STACCATO Stow Anticipatory Care Community Assessment Tool Dr Paul Cormie Sandra Pratt NHS Borders

What is it? Computer based assessment tool for comprehensive functional and social assessment in patient’s home Computer based assessment tool for comprehensive functional and social assessment in patient’s home 3 scenarios: 3 scenarios: –Current situation –Patient unwell –Carer unavailable Risk prediction Risk prediction Decision support software to enable consistency in addressing unmet need and anticipatory care planning Decision support software to enable consistency in addressing unmet need and anticipatory care planning Information directory individual to each patient Information directory individual to each patient

The aims … 1.Preventing crises: falls, falls, carer stress, carer stress, nutrition, nutrition, aspiration (pneumonia & UTI) aspiration (pneumonia & UTI) 2.Preventing admission if a crisis arises: Predict problems likely to arise if patient or their carer becomes unwell – logical approach to anticipatory care planning Predict problems likely to arise if patient or their carer becomes unwell – logical approach to anticipatory care planning

The aims … 3.Improving discharge planning should admission be necessary – the next step: Detailed information on functional and social status prior to the problem resulting in admission Detailed information on functional and social status prior to the problem resulting in admission Optimal use of health care professionals in hospital Optimal use of health care professionals in hospital Discharge planning starting within 24 hours of admission Discharge planning starting within 24 hours of admission Communication tool with primary care Communication tool with primary care

Progress so far… Rolled out as LES across NHS Borders – all GP practices opted in Rolled out as LES across NHS Borders – all GP practices opted in Full Social Work engagement – adapted their IT system to host assessments & collect evaluation data Full Social Work engagement – adapted their IT system to host assessments & collect evaluation data Out of Hours – storing assessments on shared folder in hospital & noting availability on NHS24 record Out of Hours – storing assessments on shared folder in hospital & noting availability on NHS24 record Voluntary Organisations fully involved – Neighbourhood Links, PRTC, BIAS Voluntary Organisations fully involved – Neighbourhood Links, PRTC, BIAS

Funding….. eHealth LTC funding : eHealth LTC funding : –13 laptops for use by primary care teams in NHS Borders to carry out the patient assessments in their own home. –Provide backfill for the District Nurse on the project team to carry out training on the use of the tool in each of the primary care teams in NHS Borders –Enable a quantitative evaluation of the effectiveness of the tool

Other Funding … NHS Borders: NHS Borders: –Anticipatory Care Local Enhanced Service (GPs) & additional resource for district nurses Change Fund: Change Fund: –additional social care including Bordercare, voluntary organisations, Scottish Govt: Scottish Govt: –qualitative evaluation through University of Edinburgh 2012 Endless amounts of Paul’s time…. Endless amounts of Paul’s time….

Challenges …. IM&T: configuration of laptops; information sharing with OOHs and Social Work; IM&T: configuration of laptops; information sharing with OOHs and Social Work; DN access to Social Work IT system – practicalities DN access to Social Work IT system – practicalities Communication– making sure everyone is in the loop, engages & understands Communication– making sure everyone is in the loop, engages & understands Managing anxiety about: Managing anxiety about: –potential impact on DN capacity –competency with use of IT –Changing working practice

Evaluation … Number of ACPs in place Number of ACPs in place Number of plans activated; times activated & outcomes Number of plans activated; times activated & outcomes Numbers admitted / readmitted (longer timescale) Numbers admitted / readmitted (longer timescale) Identification of unmet need & additional care / services needed to support at home Identification of unmet need & additional care / services needed to support at home Related referrals to voluntary organisations Related referrals to voluntary organisations Feedback from DNs: use of assessment tool & process; activation of ACPs Feedback from DNs: use of assessment tool & process; activation of ACPs Patient & carer feedback Patient & carer feedback Longer term qualitative evaluation (Edinburgh University) Longer term qualitative evaluation (Edinburgh University)

Future developments More detailed social care planning section More detailed social care planning section Hospital discharge planning section Hospital discharge planning section Care Home assessment Care Home assessment Tentative plans for a polypharmacy risk assessment section Tentative plans for a polypharmacy risk assessment section