Transcript Greenwich Bed Utilisation

The Balance of Care Group
Alternatives to Hospital
MODELS OF INTEGRATED CARE
Tom Bowen
www.balanceofcare.com
+44 7768 123865
ORAHS 2008, Toronto, 29 July 2008
Rich picture available from process flow
Preadmission
Pre
admission
Social details
alone,
carers,
residence
Risk factors:
age, drugs,
comorbidities,
psychiatric/
dementia,
falls
Preventative
care
Disease
management
Managed
populations
Admission
Diagnosis
Source of
referral
Admission
diagnosis
Time
Waiting time
Route
Decision
maker
Reason for
admission
Alternatives
to admission
to acute
setting
Treatment
Discharge
Re-admission
Discharge
planning
‘Revolving
door’
Inpatient
diagnosis
Delays in
planning
Delays in
diagnosis
Delays in
execution
Avoidable
e.g. chronic
disease
management
Alternative
sites for
discharge
Alternative
sites for
readmission
Delays in
therapy
Chronic
disease
Alternative
access for
diagnosis
Alternative
settings for
therapy
(especially
rehab)
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Appropriateness Evaluation Protocol
(AEP)
• This is a validated protocol, used within the survey,
to determine whether an acute admission might have
been avoided, and whether there is an alternative to
continued occupation of an acute bed
• It is not about auditing clinical decisions for the
survey patients, but developing an understanding for
the future potential of alternative care and treatment
pathways
• Clinical judgement is involved
3
AEP Criteria
On admission
• Severity of illness
eg unconscious, unable to move (fall), acute bleeding
• Intensity of service
eg surgery + gen anaesthesia, regular monitoring, IV therapy
On day of care
• Medical services
• Nursing services
• Patient condition
eg acute confusion, other acute states, coma, fever
4
Dementia case study for
National Audit Office (2006/7)
• To identify the number and types of people with dementia
currently receiving hospital care who might potentially:
– be treated elsewhere and avoid admission
– required admission, but could now be treated elsewhere
• Point prevalence survey in Lincolnshire on 29-11-2006
– All medical and orthopaedic inpatients (667)
– All intermediate care (rehab etc) inpatients (121)
– All OPMH (older people with mental health issues) inpatients (75)
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Proportion of Patients with Mental Health or Cognitive
Issues (N=863)
Dementia
13%
Confusion
14%
No mental health
issue
60%
Anxiety/depression
8%
Psychosis
2%
Substance Misuse
2%
Other
1%
6
Location of Patients by Mental/Cognitive Issue (N=344)
140
120
OPMH
80
Intermediate care
60
Acute
40
20
M
er
th
st
an
ce
O
is
u
se
si
s
Su
b
de
pr
y/
ie
t
An
x
Ps
yc
ho
si
on
es
fu
si
on
C
on
en
t
ia
0
D
em
No of patients
100
7
Percentage of Acute Inpatients within AEP Criteria
(Dementia = 65, all other = 602)
% of patients within AEP criteria
100%
83%
85%
with dementia
80%
all other
60%
53%
40%
32%
20%
0%
on admission
on day of care
8
om
e
H
o
& m e Ow
G & n
H en So Ho
om er
c m
H e al H ial e
om &
e C
e Re al t are
& h h
Ac Sp ab Ca
N ce ec Su re
on s i a p
Ac s to li st por
ut
H
N t
om
e Ou u r
Be tp se
e
d ati e
&
Sp N &
n
ec on The ts
ia A
r
H
om Ho li st cut apy
e
m
N
on e & e Hom Be
Ac M & M e d
ut H R H Ca
e
Be eh Sup re
d ab po
& S
M up rt
H p
EM Ac Th ort
u
I C te era
on MH py
tC B
ar ed
e
Be
O d
th
er
H
No of patients
Alternatives to Continued Stay for Acute Hospital
Patients with Dementia (N=43)
12
10
8
6
Quick discharge
Remaining
4
2
0
9
Assessed risk of 'confusion' patients having dementia
(N=119)
60
No of patients
50
40
OPMH
30
IC
acute
20
10
0
High
Medium
Low
Assessed risk of dementia
10
Potential Change in Service Usage
Scenario for North Hampshire PCT
1/3
Home based
care packages
+36
+20
Community
Hospitals
NHH beds
+24
+10
+15
Care Homes
11
Potential Change in Service Usage
Scenario for North Hampshire PCT
2/3
Home based
care packages
+36
+20
+6
Community
Hospitals
NHH beds
+24
+9
+14
EMH
+10
+15
Care Homes
12
Potential Change in Service Usage
Scenario for North Hampshire PCT
3/3
Home based
care packages
+36
+20
+6
Community
Hospitals
NHH beds
+24
+9
+14
EMH
+10
+15
Care Homes
+30
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Some Key Points
• 111 out of 863 patients surveyed (13%) had a
recorded dementia diagnosis
• 65 were in acute hospital
• There may be substantial under-diagnosis or underrecording of dementia
• Majority of acute hospital patients with dementia
were outside AEP criteria on the day of the survey
• Potential alternative care settings cover a wide range
of services, specialist coordination may be needed
• Demand for rehab support for people with dementia
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Development Issues
• Can benchmark local service configurations from
previous studies:
– 15 local health economies in England
– All acute hospitals in Republic of Ireland (40% sample)
• Can apply to other ‘cuts’ of the patient pathway:
– Rehabilitation in non-acute bed and at home
– A&E/ short stay admissions
– End of Life Care
• Use to focus development of integrated care and
associated IT
• Potential for more sophisticated modelling
approaches?
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