Unique Care: Converting Unplanned Crisis into Planned Care Ruth Adam & Philip Lewer.

Unique Care: Converting Unplanned Crisis into Planned

Care

Ruth Adam& Philip Lewer

An acute hospital admission is a failure of the Health System.

The real challenge to the NHS is how to manage chronic

disease better

The trick is to convert unplanned care into planned.

Adopt a multi-skilled, multi-agency approach to ensure effective care co-ordination

Unique Care

• Integrate Health and Social Care• Deal with current referrals• Joint assessment & joint working (SAP)• Tailored packages of care• Hospital In-reach• Get the 20% on the radar

Unique Care

• Same day assessment 97% of time • Utilisation of primary care team, CPNs

Practice nurses, etc.• Involvement of Voluntary Sector• Better use of other Health

Professionals, including pharmacists, rehab, OT, rapid response teams

• Effective use of social services’ resources

Over 65s Admissions per 1,000 Population

0

50

100

150

200

250

300

350

Castlefields Runcorn

Year Pre-project Project Year

Over 65s Average Length of Stay

0

1

2

3

4

5

6

7

8


Year Pre-Project Project Year

Over 65s Bed Days per 1,000 Population

0

500

1000

1500

2000

2500


Year Pre-Project Project Year

Other Effects

• District Nurse Team didn’t need backfill• GPs’ home visits fell by 30%• Social Services budget made small saving in

Castlefields but overspent in Borough• Use of intermediate care remained stable &

within expected for population• 48 cases; admissions fell from 123 to 2 and

only three went into long term care

Money released for re-investment

Practice Population: 12,000

Saves £210,000 (US$ 408,281) per year on admissions

Over 65s Acute AdmissionsCastlefields Health Centre

0

50

100

150

200

250

300

350

1999 2000 2001 2002 2003 2004 2005

Unique Care – 5 Key Principles

1. Create a Unique Care team between health and social services

2. Create and maintain a practice based register of patients with complex needs

3. Case find patients at risk of admission

4. Establish hospital in-reach 5. Create a bespoke plan with each patient

Which patients benefit most from Unique Care?

Supported Self Care

Disease Management

Case

Management

Level 1

70-80% of an LTC population

Level 2

High Risk Patients

Level 3

Highly Complex PatientsProfessional CareSelf Care

Unique Care

Unique Care

Unique Care

• Multiple Crisis – Multiple LTC’s, complex medical & social needs, frequent admissions to hospital / A&E attendance / OOH Service

• Not attended for screening / OPA’s • Experienced major life changes e.g. bereavement,

deterioration in health, self neglect

• An older person about whom you have concerns

Which patients benefit most from Unique Care?

The Pareto principle

• 20% of supermarket products account for 80% of sales

• 20% of criminals account for 80% of the value of crime

• 20% of people who marry account for 80% of divorce statistics

• 20% of your carpet gets 80% of the wear• 20% of the clothes in your wardrobe get worn

80% of the time

Source: Koch 1998

The 20% of Patients who need 80% of the Care

• Older People• Decreased Functional Ability• Revolving Door Admissions• COPD & Heart Failure• End of Life• Psychological & Social Support• Packages of care tailored to the

individual

Postal Questionnaire

• 20 questions Yes/No answers only• One sheet of paper• Coloured ink & large font• Invitation signed by own GP• Helpline• First & second reminders

Response

• All practices in PCT recruited• 3999 identified as potential participants• 350 ruled out by cross-checking with the

practices • 3649 sent questionnaire• 302 declined to participate• 305 failed to respond• 3048 positive response (83.5%)

12 month summary• Diabetes 1.3• Lung problems 1.7• Heart problems 1.7• Stroke 1.7• Cancer 1.2• Depression 1.6• Bladder problems 1.6• Leg ulcers 2.2• Lives alone 1.0• Help if ill 1.1

• Help to get out 0.4• Bath without help 0.4• Eyesight 1.7• Memory problems 1.9• Flu Vacc 0.9• 4+ medicines 2.0• Previous admission 2.9• Fall 1.8• Bereavement 1.2• General health 0.4

Identifying At RiskStart with 10, then if ‘Yes’

• Do you have heart problems? +3• Do you have leg ulcers? +4• Can you get out of the house without

help? -5• Do you have problems with your

memory and get confused? +4• Have you been admitted to hospital for

an emergency in the last 12 months? +8• Would you say the general state of your

health is good? -4

SCORE % Pop Identified

Chance of Admission

20+ 6% 55%

15-20 7.5% 47%

10-15 11.5% 30%

<10 75% 17%

Identifying High Risk

• Tools only go so far, so don’t be rigid• Look out for repeat admittees• Severe COPD• Heart Failure• More holistic assessment • Packages of care according to need• Regular review

Has this worked elsewhere?

Enfield – Practice Population 3,600

• Emergency Admissions Reduction 50% • (12% in comparator practice) • Occupied Bed Days Reduction 70% • (10% in comparator)• Excess Bed Days Value Reduction 98% • (23% in comparator)• Spells Value Reduction 49% • (5.6% in comparator)• Total Budget Savings 67%• (8% in comparator)• Total budget savings over 5 months = £99,000• Estimate over 1 year = £237,000

ResultsReduction in admissions

Reduction in bed days

Castlefields 15% 40%

Bracknell Forest 20% 40%

Durham Dales 15% 20%

Oldham 25% 20%

Enfield 53% (12%) 70% (10%)

Avoiding one admission per week• If all 13 Durham Dales practices avoided one

admission per week, this would release money for re-investment to the tune of:

************************£642,876********************

1.2 million US$

(£951 2005/6 Durham Dales)

Feedback from sites“Unique Care has had the benefit of reducing the number of referrals to social

services……the team have helped older people to understand better what the statutory services can provide for them”

Jenny Goodall: Director, Brent Social Services

“This approach has reduced my workload a lot. Quality of care for complex housebound patients has improved immensely”

GP, Derbyshire Dales & South Derbyshire PCT

“Unique Care makes life easier for people with complex needs in many cases it’s the simplest things that have made a big difference.”

Gwyneth Oates: Care Co-ordinator

"Its a good feeling knowing that capable and caring people are there to support you if problems arise"

Patient, Durham Dales PCT

And more importantly…………..“The hospital said that I wasn’t fit to be on my own really…..after further

consideration I decided I didn’t want to go there (residential home), after all here I can do what I like, I can get up in the night, imagine

what it would be like living in somebody else’s place!”

Patient, Brent 2005.

“It’s very hard with angina. You get frightened and you just don’t know where to turn. I was able to talk to you and I know I have somebody there and it’s nice to have somebody. I did what you told me taking

my spray and not get to excited about it all and it saved me from the

phoning the ambulance”. Patient, Oldham 2005.

Health and Social Care Perspective

• Challenges

• Opportunities

• Coming together


• Those that use our services, want /deserve /need services that meet their needs, they also want to make informed choices about their lives.

• Emphasis on choice and self determination for the individual.


• The need to work together to tackle the growing numbers of people with chronic illness and long term conditions

• The need for local providers and purchases to develop services through the market place and contestability


• We are both struggling with our finances. Patients / citizens want more choice and better services – we are tempted to cost shunt rather than see the commissioning gap!

We can if we want to

• Challenge existing cultures

• Ensure the empowerment of people to take expert control of their conditions

• Delivering high quality care

What has worked

• Scrap the eligibility criteria for low level services such as – Careline (telephone response / pendant

service )– Meals on wheels ( frozen meals service )

• My Mum

Conclusion

• There is a willingness to work together especially with GPs so that we can jointly commission new and preventative services

• We want to create new care pathways and community based services so that we can manage demand and expectation together.

So what are you going to do when you go back to work……

How will you make a difference?

How will your patients know?

We can rise to the challenge…!

Philip Lewer

Tel: (07918) 600795

[email protected]

Ruth AdamTel: (0161) 236 [email protected]

mailto:[email protected]

mailto:[email protected]

Don’t React & Panic

Anticipate & Plan

References

• Practice-based commissioning, a toolkit – primary care contractingwww.primarycarecontracting.nhs.uk 2006

• Developing effective joint commissioning for adult services: lessons from history and future prospects

Nick Goodwin, Care Services Improvement Partnership 2006• The future of health and adult social care: a partnership approach for wellbeing

Local Government Association 2006• Human dimensions for change (ppt) taken from Google

Susy Cook, Gill Husband, Margaret McQuadeNHS Improvement Alliance, South Tees Hospital NHS Trust

White paper- Strong and prosperous communities (chap 7) /-Our health our care our say A whole system working a guide and discussion paper CSIP

Commissioning framework for health and well being

http://www.primarycarecontracting.nhs.uk/

Unique Care: Converting Unplanned Crisis into Planned Care Ruth Adam & Philip Lewer.

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Transcript of Unique Care: Converting Unplanned Crisis into Planned Care Ruth Adam & Philip Lewer.