Frailty Concept/ Hospital without Walls Professor Pradeep Khanna MBE Chief of Staff, Community Services Aneurin Bevan Health Board

Commissioning & Care Planning Strategic Planning Specify Outcomes Develop Business Case Procure Services Manage Demand Maintain Performance

CASE FOR CHANGE Demand will always beat supply Pressure on cost is remorseless NHS can not provide a comprehensive service on current assumptions after 2011 (Kings fund and the Institute of Fiscal Studies – IFS)

Some Facts Nearly 33% of inpatients could safely be cared for in another setting than in an acute hospital [Kings fund audit 1992; DOH 2000] 29% of patients in acute hospital beds are medically stable [43% in elderly wards] [Barbara Vaughan; Gill Withers 2002] In Wales, higher proportion of chronic long term conditions (23%) compared to England (18%); Northern Ireland (20%) Audit of 5 GP Practices in Swansea revealed 3% of population with 2 comorbidities + emergency admission accounted for 59% of hospital admissions [Ref = WAG 2007 – Designed to improve health …chronic conditions Wales] Conclusion: A focused integrated approach of Health and Social Care, Housing and Transport is recommended

Drivers For Change Wanless Report: Hard hitting facts about Health Services in Wales Designed for life: Strategic framework: Health & Social Care Services in Wales Fulfilled lives, Supportive Communities: Emphasis on Social Care Making the connections [Public involvement & redesign services around the needs of the users] 5. Primary Care & Community Services Strategy (Chris Jones)

Current System of Care “Push System full of Black Holes” Local government FRAGMENTED AND DISORGANISED COMMMUNITY BASED CARE COM NURS E TMS HEALTH SOCIAL HOSPITAL BASED CARE DISCHARGE INCREASING DEPENDENCY INCREASING COMPLEXITY DECREASING FUNCTIONALITY PRIMARY CARE DEPENDENT FRAIL NH RH OOH AE INDEPENDENT FIT PARA MED NHSD PUSH Patient journey

Hospital-at-Home: definition……… Hospital care but delivered in the person’s own home !!! HaH = “….a service that provides active treatment by health care professionals, in the patient’s home, of a condition that would otherwise require acute hospital in-patient care, always for a limited period.” Cochrane definition, 2005 Combination of personal support & rehabilitation care

Admission Avoidance Hospital at Home/Inpatient Care (Review) [Systematic Review & Meta Analysis] Mortality at 3 months NS (P= 0.15) Mortality at 6 months Significant (P=0.005) Readmission Rates NS (P=0.08) (within 3 months) Functional Ability (12 months) i. Quality of Life ii. Physical abilities iii. Cognitive Status NS Reference: Sheppard S, Doll H, Etal: The Cochrane Library 2009: Issue 3

Hospital at Home CLINICAL OUTCOME: (Adverse Events & Medical Complications) Bowel Complications = 22.5% (96% C.I = 34% to 10.82) Urinary Complications = 14.4% (95% C.I = 25.4% to 3.3%) c. Antipsychotic Prescribing = 14% (95% C.I = 28% to 0.3%) in Dementia Patients COPD = Antibiotic = 18% (95% = 34.6% to 1.4%) PATIENT SATISFACTION: Significant (P < 0.0001) 3. ECONOMIC ANALYSIS: (Co Morbidity: Older Group) Costs = Per episode $2011; 95% C.I (= $2800 to $1222) = Per day $293; 95% C.I (= $318 to $268) CONCLUSION: Admission Avoidance Hospital at home can provide an effective alternative for selected group of Patients (Outcome Similar)

Early Supported Discharge Teams Vs Conventional Care 11 Trials (6 countries) Outcome Patients randomised Summary result (95% CI) P Values Patients’ outcomes Death or dependency 1597 0.79 (0.64 to 0.97) 0.02 Death or institution 1398 0.74 (0.56 to 0.96) Extended ADL Score 1051 0.12 (0 to0.25) 0.05 Satisfied with outpatient services 513 1.60 (1.08 to 2.38) Carer outcomes Subjective health status score 613 0 (-0.25 to 0.24) 0.97 279 1.56 (0.87 to 2.81) 0.14 Resource outcomes Length of hospital stay 1015 -7.7 (-10.7 to - 4.2) <0.0001 Readmission to hospital 633 1.14 (0.80 to 1.63) 0.48 Conclusion: “Appropriately Resourced and Co-ordinated Services” in clearly defined Target Groups has clear potential benefits Langhorne P, et al - Lancet 2005;365;501-506

THE EVIDENCE-BASE FOR INTERMEDIATE CARE RCTs HOSPITAL-AT-HOME 22 DAY HOSPITAL 12 NURSE-LED UNITS 10 COM. REHAB.TEAMS 2 CARE HOME REHAB. 1 COMMUNITY HOSPITAL 1 Message: (a) Target people with greatest clinical need (Frailty) (b) Integrate I.C with Mainstream Services  Expensive Very expensive  Shifts costs to social care 

Messages From Research Develop closer integration between IC and Mainstream Services Target Patients with greatest clinical need: Frailty Place stronger focus on Admission Avoidance Scheme (Health & Social Care) (Closer liaison with Ambulance Service, 3rd Sector, A&E, Mental Health) VANTAGE POINT Reablement: More Research/Evaluation needed

Clinical Futures: Gwent Newport Caerphilly Torfaen Blaenau Gwent Monmouth Powys Other All Gwent medical 117 121 96 82 77 1 7 501 surgical 2 8 total 119 122 98 83 79 509 38 39 31 26 25 162 places at-home 81 67 57 54 5 347 total places Intermediate Care and/or Non-acute Non-acute beds and places required by LHB 2014-15 with new MoC NHS etc beds Provided as 509 ADDITIONAL BEDS IN ALL BY 2014/15 *Selected HRGs – need to give examples

Joint Partnership Sub-Group 5 LHB CEOs, Trust CEO and 5 LA CEOs Aims: to develop better services along whole patient journey through closer working. To find better way of supporting people who end up needing Continuing Care Frailty Pathway chosen Gwent wide multi-agency, multi-professional workshop held April Task and Finish Groups to expand /develop ideas.

Frailty Programme Board Membership Chair – Alison Ward, CEO, Torfaen LA LA reps (social care) LHB reps Trust Corporate and Divisional reps Voluntary sector GP Ambulance Work Streams Independent Living and Reablement Urgent Response and Intervention Capacity and Financial Modelling

Frailty Syndrome (Environmental x social factors) Frailty = (Dependency x vulnerability x co-morbidity) + (Environmental x social factors)

Physical characteristics What is it? Physical characteristics Multidimensional Weakness Slowness Poor endurance Weight loss Physical inactivity Socio-demographic Biomedical Functional Effective and cognitive components 20

FRAILTY PREVENT/ DELAY ADVERSE OUTCOMES PROVIDE CARE PREVENT FRAILITY MODIFIERS Biological Psychological Social 22

Prevalence of Frailty 3 or more of the outcome Age 65-69 70-74 75-79 80-84 85+ %Frailty 18.3 21.7 32.1 32.5 48.8 Estimated numbers of frail elderly people by Local Authority Estimated Total Blaenau Gwent 604 621 838 563 646 3275 Caerphilly 1399 1402 1816 1154 1231 7002 Monmouthshire 784 825 1043 695 864 4211 Newport 1127 1222 1472 1085 1156 6062 Torfaen 797 844 1105 683 712 4141 Total by age band 4177 4914 6274 4180 4609 24154 Source: Census 2001

Happily Independent

What we stand for: Principles & Values The underpinning principle of the Gwent Frailty Programme is to provide: ‘Help when you need it to keep you independent’ The mantra for those delivering services is to provide help that is Sustaining independence. We start with a view that the present system is untenable and that we are not treating people as well as we could or in a way that best uses the available resources and skills. We believe that people are made more helpless and lose the vital ingredients of confidence and control by present processes that lead to hospitalisation. We believe that people want to and can stay longer and more successfully in their own home environment provided that is of an acceptable standard, e.g. is warm and safe and accesses technology such as Telecare. We believe that people should not be in institutional care unless absolutely necessary. We firmly believe that people have to be seen as individuals with a life, a history, a future. Consequently, at a time when they can be most fearful then it is more important to respect and listen to what they want and need and provide simple, clear communication ideally through one allocated coordinator. We believe that people are the experts in their own life and that we need to tap into that expertise. We know that we can do a better job if we work together and that we need each others professional perspectives. We uphold the necessity of real multi agency work where each profession keeps its own distinctive colour and by sharing our expertise we deliver the sort of service that people deserve. We see the need for locality work that is integrated at the health and social care delivery end and is based on:Shared values Joint ownership Joint outcomes The Person at the centre We consider that the integrity of separate organisations within health and social care can add to the dynamism and productivity of the model. We believe that a range of community activities and services are key to ensuring that people are supported in maintaining and returning to independent living.

Outcomes: What frail people tell us they want Be able to remain living in their own home with support Receive services in their home Be listened to by people who are responsible for providing services to assist them Have their health and social care problems solved quickly and considered as a whole rather than individually. Be safe and secure Live in good quality homes Be able to cook, wash, clean and go out Be able to maintain their standards Be financially stable to make independent choices Be receiving the benefits available to enable them to live independently Not be lonely Have a supportive family Have good friends and neighbours keeping an eye out for them Have company Be going out to social activities Have planned for old age Be accessing peer support Be able to keep a pet if they so wish

Frail Elderly Workforce Skills Matrix Specialist Health Care Skills Health Care Skills Social Care Skills Generic Worker Skills Specialist Social Care Skills

Generalist as the New Specialist (Intermediate Care) GP’s Changing Roles Geriatrician Changing Roles AHP’s Changing Roles Training In The Community

Community Nursing Service Based on Nursing Strategy: Wales (Coordination of care) 24 hour Nursing cover in each locality Overnight on call nursing service including Twilight nursing Key role in early identification & proactive care of frail clients

Common Service Characteristics (I.C) Urgent Response & Intervention Reablement & Independent Living ACCESS Via locality Single Point of Access HOURS OF OPERATION 7 days a week 365 days a year 8am to 10pm 7 days a week 365 days a year 8am to 8pm RESPONSE TIME 2-4 hours (for both health and social care components) 24 hours ASSESSMENT Comprehensive Needs & Frailty Index Assessment Agreed shared assessment document SERVICE PROVISION Management/Hospital @ Home upto 14 days Approximately 6 weeks reabilitation and reablement support No charge to user for first 6 weeks ACCESS TO ‘Hot Clinics’ for rapid access to specialist and diagnostic support (Monday to Friday) Specialists including psychology, dietetics, pharmacy, speech & language therapy, podiatry, EMI teams. Rapid access to equipment and adaptations. WORKFORCE Flexible Health & Social Care Workforces

Components of Comprehensive Needs Assessment 1 Medical assessment 2 Assessment of functioning 3 Psychological assessment Social assessment Environmental assessment Elements Co-morbid conditions Medication review Nutritional status Activities of daily living Gait and balance Mental status Assessment of needs, assets and resource eligibility Home safety, transportation and tele-health

Proposed Locality Structure Joint Chair: Director of Social Services Locality Manager (Health) Members: Project Manager Human Resource Finance Intermediate Care Consultant General Practitioner Lead Nurse Voluntary Sector Co-opted Members: Pharmacist, Mental Health, Therapies, CHC

Urgent Response & Intervention Comprises of three key elements: Urgent Comprehensive Assessment (Health & Social Care) Rapid Response Intervention (health) Social Care Crisis Intervention

Proposed Capacity Model (Crisis Management) Aims Better management at home or in a community setting. Engagement with care homes and the independent sector. Management of patients in Accident & Emergency Patients handed over to DN teams on discharge from service Main Functions Assessment of 200 new patients per month for acute exacerbations of chronic conditions and associated disorders. Follow-up of 200 patients per month. 7-day presence in A & E and MAU to assess patients and prevent admissions, pulling them back into the community, as required. Daily Hot Clinics for each borough, run by ACAT/RRT for the provision of advice for GPs. Formal links with other specialties, including General Medicine, Falls, Trauma & Orthopaedics. On-going management of patients at home for a 5 – 7 day length of stay (care package) The Gwent-wide combined team of ACAT, Rapid Response and PATH to provide around 70 virtual beds across Gwent.

Staffing Model (Crisis Management) Based on population of 70-90k 1 wte Consultant Specialist 2 wte Staff Grades or GPswSI (salaried GPs) 4 wte Band 7 10 wte Band 6 3 wte Band 4 Reablement Officers 1 wte Band 6 OT for Reablement 1 wte Social Worker Approx 50 wte generic Health & Social Care Support Workers, and/or Rapid Access to Immediate Home Care 1 wte Secretarial Staff and 2 wte Typists shared with the Reablement Team

Independent Living & Reablement Approximately 6 weeks coordinated review and reablement to sustain independence Rapid access to equipment and minor adaptations Care & Wellbeing Workers able to work across the different elements of the integrated locality team

Proposed Capacity Model for Locality Reablement Teams (1) Based on 70-90k population 5 WTE Occupational Therapists (able to work across ACAT, PATH and Reablement) 5 WTE Physiotherapists 50 Band 3 Generic Support Workers* 2 WTE Case Managers (role needs to be clarified) 2 WTE Social Workers * Proportion of generic support workers up-skilled to perform some functional assessments? Shared resources: IT officer Training and Development officer Administrative Support Hot clinics for Falls, Gen Med and Orthopaedics

Proposed Capacity Model for Locality Reablement Teams (2) Sessional support from: 2 WTE Dieticians 2 WTE Speech and Language Therapists 2 WTE Psychiatric Liaison Nurse (1 for older people, 1 for younger people) Podiatrist – unable to quantify because many clients using private 1 WTE Community Pharmacologist attached to PATH and Reablement

Implementation Workstreams Communication & Stakeholder Engagement Workforce Planning Governance & Structure Outcome Indicators, Performance and Continuous Improvement Information sharing & Single Point of Access Locality Planning (including longer-term care and interfaces with other services) Financial Modelling/ Building the Business Case

Communication & Stakeholder Engagement Workstream lead: Dr Liam Taylor Development of a communication strategy for all key stakeholders Specific programmes of work – a. Stakeholder Briefings b. Staff Communication c. Public Engagement d. Power Brokers (Politicians and Executive Key Members)

Financial Planning Use the outputs from the other workstreams to: Workstream lead: Nigel Stephens Use the outputs from the other workstreams to: confirm demand map capacity identify the resource gaps calculate the financial requirements Set up pooled budget arrangements

Locality Planning (including longer-term care and interfaces with other services) Workstream lead: Jo Williams Support planning for preventative services and delivery at locality level Ensure that core standards are met and outcomes achieved. Key Aims: a. Each locality sharing innovation b. Joint problem solving c. Work through operational challenges d. accessing expertise

Information Sharing & Single Point of Access Workstream lead: Jayne Griffiths Single Point of access Information System and Develop agreed information sharing protocols Develop safe means of electronic transfer

Outcome Indicators, Performance & Continuous Improvement Workstream lead: Angela Jones Use the Outcomes-Based Approach. Happily Independent:(5 key elements) Be able to remain living in their own home with support Receive services in their home Be listened to by people who are responsible for providing services to assist them Have their health and social care problems (holistically) solve quickly Have a general good health

Governance & Structures Workstream Lead: Bobby Bolt Agreed standards and protocols 3 Groups of work: a. Clinical accountability b. Operational issues c. Clear lines of management (professional and regulatory issues)

Workforce Planning Workstream lead: Kevin Barber Challenges: To Integrate - a. 6 organisations b. 9 professional groups Key Aims: a. Harmonising the structure (extremelly complex) b. Managing the transition c. Managing multi-agency staff groups (responsibility, accountability, training and development)

Next Steps Capacity Plan Service Model Financial Plan Workforce Plan

Resource Package Wanless funds (WAG) – Approx £5million:2004 Public Service Committee (Chaired by Finance Minister – Wales): £60million over 2009/10 and 2010/11 (Scheme: Invest To Save) 3. Transitional cash required: £20million (Fund new teams and manage additional capacity) 4. Over time: ● Shifting of resources from Secondary to Primary Care ● ? Nursing and Residential Purchasing Budgets ● Continuing Care Budget

Current Situation 1 +- - + Locality Frailty care model (DGH) Co-located teams Single point of referral Community Consultant Caerphilly +- - + Newport Torfaen Blaenau Gwent Monmouthshire

Current Situation 2 *Referral criteria variable in all 5 localities. Locality Consultant operational team Primary and secondary interface Rapid response ACAT Reablement team Formal GP involvement Caerphilly +- + - Newport Torfaen Blaenau Gwent Monmouthshire

Performance Indicators As per Frailty Programme Work stream and including: Pre-crisis Assessment (CGA): 100% offered within 28 days An episode of crisis requiring hospitalisation should normally require no more than 72 hours in hospital Service responses will be delivered within agreed time limits 50% of frail older people will be managed in the community during an episode of crisis 80% of frail older people with a social crisis will be maintained at home 75 % of rehabilitation services for frail older people will be based and delivered in the community. Assessment of equipment needs delivered within 24 hours Equipment provided within 72 hours of assessment

Paul Williams Director General, Health & Social Services Chief Executive, NHS Wales I want the service to focus on: Changing behaviour not structures; Collaboration not confrontation; Planning not commissioning; Whole systems not hospitals; Clinical engagement; Partnership working; and Wellness not illness (1st October 2009)