The Balance of Care Group

Alternatives to HospitalMODELS OF INTEGRATED CARE

Tom Bowenwww.balanceofcare.com+44 7768 123865

ORAHS 2008, Toronto, 29 July 2008

2

Pre admission

Pre admission Admission Diagnosis Treatment Discharge Re-admission

Social details

alone, carers, residence

Risk factors:

age, drugs, co-morbidities,

psychiatric/

dementia, falls

Preventative care

Disease managementManaged populations

Source of referral

Time

Waiting time

Route

Decision maker

Reason for admission

Alternatives to admission to acute setting

Admission diagnosis

Inpatient diagnosis

Delays in diagnosis

Chronic disease

Alternative access for diagnosis

Delays in therapy

Alternative settings for therapy (especially rehab)

Discharge planning

Delays in planning

Delays in execution

Alternative sites for discharge

‘Revolving door’

Avoidable e.g. chronic disease management

Alternative sites for readmission

Rich picture available from process flow

3

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

4

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

5

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)

6

Proportion of Patients with Mental Health or Cognitive Issues (N=863)

Dementia13%

Confusion14%

Anxiety/depression8%

Psychosis2%

Substance Misuse2%

Other1%

No mental health issue60%

7

Location of Patients by Mental/Cognitive Issue (N=344)

0

20

40

60

80

100

120

140

Demen

tia

Confus

ion

Anxiet

y/dep

ress

ion

Psych

osis

Substa

nce

Misu

se

Other

No

of p

atie

nts

OPMH

Intermediate care

Acute

8

Percentage of Acute Inpatients within AEP Criteria(Dementia = 65, all other = 602)

83%

32%

85%

53%

0%

20%

40%

60%

80%

100%

on admission on day of care

% o

f pat

ient

s w

ithin

AE

P c

riter

ia with dementia

all other

9

Alternatives to Continued Stay for Acute Hospital Patients with Dementia (N=43)

0

2

4

6

8

10

12

Own

Home

Home

& Socia

l Car

e

Home

& Gen

eral

Hea

lth C

are

Home

& Reh

ab S

uppor

t

Home

& Spec

ialis

t Nurs

e

Acces

s to

Out

patie

nts

Non A

cute

Bed

& T

herap

y

Non A

cute

Bed

Home

& Spec

ialis

t Hom

e Car

e

Home

& MH S

uppor

t

Home

& MH R

ehab

Suppo

rt

Non A

cute

Bed

& M

H The

rapy

Acute

MH B

ed

EMI C

ont C

are

Bed

Oth

er

No

of p

atie

nts

Quick discharge

Remaining

10

Assessed risk of 'confusion' patients having dementia (N=119)

0

10

20

30

40

50

60

High Medium Low

Assessed risk of dementia

No

of

pa

tien

ts

OPMH

IC

acute

11

NHH beds

Care Homes

Home basedcare packages

CommunityHospitals

+36

+24

+20

Potential Change in Service UsageScenario for North Hampshire PCT

1/3

+15

+10

12

NHH beds

Care Homes

Home basedcare packages

CommunityHospitals

+36

+24

+20

+14

Potential Change in Service UsageScenario for North Hampshire PCT

2/3

EMH

+15

+9

+6

+10

13

NHH beds

Care Homes

Home basedcare packages

CommunityHospitals

+36

+24

+20

+14

Potential Change in Service UsageScenario for North Hampshire PCT

3/3

EMH

+15

+9

+6

+10

+30

14

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

under-recording 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

15

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?