Transcript Developing the alternatives to hospital care

‘Whole System’ Models of Care
for Older People
Tom Bowen
The Balance of Care Group
ORAHS 2004, Stockholm, Sweden
28 June 2004
Content
• Health status of older people
• ‘Integrated’ and ‘intermediate’ care
• Balance of Care models
• Appropriateness Evaluation Protocol surveys
• Comparison of UK local health economies
Health Status of Older People
• Manton (US) estimated disability reducing by
1.3% p.a. in over 75s
• Lagergren (Sweden) has shown that health and
social care costs continue to concentrate in last two
years of life
• Dixon et al (UK) show that the number of acute
hospital bed days in last 3 years of life does not
increase with age (2004)
• Some debate about ‘compression of morbidity’
Developing a community focus
• Kaiser Permanente
– focus on chronic disease management
• Adcroft Surgery
– occupied bed days reduced by 20% in local
hospitals
• South Bucks EPICS scheme
– Managed population 4,200 elderly and saved 561
bed days in first 5 months
• EverCare Project
– Ten pilot PCTs in UK
– 30-35% admissions from 1% of population
Intermediate Care
• Driven by wish to free up acute beds
• In-between acute hospital care and primary
care
• ‘Step up’ and ‘step down’
• Could be bed or community based
• Cuts across professions, organisations and
budgets
Balance of Care model
Phase of Care
Care Option
Alternative to
admission
Post-acute
intensive
(up to 7 days)
Older
People
IC care
Intervention
Provider
Community
nurse
Care
Option 1
Care Co-ordinator
NHS
Physiotherapist
Supported
discharge
(up to 14 days)
Rehab/ recovery
(up to 28 days)
Care
Option 2
Speech therapist
Care
Option 3
Occ. therapist
Local
Authority
Care assistant
“slow stream rehab”
(up to 42 days)
Care
Option 4
Voluntary &
Independent sector
 Balance of Care Group
Rich Picture of Process Flow
Community
Admission
Diagnosis
Treatment
Discharge
Rich Picture of Process Flow
Admission
Diagnosis
Treatment
Discharge
Acute care
Social circs
Referral detail
Investigations
Rehabilitation
Risk factors
Admission reason
Assessment
Interim care
Discharge planning
DATA
Community
Rich Picture of Process Flow
Community
Admission
Diagnosis
Social circs
Referral detail
Investigations
Treatment
Discharge
Rehabilitation
Risk factors
Admission reason
Discharge planning
Assessment
DATA
Acute care
Chronic
Disease
Management
Admission
avoidance
Alternative
diagnostics
settings
Alternative
therapy
settings
Earlier
discharge
ALTERNATIVES
Interim care
Point Prevalence Surveys
• All inpatients in selected specialties on a single day
• Acute and elderly medicine, & orthopaedics
• Data collected from casenotes by clinical staff
• Use Appropriateness Evaluation Protocol (AEP) to
identify possibly ’non-acute’ patients
• Also survey non-acute hospitals
• Follow up discharge outcomes to provide basis for
demand analysis
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
Results from Typical Acute Hospital
• 12% of all patients
admitted outside AEP
criteria
• 43% of all patients
outside AEP criteria
on day of survey
• Clinicians assess
preferred alternative
type and location of
care
Age of patients in acute hospital
85+
21%
75-84
32%
18-64
25%
65-74
22%
No of patients by AEP status in acute hospital
180
160
No of patients
140
120
100
Outside AEP
Within AEP
80
60
40
20
0
18-64
65-74
75-84
Age
85+
AEP comparison for medical patients
Outside AEP
on admission
Outside AEP
on the day
East Berkshire
15%
47%
Cambridge
16%
47%
Oxfordshire
20%
49%
East Surrey
15%
50%
NW Surrey
16%
57%
Some implications
• Alternatives focussed on rehabilitation services
(c50%)
• Remainder have continuing care needs, or could just
go home earlier
• AEP values characterise the nature of the UK hospital
service, and potential to develop
• Change to the clinical process is needed if service
development to deliver benefits