1. Role of Risk Prediction in achieving our 2020 Vision Dr Anne Hendry National Clinical Lead for Quality JIT Associate

2. 21% rise in 65+ from 2006 – 2016 62% rise by 2031 38% rise in 85+ by 2016 144% rise by 2031 1 in 3 aged 75+ have two or more Long Term Conditions Headline Projections

3. LTC Prevalence by Age

4. Most people with any long term condition have multiple conditions in Scotland – Scottish School of Primary Care

5. Projected Demand for Health and Social Care, All Ages, 2008/09 prices.

6. Projected Scottish Government spending

7. Sustainable Quality

8. A 2020 Vision Integrated primary and social care, and more effective working with the Voluntary sector A focus on prevention, anticipation and supported self management in order that everyone can live longer healthier lives at home, or in the community as long as possible. When hospital treatment is required, and cannot be provided in a community setting, day case treatment should be the norm and it should be provided in the place which can guarantee highest quality, safety and a good experience. A focus on ensuring that people get back into their home or community environment as soon as appropriate, with minimal risk of re-admission.

9. Reshaping Care Pathway

11. Anticipatory Care and Self Management

12. Day Care and Respite Residential Care Care and support at Home Rehabilitation / reablement Extra Care Housing support Meals Laundry Third Sector capacity Primary Care Team & Care Managers Tele Health Tele Care Integrated Locality Team Hub Integrated Locality Team

13. Telehealthcare

14. Anticipatory Care Planning

15. Anticipatory Care Plans Highland Cohort with ACP in place 34% reduction in emergency new admissions and a 57% reduction in emergency OBDs compared to previous year No ACP but SPARRA risk > 50% (control) 56% increase in emergency new admissions and an 83% increase in emergency OBDs compared to previous year

16. Complex Polypharmacy

17. Chronic Medication Service 1. Registration of Patients 81,100 by 1224 community pharmacists 2. Pharmaceutical care Planning 3. Therapeutic Partnership to generate serial prescription 24-48 weeks

18. Serial Dispensing Early Adopters 42 GP practices and 84 Community Pharmacists across 12 NHS boards 3000 serial prescriptions for 5500 medicines for approx. 1000 patients SG working with Health Boards to extend this to all by April 2013