Unique Care: Converting Unplanned Crisis into Planned Care RUTH ADAM PHILIP LEWER

An acute hospital admission is a failure of the Health System. The real challenge to the NHS is how to manage chronic disease better

The trick is to convert unplanned care into planned. Adopt a multi-skilled, multi-agency approach to ensure effective care co-ordination

Unique Care Integrate Health and Social Care Deal with current referrals Joint assessment & joint working (SAP) Tailored packages of care Hospital In-reach Get the 20% on the radar

Unique Care Same day assessment 97% of time Utilisation of primary care team, CPNs Practice nurses, etc. Involvement of Voluntary Sector Better use of other Health Professionals, including pharmacists, rehab, OT, rapid response teams Effective use of social services’ resources

Over 65s Admissions per 1,000 Population

Over 65s Average Length of Stay

Over 65s Bed Days per 1,000 Population

Other Effects District Nurse Team didn’t need backfill GPs’ home visits fell by 30% Social Services budget made small saving in Castlefields but overspent in Borough Use of intermediate care remained stable & within expected for population 48 cases; admissions fell from 123 to 2 and only three went into long term care

Money released for re-investment Practice Population: 12,000 Saves £210,000 (US$ 408,281) per year on admissions

Over 65s Acute Admissions Castlefields Health Centre SS Essential So what’s in it for them? What are the hooks? Increasing the number of people supported to live at home Reduced nursing home placements Achieving 24 hour assessment Reducing duplication SAP Better referrals and understanding from health re FACS criteria But need to establish local win/wins.

Unique Care – 5 Key Principles Create a Unique Care team between health and social services Create and maintain a practice based register of patients with complex needs Case find patients at risk of admission Establish hospital in-reach Create a bespoke plan with each patient 4. Here add in examples of joint working from: Brent – Working with CCT Bracknell Forest – 999 Category 3 response Southwark – Electronic flagging system Selby & York – Patient Passport Re-iterate response from frontline staff, achieving what always knew needed to happen – increases job satisfaction and reduced stress. Wards and A&E love it

Highly Complex Patients Which patients benefit most from Unique Care? Level 3 Highly Complex Patients Case Management Unique Care Professional Care Level 2 High Risk Patients Unique Care Disease Management Self Care Level 1 70-80% of an LTC population Unique Care Supported Self Care

Which patients benefit most from Unique Care? Multiple Crisis – Multiple LTC’s, complex medical & social needs, frequent admissions to hospital / A&E attendance / OOH Service Not attended for screening / OPA’s Experienced major life changes e.g. bereavement, deterioration in health, self neglect An older person about whom you have concerns

The Pareto principle 20% of supermarket products account for 80% of sales 20% of criminals account for 80% of the value of crime 20% of people who marry account for 80% of divorce statistics 20% of your carpet gets 80% of the wear 20% of the clothes in your wardrobe get worn 80% of the time Source: Koch 1998

The 20% of Patients who need 80% of the Care Older People Decreased Functional Ability Revolving Door Admissions COPD & Heart Failure End of Life Psychological & Social Support Packages of care tailored to the individual

Postal Questionnaire 20 questions Yes/No answers only One sheet of paper Coloured ink & large font Invitation signed by own GP Helpline First & second reminders

Response All practices in PCT recruited 3999 identified as potential participants 350 ruled out by cross-checking with the practices 3649 sent questionnaire 302 declined to participate 305 failed to respond 3048 positive response (83.5%)

12 month summary Diabetes 1.3 Lung problems 1.7 Heart problems 1.7 Stroke 1.7 Cancer 1.2 Depression 1.6 Bladder problems 1.6 Leg ulcers 2.2 Lives alone 1.0 Help if ill 1.1 Help to get out 0.4 Bath without help 0.4 Eyesight 1.7 Memory problems 1.9 Flu Vacc 0.9 4+ medicines 2.0 Previous admission 2.9 Fall 1.8 Bereavement 1.2 General health 0.4

12 month summary Diabetes 1.3 Lung problems 1.7 Heart problems 1.7 Stroke 1.7 Cancer 1.2 Depression 1.6 Bladder problems 1.6 Leg ulcers 2.2 Lives alone 1.0 Help if ill 1.1 Help to get out 0.4 Bath without help 0.4 Eyesight 1.7 Memory problems 1.9 Flu Vacc 0.9 4+ medicines 2.0 Previous admission 2.9 Fall 1.8 Bereavement 1.2 General health 0.4

Identifying At Risk Start with 10, then if ‘Yes’ Do you have heart problems? +3 Do you have leg ulcers? +4 Can you get out of the house without help? -5 Do you have problems with your memory and get confused? +4 Have you been admitted to hospital for an emergency in the last 12 months? +8 Would you say the general state of your health is good? -4

SCORE % Pop Identified Chance of Admission 20+ 6% 55% 15-20 7.5% 47% 10-15 11.5% 30% <10 75% 17%

Identifying High Risk Tools only go so far, so don’t be rigid Look out for repeat admittees Severe COPD Heart Failure More holistic assessment Packages of care according to need Regular review

Has this worked elsewhere?

Enfield – Practice Population 3,600 Emergency Admissions Reduction 50% (12% in comparator practice) Occupied Bed Days Reduction 70% (10% in comparator) Excess Bed Days Value Reduction 98% (23% in comparator) Spells Value Reduction 49% (5.6% in comparator) Total Budget Savings 67% (8% in comparator) Total budget savings over 5 months = £99,000 Estimate over 1 year = £237,000

Reduction in admissions Results Reduction in admissions Reduction in bed days Castlefields 15% 40% Bracknell Forest 20% Durham Dales Oldham 25% Enfield 53% (12%) 70% (10%)

Avoiding one admission per week If all 13 Durham Dales practices avoided one admission per week, this would release money for re-investment to the tune of: ************************£642,876******************** 1.2 million US$ (£951 2005/6 Durham Dales)

Feedback from sites “Unique Care has had the benefit of reducing the number of referrals to social services……the team have helped older people to understand better what the statutory services can provide for them” Jenny Goodall: Director, Brent Social Services  “This approach has reduced my workload a lot. Quality of care for complex housebound patients has improved immensely” GP, Derbyshire Dales & South Derbyshire PCT “Unique Care makes life easier for people with complex needs in many cases it’s the simplest things that have made a big difference.” Gwyneth Oates: Care Co-ordinator "Its a good feeling knowing that capable and caring people are there to support you if problems arise" Patient, Durham Dales PCT

And more importantly………….. “The hospital said that I wasn’t fit to be on my own really…..after further consideration I decided I didn’t want to go there (residential home), after all here I can do what I like, I can get up in the night, imagine what it would be like living in somebody else’s place!” Patient, Brent 2005. “It’s very hard with angina. You get frightened and you just don’t know where to turn. I was able to talk to you and I know I have somebody there and it’s nice to have somebody. I did what you told me taking my spray and not get to excited about it all and it saved me from the phoning the ambulance”. Patient, Oldham 2005.

Health and Social Care Perspective Challenges Opportunities Coming together

Health and Social Care Perspective Those that use our services, want /deserve /need services that meet their needs, they also want to make informed choices about their lives. Emphasis on choice and self determination for the individual.

Health and Social Care Perspective The need to work together to tackle the growing numbers of people with chronic illness and long term conditions The need for local providers and purchases to develop services through the market place and contestability

Health and Social Care Perspective We are both struggling with our finances. Patients / citizens want more choice and better services – we are tempted to cost shunt rather than see the commissioning gap!

We can if we want to Challenge existing cultures Ensure the empowerment of people to take expert control of their conditions Delivering high quality care

What has worked Scrap the eligibility criteria for low level services such as Careline (telephone response / pendant service ) Meals on wheels ( frozen meals service ) My Mum

Conclusion There is a willingness to work together especially with GPs so that we can jointly commission new and preventative services We want to create new care pathways and community based services so that we can manage demand and expectation together.

So what are you going to do when you go back to work…… How will you make a difference? How will your patients know?

We can rise to the challenge…! Philip Lewer Tel: (07918) 600795 philip.lewer@btinternet.com Ruth Adam Tel: (0161) 236 1566 ruth.adam@btinternet.com

Don’t React & Panic Anticipate & Plan

Don’t React & Panic Anticipate & Plan

References Practice-based commissioning, a toolkit – primary care contracting www.primarycarecontracting.nhs.uk 2006 Developing effective joint commissioning for adult services: lessons from history and future prospects Nick Goodwin, Care Services Improvement Partnership 2006 The future of health and adult social care: a partnership approach for wellbeing Local Government Association 2006 Human dimensions for change (ppt) taken from Google Susy Cook, Gill Husband, Margaret McQuade NHS Improvement Alliance, South Tees Hospital NHS Trust White paper- Strong and prosperous communities (chap 7) /-Our health our care our say A whole system working a guide and discussion paper CSIP Commissioning framework for health and well being