Role of Risk Prediction in achieving our 2020 Vision

Dr Anne Hendry

National Clinical Lead for Quality

JIT Associate

• 21% rise in 65+ from 2006 – 2016

62% rise by 2031

• 38% rise in 85+ by 2016• 144% rise by 2031

• 1 in 3 aged 75+ have two or more

Long Term Conditions

Headline Projections

LTC Prevalence by Age People reporting a chronic condition (by age)

0

10

20

30

40

50

60

70

80

1972 1975 1981 1985 1991 1995 1996 1998 1998 2000 2001 2002

Year (note: data from1998 is w eighted)

% o

f s

am

ple

0-4y

5-15y

16-44y

45-64y

65-74y

75+

Most people with any long term condition have multiple conditions in Scotland – Scottish School of Primary Care

Projected Demand for Health and Social Care, All Ages, 2008/09 prices.

Health and Social Care Demand Projections, £ mn, 2008/09 prices

5,000

6,000

7,000

8,000

9,000

10,000

11,000

12,000

13,000

14,000

15,000

2010 2015 2020 2025 2030

Year

Co

st £

mn

HLE constant

Change HLE = 0.5 change LE

Change HLE = Change LE

Projected Scottish Government spending

20,000

22,000

24,000

26,000

28,000

30,000

32,000

£ M

illio

ns (

2010

-11

Pric

es)

2009-10 2025-2616 years

£42 billion

Sustainable Quality

A 2020 Vision

• Integrated primary and social care, and more effective working with the Voluntary sector

• A focus on prevention, anticipation and supported self management in order that everyone can live longer healthier lives at home, or in the community as long as possible.

• When hospital treatment is required, and cannot be provided in a community setting, day case treatment should be the norm and it should be provided in the place which can guarantee highest quality, safety and a good experience.

• A focus on ensuring that people get back into their home or community environment as soon as appropriate, with minimal risk of re-admission.

Reshaping Care Pathway

Population model

Professional Care

Self Managem

ent

Care Care ManagementManagement

DiseaseDiseaseManagementManagement

Supported Supported Self CareSelf Care

Level 3Level 3Complex coComplex co--morbidity morbidity 3 3 –– 5%5%

Level 2Level 2Poorly controlled single Poorly controlled single disease 15 disease 15 –– 20%20%

Level 1Level 1Well controlled Well controlled (70(70--80% of LTC 80% of LTC population)population)

Population Wide Prevention, Health Improvement & Health Promotion

Anticipatory Care and Self Management

Day Care and Respite

Residential Care

Care and support at

Home

Rehabilitation / reablement

Extra Care Housing support

Meals

Laundry

Third Sector capacity

Primary Care Team & Care

Managers

Tele Health

Tele Care

Integrated Locality Team

Hub

Integrated Locality Team

Telehealthcare

Anticipatory Care Planning

Anticipatory Care Plans Highland

• Cohort with ACP in place

34% reduction in emergency new admissions and a 57% reduction in emergency OBDs compared to previous year

• No ACP but SPARRA risk > 50% (control)

56% increase in emergency new admissions and an 83% increase in emergency OBDs compared to previous year

Complex Polypharmacy

Chronic Medication Service

1. Registration of Patients

81,100 by 1224 community pharmacists

2. Pharmaceutical care Planning

3. Therapeutic Partnership to generate serial prescription 24-48 weeks

Serial Dispensing Early Adopters

• 42 GP practices and 84 Community Pharmacists across 12 NHS boards

• 3000 serial prescriptions for 5500 medicines for approx. 1000 patients

• SG working with Health Boards to extend this to all by April 2013

NHS Scotland Rate per 1,000 Attendance at Emergency Departments and Admissions for Females by Age Group from

0ct 2010 to Sep 2011

-

50

100

150

200

250

300

350

400

450

0-4

5-9

10-1

4

15-1

9

20-2

4

25-2

9

30-3

4

35-3

9

40-4

4

45-4

9

50-5

4

55-5

9

60-6

4

65-6

9

70-7

4

75-7

9

80-8

4

85+

age

rate

Attendance Rate

Admission Rate