Anticipatory Care Planning
Dr Anne Hendry National Clinical Lead for Integrated CareJoint Improvement Team
Anticipatory Care Planning Self Management
Top Ten Improvement Actions
Risk prediction in primary care
Case / Care Management
Anticipatory Care Planning
Support for Self Management
Intermediate care
Telehealth and Telecare
Reablement and Rehabilitation
Medicine reconciliation & pharmaceutical care
Reduction in delayed discharge
Hospital pathways for frailty and delirium
14% reduction in rate of hospital bed days 06/07 – 10/11
Prevention and Health Improvement
Emergency
admissions
Acute
sectorVery High
Lower risk
Medium risk
High risk
LTC Collaborative
SPARRA Tool
Outpatient(1 year)
Emergency Department(1 year)
Prescribing (1 year)
Outcome Year(1 year)
OUTCOME PERIOD
Hospitalisation(3 years)
PRE-PREDICTION PERIOD
Psychiatric Admission(3 years)
Any recent admissions to a psychiatric unit ?
Any A&E attendances in the past year?
What type of outpatient
appointments did the patient have?
Any prescriptions for e.g. dementia drugs? Or
substance dependence?
How many outpatient appointments?
What age is the patient?
How many previous emergency admissions
has the patient had?
How many prescriptions?
Any previous admissions for a long term condition
(such as epilepsy?
www.isdscotland.org/dhipwww.isdscotland.org/dhip
SPARRA Cohorts
Frail Elderly
All cohorts
Younger ED
LTC
Age
Prescriptions in specific BNF chapters
Deprivation
Alcohol/ substance misuse related admissions
Prescriptions for specific groups of drugs
Psychiatric admissions Deprivation
New OP attendancesPolypharmacy
ED attendances
Emergency bed days
LTC related admissions
Emergency / elective / daycase admissions
Prescriptions/admissions indicating particular conditions
New OP attendances for MH
www.isdscotland.org/dhipwww.isdscotland.org/dhip
Patient Risk Trajectories 2 – Over 75 (Frail Elderly)
www.isdscotland.org/dhipwww.isdscotland.org/dhip
www.isdscotland.org/dhipwww.isdscotland.org/dhip
Patient Risk Trajectories 3 – YED
Lifestyle Interventions
> 60%40 - 60%20- 40%
SPARRA SCORE < 20%
People at moderate risk of emergency admission.
Likely to attend the practice or a nurse specialist for follow up
Their ACP is usually best developed by the GP and the
Practice team
Long Term Conditions
Patients at highest risk of emergency admission to hospital
Likely to be receiving care or managed by the Community Team
Many already have an ACP
Their ACP is usually developed by the Community Team or nurse
specialist involved
Anticipatory Care Continuum of Risk
1st choice for QOF ACP
2nd choice for QOF ACP
People with lowest risk of emergency
admission to hospital.
Likely to need simple information, advice and support to help them to stay well and manage
their conditions
Electronic Key Information Summary
15,000 KIS accessed in October
Feedback from patients
Very happy to share this information with relevant others
Gives confidence when GP surgery closed
Surprised that this was not happening already
No problem as long as information is ‘secure’
Excellent idea
Would not want some sensitive information from medical notes shared with others
What GPs liked
Good breadth of information
Ability to add descriptive text
Easy to use and navigate
Good design and workflow
Structured, concise and easy to fill in
Excellent for sharing info with relevant others
Users in A&E
Information is clear and concise
Would be good if we could also write to KIS rather than read-only
Some of the KISs in pilot were of limited quality
This information could dramatically improve the care we provide
Good that it is not just for palliative care
Anticipatory care information particularly useful
ACP Evaluation
1. Nairn Study: Baker, Leak et al Br J General Practice Feb 2012 RCT with a net saving of £190 per patient for the ACP cohort
2. Highland study of emergency admissions and bed days for older people in care homes and the top 1% risk group living at home 2 cohorts matched for SPARRA risk – 1556 in each cohort
No ACP - emergency admissions and bed days ↑by 51% and 49% ACP - emergency admissions and bed days ↓ by 38% and 49%
3. York Health Economics Report
4. Local Evaluations
What are the things that
matter most to me at this point
in time?
Being more able to understand &
manage my health, condition
or treatment
Being more able to understand &
manage my health, condition
or treatment
Personal Outcomes Maintaining and
enjoying a good
quality of life
Policy Alignment
2020 Vision
Everyone is able to live longer healthier lives at home, or in a homely setting.
> Integrated health and social care, a focus on prevention, anticipation and supported self management.
> When hospital treatment is required, and cannot be provided in a community setting, day case treatment will be the norm.
> Care will be provided to the highest standards of quality and safety, with the person at the centre of all decisions.
> There will be a focus on ensuring that people get back to their home or community as soon as appropriate, with minimal risk of re-admission.
Intermediate Care
Ca
re H
om
es
Community Assessment & Rehabilitation
Respite
Intensive Home Support
Very Sheltered Housing
Assistive Technology
Community Alarms
Home Support
Care Management
Community Health Services
Palliative Care
Continence/Falls Services
Ac
ute
Ho
sp
ital
Servic
es
Community Pharmacy
Carers Support
Integrated Health & Social Care Services
Health Promotion
Sheltered Housing
Locality Link Officers
Activity Programmes
Voluntary Organisations and Supports
Supports & Services for Older People in North Lanarkshire
Locality Planning - Local and Personal
Most people with any long term condition have multiple conditions in Scotland
Guidelines and the current organisation of care do not reflect this reality.
Guthrie B et al, BMJ 2012;345:e6341; Hughes L et al, Age and Ageing 2013;42:62-69
Reshaping Care Pathway
CHILDRENYOUNG PEOPLE
FAMILIES
ADULTS OLDER
ADULTS
PEOPLE AT WORK
Using care pathways
Working with other agencies & disciplines as partners
Strengthening leadership
& team working
Delivering safe, high quality care, treatment & rehabilitation
Improving efficiency & optimising workforce
capacity and capability
Anticipating health
needs & responding
earlier
Promoting health &
addressing inequality
Building workforce capacity & capability
Providing choice &
care in the right
setting
Working with
clients, carers &
patients as partners
Modernising Nursing in the
community
Utilising Telecare & Telehealth technology
Utilising high quality
clinical outcomes
Informing practice
with policy, research & evidence
Enabling and
supporting self care
Developing skills &
knowledge through
education
Effective
Person-centred
Community Services programme
Technology Enabled Integrated Community Team
http://www.knowledge.scot.nhs.uk/chin