National Audit of Intermediate Care National Conference Birmingham, Sept 12 th 2012 Professor Finbarr C. MARTIN Geriatrician Guys and St Thomas’ Hospitals & King’s College London President, British Geriatrics Society

Intro Well done ! Starting data informed discussion is good Linking organisational and patient level data is good This was a vital first step

How did we get here? (and what might we have lost sight of on route?) Damon has given the policy context and aspiration The aspirations are at many levels –Improved experience for patients –?? For carers –Better outcomes for patient? –More sustainable public services (ie efficiency) –Reducing inequity and inequalities Being integrated or even being the glue in the system is proving a challenge Are the 1 0, 2 0 and social care building blocks the problem?

Key considerations What service problem are we trying to solve ? - a system level diagnosis is needed JSNA What is the clinical nature of the work ? - necessary to define the skills needed Who are the right patients/users ? - need evidence of ability to benefit How is it done best - dearth of evidence on this What are the success parameters ? - at system and individual levels

What are JSNA may wish to consider (From DH guidance) ● the number and occupancy of beds in acute and community ● incidence rates of emergency admissions for people over 75 ● the average length of stay for certain index conditions ● the rates of new admissions to care homes ● the pattern of repeat admissions ● discharge locations from acute care eg. of people over 75 ● the locations of people 3 and 12 months after leaving IC ● the number of people receiving intensive home care.

Key considerations What service problem are we trying to solve ? - a system level diagnosis is needed JSNA What is the clinical nature of the work ? - necessary to define the skills needed Who are the right patients/users ? - need evidence of ability to benefit How is it done best - dearth of evidence on this What are the success parameters ? - at system and individual levels

Some Clinical issues Criteria for acceptance –Medically stable –Ability to benefit from rehab –Needing significant mental health input Does it matter that geriatricians were hardly involved in this service largely for older people? Should post acute care be an opportunity for systematic CGA based care? What is in the black box (ie patients as well as the interventions!)

Illness, recovery and interdisciplinary inputs intensity Time from onset of disabling illness nursing medicine physio occupational therapy social work (adapted from HAS Thematic review 1997) Timely hospital discharge

Vicious Cycle of Dependency Incomplete recovery Readmissionsand LTCincreased dependency Vulnerable to change This is what IC is trying to impact

Some Clinical issues Criteria for acceptance –Medically stable –Ability to benefit from rehab –Needing significant mental health input Does it matter that geriatricians were hardly involved in this service largely for older people? Should post acute care be an opportunity for systematic CGA based care? What is in the black box (ie patients as well as the interventions!)

Does the evidence from RCTs help ? RCTs can clarify causality, ie treatment x given to patient y produces outcome z (more commonly than chance or placebo, but not always) so what is treatment x ? and who is patient y ? what is the importance of the context ? what else affects outcome and individual variation ?

Who is patient y eg. Supported discharge teams LambethGloucester Bartel 15 (11-18) 16 (15 -17) Cognitive impairment mild/moderate nil/mild morale lowlow functional change slightslight Controls at home 40%66% (at 6 months) Impact of interventionsignificantnot significant

What does success imply? Low morale or high discharge related anxiety may : –predict those most likely to benefit –predict those with higher rate of adverse outcomes Δ Risk adverse schemes miss the point !!

What is treatment x ? –eg duration Supported/Early discharge teams costs Kettering (acute) orthopaedic4-6 days same or less West London (rehab)orthopaedic 9 daysmore Kettering (acute) chest disease etc9 dayssame or less Bristol (mixed rehab)15 dayssame Lambeth (mixed older people)22 daysless Nottingham (mixed older people )less So we need to know the nature of the problem to be solved, and for whom, to interpret the LOS and resources etc

How might audit help? Later presentations make good suggestions Encourage commissioners to be strategic Encourage services to combine clinical governance across sectors Encourage clarity of purpose s Be holistic rather than functional