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Frailty Concept/ Hospital without Walls
Professor Pradeep Khanna MBEChief of Staff, Community Services
Aneurin Bevan Health Board
Commissioning & Care Planning
• Strategic Planning
• Specify Outcomes
• Develop Business Case
• Procure Services
• Manage Demand
• Maintain Performance
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)
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
WHO has identified that chronic conditions will be the leading cause of disability and death by 2020
Targets
Reduce number of emergency bed days by 5%
• Analysis of NHS use indicates that effective chronic disease management presents significant scope to reduce avoidable hospital admissions
• For patients with more than one condition the costs are six times higher than people with only one
Drivers For Change
1. Wanless Report: Hard hitting facts about Health Services in Wales
2. Designed for life: Strategic framework: Health & Social Care Services in Wales
3. Fulfilled lives, Supportive Communities: Emphasis on Social Care
4. Making the connections [Public involvement & redesign services around the needs of the users]
5. Primary Care & Community Services Strategy (Chris Jones)
HOSPITALBASED CARE
PRIMARY CARE
OOH
FRAGMENTED AND DISORGANISED COMMMUNITY BASED CARE
PUSH
PUSH
Current System of Care “Push System full of Black Holes”
AE
DISCHARGE
INCREASING DEPENDENCY
INCREASING COMPLEXITY
DECREASING FUNCTIONALITY
Patient journey
NH RH
NHSDPARA MED
Local government
FIT
FRAILDEPENDENT
INDEPENDENT
HEALTH SOCIAL
COM
NURSE
TMS
HOSPITALBASED CARE
AS
SE
SS
DIR
EC
T
PRIMARY CARE
OOH
ORGANISED SYSTEM OF INTERGRATED COMMUNITY SERVICES
PULL
PULLPULL
PULL
SHARED INFORMATION BASED ON GP RECORD
Future System of Care “Seamless Pull System with Integrated Access to Information”
Locnet
Patient journey
COMSHUB
Resourceteam
Primary Care Support Unit
COM
NURSE
TMS
Hospital-at-Home: definition………
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
Hospital care but delivered in the person’s own home !!!
Admission AvoidanceHospital at Home/Inpatient Care
(Review)
[Systematic Review & Meta Analysis]
1. Mortality at 3 months NS (P= 0.15)2. Mortality at 6 months Significant (P=0.005)3. Readmission Rates NS (P=0.08) (within 3 months)4. 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
Hospital at Home
1. CLINICAL OUTCOME: (Adverse Events & Medical Complications)
a. Bowel Complications = 22.5% (96% C.I = 34% to 10.82)
b. 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
d. COPD = Antibiotic = 18% (95% = 34.6% to 1.4%)
2. 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)
4. CONCLUSION: Admission Avoidance Hospital at home can provide an effective
alternative for selected group of Patients (Outcome Similar)
Early Supported Discharge Teams Vs Conventional Care11 Trials (6 countries)
Outcome Patients randomised Summary result
(95% CI)
P Values
Patients’ outcomes
Death or dependency 1597 0.79 (0.64 to 0.97) 0.02
Death or institution 1398 0.74 (0.56 to 0.96) 0.02
Extended ADL Score 1051 0.12 (0 to0.25) 0.05
Satisfied with outpatient services
513 1.60 (1.08 to 2.38) 0.02
Carer outcomes
Subjective health status score
613 0 (-0.25 to 0.24) 0.97
Satisfied with outpatient services
279 1.56 (0.87 to 2.81) 0.14
Resource outcomes
Length of hospital stay 1015 -7.7 (-10.7 to - 4.2) <0.0001
Readmission to hospital 633 1.14 (0.80 to 1.63) 0.48
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
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
Very expensive
Shifts costs to social care
Expensive
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
Clinical Futures: Gwent
Newport Caerphilly Torfaen
Blaenau
Gwent
Monmouth Powys Other All Gwent
medical 117 121 96 82 77 1 7 501
surgical 2 1 2 1 2 1 0 8
total 119 122 98 83 79 1 7 509
38 39 31 26 25 0 2 162
places at-home 81 83 67 57 54 1 5 347
total places 119 122 98 83 79 1 7 509
Intermediate
Care and/or
Non-acute
Non-acute beds and
places required by LHB
2014-15 with new MoC
NHS etc beds
Provided as
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.
Frailty Programme Board
• 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 Syndrome
• Frailty = (Dependency x vulnerability x
co-morbidity)
+
(Environmental x social factors)
What is it?
Physical characteristics Multidimensional
• Weakness• Slowness• Poor endurance• Weight loss • Physical inactivity
• Socio-demographic• Biomedical• Functional• Effective and cognitive
components
PREVENT
FRAILITY
DELAY FRAILT
Y
PREVENT/ DELAYADVERSE OUTCOMESPROVIDE CARE
MODIFIERSBiological
PsychologicalSocial
Age 65-69 70-74 75-79 80-84 85+
%Frailty 18.3 21.7 32.1 32.5 48.8
Estimated numbers of frail elderly people by Local Authority Estimated Total
Blaenau Gwent 604 621 838 563 646 3275
Caerphilly 1399 1402 1816 1154 1231 7002
Monmouthshire 784 825 1043 695 864 4211
Newport 1127 1222 1472 1085 1156 6062
Torfaen 797 844 1105 683 712 4141
Total by age band 4177 4914 6274 4180 4609 24154
Prevalence of Frailty 3 or more of the outcome
Source: Census 2001
Happily Independent
What we stand for:Principles & Values
The underpinning principle of the Gwent Frailty Programme is 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.
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.
Specialist Health Care Skills
Social Care Skills
Health Care Skills
Specialist Social Care Skills
Generic WorkerSkills
Frail Elderly Workforce Skills Matrix
Generalist as the New Specialist(Intermediate Care)
• GP’s Changing Roles
• Geriatrician Changing Roles
• AHP’s Changing Roles
• Training In The Community
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
Common Service Characteristics (I.C)
Urgent Response & Intervention Reablement & Independent Living
ACCESS Via locality Single Point of Access Via locality Single Point of Access
HOURS OF OPERATION 7 days a week 365 days a year 8am to 10pm 7 days a week 365 days a year 8am to 8pm
RESPONSE TIME 2-4 hours (for both health and social care components)
24 hours
ASSESSMENT Comprehensive Needs & Frailty Index Assessment
Agreed shared assessment document
SERVICE PROVISION Management/Hospital @ Home upto 14 days Approximately 6 weeks reabilitation and reablement
support
No charge to user for first 6 weeks
ACCESS TO ‘Hot Clinics’ for rapid access to specialist and diagnostic support (Monday to Friday)
Specialists including psychology, dietetics, pharmacy, speech &
language therapy, podiatry, EMI teams.
Rapid access to equipment and adaptations.
WORKFORCE Flexible Health & Social Care Workforces Flexible Health & Social Care Workforces
Components of Comprehensive Needs Assessment Components 1 Medical assessment
2 Assessment of functioning
3 Psychological assessment
4 Social assessment
5 Environmental assessment
ElementsCo-morbid conditionsMedication reviewNutritional status Activities of daily livingGait and balance
Mental status
Assessment of needs, assetsand resource eligibility
Home safety, transportation and tele-health
Proposed Locality StructureJoint Chair: Director of Social Services
Locality Manager (Health)
Members: Project ManagerHuman ResourceFinanceIntermediate Care ConsultantGeneral PractitionerLead NurseVoluntary Sector
Co-opted Members: Pharmacist, Mental Health, Therapies, CHC
Urgent Response & Intervention
Comprises of three key elements:
Urgent Comprehensive Assessment (Health & Social Care)
Rapid Response Intervention (health)
Social Care Crisis Intervention
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.
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
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
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
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
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
Communication & Stakeholder Engagement
Workstream lead: Dr Liam Taylor
• Development of a communication strategy for all key stakeholders
Specific programmes of work –a. Stakeholder Briefingsb. Staff Communicationc. Public Engagementd. Power Brokers (Politicians and Executive Key Members)
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
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
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
Outcome Indicators, Performance & Continuous
ImprovementWorkstream lead: Angela Jones
Use the Outcomes-Based Approach.Happily Independent:(5 key elements)1. Be able to remain living in their own home with
support2. Receive services in their home3. Be listened to by people who are responsible for
providing services to assist them 4. Have their health and social care problems
(holistically) solve quickly5. Have a general good health
Governance & Structures
Workstream Lead: Bobby Bolt
• Agreed standards and protocols• 3 Groups of work:
a. Clinical accountabilityb. Operational issuesc. Clear lines of management
(professional and regulatory issues)
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)
Next Steps
Service Model
Capacity Plan
WorkforcePlan
Plan
Service Model
Capacity Plan
WorkforcePlan
FinancialPlan
Key Milestones
Business case submitted by October 2009
Groundwork from workstreams completed by end of March 2010
First locality ready for roll out April/May 2010
Implemented in all localities by end of March 2011
Resource Package1. Wanless funds (WAG) – Approx £5million:2004
2. 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
Current Situation 1
Locality Frailty care model
(DGH)
Co-located teams
Single point of referral
Community Consultant
Caerphilly +- - - +Newport +- +- - +Torfaen +- + - +Blaenau Gwent + - - -Monmouthshire + - - -
Current Situation 2*Referral criteria variable in all 5 localities.
Locality Consultant operational team
Primary and secondary interface
Rapid response
ACAT Reablement
team
Formal GP involvement
Caerphilly +- + + - + -
Newport +- +- + - + +-Torfaen +- +- + + + +-Blaenau Gwent +- +- + - + -Monmouthshire - - +- - + -
Activity Figures: Non Elective: Adult Medicine (Since 1999 till 2008 = 53% increase)
6.5
6.3
5.7
5.2
7.1
8.2
8.0
8.4
7351
9261
10728
11336
(+54%)
Since 2000.
12902
14053
14046
13615
(+5.5%)
Since 2000.
1999-2000
2002-2003
2005-2006
2007-2008
LOS NHHLOS RGHNHHRGH
Reduction Of 90 Community Hospital Beds
Performance Indicators
As per Frailty Programme Work stream and including:• Pre-crisis Assessment (CGA): 100% offered within 28 days• An episode of crisis requiring hospitalisation should normally require
no more than 72 hours in hospital• Service responses will be delivered within agreed time limits• 50% of frail older people will be managed in the community during
an episode of crisis• 80% of frail older people with a social crisis will be maintained at
home• 75 % of rehabilitation services for frail older people will be based
and delivered in the community.• Assessment of equipment needs delivered within 24 hours • Equipment provided within 72 hours of assessment
Locality Steering Board (tri-partite)Health, social services, LHBs, voluntary sector
Operational Team (Operational Clinical Team)+
Consultant Doctor, Consultant Nurse, Senior Social WorkerConsultant Rehabilatationist
Single point of referral
= Prevention of admission
= Early supported discharge
= Chronic long terms conditions mgt
Integrated Intermediate Care (frailty) Model (Gwent)
Generic Support Workers (Multi-disciplinary)
Path ContinenceCardiac failure
1. Chronic disease mgt-
Joint daycare
Palliative care
Wound mgtStroke
COPD
Neuro degenerative
Rapid response
Chronic conditions specialists
ACAT
Reablement2. Chronic
conditions mgt-
Mental Health
(dementia)
Expert patient scheme
District nursing (generalist role)
Community hospitals
Frailty care model
Pan-Gwent Intermediate Care (frailty) Steering BoardChief Executives- Trust, LHB, LAs
Mental Health Teams
Care support/ respite care
Self care
Assistive technology/
smart houses
= Independent living within the community
Roles-1) Standard setting2) Uniformity of service
across Gwent3) Performance
management4) Financial
management
= Continuing care + transport
Social crisis mgt
Co
ntin
uin
g care
Tran
spo
rt
Paul WilliamsDirector General, Health & Social Services
Chief Executive, NHS Wales
I want the service to focus on:
• Changing behaviour not structures;• Collaboration not confrontation;• Planning not commissioning;• Whole systems not hospitals;• Clinical engagement;• Partnership working; and• Wellness not illness
(1st October 2009)