Transcript Slide 1

Frailty Concept/ Hospital without
Walls
Professor Pradeep Khanna MBE
Chief of Staff, Community Services
Aneurin Bevan Health Board
Commissioning & Care Planning
• Strategic Planning
• Specify Outcomes
• Develop Business Case
• Procure Services
• Manage Demand
• Maintain Performance
CASE FOR CHANGE
• Demand will always beat supply
• Pressure on cost is remorseless
• NHS can not provide a comprehensive service
on current assumptions after 2011
(Kings fund and the Institute of Fiscal Studies
– IFS)
Some Facts
• Nearly 33% of inpatients could safely be cared for in another setting than in
an acute hospital [Kings fund audit 1992; DOH 2000]
• 29% of patients in acute hospital beds are medically stable [43% in elderly
wards] [Barbara Vaughan; Gill Withers 2002]
• In Wales, higher proportion of chronic long term conditions (23%)
compared to England (18%); Northern Ireland (20%)
• Audit of 5 GP Practices in Swansea revealed 3% of population with 2
comorbidities + emergency admission accounted for 59% of hospital
admissions [Ref = WAG 2007 – Designed to improve health …chronic
conditions Wales]
• Conclusion: A focused integrated approach of Health and Social Care,
Housing and Transport is recommended
WHO has identified that chronic conditions will be
the leading cause of disability and death by 2020
Targets
Reduce number of emergency bed days by 5%
• Analysis of NHS use indicates that effective chronic disease
management presents significant scope to reduce avoidable
hospital admissions
• For patients with more than one condition the costs are six
times higher than people with only one
Drivers For Change
1.
Wanless Report: Hard hitting facts about Health Services in
Wales
2.
Designed for life: Strategic framework: Health & Social
Care Services in Wales
3.
Fulfilled lives, Supportive Communities: Emphasis on
Social Care
4.
Making the connections [Public involvement & redesign
services around the needs of the users]
5.
Primary Care & Community Services Strategy (Chris Jones)
Current System of Care “Push System full of Black Holes”
PUSH
Local government
FRAGMENTED AND DISORGANISED COMMMUNITY BASED CARE
DISCHARGE
HEALTH
SOCIAL
DEPENDENT
PRIMARY CARE
FRAIL
HOSPITAL
BASED CARE
NH
AE
RH
INCREASING
COMPLEXITY
INCREASING
INDEPENDENT
DECREASING
FUNCTIONALITY
N
U
R
S
E
DEPENDENCY
PARA MED PUSH
Patient journey
OOH
C
O
M
FIT
NHSD
T
M
S
Future System of Care “Seamless Pull System with Integrated Access to
Information”
PULL
PULL
ASSESS
ORGANISED SYSTEM OF INTERGRATED COMMUNITY SERVICES
HOSPITAL
BASED CARE
COMS
HUB
PRIMARY CARE
DIRECT
SHARED INFORMATION BASED ON GP RECORD
Resource
team
OOH
Primary Care
Support Unit
PULL
Patient journey
PULL
C
O
M
N
U
R
S
E
T
M
S
Loc
net
Hospital-at-Home: definition………
Hospital care but delivered in the person’s
own home !!!
HaH = “….a service that provides active treatment by
health care professionals, in the patient’s home, of a
condition that would otherwise require acute hospital inpatient care, always for a limited period.”
Cochrane definition, 2005
Combination of personal support &
rehabilitation care
Admission Avoidance
Hospital at Home/Inpatient Care
(Review)
[Systematic Review & Meta Analysis]
1.
2.
3.
4.
Mortality at 3 months
Mortality at 6 months
Readmission Rates
(within 3 months)
Functional Ability (12 months)
i. Quality of Life
ii. Physical abilities
iii. Cognitive Status
Reference: Sheppard S, Doll H, Etal: The Cochrane Library 2009: Issue 3
NS (P= 0.15)
Significant (P=0.005)
NS (P=0.08)
NS
Hospital at Home
1.
a.
b.
c.
d.
CLINICAL OUTCOME:
Bowel Complications
Urinary Complications
Antipsychotic Prescribing
in Dementia Patients
COPD = Antibiotic
(Adverse Events & Medical Complications)
=
=
=
22.5% (96% C.I = 34% to 10.82)
14.4% (95% C.I = 25.4% to 3.3%)
14%
(95% C.I = 28% to 0.3%)
=
18%
2.
PATIENT SATISFACTION:
3.
ECONOMIC ANALYSIS:
(Co Morbidity: Older Group)
4.
CONCLUSION:
(95% = 34.6% to 1.4%)
Significant (P < 0.0001)
Costs = Per episode $2011; 95% C.I (= $2800 to $1222)
= Per day
$293; 95% C.I (= $318 to $268)
Admission Avoidance Hospital at home can provide an effective
alternative for selected group of Patients (Outcome Similar)
Early Supported Discharge Teams Vs Conventional Care
11 Trials (6 countries)
Outcome
Patients randomised
Summary result
(95% CI)
P Values
Death or dependency
1597
0.79 (0.64 to 0.97)
0.02
Death or institution
1398
0.74 (0.56 to 0.96)
0.02
Extended ADL Score
1051
0.12 (0 to0.25)
0.05
Satisfied with outpatient
services
513
1.60 (1.08 to 2.38)
0.02
Subjective health status
score
613
0 (-0.25 to 0.24)
0.97
Satisfied with outpatient
services
279
1.56 (0.87 to 2.81)
0.14
Length of hospital stay
1015
-7.7 (-10.7 to - 4.2)
<0.0001
Readmission to hospital
633
1.14 (0.80 to 1.63)
0.48
Patients’ outcomes
Carer outcomes
Resource outcomes
Conclusion: “Appropriately Resourced and Co-ordinated Services” in clearly
defined Target Groups has clear potential benefits
Langhorne P, et al - Lancet 2005;365;501-506
THE EVIDENCE-BASE FOR
INTERMEDIATE CARE
RCTs
•
HOSPITAL-AT-HOME
22
•
DAY HOSPITAL
12
•
NURSE-LED UNITS
10
•
COM. REHAB.TEAMS
2
•
CARE HOME REHAB.
1
•
COMMUNITY HOSPITAL
1

Expensive
Very expensive

Shifts costs to social care
Message: (a) Target people with greatest clinical
need (Frailty)
(b) Integrate I.C with Mainstream
Services

Messages From Research
• Develop closer integration between IC and Mainstream Services
• Target Patients with greatest clinical need: Frailty
• Place stronger focus on Admission Avoidance Scheme (Health & Social
Care)
(Closer liaison with Ambulance Service, 3rd Sector, A&E, Mental Health)
VANTAGE POINT
• Reablement:
• More Research/Evaluation needed
Clinical Futures: Gwent
2014-15 with new MoC
Non-acute beds and
places required by LHB
Blaenau
Newport
Caerphilly
Torfaen
Monmouth
Powys
Other
All Gwent
Gwent
Intermediate
medical
Care and/or
surgical
Non-acute
total
117
121
2
119
96
1
122
2
82
1
77
2
1
7
1
0
501
8
98
83
79
1
7
509
Provided as
NHS etc beds
places at-home
total places
38
39
31
26
25
0
2
162
81
83
67
57
54
1
5
347
98
83
79
1
7
509
119
122
Joint Partnership Sub-Group
• 5 LHB CEOs, Trust CEO and 5 LA CEOs
• Aims: to develop better services along whole
patient journey through closer working. To find
better way of supporting people who end up
needing Continuing Care
• Frailty Pathway chosen
• Gwent wide multi-agency, multi-professional
workshop held April
• Task and Finish Groups to expand /develop
ideas.
Frailty Programme Board
• Membership
– Chair – Alison Ward,
CEO, Torfaen LA
– LA reps (social care)
– LHB reps
– Trust Corporate and
Divisional reps
– Voluntary sector
– GP
– Ambulance
• Work Streams
– Independent Living and
Reablement
– Urgent Response and
Intervention
– Capacity and Financial
Modelling
Frailty Syndrome
• Frailty = (Dependency x vulnerability x
co-morbidity)
+
(Environmental x social
factors)
What is it?
Physical characteristics Multidimensional
•
•
•
•
•
Weakness
Slowness
Poor endurance
Weight loss
Physical inactivity
•
•
•
•
Socio-demographic
Biomedical
Functional
Effective and cognitive
components
PREVENT
FRAILITY
DELAY
FRAILTY
PREVENT/ DELAY
ADVERSE OUTCOMES
PROVIDE CARE
MODIFIERS
Biological
Psychological
Social
Prevalence of Frailty
3 or more of the outcome
Age
%Frailty
65-69
70-74
75-79
80-84
85+
18.3
21.7
32.1
32.5
48.8
Estimated numbers of frail elderly people by Local Authority
Estimated Total
Blaenau Gwent
604
621
838
563
646
3275
Caerphilly
1399
1402
1816
1154
1231
7002
Monmouthshire
784
825
1043
695
864
4211
Newport
1127
1222
1472
1085
1156
6062
Torfaen
797
844
1105
683
712
4141
Total by age band
4177
4914
6274
4180
4609
24154
Source: Census 2001
Happily
Independent
What we stand for:
Principles & Values
The underpinning principle of the Gwent
Frailty Programme is to provide:
‘Help when you need it to keep you
independent’
The mantra for those delivering services is
to provide help that is
Sustaining independence.
Outcomes:
What frail people tell us they want
Be able to remain living in their own home with
support
Receive services in their home
Be listened to by people who are responsible
for providing services to assist them
Have their health and social care problems
solved quickly and considered as a whole
rather than individually.
Frail Elderly Workforce
Skills Matrix
Specialist Health Care Skills
Health Care Skills
Generic Worker
Skills
Social Care Skills
Specialist Social Care Skills
Generalist as the New Specialist
(Intermediate Care)
• GP’s Changing Roles
• Geriatrician Changing Roles
• AHP’s Changing Roles
• Training In The Community
Community Nursing Service
• Based on Nursing Strategy: Wales
(Coordination of care)
• 24 hour Nursing cover in each locality
• Overnight on call nursing service including
Twilight nursing
• Key role in early identification & proactive care of
frail clients
Common Service Characteristics (I.C)
Urgent Response & Intervention
Reablement & Independent Living
ACCESS
Via locality Single Point of Access
Via locality Single Point of Access
HOURS OF OPERATION
7 days a week 365 days a year 8am to 10pm
7 days a week 365 days a year 8am
to 8pm
RESPONSE TIME
2-4 hours (for both health and social care
components)
24 hours
ASSESSMENT
Comprehensive Needs & Frailty Index
Assessment
Agreed shared assessment
document
SERVICE PROVISION
Management/Hospital @ Home upto 14 days
Approximately 6 weeks
reabilitation and reablement
support
No charge to user for first 6 weeks
ACCESS TO
‘Hot Clinics’ for rapid access to specialist and
diagnostic support (Monday to Friday)
Specialists including psychology,
dietetics, pharmacy, speech &
language therapy, podiatry, EMI
teams.
Rapid access to equipment and
adaptations.
WORKFORCE
Flexible Health & Social Care Workforces
Flexible Health & Social Care
Workforces
Components of Comprehensive Needs Assessment
Components
1
Medical assessment
2
Assessment of functioning
3
Psychological assessment
Elements
Co-morbid conditions
Medication review
Nutritional status
Activities of daily living
Gait and balance
Mental status
4
Social assessment
Assessment of needs, assets
and resource eligibility
5
Environmental assessment
Home safety, transportation and
tele-health
Proposed Locality Structure
Joint Chair:
Director of Social Services
Locality Manager (Health)
Members:
Project Manager
Human Resource
Finance
Intermediate Care Consultant
General Practitioner
Lead Nurse
Voluntary Sector
Co-opted Members:
Pharmacist, Mental Health,
Therapies, CHC
Urgent Response & Intervention
Comprises of three key elements:
Urgent Comprehensive Assessment
(Health & Social Care)
Rapid Response Intervention (health)
Social Care Crisis Intervention
Proposed Capacity Model
(Crisis Management)
•
Aims
–
–
–
–
•
Better management at home or in a community setting.
Engagement with care homes and the independent sector.
Management of patients in Accident & Emergency
Patients handed over to DN teams on discharge from service
Main Functions
– Assessment of 200 new patients per month for acute
exacerbations of chronic conditions and associated disorders.
– Follow-up of 200 patients per month.
– 7-day presence in A & E and MAU to assess patients and
prevent admissions, pulling them back into the community,
as required.
– Daily Hot Clinics for each borough, run by ACAT/RRT for
the provision of advice for GPs.
– Formal links with other specialties, including General
Medicine, Falls, Trauma & Orthopaedics.
– On-going management of patients at home for a 5 – 7 day
length of stay (care package)
– The Gwent-wide combined team of ACAT, Rapid Response
and PATH to provide around 70 virtual beds across Gwent.
Staffing Model
(Crisis Management)
• Based on population of 70-90k
–
–
–
–
–
–
–
–
1 wte Consultant Specialist
2 wte Staff Grades or GPswSI (salaried GPs)
4 wte Band 7
10 wte Band 6
3 wte Band 4 Reablement Officers
1 wte Band 6 OT for Reablement
1 wte Social Worker
Approx 50 wte generic Health & Social Care Support Workers,
and/or Rapid Access to Immediate Home Care
– 1 wte Secretarial Staff and 2 wte Typists shared with the
Reablement Team
Independent Living & Reablement
Approximately 6 weeks coordinated
review and reablement to sustain
independence
Rapid access to equipment and
minor adaptations
Care & Wellbeing Workers able to
work across the different elements
of the integrated locality team
Proposed Capacity Model for
Locality Reablement Teams (1)
Based on 70-90k population
• 5 WTE Occupational Therapists (able to work across ACAT,
PATH and Reablement)
• 5 WTE Physiotherapists
• 50 Band 3 Generic Support Workers*
• 2 WTE Case Managers (role needs to be clarified)
• 2 WTE Social Workers
*
Proportion of generic support workers up-skilled to perform some functional
assessments?
Shared resources:
• IT officer
• Training and Development officer
• Administrative Support
• Hot clinics for Falls, Gen Med and Orthopaedics
Proposed Capacity Model for
Locality Reablement Teams (2)
Sessional support from:
• 2 WTE Dieticians
• 2 WTE Speech and Language Therapists
• 2 WTE Psychiatric Liaison Nurse (1 for older people, 1 for
younger people)
• Podiatrist – unable to quantify because many clients using
private
• 1 WTE Community Pharmacologist attached to PATH and
Reablement
Implementation Workstreams
•
•
•
•
•
•
Communication & Stakeholder Engagement
Workforce Planning
Governance & Structure
Outcome Indicators, Performance and Continuous
Improvement
Information sharing & Single Point of Access
Locality Planning (including longer-term care and interfaces
with other services)
•
Financial Modelling/ Building the Business Case
Communication & Stakeholder
Engagement
Workstream lead: Dr Liam Taylor
• Development of a communication strategy for all
key stakeholders
Specific programmes of work –
a. Stakeholder Briefings
b. Staff Communication
c. Public Engagement
d. Power Brokers (Politicians
and Executive Key Members)
Financial Planning
Workstream lead: Nigel Stephens
Use the outputs from the other workstreams
to:
• confirm demand
• map capacity
• identify the resource gaps
• calculate the financial requirements
• Set up pooled budget arrangements
Locality Planning
(including longer-term care and interfaces with other services)
Workstream lead: Jo Williams
• Support planning for preventative services and delivery at locality
level
• Ensure that core standards are met and outcomes achieved.
• Key Aims:
a. Each locality sharing
innovation
b. Joint problem solving
c. Work through operational
challenges
d. accessing expertise
Information Sharing &
Single Point of Access
Workstream lead: Jayne Griffiths
• Single Point of access
• Information System and
Develop agreed information
sharing protocols
• Develop safe means of
electronic transfer
Outcome Indicators, Performance &
Continuous Improvement
Workstream lead: Angela Jones
Use the Outcomes-Based Approach.
Happily Independent:(5 key elements)
1. Be able to remain living in their own home with
support
2. Receive services in their home
3. Be listened to by people who are responsible for
providing services to assist them
4. Have their health and social care problems
(holistically) solve quickly
5. Have a general good health
Governance & Structures
Workstream Lead: Bobby Bolt
• Agreed standards and protocols
• 3 Groups of work:
a. Clinical accountability
b. Operational issues
c. Clear lines of
management (professional
and regulatory issues)
Workforce Planning
Workstream lead: Kevin Barber
Challenges: To Integrate a. 6 organisations
b. 9 professional groups
Key Aims:
a. Harmonising the structure
(extremelly complex)
b. Managing the transition
c. Managing multi-agency staff
groups (responsibility, accountability,
training and development)
Next Steps
Capacity Plan
Capacity Plan
Service
Model
Service
Model
Workforce
Workforce
Plan
Plan
Financial
Plan
Plan
Key Milestones
Business case submitted by October 2009
Groundwork from workstreams completed
by end of March 2010
First locality ready for roll out April/May
2010
Implemented in all localities by end of
March 2011
Resource Package
1.
Wanless funds (WAG) – Approx £5million:2004
2.
Public Service Committee (Chaired by Finance Minister – Wales):
£60million over 2009/10 and 2010/11
(Scheme: Invest To Save)
3.
4.
Transitional cash required:
£20million
(Fund new teams and manage additional capacity)
Over time:
●
Shifting of resources from Secondary to Primary Care
●
? Nursing and Residential Purchasing Budgets
●
Continuing Care Budget
Current Situation 1
Locality
Caerphilly
Newport
Torfaen
Blaenau Gwent
Monmouthshire
Frailty care
model
(DGH)
++++
+
Co-located
teams
++
-
Single point
of referral
-
Community
Consultant
+
+
+
-
Current Situation 2
*Referral criteria variable in all 5 localities.
Locality
Consultant
operational
team
Primary and Rapid
secondary
response
interface
ACAT
Reablement
team
Formal GP
involvement
Caerphilly
+-
+
+
-
+
-
Newport
+-
+-
+
-
+
+-
Torfaen
+-
+-
+
+
+
+-
Blaenau Gwent
+-
+-
+
-
+
-
Monmouthshire
-
-
+-
-
+
-
Activity Figures: Non Elective: Adult Medicine
(Since 1999 till 2008 = 53% increase)
RGH
1999-2000
2002-2003
2005-2006
2007-2008
NHH
12902
14053
14046
13615
7351
9261
10728
11336
(+5.5%)
Since 2000.
(+54%)
Since 2000.
LOS RGH
7.1
8.2
8.0
8.4
Reduction Of 90 Community Hospital Beds
LOS NHH
6.5
6.3
5.7
5.2
Performance Indicators
As per Frailty Programme Work stream and including:
• Pre-crisis Assessment (CGA): 100% offered within 28 days
• An episode of crisis requiring hospitalisation should normally require
no more than 72 hours in hospital
• Service responses will be delivered within agreed time limits
• 50% of frail older people will be managed in the community during
an episode of crisis
• 80% of frail older people with a social crisis will be maintained at
home
• 75 % of rehabilitation services for frail older people will be based
and delivered in the community.
• Assessment of equipment needs delivered within 24 hours
• Equipment provided within 72 hours of assessment
Integrated Intermediate Care (frailty) Model (Gwent)
Pan-Gwent Intermediate Care (frailty) Steering Board
Chief Executives- Trust, LHB, LAs
= Prevention of admission
Locality Steering Board (tri-partite)
Health, social services, LHBs, voluntary sector
= Early supported discharge
= Chronic long terms conditions mgtOperational Team (Operational Clinical Team)
+
Consultant Doctor, Consultant Nurse, Senior Social Worker
= Independent living within the
Consultant Rehabilatationist
community
= Continuing care + transport
Single point of
referral
Reablement
1. Chronic
disease mgt-
Path
Cardiac failure
2. Chronic
conditions mgt-
District nursing
(generalist role)
Palliative care
Assistive
technology/
smart houses
ACAT
Social crisis mgt
COPD
Wound mgt
Community
hospitals
Stroke
Frailty care
model
Neuro
degenerative
Mental
Health
(dementia)
Generic Support Workers (Multi-disciplinary)
Mental Health Teams
Care support/
respite care
Self care
Transport
Continence
Chronic conditions
specialists
Joint day
care
Expert patient
scheme
Continuing care
Rapid response
Roles1) Standard setting
2) Uniformity of service
across Gwent
3) Performance
management
4) Financial
management
Paul Williams
Director General, Health & Social Services
Chief Executive, NHS Wales
I want the service to focus on:
•
•
•
•
•
•
•
Changing behaviour not structures;
Collaboration not confrontation;
Planning not commissioning;
Whole systems not hospitals;
Clinical engagement;
Partnership working; and
Wellness not illness
(1st October 2009)