Keynote Session 5: Integrating Care in the Highland: Our Story So Far

Integrating Care in the

Highlands:

our story so far

Intro Film Clip

Integrating care in the Highlands

our story so far

Adrian Baker, GP

Elaine Mead, Chief Executive

Integrating care in the Highlands:

About a journey from 2005

NHS HIGHLAND (Highland Council and Argyll & Bute Council Areas)

Actual and projected number of people aged over 75: 1981 to 2031 Source: General Register Office for Scotland

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

50,000

Why did we need to integrate care?

• High level of delayed discharges

• Early (young) admissions to care homes

• Lack of alternatives to hospital admission

• Unnecessary and avoidable admissions

• Limited care at home access

• Lack of ‘joined-up’ services

New admissions to care home

75.4

75.9 75.7 75.8

76.3

72.5

73.2

73.7

73

73.4

70

71

72

73

74

75

76

77

2008 2009 2010 2011 2012

Average age at admission

Scotland

Highland

What do people want?

• Maintain good health

• Maintain independence

• Prevent unnecessary hospital admissions

• Support carers to care

• Stay in their own homes for as long as

possible

Cost and quality of experience

Independent

Supported self care

Care at Home

Hospital at Home

Community Hospital

Residential Care

Acute Hospital Care Better

Experi

ence In

cre

asin

g C

osts

Journey of dependence

• Home Care £6K / pt /year

• NHS 24 = NHS Direct £36.67 / call

• OOH contact £68.00

• GP in hours contact £30.00

• District nurse £40.89

• A&E £92.50

• Admission (Ave 10 days) £2,784

• Long stay care £20K to £40K+

Integrating – what?

Acute

Health

3rd Sector,

voluntary

People

Community

resilience

Health &

Social

Integrating health & social care

2005 2011-12

2020

Integrating health

2005 2011-12

2020

Unscheduled Care

Anticipatory

Polypharmacy

Whole system flow

A&E waits

• A&E waits compromised when no flow

• Medical admissions redirected through

A&E

• Trauma space compromised

• Patients waiting on trolleys

• Long minor patients waits

Actions in hospital

• Acute physician

• AMAU (assessment not admission)

• Nurse call triage

• Focus on planned date of discharge

• Reduce bed stays for tests

• Reduce medical outliers

• Maximise community hospitals

Percentage Compliance with the Four Hour Target: July 2007 to March 2013

NHS Highland and NHS Scotland

NHS Scotland

NHS Highland

88%

90%

92%

94%

96%

98%

100%

Jul-07 Jan-08 Jul-08 Jan-09 Jul-09 Jan-10 Jul-10 Jan-11 Jul-11 Jan-12 Jul-12 Jan-13

Month

Pe

rce

nta

ge

of

pa

tie

nts

sp

en

din

g le

ss t

ha

n f

ou

r

ho

urs

in

A&

E

Nairn Town and County

The Gatekeeper and the Wizard: a fairy tale. (Br Med J 1989;298:172-3)

“The wizard asked the Minister for bigger and better

crystal balls and more powerful magic potions. But it

was no good….”

Healthy Aging

Lots happening

• SPARRA

• Casefinding

• Anticipatory Care

• Polypharmacy

• Hospital at Home

• Community Hospitals

• Virtual Ward

• Unscheduled Care – Flow 5!

Nairn Case Finder 2006/07 Nairn Cumulative Emergency Bed days

5%=44%

List

Be

d D

ay

s

100%

100%

Anticipating

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

Homework

• Power of Attorney

– Welfare – who do you want to decide on this?

– Finance – who do you want to have control of your financial affairs?

• Will – do you have a will?

• Do you have a Living Will and if so who knows?

The Numbers

• Initial study 2005-8 100 patients and 100 controls

• 15-16% mortality rate in the year.

• Survivors, 42% fewer admissions (P = 0.002)

• 52% fewer bed days (P = 0.020)

• The cost of hosptialisation of the study population was reduced by 50%. (P = 0.029)

• The control population had 11 patients die in hospital, the study population had 3 deaths in hospital (P = 0.007)

At scale for >5,000 patients

• By 31st March 2011, 5,329 patients who had received ACPs, demonstrated:

– 29% reduction in emergency new admissions, and

– 47% reduction in occupied bed days.

• Patients with a SPARRA score of ≥ 50% but no ACPA in place showed:

– 59% increase in emergency new admissions,

– 63% increase in occupied bed days

Impact

• For end of life care there is more chance of dying at home rather than in hospital if a ACP is in place.

• In the practice, there are less chaotic home visits, more structured and organised times with families and less work regarding crisis guardianship cases.

Lillian – Our Highland Esther

Small tests of change

Gaining 2 beds for £3K a month DD days in Hospital and Community, Nairn, 2007 - 11

0

20

40

60

80

100

120

140

160

180

200

Apr-0

7

Aug-0

7

Dec

-07

Apr-0

8

Aug-0

8

Dec

-08

Apr-0

9

Aug-0

9

Dec

-09

Apr-1

0

Aug-1

0

Dec

-10

Apr-1

1

Aug-1

1

Date

DD

's p

er

mo

nth DD's in Hospital

Ave LOS pre 70h

Ave LOS post 70h

DD days in the community

Frailty / Dementia Trajectory

Function

Decline in ADL’s &

Memory

Death

First Acute

Problem

TIME 3-10 years

Unable to

self care

High

Low

A Highland Huddle

Dementia Film Clip

Carers

Percentage of last 6 months of life spent at home or in a community setting

2 3 4 5 6NHS Highland

SCOTLAND

89.0

89.5

90.0

90.5

91.0

91.5

92.0

92.5

93.0

93.5

2006/07 2007/08 2008/09 2009/10 2010/11

% of last six months of life spent at home or in a community setting

Trend in care home places for older people, 1999/00 to 2011/12

1999/00 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11

NHS Highland

SCOTLAND

0%

20%

40%

60%

80%

100%

120%

1999/00 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12

Care Home Places for Older People

Trend in bed days by type of admission,

Highland residents 2001 -2012

Changing Landscape

• These things had and continue to have an

impact…

BUT

It won’t be enough

to make it better for the

people of the Highlands

Commitment

Integration of Services

“Banish the artificial divide between health

and social care and involve charities,

social enterprises and community groups

more closely in service provision.”

Scottish Older Peoples Assembly, 2010

Ambition to devolve decision making to

integrated front line teams

Single management and single budget for

ALL health & social care in a locality

Lead Agency approach

• NHS Board and the Highland Council moved to explore the benefits of a lead agency model

• NHS Highland - Older adults

• The Highland Council - Children’s services

• CEOs committed to STOP if any identified detriment to adults and children as a result

• Agreement made in December 2010 with plan to go live April 2012

Statement of Intent

“We will improve the quality and reduce

the cost of service through the creation of

new, more simple organisational

arrangements that are designed to

maximise outcomes.”

The Highland Council & NHS Highland

16 December 2010

Scale of change: some numbers

• Social care staff to NHS Highland = 1,500

• Budget to NHS Highland = £90m

• Health staff to Highland Council = 250

• Budget to Highland Council = £8m

• Buildings occupied under licence to NHSH

• Partnership Agreement = 400 pages

March 2012

Partnership Agreement signed

“Merger not a take over”

NHS Highland now delivers care:

• In hospitals

• In care homes

• In the communities, and

• At home

For patients and clients across the north of

Highland

Working closely with Argyll and Bute Council

to develop a model to support integration

of adult care in this area

But our journey continues

• Working to change culture & attitudes

• Developing shared language and approaches

• Working across boundaries ……

Lots of opportunities

• RNI Community

Hospital

• Mackenzie Centre

• York Day Hospital

(Inverness)

Film clip

Working with the third

and voluntary sector

Maximise

use of

technology

Building community resilience

Integration, integration, integration

2005 2011-12

2020

Str

uctu

ral C

hange

Re-d

esig

n W

ork

…………………… R

e-d

esig

n W

ork

Re-d

esig

n W

ork

Third and voluntary sector

Community resilience

Partners in care

Inte

gra

ting H

ealth

Family &Friends

Care Home

Day Services

Acute

Hospital

Neighbours

Home

Carers

Respite

Care

Physio GP

Day

Services

Consultants

Residential

Care

Social

Workers

Pharmacy District

Nurse

OT

Voluntary

Community

Hospital Care Co-

ordinator

Communities

3rd Sector

A new model

for care and

caring

Film clip

And our last message ?

It is not hard!

It is really hard …

But it is worth it

Thank you