maggie kemmner: an area-based approach to effectively designing patient-centred services
TRANSCRIPT
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Social care Social care
An area-based approach to designing effective person-centred services Maggie Kemmner Lambeth & Southwark Integrated Care Programme
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Lambeth & Southwark partners
Our partnership includes: • Two acute & community healthcare providers • Mental health provider • Social care in two boroughs • Up to 99 GP practices
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Holistic care:
Older
people
Long-term conditions
in working-age adults
A new system where we all
think and work together
differently
IT & informatics How & what organisations are paid Governance across participating organisations Workforce & change in practice
Our approach combines pathway and system design
Redesigned services and care pathways
Our goals: • Healthier and more independent people
• People have a better, coordinated experience
• Increased value for our spend on local health and social care
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Older people in Lambeth and Southwark – current picture
50000 People
(incl 7000 85+, 14500 BME)
8% of GP lists (Ranging 3-18%) Approx 5% unregistered?
1040 receive intensive home care 1055 live in care homes 6000 a year referred to district nursing, 600 to community matrons 17700 live alone 28000 live in social housing 3400 care for others
29000 annual ED attendances (KCH and STT) 330 people attend ED >4 times a year …of which 56 are hardly ever admitted …of which 55 are almost always admitted 18500 annual emergency admissions …of which 3500 discharged on the same day …of which 1420 last over 30 days 92000 annual outpatient attendances …and 1970 people attend at least monthly 170 admissions to MHOA/SLaM beds 1300 people on CMHT caseload
23600 have a limiting long-term illness 8900 need help with mobility 12800 fall each year
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Holistic integrated care for older people – not a disease-based approach for two reasons…
- Reality of people’s experience: Over 50% of people in Scotland aged 65+ have more than one LTC (Mercer et al 2011) - Enables coordinated focus on greatest needs and risks, improved experience - Local people said we had to! Need sufficient impact to close beds and shift funding A meaningful group to all partners; cross-sector data availability
…With a great byproduct:
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A whole population approach, to identify risks early; with interventions tailored to levels of risk and individual need, to prevent
deterioration in individual cases
50,000 older people: All risk stratified
25,000 proactively assessed annually
5,000 case managed Generic approach based on level of risk
Prioritises action for those interacting heavily with the system
Picks up issues for those not yet interacting heavily with the system
Coordination of care for those with multiple needs
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Also need to provide the right tailored interventions, to prevent deterioration for individuals
We reviewed the last 3 years’ emergency admissions
Long term conditions
Infections
Trauma & falls with senility
Cardiovascular events
Other specified
Other not classified
Cancer
21%
18%
13% 10%
7%
19%
12%
All emergency bed-days* at GSTT and KCH, Apr 08- Mar 11 (Age 65+)
To identify avoidable admissions To prioritise conditions where we needed to have impact
To work out whether proactive interventions or an alternative acute response could help
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Need to respond to what people are being admitted to hospital for…
Long term condition, deterioration well understood/predictable
Acute onset, unpredictable, no previous symptoms
Treatment can be delivered in ambulatory/home settings
Treatment/diagnosis requires a hospital procedure
More likely that planned and/or rapid community interventions will help
Less likely that planned OR rapid community interventions will help
More likely that only rapid community interventions will help
Treatment can be delivered in ambulatory/home settings
ConditionAnnual admissions
Annual bed-days
% of people dying in hospital
% people admitted who don't have a hospital procedure*
% less activity at weekends
% of these admissions that are ACS**
Respiratory Influenza, Pneumonia 508 6940 25% 72% 13% 56%Other 233 2398 15% 73% 6% 43%
Urinary tract 593 9003 6% 76% 21% 42%Skin mostly cellulitis, some non-chron 140 1713 4% 71% 40% 33%Septicaemia (blood infections leading to whole-body i 68 1163 45% 68% 14% n/agastro-intestinal 56 889 9% 80% -17% 28%Grand Total 1596 22106 15% 74% 16% 43%
Eg Infections
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A whole population approach, to identify risks early; with interventions tailored to levels of risk and individual need
50,000 Older People: All risk stratified
25,000 proactively assessed annually
5,000 case managed
Specific tailored interventions on falls, dementia, nutrition and infection pathways
Generic approach based on level of risk
Prioritises action for those interacting heavily with the system
Picks up issues for those not yet interacting heavily with the system
Coordination of care for those with multiple needs
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Wave 1: Older People target impact, year 3, against baseline (Emergency) Activity for all people aged 65+
Note: Length of stay savings are net after all avoided admissions, i.e., no double counting
Acute care Impact Admission avoidance: Overall impact on bed days, % 9.7%
Overall impact on bed days, # 10,752
Equivalent number of freed up beds (assuming 100% occupancy)
~29
Length of stay reduction:
Overall impact on bed days % 4.7%
Overall impact on bed days # 5,170
Equivalent number of freed up beds ~14
Total: Overall impact on bed days, % 14.4%
Freed beds across GSTT and KCH: ~44
Social care Impact
Long term care package reductions:
Reductions in nursing home caseload (would expect some impact but too difficult to model)
0 beds
Reductions in residential caseload 30 beds
NET reduction in domiciliary care caseload
114 packages
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HALF are assessed
annually to identify risks proactively
Better geriatrician
access: phoneline and bookable hot
clinic alongside A&E
simplified discharge process
Rapid response team and
HomeWard acute nursing
Expansion in reablement
10% are case
managed (in primary care and by community matrons),
supported by CMDT
People needing social care
Higher risk patients
People who don’t need specialist assessment
People who are admitted
All older people aged 65+
Advice & increased
investment in preventative interventions
*
People with specific risks
People who can stay at home
People needing specialist & MDT input
People in acute crisis
Support for urgent
response in general practice
People who present at A&E
Better urgent response…
Better prevention…
ALL are regularly risk-
stratified based on
level of past service
interaction
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Where next?
• Expansion of CMDTs to 100% coverage by Jan 2013 (currently at 50%) • Supporting implementation and starting learning cycles (introducing our Value-based reporting system and formative evaluation)
• Developing a holistic approach to working age adults with LTCs • Virtual patient record procurement • Work to develop a capitated budget
Thank you!