Transcript To Cover: Some but not all:-

Successful population ageing - the
challenge for acute care
Dr Ian Sturgess
Partner,
NHS Interim Management and Support
Senior Clinical Lead,
Emergency Care Intensive Support Team
To Cover:
Some but not all:-
• I: The success story of population ageing
• II: The need to focus on prevention and
anticipatory care
• III: What ageing really means for health and
wellbeing – a balanced view
• IV: The financial climate
• V: Older people as key service users: “Older
People R US”
• VI: And services for them as key to the efficiency
challenge
• VII: Implications for general practice and
commissioning
A whole system perspective
Focus on CDM and more effective responses to urgent care needs –
ACS condition management
Clear operational performance framework and integrated in to primary care
Improved integration with primary care responders
Front load senior decision process incl
primary care
General
Practice &
GP OOH
Community
Support
Health
Promotion
Ambulance
Service & GP
OOH
Discharge Process
A+E
MAU/SAU/
Short Stay
Optimise
ambulatory
emergency care
Inpatient
Wards
Redesign
to left shift
LOS
Information flow converting the unheralded to the heralded
Preventative/
Predictive care
Disease management
Managed populations
Alternatives
to acute
admission
settings
Alternative
access for
diagnosis
Alternative
settings for
therapy
Alternative
sites for
discharge
Alternative
sites for
readmission
Lots of policy effort over the last 30 years to reduce
the fragmentation between health and social care
Every system is perfectly designed to achieve
the results it achieves
What are we trying to achieve?
Getting patients better faster and safer
Safety
Ideal Care
Flow
Improving outcomes
•
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No avoidable deaths
No harm
No unnecessary pain
No waste
No delays
No feelings of helplessness
No inequality
Getting everyone on the
‘same page’
• NOT - ‘Hitting the target but
missing point’
Reliability
‘Data’ vs ‘Intelligence’
Usefulness of ‘Delayed Transfer of Care’ measure?
• Activity vs Demand : capacity analysis
– Predictive modelling
• Averages vs variance
• Point prevalence vs run charts/Statistical Process
Control/CUSOM Charts
• Response to variance
– Special cause vs Common cause
– Capability assessment
For strategic planning, monitoring impact of projects,
and operational management.
Building a Cascade of Measures
Outcome - system level eg admissions,
death, harm, Institutionalisation etc
L1
System
L2
Board & CEO
Process + Outcome
L3
Service Line
L4
Process (+ Outcome)
Microsystems: Units, Depts
L 5
Physician & Patient
Individual
Process Metrics
Adapted from Lloyd & Caldwell
I: The success story of population
ageing
Over the last 50 years, trend has moved from a ‘rectangularisation’ to an
a ‘elongation’ (from “old” to “older”) Number over 80 has doubled in past
two decades (See BMJ 2010 “oldest old double”)
Around 18% of all
deaths were
before 65 in 2006
– the same
proportion as in
1991
Distribution of death England 1841 - 2006
100%
90%
1981
1991
80%
1941
70%
2001
60%
50%
1841
2006
40%
30%
20%
10%
0%
1
5
9
13
17
21
Source: mortality.org, originally ONS
25
29
33
37
41
45
49
53
57
61
65
69
73
77
81
85
89
93
97
101 105 109
12
II: The need to focus on prevention
and anticipatory care
Could do better on prevention e.g. Activity
(Age UK PCMD 2012)
Primary Prevention? e.g. Obesity. Men. (England)
III: What ageing really means for
health and wellbeing
How older people define wellbeing:
Bio-Psycho-Social.
Not just medical model of “absence of disease”
• Control over daily life
• Personal care and
appearance
• Food and drink
• Accommodation
(cleanliness and comfort)
• Personal safety
• Social participation
• Occupation/activity
• Dignity (in care) once you
are acutely ill or dependent
on care
Wider Determinants: Potential for multiple
disadvantages. Role of local government,
benefits, housing etc?
Frailty –
(only around 6% of over 65s but very high proportion
of service use and predicts poor outcomes and high mortality)
Fried Criteria for frailty
Weight loss, exhaustion, weakness, slow walking speed,
diminished physical activity
”Frailty is a failure to integrate responses in the face of stress.
This is why diseases manifest themselves as the “geriatric
giants”….functions …such as staying upright, maintaining
balance and walking are more likely to fail, resulting in falls,
immobility, incontinence, delirium or general failure to thrive .
A small insult can result in catastrophic loss of function”
Rockwood Age Ageing 2004
i.e. Poor Functional Reserve
Fried 1999
Problems with traditional LTC approach. See
Oliver D, Br J Gen Practice 2012)
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“Cut and paste” of Kaiser Pyramid
Too much “single disease” thinking
QOF can reinforce this
In turn, drives prescribing without due regard to drug/drug
or drug/disease interaction, risk-benefit/therapeutic goals or
evidence of benefit in oldest old or complex multi-morbidity
Common conditions of ageing often neglected
Support for carers?
Where are frailty syndrome and disability?
Crisis response (24/7) and adequate access to alternatives
to hospital crucial to admission prevention.
Artificial divide between LTC pathway and acute care/social
care pathways. Fundamentally interdependent
Reported prevalence of disability clearly rises
with age.
Disability distribution over age
100%
90%
Individuals without
a disability,
including limiting
long standing
illness
80%
70%
60%
50%
40%
30%
Individuals with a
disability, including
limiting long
standing illness
20%
10%
0%
0-15
16-24
25-34
22 Source: Family Resources Survey 2007
35-44
45-54
55-59
60-64
65-74
75-84
85+
V: Older people (often with complex needs)
as core patients/clients
Getting their care right is key to delivering the
efficiency challenge
People over 65 (England)...
• 60% adult social care spend (£9bn)
– 1.25 M out of 1.7 m users
• 37% NHS Primary Care spend (£27bn)
• 46% acute care spend (£ 27bn)
• 12% NHS budget is on community health care
(largely older people) (c £12bn)
• 66% drug budget (including GMS)
• Often those interdependent on multiple services
(e.g. 60% of home care service users have been in hospital
in previous year. 80% of delayed transfers are over 70)
• Population ageing means this trend will continue
Trends in hospital admissions in England,
>75 years
Emergency Bed days per person per
annum by age and gender
Factors driving rate of use of emergency hospital
beds
Read Freakonomics and Super Freakonomics!
Supply side drivers in healthcare are alive and well in our ‘service level
designs’. Result = increased unintended consequences
Reduction in
length of stay
Provider efficiency
Less severe
cases admitted
Better and more
efficient care
More beds
available
System inefficiency
Admission
threshold reduced
Lower acuity cases using costly inpatient
care
Managing the Streams
Identify the stream
– Short stay
Sick specialty
Sick frail
– Allocate early to teams skilled in that stream
Complex
250
Number of patients
Short stay – manage to the hour
Maximise ambulatory care
200
Clarity of specialty criteria
Specialty case management plan at
Handover – no delays
Green bed days vs red bed days
150
Minimise handover
Decompensation risk
Early assertive management
Green bed days vs red bed days
100
Complex needs – how
much is decompensation?
Detect early and design
simple rules for discharge
50
0
1
3
5
7
9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59
Length of stay (days)
Roland M BMJ 2012. Preventing Emergency Admissions –
excessive focus on “frequent flyers”?
Does current GP consultation model and QOF allow comprehensive
assessment/anticipatory care etc in older people with complex needs?
Quality Care For Older People With Urgent &
Emergency Care Needs: Silver Book
An intercollegiate body of work describing care
standards for older people over the first 24
hours of an urgent care episode, with the
specific remit to:
• help decrease variations in practice
• influence the development of appropriate services
across the urgent care system
• identify and disseminate best practice
• influence policy development
Silver Book Membership
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Age UK
Association of Directors of Adult Social Services
British Geriatrics Society
Chartered Society of Physiotherapy
Community Hospitals Association
College of Emergency Medicine
College of Occupational Therapists
National Ambulance Service Medical Directors
Royal College of General Practitioners
Royal College of Nursing
Royal College of Physicians
Royal College of Psychiatrists
Society for Acute Medicine
Purpose Of Silver Book
• Describes the issues relating to older people accessing
urgent care in the first 24 hours irrespective of provider
• Describes the competencies required to respond
• Recommends urgent care standards for older people - first
24 hrs of an acute care episode
• Contextualises health & social care for older people & at
the interface
• Aimed to improve satisfaction and outcomes for older
people in urgent care & satisfaction amongst staff
Standards:
All older people accessing urgent care should be
routinely assessed for (based on priorities)
pain
delirium, dementia
depression
nutrition/hydration
skin
sensory loss
falls & mobility
activities of daily living
continence
vital signs
safeguarding
end of life care issues
Recommendations
• Generic – across all settings in first 24 hrs; including
discharge planning
• Specific – include
- Primary care
- Community hospitals
- ED/UC/AMU
- Mental health
- Safeguarding
- Major incident planning
- Commissioning
- Training and development for all staff groups
VI: Services for older people as the
key to the efficiency challenge?
Ageing Population: 10 + Challenges for General
Practice Oliver D. Br J Gen Practice 2012. Editorial.
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1. Address the efficiency challenge (through care of older people)
2. Improve quality and combat discrimination
3: Greater focus on prevention
4. Proactive care of people with multiple LTC & age-related conditions
5. Addressing frailty and co-morbid disability
6. Dementia (earlier diagnosis and support)
7. Crisis intervention and rapid response /support
8. Prescribing and medicines management
9. Input to nursing and residential homes
• 10. Integration, continuity and system leadership
• (11. Support and advice for carers)
• (12. Intermediate care, step up and step down, bed based and home based.
Adequate medical and healthcare inputs and leadership. Smart use of beds
and places)
• (13. What happens within acute care and around discharge and early postdischarge [transitional ] care really counts.
Critical Themes to Support Transformation
1. Quality and system improvement as a core strategy
2. Organizational capacities and skills to support performance
improvement
3. Robust primary care teams at the centre of the delivery system
4. Engaging patients in their care and in the design of care.
5. Promoting professional cultures that support teamwork,
continuous improvement and patient engagement
6. More effective integration of care that promotes seamless care
transitions
7. Information as a platform for guiding improvement
8. Effective learning strategies and methods to test and scale up
9. Leadership activities that embrace common goals and align
activities throughout the organization.
10. Providing an enabling environment buffering short-term
factors that undermine success
Defining ‘Integration’
• There are different, but interconnected levels of integration
SYSTEMIC (MACRO)
Eg integrated health and
social care systems (Wales,
NI)
ORGANISATIONAL (MESO)
Health and social care
integration through care trusts
TEAM OR SERVICE
(MICRO)
Eg integrated health and social
care teams
• The ‘degree’ of integration varies (Leutz 1999)
LINKAGE
Cooperation between
teams & organisations
(eg shared resources or
protocols)
COORDINATION IN NETWORKS
Existing organisations working
within networks/ partnership
agreements
FULL INTEGRATION
Organisational merger or JV
Organisational integration: Torbay care
trust
• Five locality health and social care teams linked to GP practices.
• Unified assessment processes
• Health and social care coordinators act as a single point of contact.
• Focus on vulnerable elderly people targeted through risk prediction
• Impact
• Reduced use of hospital beds (daily average number of occupied
beds fell from 750 in 1998-9 to 502 in 2009-10)
• Low use of emergency bed days among people aged ≥65 (1920/1000
population compared with regional average of 2698/1000 population
in 2009-10)
• Minimal delays in transfers of care
Don’t forget Nursing and
Residential Care
•Median 9 meds per resident. For each med, 10% error rate in
prescribing, admin, monitoring (Barber et al CHUMS study)
•Still too many patients being admitted to hospital to die or where
earlier intervention could have kept them in NH
• Failing the Frail: A Chaotic
Approach to
Commissioning Healthcare
Services for Care Homes
• Deficiencies in
– Inclusion in commissioning
– Specialist primary/community
healthcare services (whole
range)
– Response Standards/Referral
From NHS
Institute LTC
in Older
People.
Gilmour
Frew
The Challenge
Fundamental change to the delivery system is needed,
with greater emphasis on:
• preventing illness and tackling risk factors
• supporting people to live in their own homes and offering a wider
range of housing options in the community
• providing high standards of primary care in all practices to enable
more services to be delivered in primary care, where appropriate
• making more effective use of community health services and
related social care, and ensuring these services are available 24/7
when needed
• using acute hospitals and care homes only for those people who
cannot be treated or cared for more appropriately in other settings
• integrating care around the needs of people and populations.
Transforming The Delivery Of Health And Social Care The Case For Fundamental
Change – King’s Fund 2012