Role of Risk Prediction in achieving our 2020 Vision
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Transcript of Role of Risk Prediction in achieving our 2020 Vision
Role of Risk Prediction in achieving our 2020 Vision
Dr Anne Hendry
National Clinical Lead for Quality
JIT Associate
• 21% rise in 65+ from 2006 – 2016
62% rise by 2031
• 38% rise in 85+ by 2016• 144% rise by 2031
• 1 in 3 aged 75+ have two or more
Long Term Conditions
Headline Projections
LTC Prevalence by Age People reporting a chronic condition (by age)
0
10
20
30
40
50
60
70
80
1972 1975 1981 1985 1991 1995 1996 1998 1998 2000 2001 2002
Year (note: data from1998 is w eighted)
% o
f s
am
ple
0-4y
5-15y
16-44y
45-64y
65-74y
75+
Most people with any long term condition have multiple conditions in Scotland – Scottish School of Primary Care
Projected Demand for Health and Social Care, All Ages, 2008/09 prices.
Health and Social Care Demand Projections, £ mn, 2008/09 prices
5,000
6,000
7,000
8,000
9,000
10,000
11,000
12,000
13,000
14,000
15,000
2010 2015 2020 2025 2030
Year
Co
st £
mn
HLE constant
Change HLE = 0.5 change LE
Change HLE = Change LE
Projected Scottish Government spending
20,000
22,000
24,000
26,000
28,000
30,000
32,000
£ M
illio
ns (
2010
-11
Pric
es)
2009-10 2025-2616 years
£42 billion
Sustainable Quality
A 2020 Vision
• Integrated primary and social care, and more effective working with the Voluntary sector
• A focus on prevention, anticipation and supported self management in order that everyone can live longer healthier lives at home, or in the community as long as possible.
• When hospital treatment is required, and cannot be provided in a community setting, day case treatment should be the norm and it should be provided in the place which can guarantee highest quality, safety and a good experience.
• A focus on ensuring that people get back into their home or community environment as soon as appropriate, with minimal risk of re-admission.
Reshaping Care Pathway
Population model
Professional Care
Self Managem
ent
Care Care ManagementManagement
DiseaseDiseaseManagementManagement
Supported Supported Self CareSelf Care
Level 3Level 3Complex coComplex co--morbidity morbidity 3 3 –– 5%5%
Level 2Level 2Poorly controlled single Poorly controlled single disease 15 disease 15 –– 20%20%
Level 1Level 1Well controlled Well controlled (70(70--80% of LTC 80% of LTC population)population)
Population Wide Prevention, Health Improvement & Health Promotion
Anticipatory Care and Self Management
Day Care and Respite
Residential Care
Care and support at
Home
Rehabilitation / reablement
Extra Care Housing support
Meals
Laundry
Third Sector capacity
Primary Care Team & Care
Managers
Tele Health
Tele Care
Integrated Locality Team
Hub
Integrated Locality Team
Telehealthcare
Anticipatory Care Planning
Anticipatory Care Plans Highland
• Cohort with ACP in place
34% reduction in emergency new admissions and a 57% reduction in emergency OBDs compared to previous year
• No ACP but SPARRA risk > 50% (control)
56% increase in emergency new admissions and an 83% increase in emergency OBDs compared to previous year
Complex Polypharmacy
Chronic Medication Service
1. Registration of Patients
81,100 by 1224 community pharmacists
2. Pharmaceutical care Planning
3. Therapeutic Partnership to generate serial prescription 24-48 weeks
Serial Dispensing Early Adopters
• 42 GP practices and 84 Community Pharmacists across 12 NHS boards
• 3000 serial prescriptions for 5500 medicines for approx. 1000 patients
• SG working with Health Boards to extend this to all by April 2013
NHS Scotland Rate per 1,000 Attendance at Emergency Departments and Admissions for Females by Age Group from
0ct 2010 to Sep 2011
-
50
100
150
200
250
300
350
400
450
0-4
5-9
10-1
4
15-1
9
20-2
4
25-2
9
30-3
4
35-3
9
40-4
4
45-4
9
50-5
4
55-5
9
60-6
4
65-6
9
70-7
4
75-7
9
80-8
4
85+
age
rate
Attendance Rate
Admission Rate