Case Management, Case Management, Admissions, Discharges & Admissions, Discharges &

Time Release SavingsTime Release Savings

Paul LeakPaul LeakSimon SteerSimon Steer

Development PathDevelopment Path

Delayed Discharge Delayed Discharge Performance….VariablePerformance….Variable

Emergency Elderly Admission Emergency Elderly Admission Rates…VariableRates…Variable

Historic Investment Patterns…Historic Investment Patterns…VariableVariable

Development RoadDevelopment Road

Long Term ConditionsLong Term Conditions Nairn Case FinderNairn Case Finder Implications For Elderly Care Implications For Elderly Care

Programme Programme and now… Time Release and now… Time Release

SavingsSavings

Delayed Discharge Delayed Discharge 2005/06 Performance2005/06 Performance Target 34; Actual 10Target 34; Actual 10 Six Week Target 19; Actual 3Six Week Target 19; Actual 3 Acute Target 5; Actual 2Acute Target 5; Actual 2 Max Wait 56 daysMax Wait 56 days 384 patients……384 patients……29,582 bed days!29,582 bed days! …….the wrong targets?.the wrong targets? 2004/052004/05…… 264 patients; 27,629 bed days! 264 patients; 27,629 bed days!

90% of Delayed Discharges were Elderly 90% of Delayed Discharges were Elderly Emergency AdmissionsEmergency Admissions

Explanation?Explanation?

The system is moving faster….The system is moving faster….But only to deal with more people But only to deal with more people

being admitted.being admitted.

Match Practice data with Match Practice data with Hospital utilisation data to Hospital utilisation data to predict unplanned admissionspredict unplanned admissionsAge/Sex/Behaviour: GPASSAge/Sex/Behaviour: GPASSChronic Disease Registers: Chronic Disease Registers: GPASSGPASSHospital Admission/Attendance Hospital Admission/Attendance data: PASdata: PASLogistic regressionLogistic regressionAlgorithm Algorithm Probability of admission in next Probability of admission in next twelve monthstwelve months

Lodgehill CasefinderLodgehill Casefinder

Lodgehill CasefinderLodgehill CasefinderROC CurveROC Curve

Area under ROC curve = 0.7943

Se

nsi

tivi

ty

1 - Specificity0.00 0.25 0.50 0.75 1.00

0.00

0.25

0.50

0.75

1.00

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Proportion of patients (%)

Adm

issi

ons/

FCE/

OBDs/

Cos

t

Patient admissionsFCE admissionsBed daysAdmission cost

Lodgehill FindingsLodgehill Findings

CD patients responsible for:CD patients responsible for: 66% Emergency Admission bed days66% Emergency Admission bed days 62% of Emergency Admissions62% of Emergency Admissions 82% Elderly Emergency admissions82% Elderly Emergency admissions

Odds ratio for Emergency admission=3.01 (2.95-3.07)Odds ratio for Emergency admission=3.01 (2.95-3.07)

CD Prevalence:CD Prevalence: 25% of list have CD25% of list have CD 16%<65 years16%<65 years 63%>65 years63%>65 years 78% of DD patients had CD78% of DD patients had CD

Working Hypothosis On Working Hypothosis On CaseloadsCaseloads A 75% match between referral A 75% match between referral

and nomination processes?and nomination processes? Top 101 will be present due to Top 101 will be present due to

complexity/level/cost/fluctuating complexity/level/cost/fluctuating need?need?

The patient care may be led by The patient care may be led by either service, but is likely to either service, but is likely to appear on both caseloads?appear on both caseloads?

Lodgehill FindingsLodgehill Findings

Presence on Community Nursing caseload of Top 101

9

2468

Community Psychiatric NursingCommunity NursingNot Known

Lodgehill FindingsLodgehill Findings

Presence on SW caseload of Top 101

51

24

26

OpenClosedNot Known

Lodgehill FindingsLodgehill Findings

Top 101 as proportion of Nairn SW caseload

92%

8%

OtherTop 101

Lodgehill FindingsLodgehill Findings

Open Cases by Type of Worker

61%

35%

4%

Care AssessorSocial WorkerOccupational Therapist

Admissions From CPN Admissions From CPN CaseloadCaseload

Admissions From CPN caseload

93%

7%

Not admitted

Admitted

Admissions From SW Admissions From SW CaseloadCaseload

2005/06 Admissions from SW Caseload

24%

76%

Admitted

Not Admitted

%CPN Caseload %CPN Caseload By Risk ScoreBy Risk Score

0%

35%

70%

Perc

enta

ge o

f Clie

nt G

roup

0 to 0.

05

0.06 t

o 0.10

0.11 t

o 0.15

0.16 t

o 0.20

0.21 t

o 0.25

0.26 t

o 0.30

0.31 t

o 0.35

0.36 t

o 0.40

0.41 t

o 0.45

0.46 t

o 0.50

0.56 t

o 0.60

Risk Score

Nairn Community Mental Health Team Percentage of Caseload by Risk Score

Social Work CaseloadSocial Work Caseload

Risk Distribution of Social Work Case Load - Percentage

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

0.00to

0.05

0.05to

0.10

0.10to

0.15

0.15to

0.20

0.20to

0.25

0.25to

0.30

0.30to

0.35

0.35to

0.40

0.40to

0.45

0.45to

0.50

0.50to

0.55

0.55to

0.60

0.60to

0.65

0.65to

0.70

0.70to

0.75

0.75to

0.80

0.80to

0.85

0.85to

0.90Risk

Perc

enta

ge

The Patient QuizThe Patient Quiz

MaleMale 51years51years No admissionsNo admissions No Chronic No Chronic

diseasedisease Moderate Moderate

drinker and drinker and withdrawing withdrawing smokersmoker

Risk 1.4%Risk 1.4%

FemaleFemale 72 years72 years Asthma, COPD, Asthma, COPD,

CHD and LVDCHD and LVD MarriedMarried Ex smoker and Ex smoker and

TTTT 4 admissions 4 admissions

2005/62005/6 Risk 74%Risk 74%

Questions and ConfoundersQuestions and Confounders

Is a low score a measure of Is a low score a measure of prevention?prevention?

Is an admission the trigger Is an admission the trigger stopping subsequent stopping subsequent admission?admission?

What doesn’t get picked up; eg What doesn’t get picked up; eg behaviour issues?behaviour issues?

What about carers?What about carers?

Resource Use IssuesResource Use Issues

How complex are the needs?How complex are the needs? Who is carrying the case?Who is carrying the case? Is it being reviewed?Is it being reviewed? Is resource being freed and Is resource being freed and

targeted?targeted? Eligibility for service?Eligibility for service?