tackling failure demand for emergency care
DESCRIPTION
by John Keast and Beverly Stretton-Brown of East Devon PCT shown at the 3rd Lean Healthcare Forum 2006 ran by the Lean Enterprise AcademyTRANSCRIPT
Tackling Failure Demand in East Devon PCT
John Keast, Service Improvement & Redesign Manager
&Beverly Stretton-Brown,
Locality Commissioning Programme Manager
Practice Based Commissioning,Lean & Long Term Conditions• A brief Look at the East Devon Practice
Based Commissioning (PBC) Scheme & understanding the Payment by Results system
• Examples of Long Term Condition (LTC) initiatives supported through PBC
• An Holistic Approach
East Devon Profile• 13 Practices• 7 Community
Hospitals• Population of 118,000• High Elderly
Population – 27% over 65’s
• Wide Geographical Rural Area - Low population Density
• One Main Acute Provider –Foundation Trust
• PBC Introduced 2004/05
DGH
CH
CHCH
CH
CH
CHCH
27 Miles
East Devon Values– Ensuring patient is seen in right place, at right
time, by right person– Ensuring patients to be treated as close to home
as possible– Developing Local Services, as an alternative to
Secondary Care– Developing & Improving services that are patient
centred– Removal of waste– Providing proactive ‘up stream’ care for Patients
with LTC– Achieving Financial Balance– Consensus Building
Block BudgetPart B, C & DRDE Contract
(£14.7 m)
PBC Commissioning Budget
Part A RDE ContractAll other providersInpatient (£45 m)
Outpatient (£7.4 m)
Provider Budget
(£30 m)
PCT HQ &
Shared Services
Released
50%
GP’s
Resources
50%
PCTSecondaryCare
Services
EDCH Services
Community Services
InterfaceServices
ShiftedActivity from
Sec Care
11733 £5,969,9474658 £9,026,783747 £1,604,7841158 £1,168,1606563 £11,799,72710124 £19,827,6623058 £7,219,131523 £794,364
13705 £27,841,156
32001 £45,610,830
East Devon Commissioning Budget 2005/06 Part A Contract
£0
£5,000,000
£10,000,000
£15,000,000
£20,000,000
£25,000,000
£30,000,000
Day case Inpatient Elective Inpatient Non-Elective
Secondary Care Community Care
Total In-Patient (PbR)Budget £45m
There is nothing more!
£27.8m
£11.7m
£5.9m
Practice Budget Statement
Case Type Provider Volume CostDaycase Elective Main Acute Provider 1146 £683,576
East Devon Community Hospitals 480 £263,845Other Trusts 10 £6,400Total 1636 £953,820
Inpatient Elective Main Acute Provider 618 £1,211,704East Devon Community Hospitals 197 £436,450Other Trusts 26 £106,835Total 841 £1,754,988
Inpatient Non-Elective Main Acute Provider 1129 £2,704,548East Devon Community Hospitals 298 £656,118Other Trusts 19 £77,023Total 1446 £3,437,689
3923 £6,146,498
Agreed Baseline 2005/06
Grand Total
Non Elective Admissions to DGH 0 to 2 Day LOS
April 2004 to March 2005
£0
£50,000
£100,000
£150,000
£200,000
£250,000
0 Day LOS 1 Day LOS 2 Day LOSLength of Stay
Cos
t
Many patients with Long Term Conditions
Total £540K on<2 days LoS
Non-Elective Admissions to Local Acute Provider April - July 04 LOSTotal Cost
Patient A D20 Chronic Obstructive Pulmonary Disease or £1,917 27/03/2004 07/04/2004 11Patient A D20 Chronic Obstructive Pulmonary Disease or £1,917 08/04/2004 12/04/2004 4Patient A D20 Chronic Obstructive Pulmonary Disease or £1,917 06/05/2004 16/05/2004 10Patient A D20 Chronic Obstructive Pulmonary Disease or £1,917 17/05/2004 07/06/2004 21Patient A D20 Chronic Obstructive Pulmonary Disease or £1,917 27/06/2004 06/07/2004 9 £9,586Patient B Q13 Diagnostic Radiology - Arteries or Lymphat £4,779 24/04/2004 07/06/2004 44Patient B E19 Heart Failure or Shock <70 w /o cc £1,887 08/06/2004 08/06/2004 0Patient B E19 Heart Failure or Shock <70 w /o cc £1,887 22/06/2004 02/07/2004 10 £8,553Patient C G15 Therapeutic Pancreatic or Biliary Procedure £4,135 18/03/2004 27/04/2004 40Patient C G15 Therapeutic Pancreatic or Biliary Procedure £4,135 01/05/2004 28/05/2004 27 £8,271Patient D C54 Mouth or Throat Procedures - Category 6 £7,984 13/04/2004 14/05/2004 31 £7,984Patient E L51 Chronic Renal Failure £2,516 19/05/2004 20/05/2004 1Patient E L05 Kidney Intermediate Endoscopic Procedure £5,118 20/07/2004 21/07/2004 1 £7,634
Identifying frequent users of secondary Care
Invest to Save initiatives around LTC – value stream• Community Liaison Worker
– linked to practice DNs & LTC– Avoiding delayed discharge & reducing LOS
• Generic Worker– patients discharged from hospital with LTC –
avoiding re-admission• Integrated Teams Approach
– Additional Nursing & DN Hours– In House Social Care Workers, Pharmacist &
Physio/OT– ‘Chief Engineer’
The Business Case for Invest to Save Initiative Additional Nurse, Practice Based SW Hours &
Clinical Pharmacy (Cost: £39,000 pa)• Benefits to Patients
– ‘Case manage’ at risk patients – Integrated health and social care
– Develop a LTC register for ‘at risk’ patients to support proactive management
– Managing patients in/close to home • Forecast Benefits to Practice
– Forecast prevention of 4 admissions per month: Forecast release resources: £96,000 pa for local investment
GP Admissions to RDE
20
40
60
80
100
12005
/11/
2004
26/1
1/20
04
17/1
2/20
04
01/0
7/20
05
28/0
1/20
05
18/0
2/20
05
03/1
1/20
05
04/0
1/20
05
22/0
4/20
05
13/0
5/20
05
06/0
3/20
05
24/0
6/20
05
15/0
7/20
04
08/0
5/20
05
26/0
8/20
05
16/0
9/20
05
10/0
7/20
05
28/1
0/20
05
18/1
1/20
05
09/1
2/20
05
30/1
2/20
05
20/0
1/20
06
02/1
0/20
06
A/E admissions
30
40
50
60
70
80
90
100
05/11
/2004
26/11
/2004
17/12
/2004
01/07
/2005
28/01
/2005
18/02
/2005
03/11
/2005
04/01
/2005
22/04
/2005
13/05
/2005
06/03
/2005
24/06
/2005
15/07
/2004
08/05
/2005
26/08
/2005
16/09
/2005
10/07
/2005
28/10
/2005
18/11
/2005
09/12
/2005
30/12
/2005
20/01
/2006
02/10
/2006
Period
Indi
vidu
al V
alue
Special Cause Flag
£340K underspent on EmergencyAdmissions for 05/06
A
Primary Care
B
Managing the end to end process
C D E• 30 - 70% of work
doesn’t add value for patient
• up to 50% of process steps involve a “handoff”, leading to error, duplication or delay
• no one is accountable for the patient’s “end to end” experience
• job roles tend to be narrow and fragmented
organisational/departmental boundaries
Breast Cancer Process
Neurological Care
Developing Integration
• Highly skilled generalists (80/20)• Whole teams become proactive• Reduces waste in many ways• Improves whole systems working• Teams working on patient flows
Co-ordinating patient flows at a locality level –the role of the ‘Chief Engineer’!
Patient’s Journey
GP Practice
Practice Nurses
Intermediate Care
District Nurses
Social Services
Occupational Therapists
Physio-therapists
Leadership capacity to support patients’ flow across the current “functional” roles (more integration)
Additional PCT Initiatives - Whole systems approach• 24 Hour Access to Intermediate Care• Weekend OT at A&E• Whole systems approach to avoiding Falls• Practice link to Discharge Co-ordinator in
Secondary Care• Long Term Conditions Nurse Pilot
– Care for housebound patients with LTC focus on Diabetes, CHD & COPD
Emergency Admissions to RDE from Axminster Practice
0
5
10
15
20
25
30
05/11
/2004
26/11
/2004
17/12
/2004
01/07
/2005
28/01
/2005
18/02
/2005
03/11
/2005
04/01
/2005
22/04
/2005
13/05
/2005
06/03
/2005
24/06
/2005
15/07
/2004
08/05
/2005
26/08
/2005
16/09
/2005
10/07
/2005
28/10
/2005
18/11
/2005
25/11
/2005
30/12
/2005
20/01
/2006
02/10
/2006
03/03
/2006
24/03
/2006
14/04
/2006
05/05
/2006
Period
Indi
vidu
al V
alue
Special Cause Flag
LTC Post commenced10% reduction
Patient No. Date 1st Reading Date 2nd Reading
26503 09 05 05 7.7 20 04 06 7
1779 03 06 05 9.1 23 03 06 8.5
6790 13 02 04 14 03 05 06 7.1
6185 18 10 05 12.7 05 04 06 7.2
2170 16 05 05 8.9 01 03 06 6.9
25612 06 08 04 9.6 22 08 05 7.7
4160 10 05 06 13.5 19 01 06 10.2
4042 17 10 05 7.1
465 03 06 05 6 21 11 05 5.1
1687 28 06 05 10.7 13 10 05 4.8
13666 01 12 05 7.5 25 04 06 6.1
1478 02 08 05 5.8 24 04 06 6
10441 20 06 05 14.2 03 02 06 6.4
Reducing the HbA1C in Case Managed Diabetic patients
Additional PCT Initiatives – Whole Systems Approach• Move to Locality Commissioning
– Project Blue Sky– Establish formal structures to plan, monitor,
purchase develop & improve– Based on local need and priority– Locality/whole systems thinking– Health, Social Care and Patients & Public
input
Final thought ….
“Overnight success takes years to
achieve”
