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Strategic modelling solutions for unscheduled care
An example using system dynamics and local engagement to address key capacity and planning questions
May 2013
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An introduction to WSP
www.thewholesystem.co.uk 2
Strategy and partnership development in health and social care using simulation and modelling as a key tool;Our business is strategy development and supporting sustainable change – when modelling & simulation helps then we use it (which is quite a lot!).
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System Dynamics
www.thewholesystem.co.uk 3
“The investigation of the information-feedback characteristics of (managed) systems and the use of models for the design of improved organisational form and guiding policy” (Forrester 1961);Characteristics:
Systems thinking - integrative and holistic; Enabled by sharing mental models and group model
building; Understanding ‘cause & effect’ and system behaviour; Exploring behaviour over time, delays and feedback.
Rooted in ‘thinking’ not in ‘data’ – issue focussed – a learning tool relying on iterative learning rather than final answers.
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The world of systems thinking
The spectrum that is ‘systems thinking’……
The Whole Systems Partnership 4
Deterministic – cause and
effect
Fatalistic – the system rules
Philosophical pragmatism – the muddle-
through middle ground
Micro-management
Machiavellian
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The WSP approachDistinctive in that it recognises the tendencies to swing between the extremes, and that within any local group people will lean toward one or the other approach;Distinctive in believing that co-production with local stakeholders and engagement with the issues provides the most likely route to sustainable long term change;We therefore use systems dynamics to strengthen local partnership working rather than to give the right answer – although we are pretty challenging when our analysis and modeling points away from the local consensus!
Whole System Partnership 5
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Unscheduled care in a local DGH
Strategies to address capacity challenges
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Local contextNorth East Lincolnshire is a small health care system serving the town of Grimsby and surrounding rural population of around 170,000 people;The DGH has around 440 beds;Monthly A&E attendances are around 4,500 of which approximately 1,000 are admitted;The Care Trust Plus (the equivalent of the PCT/CCG before April 2013) has already invested heavily in intermediate care services over recent years.
Whole System Partnership 7
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Issue definitionKey issue: How will re-design proposals associated with 1) Emergency
Ambulatory Care Model; 2) Intermediate Tier Diversion at A&E; and 3) earlier discharge impact on DPOW bed requirements & Intermediate Tier/community capacity?
Areas of impact to be explored: Pre-A&E saved admissions (RR/CCM in place); A&E divert to Int Tier through GP/RR presence on Majors
corridor; Emergency ambulatory care saved admissions; Early discharge for people, including but not exclusively
with >28 day LOS.
Whole System Partnership 8
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Factors to be consideredNeed to set in the context of: Underlying demographics; Recent trends in admissions and how they
relate to the above; Historic levels of impact of the intermediate
tier developments; The parallel development of an emergency
ambulatory care model of service and any overlap or potential double-counting.
Whole System Partnership 9
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Model structure & key interventions for redesign
Whole System Partnership 10
Majors
1 Pre-hospital impact of new models of crisis response in community
A&E decision process
2 Divert to Int Tier or other
No ongoing need for treatment or support
Need for treatment or support
GP presence
3 Suitable for Emergency Ambulatory Care
MAU
Specialty Ward
Admit
Discharge
4 Earlier discharge to Int Tier, shortened length of stay
Discharge
GP admission
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Scaling potential for emergency ambulatory care and Int Tier diverts
PAS data DPOW admissions Dec 08 to May 11 supplied by NLAG informatics, average of c.845pw made up of:
Elective 440pw; Obs & Gynae 155pw; Non-elective (and therefore potential for Emergency Ambulatory
Care) = c.250pw (29% of all admissions).
Mapped HRG for non-elective admissions to clinical scenarios based on NHS Institute Directory of Ambulatory Care for adults (version 2, March 2010), potential of c.100pw (15 surgical and 85 medical) – need clinical opinion about the extent to which potential could/would be realised, for each clinical scenario in the local context.
Whole System Partnership 11
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Impact of Emergency Ambulatory care on intermediate tier potential
The 100 potential admissions for EA is split: 15 being surgical (all ages); 25 being medical (<50) 15 being medical (50 to 65); 45 being medical (>65).
Assume that suitability of EA ‘trumps’ suitability for intermediate tier diversion;Non-elective, medical >50 admissions totalled on average 140pw;Medical admissions >50 suitable for EA is 60, therefore potential for intermediate tier divert is c.80pw.
Whole System Partnership 12
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Potential for Intermediate Tier = 140pw less 60
= 80pw
Scaling the potential for emergency ambulatory care and Int Tier diverts
Whole System Partnership 13
Total = 845pw
DPOW PAS data for Dec 08 to May 11, NE Lincs residents, average weekly admission:
Obs & Gynae = 155pw
Elective = 440pw Non-elective = 250pwSurgical = 250pw
Medical = 190pw
Surgical = 70pwMedical = 180pw140pw >50yrs old
Pote
ntia
l for
Em
erg
ency
A
mbula
tory
ca
re
(c.100pw
w
ith 6
0
>5
0)
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Scaling the AEC pathwayClinical review of HRG clinical scenarios that are suitable for AEC, which identified:
The proportion of those deemed suitable for AEC that could be diverted given the current level of services in the community;
Additional services that would need to be in place to optimise the model in NE Lincs;
The proportion of these patients that would also need intermediate care support if not admitted.
53% of admissions within the AEC clinical scenarios were deemed to be divertible equivalent to 43 medical patients a week and 11 surgical;23 patients pw would require follow-up and 5 pw would need AV antibiotics.
Whole System Partnership 14
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Scaling diversion at A&EThe current scheme for diversion to the intermediate tier from the A&E Majors corridor is based on an economic case for 3 diversions per day (operating on M/F, 9-5) or c.15pw;Need to identify the achievability of this ‘target’ through the analysis of the __pw admissions seen in March to May 2011.
Whole System Partnership 15
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Alternative pathways through Int Tier (including initial assumptions)
Whole System Partnership 16
2 Divert from A&E to Int Tier or other support
IC bed
<28 days LOS for
>65yr olds
4 Earlier discharge to Int Tier, shortened length of stay
Home
IC
Ave reduction in LOS of 1
day
10%
IC @ home
50%
50%
Home
>28 days LOS for all patients
42 LOS
Recuperation
21 LOS
Home100%
Diverts not needing Int Tier
Home
40%
Ave reduction in LOS of 20
days
60% RR 25%
75%
Home67%
33%
Home
90%
3 LOS
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Assumptions within the Intermediate Tier
The assumptions on the following pages still need testing and validation through an iterative process between professional/clinical opinion and data gathering;For A&E diversion:
33% of medical admissions with potential for diversion are diverted with the target being achieved gradually over the next 2 years;
40% of these diverts do not need intermediate tier interventions; The remainder receive RR support for 3 days; 25% of these then remain in a recuperation bed facility; Of the remaining 75% one third are admitted to IC (bed or home)
whilst the other two thirds go home.
Whole System Partnership 17
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Assumptions within the Intermediate Tier (contd)
For early discharge: For people currently staying over 28 days these are
discharged on average 20 days earlier and all go to a recuperation bed;
For >65yr olds staying less than 28 days their hospital LOS is reduced on average by 1 day (from 7.25 days) and 10% of this cohort are transferred to IC (bed or home).
Within the Intermediate Tier: Recuperation beds have an ALOS of 21 days; IC referrals are supported 50/50 at home and in a bed; IC at home or in a bed is provided for 6 weeks (42
days).
Whole System Partnership 18
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Model demonstration......
Whole System Partnership 19
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Model outputs – medical beds
2009/10 bed base of 146 beds (with 90% occupancy) would rise to 161 without any enhanced AEC or intermediate tier pathways, but would fall to 96 with these services optimised by March 2014;A ‘swing-bed’ policy would need to be in place to accommodate up to 30 additional beds at peak times without resulting in significant outliers.
Whole System Partnership 20
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Model outputs – Intermediate Tier
Rate of diversions/admissions across the new pathways once optimised in March 2014:
50pw combined diversions from A&E going to either AEC or Int Tier or direct home;
33pw entering the AEC pathway; 7pw new RR referrals; 5pw new IC admissions (combined home and bed); 5pw new admissions to recuperation beds.
Whole System Partnership 21
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Model outputs – Intermediate Tier
New capacity required in the Intermediate Tier once new pathways are optimised in March 2014:
Rapid Response caseload +3; IC @ home caseload +14; IC beds +14 (interchangeable in the model with home
support); Recuperation beds +19.
Whole System Partnership 22
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What happened nextInformation was taken and put into context of the overall bed position to consider and redesign factors such as: The effects of medical outliers and the demand for
surgical beds; Cancelled operations due to bed pressures; Bed and ward structure for all medical specialties; Nursing and resources for new bed structure.
Internal process improvement was scheduled to enable the results of the model to be implemented.
Whole System Partnership 23
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Appendix: Changes in the number of non-elective medical admissions
The dataset being used can provide 3 comparative periods of March to May 2009, 2010 and 2011;Local demographic data can identify a rate per 1,000 population (by age band) for each year and identify any differences between these three years;We can also identify the expected number of medical non-elective admissions in 2011 based on 2009 rates per thousand population;Any gap between actual and expected needs to be understood at least in part by the impact of intermediate tier developments for pre-hospital diversion.
Whole System Partnership 24
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Scaling the pre-hospital diversion
Since 2009 two initiatives have been taken to effect pre-hospital diversion for non-elective medical admissions: Complex Case Management Teams have performed a
rapid response function (primarily during the day and for people already on their case loads) – estimates of saved admissions by early 2011 are 12pw;
The Rapid Response function within the intermediate tier has been enhanced coupled with redesign at the Beacon – original modelling suggested saved admissions of 7pw, analysis from Oct-Dec 2010 suggested 11pw whilst figures from April, May and August 2011 suggests 9pw.
Whole System Partnership 25