1. Anticipatory Care “..Behold the Throne of Chaos and with him Sable-vested Night The consort of his Reign..” Adrian Baker Paul Leak Simon Steer

2. Use of resources matters Lowest EEA (>65) Save 1,787 admissions 28,141 bed days saved £7.335 M Saved Highest EEA (>65) An extra 3,542 Admissions 59,264 extra bed days £16, 017 M extra costs

3. ANTICIPATING

4. MINORITY REPORT THEY ARE ADMITTED

5. The Nairn Anticipatory Care Pilot Origins NHS Highland Delayed Discharges Dec 2005 DD’s = 90 % EEA’s Case finder algorithm using Primary Care data MIXING -Age / sex/ LTC’s / OPD’s / Inpatient episodes (SPARRA Development -Primary Care Data)

6. A WILLING PRACTICE ? Long haired lilac, orange and white satin Peruvian

7. A WILLING PRACTICE ?

8. The Nairn Case Finder

9. The Nairn Anticipatory Care Pilot Target top 5% Non Recurrent Investment= £125k To pay for: -1.2 WTE Case Manager(Nurse/OT/SW); -1 WTE Junior Physio; -0.75 WTE Senior OT; -2 WTE Care Assistants; -GP time? Breakeven reduction in bed days=15% …..and targeted use of existing Resource

10. Measures Outcomes 1.EQ-5D 2.ACP was it followed? 3.eSSA’s 4.Preferred Place of Care. Did we deliver? Quantifiable 1.Occ bed days 2.DD days 3.LOS 4.Admission rate 5.Re admission rate 6.5% Risk score 7. 5% Health Status

11. The Anticipatory Care Plan (ACP) Carer or Cared for status, what happens ? Acute medical problem Acute surgical problem Discussion of condition by professional Preferred Place of Care Resuscitation status

12. Dr Baker discusses options for the Anticipatory Care Plan

13. The go anywhere eSSA ? With the ACP within it and accessible 24/7. Consent and jointly signed by assessor and patient Data sharing with other agencies

14. The eSSA in practice

15. The Review Cycle GP & Hospital systems eSSA & ACP Provide Unmet need Data Capture Case Finder Patient

16. Case Manager Overview of the S&P 500 Ensure eSSA and ACP are completed Complete EQ-5D Who, where, how, what, why, when Case conference for long-stay patients Care plan updates for SAS and PCEC Coordinating and reviewing role Initially tasked on Nursing & Residential

17. Generic Care Assistants Out there with the patients Providing hands on care Coached and educated by –Nurses, CMHT, Physio, OT, Dietetics, SALT, GP’s, social services Prevent nutrition problems, falls, early warning, gritting paths, income maximisation, enhancing safety

18. The Nairn Anticipatory Care Pilot: Update Staff: -Case managers: January; -AHPs: June; -Care Assistants: June TeleHealth Mini Lab Preparatory work: -eSSA & ACP for top 5% -SAS & Fridges? -Establish Data flows -Gather Baseline data

19. The Nairn Anticipatory Care Pilot Practicalities Re-calculate Risk scores monthly Alerts: -Case managers informed of Admissions from 5% Cohort-weekly -Patient Admission System Flag: Admission ward staff Consult eSSA and Anticipatory Care plan. Bed day use reports NSD Data Warehouse/System watch-Jill Smith

20. Year to date Bed Days Used by Top 5% 134 Patients Admitted to 03/12/2006 from top 5%

21. Nairn Emergency Cost Curve

22. LTCs Cumulative Excess Cost=£1.3m

23. Nairn Pilot Matrix:Top 5% 45 100 52 347 NHS Unknown Social Work Unknown Social Work Known NHS Known

24. Focus on this 3am, 80 years old, sore leg Can I………... Assess and keep at home with appropriate input? Admit to Community Hospital? Admit to a Consultant bed?

25. Risk Scoring in reality

26. To Prevent This