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Frailty Concept/ Hospital without Walls

Frailty Concept/ Hospital without Walls. Professor Pradeep Khanna MBE Chief of Staff, Community Services Aneurin Bevan Health Board. Commissioning & Care Planning. Strategic Planning Specify Outcomes Develop Business Case Procure Services Manage Demand Maintain Performance.

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Frailty Concept/ Hospital without Walls

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  1. Frailty Concept/ Hospital without Walls Professor Pradeep Khanna MBE Chief of Staff, Community Services Aneurin Bevan Health Board

  2. Commissioning & Care Planning • Strategic Planning • Specify Outcomes • Develop Business Case • Procure Services • Manage Demand • Maintain Performance

  3. CASE FOR CHANGE • Demand will always beat supply • Pressure on cost is remorseless • NHS can not provide a comprehensive service on current assumptions after 2011 (Kings fund and the Institute of Fiscal Studies – IFS)

  4. Some Facts • Nearly 33% of inpatients could safely be cared for in another setting than in an acute hospital [Kings fund audit 1992; DOH 2000] • 29% of patients in acute hospital beds are medically stable [43% in elderly wards] [Barbara Vaughan; Gill Withers 2002] • In Wales, higher proportion of chronic long term conditions (23%) compared to England (18%); Northern Ireland (20%) • Audit of 5 GP Practices in Swansea revealed 3% of population with 2 comorbidities + emergency admission accounted for 59% of hospital admissions [Ref = WAG 2007 – Designed to improve health …chronic conditions Wales] • Conclusion: A focused integrated approach of Health and Social Care, Housing and Transport is recommended

  5. Drivers For Change • Wanless Report: Hard hitting facts about Health Services in Wales • Designed for life: Strategic framework: Health & Social Care Services in Wales • Fulfilled lives, Supportive Communities: Emphasis on Social Care • Making the connections [Public involvement & redesign services around the needs of the users] 5. Primary Care & Community Services Strategy (Chris Jones)

  6. PUSH INCREASING COMPLEXITY DECREASING FUNCTIONALITY INCREASINGDEPENDENCY PUSH Current System of Care “Push System full of Black Holes” Local government COM NURS E TMS FRAGMENTED AND DISORGANISED COMMMUNITY BASED CARE HEALTH SOCIAL HOSPITAL BASED CARE DISCHARGE PRIMARY CARE DEPENDENT FRAIL NH RH OOH AE INDEPENDENT FIT PARA MED NHSD Patient journey

  7. Hospital-at-Home: definition……… Hospital care but delivered in the person’s own home !!! HaH = “….a service that provides active treatment by health care professionals, in the patient’s home, of a condition that would otherwise require acute hospital in-patient care, always for a limited period.” Cochrane definition, 2005 Combination of personal support & rehabilitation care

  8. Admission AvoidanceHospital at Home/Inpatient Care(Review) [Systematic Review & Meta Analysis] • Mortality at 3 months NS (P= 0.15) • Mortality at 6 months Significant (P=0.005) • Readmission Rates NS (P=0.08) (within 3 months) • Functional Ability (12 months) i. Quality of Life ii. Physical abilities iii. Cognitive Status NS Reference: Sheppard S, Doll H, Etal: The Cochrane Library 2009: Issue 3

  9. Hospital at Home • CLINICAL OUTCOME: (Adverse Events & Medical Complications) • Bowel Complications = 22.5% (96% C.I = 34% to 10.82) • Urinary Complications = 14.4% (95% C.I = 25.4% to 3.3%) c. Antipsychotic Prescribing = 14% (95% C.I = 28% to 0.3%) in Dementia Patients • COPD = Antibiotic = 18% (95% = 34.6% to 1.4%) • PATIENT SATISFACTION: Significant (P < 0.0001) 3. ECONOMIC ANALYSIS: (Co Morbidity: Older Group) Costs = Per episode $2011; 95% C.I (= $2800 to $1222) = Per day $293; 95% C.I (= $318 to $268) • CONCLUSION: Admission Avoidance Hospital at home can provide an effective alternative for selected group of Patients (Outcome Similar)

  10. Early Supported Discharge Teams Vs Conventional Care11 Trials (6 countries) Conclusion: “Appropriately Resourced and Co-ordinated Services” in clearly defined Target Groups has clear potential benefits Langhorne P, et al - Lancet 2005;365;501-506

  11. THE EVIDENCE-BASE FOR INTERMEDIATE CARE RCTs • HOSPITAL-AT-HOME 22 • DAY HOSPITAL 12 • NURSE-LED UNITS 10 • COM. REHAB.TEAMS 2 • CARE HOME REHAB. 1 • COMMUNITY HOSPITAL 1 Message: (a) Target people with greatest clinical need (Frailty) (b) Integrate I.C with Mainstream Services  Expensive Very expensive  Shifts costs to social care 

  12. Messages From Research • Develop closer integration between IC and Mainstream Services • Target Patients with greatest clinical need: Frailty • Place stronger focus on Admission Avoidance Scheme (Health & Social Care) (Closer liaison with Ambulance Service, 3rd Sector, A&E, Mental Health) VANTAGE POINT • Reablement: • More Research/Evaluation needed

  13. 2014-15 with new MoC Non-acute beds and places required by LHB Blaenau Newport Caerphilly Torfaen Monmouth Powys Other All Gwent Gwent medical 117 121 96 82 77 1 7 501 Intermediate surgical 2 1 2 1 2 1 0 8 Care and/or Non-acute 119 122 98 83 79 1 7 509 total Provided as 38 39 31 26 25 0 2 162 NHS etc beds places at-home 81 83 67 57 54 1 5 347 119 122 98 83 79 1 7 509 total places Clinical Futures: Gwent

  14. Joint Partnership Sub-Group • 5 LHB CEOs, Trust CEO and 5 LA CEOs • Aims: to develop better services along whole patient journey through closer working. To find better way of supporting people who end up needing Continuing Care • Frailty Pathway chosen • Gwent wide multi-agency, multi-professional workshop held April • Task and Finish Groups to expand /develop ideas.

  15. Membership Chair – Alison Ward, CEO, Torfaen LA LA reps (social care) LHB reps Trust Corporate and Divisional reps Voluntary sector GP Ambulance Work Streams Independent Living and Reablement Urgent Response and Intervention Capacity and Financial Modelling Frailty Programme Board

  16. Frailty Syndrome • Frailty = (Dependency x vulnerability x co-morbidity) + (Environmental x social factors)

  17. What is it? Physical characteristics Multidimensional Weakness Slowness Poor endurance Weightloss Physical inactivity Socio-demographic Biomedical Functional Effectiveand cognitive components

  18. PREVENT/ DELAY ADVERSE OUTCOMES PROVIDE CARE PREVENT FRAILITY DELAY FRAILTY FRAILTY MODIFIERS Biological Psychological Social

  19. Prevalence of Frailty 3 or more of the outcome Source: Census 2001

  20. Happily Independent

  21. What we stand for:Principles & Values The underpinning principle of theGwent FrailtyProgrammeis to provide: ‘Help when you need it to keep you independent’ The mantra for those delivering services is to provide help that is Sustaining independence.

  22. Outcomes:What frail people tell us they want • Be able to remain living in their own home with support • Receive services in their home • Be listened to by people who are responsible for providing services to assist them • Have their health and social care problems solved quickly and considered as a whole rather than individually.

  23. Frail Elderly Workforce Skills Matrix Specialist Health Care Skills Social Care Skills Health Care Skills Generic Worker Skills Specialist Social Care Skills

  24. Generalist as the New Specialist(Intermediate Care) • GP’s Changing Roles • Geriatrician Changing Roles • AHP’s Changing Roles • Training In The Community

  25. Community Nursing Service • Based on Nursing Strategy: Wales (Coordination of care) • 24 hour Nursing cover in each locality • Overnight on call nursing service including Twilight nursing • Key role in early identification & proactive care of frail clients

  26. Common Service Characteristics (I.C)

  27. Components 1 Medical assessment 2 Assessment of functioning 3 Psychological assessment Social assessment Environmental assessment Elements Co-morbid conditions Medication review Nutritional status Activities of daily living Gait and balance Mental status Assessment of needs, assets and resource eligibility Home safety, transportation and tele-health Components of Comprehensive Needs Assessment

  28. Proposed Locality Structure Joint Chair: Director of Social Services Locality Manager (Health) Members: Project Manager Human Resource Finance Intermediate Care Consultant General Practitioner Lead Nurse Voluntary Sector Co-opted Members: Pharmacist, Mental Health, Therapies, CHC

  29. Urgent Response & Intervention Comprises of three key elements: • Urgent Comprehensive Assessment (Health & Social Care) • Rapid Response Intervention (health) • Social Care Crisis Intervention

  30. Proposed Capacity Model (Crisis Management) • Aims • Better management at home or in a community setting. • Engagement with care homes and the independent sector. • Management of patients in Accident & Emergency • Patients handed over to DN teams on discharge from service • Main Functions • Assessment of 200 new patients per month for acute exacerbations of chronic conditions and associated disorders. • Follow-up of 200 patients per month. • 7-day presence in A & E and MAU to assess patients and prevent admissions, pulling them back into the community, as required. • Daily Hot Clinics for each borough, run by ACAT/RRT for the provision of advice for GPs. • Formal links with other specialties, including General Medicine, Falls, Trauma & Orthopaedics. • On-going management of patients at home for a 5 – 7 day length of stay (care package) • The Gwent-wide combined team of ACAT, Rapid Response and PATH to provide around 70 virtual beds across Gwent.

  31. Staffing Model(Crisis Management) • Based on population of 70-90k • 1 wte Consultant Specialist • 2 wte Staff Grades or GPswSI (salaried GPs) • 4 wte Band 7 • 10 wte Band 6 • 3 wte Band 4 Reablement Officers • 1 wte Band 6 OT for Reablement • 1 wte Social Worker • Approx 50 wte generic Health & Social Care Support Workers, and/or Rapid Access to Immediate Home Care • 1 wte Secretarial Staff and 2 wte Typists shared with the Reablement Team

  32. Independent Living & Reablement • Approximately 6 weeks coordinated review and reablement to sustain independence • Rapid access to equipment and minor adaptations • Care & Wellbeing Workers able to work across the different elements of the integrated locality team

  33. Proposed Capacity Model for Locality Reablement Teams (1) Based on 70-90k population • 5 WTE Occupational Therapists (able to work across ACAT, PATH and Reablement) • 5 WTE Physiotherapists • 50 Band 3 Generic Support Workers* • 2 WTE Case Managers (role needs to be clarified) • 2 WTE Social Workers * Proportion of generic support workers up-skilled to perform some functional assessments? Shared resources: • IT officer • Training and Development officer • Administrative Support • Hot clinics for Falls, Gen Med and Orthopaedics

  34. Proposed Capacity Model for Locality Reablement Teams (2) Sessional support from: • 2 WTE Dieticians • 2 WTE Speech and Language Therapists • 2 WTE Psychiatric Liaison Nurse (1 for older people, 1 for younger people) • Podiatrist – unable to quantify because many clients using private • 1 WTE Community Pharmacologist attached to PATH and Reablement

  35. Implementation Workstreams • Communication & Stakeholder Engagement • Workforce Planning • Governance & Structure • Outcome Indicators, Performance and Continuous Improvement • Information sharing & Single Point of Access • Locality Planning(including longer-term care and interfaces with other services) • Financial Modelling/ Building the Business Case

  36. Communication & Stakeholder Engagement Workstream lead: Dr Liam Taylor • Development of a communication strategy for all key stakeholders Specific programmes of work – a. Stakeholder Briefings b. Staff Communication c. Public Engagement d. Power Brokers (Politicians and Executive Key Members)

  37. Financial Planning Workstream lead: Nigel Stephens Use the outputs from the other workstreams to: • confirm demand • map capacity • identify the resource gaps • calculate the financial requirements • Set up pooled budget arrangements

  38. Locality Planning (including longer-term care and interfaces with other services) Workstream lead: Jo Williams • Support planning for preventative services and delivery at locality level • Ensure that core standards are met and outcomes achieved. • Key Aims: a. Each locality sharing innovation b. Joint problem solving c. Work through operational challenges d. accessing expertise

  39. Information Sharing & Single Point of Access Workstream lead: Jayne Griffiths • Single Point of access • Information System and Develop agreed information sharing protocols • Develop safe means of electronic transfer

  40. Outcome Indicators, Performance & Continuous Improvement Workstream lead: Angela Jones Use the Outcomes-Based Approach. Happily Independent:(5 key elements) • Be able to remain living in their own home with support • Receive services in their home • Be listened to by people who are responsible for providing services to assist them • Have their health and social care problems (holistically) solve quickly • Have a general good health

  41. Governance & Structures Workstream Lead: Bobby Bolt • Agreed standards and protocols • 3 Groups of work: a. Clinical accountability b. Operational issues c. Clear lines of management (professional and regulatory issues)

  42. Workforce Planning Workstream lead: Kevin Barber Challenges: To Integrate - a. 6 organisations b. 9 professional groups Key Aims: a. Harmonising the structure (extremelly complex) b. Managing the transition c. Managing multi-agency staff groups (responsibility, accountability, training and development)

  43. Next Steps Capacity Plan Service Model Plan Workforce Plan Capacity Plan Service Model Financial Plan Workforce Plan

  44. Resource Package • Wanless funds (WAG) – Approx £5million:2004 • Public Service Committee (Chaired by Finance Minister – Wales): £60million over 2009/10 and 2010/11 (Scheme: Invest To Save) 3. Transitional cash required: £20million (Fund new teams and manage additional capacity) 4. Over time: ● Shifting of resources from Secondary to Primary Care ● ? Nursing and Residential Purchasing Budgets ● Continuing Care Budget

  45. Current Situation 1

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