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

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

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

5. 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

6. 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

7. Over 65s Admissions per 1,000 Population

8. Over 65s Average Length of Stay

9. Over 65s Bed Days per 1,000 Population

10. 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

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

12. 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.

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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%)

20. 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

21. 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

22. 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

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

24. 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

25. Has this worked elsewhere?

26. 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

27. 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%)

28. 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$
(£ /6 Durham Dales)

29. 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

30. 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.

31. Health and Social Care Perspective
Challenges
Opportunities
Coming together

32. 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.

33. 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

34. 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!

35. 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

36. 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

37. 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.

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

39. We can rise to the challenge…!
Philip Lewer
Tel: (07918)
Ruth Adam
Tel: (0161)

40. Don’t React & Panic
Anticipate & Plan

41. Don’t React & Panic
Anticipate & Plan

43. References
Practice-based commissioning, a toolkit – primary care contracting
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