Integrated CQUIN 2013/2014

Suggested Impact and Measures

The Context

• National Benchmarking data shows that the CCGs who are the main users of ULHT have – a higher than average rate of non-elective admission for their populations – A higher than average rate of A&E Attendance Source: NHS Comparators

The Challenge

• To Reduce the Rate of Inappropriate Medical Admissions to Lincolnshire Acute Hospitals via A&E.

• Commissioner Proposed measure: – Reduce Conversion Rate by 5%

The Response

• The Three Trusts will work together to deliver a CQUIN that encourages integration of approaches and delivers: – A reduction in inappropriate medical admissions through A&E but – The parameters for success of a CQUIN scheme require further definition

The Detail

• In 2012/13 there were a total of 143,637 attendances at ULHT A&E Departments. This was a slight reduction from 2011/2012 (145,087) • Of these 41,266 were admitted • A Conversion rate of 28.73% • Commissioners have indicated an aim of reducing this by 5% - a reduction of 7,180 admissions against the same number of attendances

Refining the detail

• Remove non-medical attendances (surgery, trauma and injury) • Remove Commissioned Pathways – Stroke – MI – Paediatrics – Maternity – Best Practice tariff • Remove Patients staying more than two days

The Final Cohort

• In 2012/13 there were a total of 26951

medical

ULHT A&E Departments attendances at • Of these 19301 were admitted • A Conversion rate of 71.6% • However only 5295 people admitted with a ‘medical’ condition stayed in hospital more than 2 days • Assumption: if people are in hospital for more than 2 days, they are ‘ill’.

Of these admissions, a proportion will be inappropriate – These are the people we need to focus on

Data Weaknesses

• Biggest cohort of A&E Diagnoses is ‘other’ • Therefore we attached the admitted spells data to refine what people were treated for following admission.

• Only one diagnosis used therefore other reasons e.g. dementia may be hidden by physical symptom in the dataset Hypotheses of impact can be tested by detailed audit

Accepted Wisdom

• People attend A&E as there’s no obvious alternative • GPs

send

people to A&E without assessment • Community services are not responsive and only react following a crisis • Admission is a ‘bad’ thing • Resources are aligned to early discharge rather than stopping admission.

• Hospitals admit to stop 4 hour breaches • All patients are from Lincolnshire • All of these can be challenged…

What the numbers say

• If you are admitted for any reason for 2 days or less and attended A&E in an ambulance, but weren’t in a care home and you don’t die (5604 people) you will usually (98%, 5495 people) be admitted.

• Assumption: If ambulances have alternative access routes to Out of Hospital services, less people would be admitted.

What the numbers say

• If you attend A&E from a Nursing Home (usually by ambulance), you will normally be admitted (98%) • Assumption: better support for Nursing Homes can reduce 999 calls

What the numbers say

• Of Patients admitted to medical specialities for short stays (less than 2 days) who don’t arrive by ambulance (2436) and don’t die, 80% (1946) are in the following HRGs: • 42 people are admitted from A&E because of Social Issues • Assumption: activity in Bold HRGs is more likely to be inappropriate. This only represents 10.4% of the total (202)

Appropriate or Inappropriate?

• Many admissions through A&E require hospital intervention as there is no other service available – e.g. chest pain, head injury, poisoning, ante-natal observation, TIA.

• A small proportion of these will be picked up through better Complex Case Management.

• Assumption: activity in Bold HRGs is more likely to be an inappropriate admission. This only represents 10.4% of the total (202)

What the numbers say?

• 208 people attend A&E and die without Admission • 294 people are admitted from A&E and die within 2 days • Assumption: a proportion can be better supported outside of hospital

How can we make an impact?

• Reduce Attendances – Stop People getting to A&E • Reduce Inappropriate Admissions – Discharge direct from A&E • Improve Quality of Admission – Manage admissions according to best practice tariff protocols – Discharge patients following short stay ambulatory intervention

Reducing Attendances

Better Case Management and more reactive community provision •How? Ensure Primary and Community Teams work together and are clear of communication routes – rapid acceptance of referral Enable ambulance crew access to community services Review Rapid Response Service Specification Work with Nursing and Care Homes to support their residents better and provide in reach where appropriate Communicate alternative routes to care to the public Ensure DOS is fully utilised Assure Access to Primary Care in an urgent situation Palliative Care – ensure rapid response incl.

St Barnabas •Current Weaknesses in-hours services only; Specialist community resources resourced mainly for planned care and advice; default can still be 999 Nursing home responsibilities can be unclear

•

Reduce Inappropriate Admissions from A&E

Early identification of patients requiring support to be discharged in A&E • Rapid Communication to Community Support Network How?

– Focus Assertive In-reach services on A&E – Develop RAPA alert system for more conditions – Enhance RAID provision to enable rapid discharge of people with mental health issues Develop PACT approach with third sector for immediate support – Work with Social Care to implement immediate packages from A&E – Develop ‘Trusted Assessor’ roles – Expand Integrated Living Team approach – Assess to Admit rather than admit to assess – Access to urgent Outpatient appointments – Senior Clinical Assessment ‘at the front door’ Current weaknesses – Coverage different across sites – Wider Community support mechanisms less developed outside of Lincoln – Complex Case Management Capacity not always available within small time window – Focus on A&E may have impact on flow through EAU

Improve Quality of Admission

Only admit those who need to be in hospital Use Best Practice to assess and start treatment in ambulatory model to the same level as the top quartile of Trusts •How?

– Further develop pathways and protocols with Primary Care to complete assessments before requesting hospital intervention – Senior Clinical Assessment ‘at the front door’ – Rapid Access for Community Staff to advice from senior clinicians – Assess for discharge on admission and aim to discharge within 12 hours • Weaknesses – Capacity in Primary Care to receive discharges

• • • • • • • • • • • • • • •

Measures

Attendance Numbers (reduce/maintain in line with national trends) Medical Admissions (number not rate)- reduce total, increase best practice, assure short stay assessment admissions.

Conversion rate attendance to admission (for ‘medical’ admissions) – (may increase if we can tackle attendance totals) Best Practice Tariff Performance – improve to top quartile Number of People discharged from A&E with support (maintain or increase) Number of people case managed (increase) Admissions of people on community complex case load through A&E (set baseline and reduce) Admissions of people on community complex case load through EAU (increase) Admissions through EAU to ambulatory care model (increase) Average length of stay (increase by taking out EAU) Assessment of ‘avoided admissions’ through action in the community (anecdotal but should increase) People discharged following short stay ambulatory admission with and without support (increase) Audit of people admitted for less than two days but not on ambulatory pathway (prove quality of care and appropriateness of admission) Admission and attendance rates by GP practice

ALL FIGURES SHOWN AS ANNUAL NUMBERS

Suggested Targets – Reducing Attendances

• 2.5% of people attending by ambulance can be diverted to alternative care (140 atts) prior to arrival • 20% of people sent to A&E from Nursing Homes can be supported to stay where they are (98 people) • 10% of people who die on attendance can be supported ‘at home’ (26 attendances) • Suggested Owners LCHST, LPFT, St Barnabas

Suggested Targets – Reducing Admissions

• of people attending by ambulance 98% continue to be admitted (138 less admissions due to reduction in attendances) • 20% of people admitted via A&E from Nursing Homes can be supported to stay where they are and reduce admissions (98 people) • 10% of people who are admitted and die within 2 days can be supported ‘at home’ (26 attendances) • 50% of people identified as being admitted for social issues can be diverted elsewhere (21) • 50% of people whose admission is

potentially inappropriate

are diverted (115) • 10% of patients attending and admitted under ‘appropriate’ HRG can be turned around within 4 hours (560) • Suggested Owners – ULHT, LCHST, LPFT, St Barnabas

Suggested Targets – Improved Admissions

• Of patients admitted under the same HRG as Best Practice Tariff for less than 7 days, but not classified as BPT, convert 20% to BPT (400) • Suggested Owner - ULHT

Next Steps

• Meet CCGs to critique information analysis • Agree Individual Organisation Targets • Develop Action Plans

Schedules to be agreed

• Trajectory for delivery • 2 year CQUIN?

• Appropriate measures for each Trust

Conclusion

• Multi-faceted actions required to deliver ‘simple’ impact on patient flow.

• Difficult to measure achievements.