Strategic modelling solutions for unscheduled care An example using system dynamics and local...

Strategic modelling solutions for unscheduled care

An example using system dynamics and local engagement to address key capacity and planning questions

May 2013

An introduction to WSP

www.thewholesystem.co.uk 2

Strategy and partnership development in health and social care using simulation and modelling as a key tool;Our business is strategy development and supporting sustainable change – when modelling & simulation helps then we use it (which is quite a lot!).

System Dynamics

www.thewholesystem.co.uk 3

“The investigation of the information-feedback characteristics of (managed) systems and the use of models for the design of improved organisational form and guiding policy” (Forrester 1961);Characteristics:

Systems thinking - integrative and holistic; Enabled by sharing mental models and group model

building; Understanding ‘cause & effect’ and system behaviour; Exploring behaviour over time, delays and feedback.

Rooted in ‘thinking’ not in ‘data’ – issue focussed – a learning tool relying on iterative learning rather than final answers.

The world of systems thinking

The spectrum that is ‘systems thinking’……

The Whole Systems Partnership 4

Deterministic – cause and

effect

Fatalistic – the system rules

Philosophical pragmatism – the muddle-

through middle ground

Micro-management

Machiavellian

The WSP approachDistinctive in that it recognises the tendencies to swing between the extremes, and that within any local group people will lean toward one or the other approach;Distinctive in believing that co-production with local stakeholders and engagement with the issues provides the most likely route to sustainable long term change;We therefore use systems dynamics to strengthen local partnership working rather than to give the right answer – although we are pretty challenging when our analysis and modeling points away from the local consensus!

Whole System Partnership 5

Unscheduled care in a local DGH

Strategies to address capacity challenges

Local contextNorth East Lincolnshire is a small health care system serving the town of Grimsby and surrounding rural population of around 170,000 people;The DGH has around 440 beds;Monthly A&E attendances are around 4,500 of which approximately 1,000 are admitted;The Care Trust Plus (the equivalent of the PCT/CCG before April 2013) has already invested heavily in intermediate care services over recent years.


Issue definitionKey issue: How will re-design proposals associated with 1) Emergency

Ambulatory Care Model; 2) Intermediate Tier Diversion at A&E; and 3) earlier discharge impact on DPOW bed requirements & Intermediate Tier/community capacity?

Areas of impact to be explored: Pre-A&E saved admissions (RR/CCM in place); A&E divert to Int Tier through GP/RR presence on Majors

corridor; Emergency ambulatory care saved admissions; Early discharge for people, including but not exclusively

with >28 day LOS.


Factors to be consideredNeed to set in the context of: Underlying demographics; Recent trends in admissions and how they

relate to the above; Historic levels of impact of the intermediate

tier developments; The parallel development of an emergency

ambulatory care model of service and any overlap or potential double-counting.


Model structure & key interventions for redesign


Majors

1 Pre-hospital impact of new models of crisis response in community

A&E decision process

2 Divert to Int Tier or other

No ongoing need for treatment or support

Need for treatment or support

GP presence

3 Suitable for Emergency Ambulatory Care

MAU

Specialty Ward

Admit

Discharge

4 Earlier discharge to Int Tier, shortened length of stay

Discharge

GP admission

Scaling potential for emergency ambulatory care and Int Tier diverts

PAS data DPOW admissions Dec 08 to May 11 supplied by NLAG informatics, average of c.845pw made up of:

Elective 440pw; Obs & Gynae 155pw; Non-elective (and therefore potential for Emergency Ambulatory

Care) = c.250pw (29% of all admissions).

Mapped HRG for non-elective admissions to clinical scenarios based on NHS Institute Directory of Ambulatory Care for adults (version 2, March 2010), potential of c.100pw (15 surgical and 85 medical) – need clinical opinion about the extent to which potential could/would be realised, for each clinical scenario in the local context.


Impact of Emergency Ambulatory care on intermediate tier potential

The 100 potential admissions for EA is split: 15 being surgical (all ages); 25 being medical (<50) 15 being medical (50 to 65); 45 being medical (>65).

Assume that suitability of EA ‘trumps’ suitability for intermediate tier diversion;Non-elective, medical >50 admissions totalled on average 140pw;Medical admissions >50 suitable for EA is 60, therefore potential for intermediate tier divert is c.80pw.


Potential for Intermediate Tier = 140pw less 60

= 80pw

Scaling the potential for emergency ambulatory care and Int Tier diverts


Total = 845pw

DPOW PAS data for Dec 08 to May 11, NE Lincs residents, average weekly admission:

Obs & Gynae = 155pw

Elective = 440pw Non-elective = 250pwSurgical = 250pw

Medical = 190pw

Surgical = 70pwMedical = 180pw140pw >50yrs old

Pote

ntia

l for

Em

erg

ency

A

mbula

tory

ca

re

(c.100pw

w

ith 6

0

>5

0)

Scaling the AEC pathwayClinical review of HRG clinical scenarios that are suitable for AEC, which identified:

The proportion of those deemed suitable for AEC that could be diverted given the current level of services in the community;

Additional services that would need to be in place to optimise the model in NE Lincs;

The proportion of these patients that would also need intermediate care support if not admitted.

53% of admissions within the AEC clinical scenarios were deemed to be divertible equivalent to 43 medical patients a week and 11 surgical;23 patients pw would require follow-up and 5 pw would need AV antibiotics.


Scaling diversion at A&EThe current scheme for diversion to the intermediate tier from the A&E Majors corridor is based on an economic case for 3 diversions per day (operating on M/F, 9-5) or c.15pw;Need to identify the achievability of this ‘target’ through the analysis of the __pw admissions seen in March to May 2011.


Alternative pathways through Int Tier (including initial assumptions)


2 Divert from A&E to Int Tier or other support

IC bed

<28 days LOS for

>65yr olds

4 Earlier discharge to Int Tier, shortened length of stay

Home

IC

Ave reduction in LOS of 1

day

10%

IC @ home

50%

50%

Home

>28 days LOS for all patients

42 LOS

Recuperation

21 LOS

Home100%

Diverts not needing Int Tier

Home

40%

Ave reduction in LOS of 20

days

60% RR 25%

75%

Home67%

33%

Home

90%

3 LOS

Assumptions within the Intermediate Tier

The assumptions on the following pages still need testing and validation through an iterative process between professional/clinical opinion and data gathering;For A&E diversion:

33% of medical admissions with potential for diversion are diverted with the target being achieved gradually over the next 2 years;

40% of these diverts do not need intermediate tier interventions; The remainder receive RR support for 3 days; 25% of these then remain in a recuperation bed facility; Of the remaining 75% one third are admitted to IC (bed or home)

whilst the other two thirds go home.


Assumptions within the Intermediate Tier (contd)

For early discharge: For people currently staying over 28 days these are

discharged on average 20 days earlier and all go to a recuperation bed;

For >65yr olds staying less than 28 days their hospital LOS is reduced on average by 1 day (from 7.25 days) and 10% of this cohort are transferred to IC (bed or home).

Within the Intermediate Tier: Recuperation beds have an ALOS of 21 days; IC referrals are supported 50/50 at home and in a bed; IC at home or in a bed is provided for 6 weeks (42

days).


Model demonstration......


Model outputs – medical beds

2009/10 bed base of 146 beds (with 90% occupancy) would rise to 161 without any enhanced AEC or intermediate tier pathways, but would fall to 96 with these services optimised by March 2014;A ‘swing-bed’ policy would need to be in place to accommodate up to 30 additional beds at peak times without resulting in significant outliers.


Model outputs – Intermediate Tier

Rate of diversions/admissions across the new pathways once optimised in March 2014:

50pw combined diversions from A&E going to either AEC or Int Tier or direct home;

33pw entering the AEC pathway; 7pw new RR referrals; 5pw new IC admissions (combined home and bed); 5pw new admissions to recuperation beds.


Model outputs – Intermediate Tier

New capacity required in the Intermediate Tier once new pathways are optimised in March 2014:

Rapid Response caseload +3; IC @ home caseload +14; IC beds +14 (interchangeable in the model with home

support); Recuperation beds +19.


What happened nextInformation was taken and put into context of the overall bed position to consider and redesign factors such as: The effects of medical outliers and the demand for

surgical beds; Cancelled operations due to bed pressures; Bed and ward structure for all medical specialties; Nursing and resources for new bed structure.

Internal process improvement was scheduled to enable the results of the model to be implemented.


Appendix: Changes in the number of non-elective medical admissions

The dataset being used can provide 3 comparative periods of March to May 2009, 2010 and 2011;Local demographic data can identify a rate per 1,000 population (by age band) for each year and identify any differences between these three years;We can also identify the expected number of medical non-elective admissions in 2011 based on 2009 rates per thousand population;Any gap between actual and expected needs to be understood at least in part by the impact of intermediate tier developments for pre-hospital diversion.


Scaling the pre-hospital diversion

Since 2009 two initiatives have been taken to effect pre-hospital diversion for non-elective medical admissions: Complex Case Management Teams have performed a

rapid response function (primarily during the day and for people already on their case loads) – estimates of saved admissions by early 2011 are 12pw;

The Rapid Response function within the intermediate tier has been enhanced coupled with redesign at the Beacon – original modelling suggested saved admissions of 7pw, analysis from Oct-Dec 2010 suggested 11pw whilst figures from April, May and August 2011 suggests 9pw.


Strategic modelling solutions for unscheduled care An example using system dynamics and local...

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