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Objective: Reducing Emergency Hospital Admissions

Objective: Reducing Emergency Hospital Admissions. Emergency Hospital Admissions: Risk Factors. Age (Babies/very young and older people) Social Deprivation Morbidity (1 or more long term conditions) Area of residence Ethnicity Social factors (Including social isolation)

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Objective: Reducing Emergency Hospital Admissions

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  1. Objective: Reducing Emergency Hospital Admissions

  2. Emergency Hospital Admissions:Risk Factors • Age (Babies/very young and older people) • Social Deprivation • Morbidity (1 or more long term conditions) • Area of residence • Ethnicity • Social factors (Including social isolation) • Environmental factors • Tools do exist to predict an individuals risk of hospital admission and help us target interventions E.g. RAIDR

  3. Better Care Fund: Context • Context: • Increasing demand for health and social care services: • Ageing population • Increasing number of people with one or more long term condition • Increasing number of avoidable emergency admissions to hospital • Increasingly complex care packages • Integrated care – can lead to improved outcomes, improved quality of care and efficiencies • Pooling health and social care resources can help to facilitate integration

  4. What is the Better Care Fund? • Announced in June 2013 • Previously known as the Integration Transformation Fund • Pooled budget across CCG and Local Authority • Funding to be spent on health and social care services based on an agreed plan between the NHS and LA’s • BCF plans to be signed off by Health and Wellbeing Boards • BCF plans are an integral part of the CCG strategic and operational plans • Aims: • closer integration of health and social care services • Improved outcomes for patients, service users and carers

  5. The Stockton Better Care Fund • Aim: to provide integrated services and pathways of care that help people to stay at home, avoid hospital admission and remain independent for as long as possible • Stockton BCF focuses on: • redesigning health and social care services for older people (with a focus on over 65 year olds). By developing integrated Multidisciplinary teams who undertake: • targeted early interventions and preventative approaches • effective crisis management • improving pathways of care for people with dementia - building on the work of the local Dementia Collaborative

  6. What could VCS organisations do to support this work? • Targeted interventions for those at highest risk of admission. Focused on the following areas: • Self-care: supporting those with Long Term Conditions to manage their own condition. Evidence shows this is most effective for some conditions such as COPD and may include: • Education programmes • Telephone health coaching • Encouraging healthy lifestyles • Support for informal care givers

  7. What could VCS organisations do to support this work? Cont’d… • Preventing social Isolation and loneliness to help maintain independence • Identifying people who are lonely / isolated • One-to-one support including Befriending • Group activities • Support with transport • Supporting falls prevention • Identifying people at risk of falls • Strength and balance training • Home hazard assessment and intervention • Referral for a falls assessment • Post discharge support • Supporting people to return home / and remain in their own homes following a hospital stay

  8. Possible measures of success • Reduced avoidable emergency admissions • Reduced admissions to long term care • Improved discharge from hospital (reducing delayed transfers of care) • Maximising the effectiveness of re-ablement to prevent re-admissions to hospital and maximise an individuals independence • Improved patient /service user experience • Improvements in self reported wellbeing (measured via an agreed tool) • Reduced loneliness and isolation • Increased fall risk assessments and reduced falls • Improved support for carers • Increasing the number of people diagnosed with dementia • Using the NHS number wherever possible to support evaluation of projects and support future working

  9. Sources of further information • Preventing loneliness and social isolation among older peoplehttp://www.scie.org.uk/publications/ataglance/ataglance60.pdf • Evidence Summary: Making best use of the Better Care Fund. http://www.kingsfund.org.uk/publications/making-best-use-better-care-fund

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