Intermediate Care In Wales April 2008!

1. Intermediate Care In WalesApril 2008! Dr Pradeep B Khanna MBE MB FRCP- Consultant Physician/Chief of Staff, Community Services & COTE/ Lead Clinician Stroke Care

2. Intermediate Care in England Prof JOHN YOUNG Head, Academic Unit of Elderly Care & Rehabilitation Bradford Hospitals & Leeds University, UK john.young@bradfordhospitals.nhs.uk

3. Why do we need intermediate care ? • Provide high quality service with better outcomes • Too many older people • Too many older people in hospital • Too many of the wrong sorts of older people in hospital • Demand to contain or reduce hospital costs = reduce length of stay An opportunity to design better services for older people

4. PROFESSIONAL RESPONSE TO INTERMEDIATE CARE “I’m going to keep my eyes tightly closed until this nasty intermediate care thing has blown over”

6. STANDARD – Intermediate Care is established as a mainstream, integrated system of health and social care which: Enables older people to maintain their health, independence and home life; Promptly identifies and respond to older peoples health and social care needs, helping to avoid crisis management and unnecessary hospital or care home admission; Enables timely discharge or transfer, promoting effective rehabilitation and independence. National Service Framework for Older People in Wales. (March 2006) Welsh Definition of Intermediate Care

7. AIMS OF INTERMEDIATE CARE • Responding to, or averting, a crisis • Admission prevention • 2. Active rehabilitation following an acute hospital stay • Early discharge • Where long-term care is being considered • Prevention of long term care • Chronic long term Conditions Management. • Expert patient programme and assistive technology

8. Integrated approach to local planning, commissioning, delivery and evaluation Early discharge or admission prevention Actions based on rapid comprehensive unified assessment and response Maximises independence with force on rehabilitation Multi-agency working –integrated teams supported by sound, network and governance Service Characteristics of Welsh Intermediate Care All components needed

9. Development of Intermediate Care

10. HOW MUCH INTERMEDIATE CARE DO I NEED ?

11. "The answer to life, the universe and everything......." 45%

12. I.C. CAPACITY Needs assessment survey in Medway & Swale (pop=372,000) Census of pts in DGH+CHs+DH+rehab centre+IC services N=871 pts…. of whom 395 (45%) in need of an IC service Clinical futures (gwent) • inpatients 634/2082 (30.45%) • I.C – 35% NHS facilities; 65% community

13. A RATHER SCARY BUSINESS Its all about integration 45% is a very big number! BUT, although size matters It’s NOT the only thing that matters

14. Summary of RCT Evidence for Intermediate Care Service Models (*Cochrane Reviews) • Nurse-led Units*10 trials? Increase mortality • (n=1,896) Increase overall LOS • Day hospital*12 trialsEffective but expensive • (n=2,867) • Care homes1 trialShift costs to social care • (n=165) • Community Hosp1 trial Cost effective • (n=490) • Hosp-at-home* >20 trials3 separate Cochrane reviews

15. 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

16. Hospital-at-Home v In-patient Care (RCTs) Reduction in hospital stay (days) for elderly medical patients But does this mean we are going to save money?

17. Hospital-at-Home Intermediate Care: Three conclusions………………………. 1. Limited RCT evidence base • 2. Flexible type of service: • Different patients groups • Early discharge and admission avoidance 3. Can reduce hospital bed use improve outcome (better ADL’s, reduce whole system costs and be cost-effective system of care BUT…. not always……….

18. Evaluation of Leeds city-wide I.C. service: “Before” & “After” study (n=1,648) Frail patients: acute E.C. admissions with “geriatric giants” Only 29% pts received I.C. over 12 months Lack of service integration NEADLI.C. ptsControls score changes (n=246) (n=246) 3months: -1.39 6months: -1.92 12months: -2.79 -2.44 -2.63 -3.26 Beds days used over 12 months = +8 days for I.C. group Young et al. Age & Ageing 2005; 34: 577

19. Bradford, UK Community Hospital StudySingle centre RCT (n=220) of CH v Acute Hospital Geriatric Dept care for patients with “Geriatric Syndromes”CH was locality-based (population of 92,000)CH provided I.C. as an early discharge service Findings: • Greater functional independence at six months Community Hospital • Improved patient experience of hospital care • Cost-effective Brit Med Journal 2005 & 2006

20. Early discharge service using a community hospital: the sooner the better? Integration • Secondary, pre-planed analysis (n=220) • Changes in Nottingham extended ADL baseline to 6 months Main reason for transfer delays was administrative Observed trial treatment effect largely due to early transfer group of patients

21. Multi-centre RCT of post-acute care in community hospitals (5 Gen Hosp; 7 CHs; n = 490) Conclusions: • Rehabilitation in the CHs was associated with a statistically significant improvement in medium term (6 month) independence outcomes – better EADL • CH associated with trends to fewer “poor” outcomes • Patient/carer experiences favour CH • Affordable cost……yes; £17,000 per (QALY) • Young et al; JAGS 2007; 55; 1995 • O’Reilly et al; Age Ageing (in press)

22. Economic study 6 month results Societal perspective for health care affordability in England is responsibility of the National Institute for Health and Clinical Effectiveness (NICE) Health care systems and technologies considered affordable when ICER less than £30,000 Therefore in English NHS……..community hospital post-acute rehabilitation care would be considered cost-effective

23. Integrated Intermediate Care Model (Gwent) Palliative care Joint day care Neuro degenerative COPD 1. Chronic disease mgt- Stroke Cardiac failure Wound mgt Path Continence Steering Board (tri-partite) Health, social services, LHBs Operational Team (Operational Manager) + Consultant Doctor, Consultant Nurse, Senior Social Worker Consultant Rehabilatationist = Admission avoidance = Early supported discharge = Chronic long terms conditions mgt Single point of referral = Independent living within the community 2. Chronic conditions mgt- Expert patient scheme Rapid response Reablement District nursing (generalist role) Chronic conditions specialists Assistive technology/ smart houses ACAT Community hospitals Frailty care model Mental Health (dementia) Generic Support Workers (Multi-disciplinary)

24. Level 1 services model - process Palliative care Joint day care Neuro degenerative COPD 1. Chronic disease mgt- Stroke Cardiac failure Wound mgt Path Continence Referral: Primary, secondary, social services, ambulance Single point of referral = Admission avoidance = Early supported discharge Unified comprehensive assessment = Chronic long terms conditions mgt = Independent living within the community 2. Chronic conditions mgt- Expert patient scheme Rapid response Reablement District nursing (generalist role) Chronic conditions specialists Assistive technology/ smart houses ACAT Community Hospitals Mental Health (dementia) Frailty care model Generic Support Workers (Multi-disciplinary)

25. Gwent Schemes (I.C)

26. Activity Figures: Non Elective: Adult Medicine (Since 1999 till 2008 = 53% increase) Reduction Of 90 Community Hospital Beds

27. Evidence-base for Intermediate Care: Conclusions………………………. 1. Limited RCT evidence base 2. Most evidence for early discharge form of I.C. 3. Evidence for HaH and CH intermediate care encouraging organisational factors are critical to success & clinical governance systems are needed to monitor outcomes BUT….