS Encounters Household AssessmentMaternal/caregiver formChild form All household members General Risk Factors General Referrals Child Risk Factors Maternal/Caregiver Risk Factors All children All pregnant women ± Caregivers Mat/CG Referrals Child Referrals Data components: mHealth intelligence * Conceptual model: other CBS encounters/stationary can be added in future, e.g. Adherence Support/Wellness Promotion & Home Based Care

9. Household AssessmentMaternal/caregiver formChild form II. CATCH (7) III. MATCH (8) I. CBS Encounters All children (3&4) All pregnant women (2) ± Caregivers All household members (1) Child Risk Factors Maternal/Caregiver Risk Factors General Risk Factors General Referrals Mat/CG Referrals Child Referrals Data components: mHealth intelligence * Conceptual model: other CBS encounters/stationary can be added in future, e.g. Adherence Support/Wellness Promotion & Home Based Care

10. Household AssessmentMaternal/caregiver formChild form * Conceptual model: other CBS encounters/stationary can be added, e.g. Adherence Sup./Wellness Prom. (5) & HBC (6) Individual level data (A&B) within household context Risk Factors Identified (C) Referrals made (D) Integration: - Sum of data is less than its separate components - Allows for simplification & decision support Data components: mHealth intelligence

11. Activity profile: Service needs & Services rendered Risk profile: New vs. known Continuous review Linkage to care: Bi-directional service loop More intelligence - Priority summaries - Scheduling & reminding - Skip-logic decision support - Process-flow - GPS mapping - Activity, Vit A and Pregnancy Test summaries (M&E) Data components: mHealth intelligence Individual level data (A&B) within household context Risk Factors Identified (C) Referrals made (D)

12. INTEROPERABILITY

13. © Western Cape Government 2012 | I. CBS Encounters 1. Identity 2. Category 3. Content i. Facility Encounters 1. Identity 2. Category 3. Content Referral table I. CBS Encounters 1. Identity 2. Category 3. Content ii. Non-Health Service Encounters 1. Identity 2. Category 3. Content Vs. Direct electronic link 1. eHealth Interoperability 2. mHealth Parallel System – transversal Linkage to care:

14. © Western Cape Government 2012 | Holding House hold Facility Source archive Clinicom PHCIS/EKAPA TIER/ETR/EDR JAC/CDU NHLS PACS/ECM Mortality Clinical Patient Staging Sources* Extract, Transform, Load, Curate Repositories Anonymous view(s) Analysis view (anonymous) Access SP layer for connectors PPIP/CHIP Prehmis mHealth OpenHIM (real-time) Daily or periodic database pulls or loading of exports Daily or periodic database pulls or loading of exports OpenHIM Clinical view Applications (eg. SPV, PHCIS) Applications (eg. SPV, PHCIS) * No record is ever changed in any source system High level architecture and data load process for the data centre Operational repots (eg. Sharepoint) Analysts Person Place Code Core tables Lookup tables Mapping tables Date (time) Encounters Episodes

15. mHealth demonstration

16. © Western Cape Government 2012 | mHealth App - live demonstration CHW Interface: Household registration and search function Pregnancy testing all the way to new child TB ± HIV algorithm HCBC activity reporting

17. © Western Cape Government 2012 | Catch & Match Goals HIA: risk mapping and strategic service planning PICH/PSG-3: Life-course approach, 1 st 1000 Days focus, Resilient families Strengthened transversal service delivery, replication of mutual learning CBS: Towards 2030: Patient-centred integrated care, engaged communities IM & Data Centre: Improved linkages to care and M&E ↓ Missed Opportunities ↑ Health & Wellness

18. © Western Cape Government 2012 | Use of Catch & Match Iterative development process Stage1 complete Strengthened HIV and TB algorithms Scale-up depends on results ± additional funding Strict data security and confidentiality measures in place Interoperability uniquely tailored to health delivery needs

19. © Western Cape Government 2012 | Questions?

20. © Western Cape Government 2012 | Acknowledgements PICH/PSG 3 Elmarie Malek Janet Giddy Health Programmes Tracey Naledi Tobeka Qukula Robin Dyers Nicola Wilson Frederick Marais Information management Aphiwe Mazomba Luthando Madliki HIA Kate Rees Juliet Evans David Coetzee Community representatives MDHS DMC (C+M Steer Comm.) DDs CHP Forum (C+M PMC) WCGH Data Centre Jembi Pilot Site Committees KESS, MP/KF, N/Tyger sub-structures CoCT Health Environment Health Department of Social Development NPOs Philani, St John, Touching Nations Afrika Tikkun, SACLA Tirelo Bosha Public Service Improvement Dep. of Public Service & Administration

21. Appendices

22. Stationery/Data captured

23. © Western Cape Government 2012 | Household-level screening

24. © Western Cape Government 2012 | Household-level screening

25. © Western Cape Government 2012 | Household member screening

26. © Western Cape Government 2012 | Household member screening

27. © Western Cape Government 2012 | Demographic/Socio-economic factorsRisk factors i. Household level Possible TB? Distance to service (GPS) Known TB, not on treatment yet? Dwelling type Would like an HIV test? Does the house have electricity Known HIV positive, not on treatment yet? Is there piped water Suspected to be pregnant/tested/pregnant Toilet type and location Delivery in last 6 weeks? Number living in household Requests family planning ii. Individual level Needs help with wound/self care Date of birth Daily meds (TB, HIV, Hpt, DM, Asthma, Mental Health, other) Sex Immunisation up to date? PMI/Clinic number (if available) Vit. A up to date? Administered by CHW? Receiving a grant? CSG, DG, FCG, OAP *Additional risk factors can be inferred from referral topics Client information from household assessment

28. © Western Cape Government 2012 | Pregnancy risk factorsChild risk factors HypertensionBirthweight DiabetesNormal Weight Other pre-existing conditionGrowth faltering HIV statusUnderweight for age: MAM TBUnderweight for age: SAM Teenage pregnancyStunted Drug problemHIV status Alcohol problemTB Violence in the household Lack of food/nutritionSuspected abuse Booked/Visits up to date?Suspected neglect Outcome of pregnancyOrphan Client information from Maternal and Child Assessments

29. 1. SOCIAL SERVICES ? Abuse, Neglect, HH violence 2. ENVIRONMENTAL HEALTH Hazards, Water & Sanitation 3. REHABILITATION (NPO’s) Substance use, Alcohol problem 4. HOME AFFAIRS Identity doc, Birth Certificate 5. SASSA Grant/s 6. HEALTH Danger signs (urgent action) HIV & TB: test/treat Self-care support Chronic Disease Management Mental Health Pregnancy test, BANC, Family pl. Immunisation, Vit A, Deworming RTHB missed, Nutrition/Growth Disability, Developmental screening Oral health, Other