anticipatory care “..behold the throne of chaos and with him sable-vested night the consort of his...
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Anticipatory Care
“..Behold the Throne of Chaos and with him
Sable-vested Night The consort of his Reign..”
Adrian Baker
Paul Leak
Simon Steer
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
ANTICIPATING
MINORITY REPORT
THEY ARE ADMITTED
The Nairn Anticipatory Care PilotOrigins
• 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)
A WILLING PRACTICE ?
Long haired lilac, orange and white satin Peruvian
A WILLING PRACTICE ?
The Nairn Case Finder
2,670=43%
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
0 1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000 9,000 10,000
Bed
Day
s
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
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
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
Dr Baker discusses options for the Anticipatory Care Plan
The go anywhere eSSA?With the ACP within it and accessible 24/7.
Consent and jointly signed by assessor and patientData sharing with other agencies
The eSSA in practice
The Review Cycle
GP & Hospital systems
Provide Unmet needData Capture
Case Finder
eSSA & ACP
Patient
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
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
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
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
Year to date Bed Days Used by Top 5%
134 Patients Admitted to 03/12/2006 from top 5%
Bed Days Used YTD
0
50
100
150
200
250
300
1 7 13 19 25 31 37 43 49 55 61 67 73 79 85 91 97 103 109 115 121 127 133
Patients
Day
s
Nairn Emergency Cost Curve
-
500
1,000
1,500
2,000
2,500
3,000
00-04 05-14 15-24 25-44 45-64 65-74 75-84 85+
5% Cohort
Rest
LTCs Cumulative Excess Cost=£1.3m
0
500,000
1,000,000
1,500,000
2,000,000
2,500,000
3,000,000
3,500,000
4,000,000
4,500,000
00-04 05-14 15-24 25-44 45-64 65-74 75-84 85+
£
Excess Cost=£1.3mExcess Cost=£1.3m
Acute Cost for No LTCs= £2.7m
Nairn Pilot Matrix:Top 5%
45
100
52
347NHS Unknown
Social Work Unknown
Social Work Known
NHS Known
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?
Risk Scoring in reality
To Prevent This
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