care co-ordinators - king's fund · care co-ordinators: better care through transition mary...

Care Co-ordinators: better care through transition

Mary Bradley Chief Executive, Age UK West Cumbria

• Why is care co-ordination important?

• What are the benefits and to whom?

• How can it be achieved?

• Can this be evidenced?

• The way forward

Why is Care Co-ordination important?

Long Term Health Conditions

• 69% of total health & social care spend in England (DM 2008) • 2025 – 18 million people will have LTC • Depression:- 25% of older people living in the community

have symptoms which warrant intervention. (85% of people over 65 do not receive any NHS support) • Dementia:- 1 person in 6 over 80 1 person in 3 over 95 now = 820,000 people in UK

Multimorbidity

% Dependent

Disability, Age and Activities of Daily Living

In eight years’ time, demographic change alone would mean that there would be:

• Nearly 2.7 million people aged 75+ with at least one limiting long term illness and over 4.3 million people aged 65+ with LLTI

• People living an average of 7-9 years at the end of their lives with a disability

• Nearly seven million older people who cannot walk up one flight of stairs without resting

• One-and-a-half million older people who cannot see well enough to recognise a friend across a road

• Over 4 million with major hearing problems • Up to a third of a million people aged 75+ with dual sensory loss • A third of a million who have difficulty bathing • Nearly a million with dementia • Between 4-7 million with urinary incontinence • One-and-a-half million suffering from depression

Typical Pathway

Awareness - Information - Diagnosis - Information - “treatment” Life adjustments - living well with - acute episodes - ageing and condition impact - carer support - palliative care - afterwards

What are the benefits and to whom?

Main stakeholder benefits Who? How? Measured?

People Health and well being Living well in later life Helping each other ‘Future proofing’ the community

Long term, whole population. Short term, each individual makes a difference

Third Sector More effective, more satisfaction, more volunteering

People helped, timeliness of intervention

NHS (health economy)

More cost effective Prevent hospital admissions, more care at home

Recognise difference between each stakeholder’s evaluation ‘on their own terms’ and the overall community benefit.

A Whole System Approach

Working together to use the resources available to the maximum effect Step changes towards:- • More self care and information • Valuing of prevention • Tackling health in equalities • Delivery of care outside of acute hospitals • Empowerment of patients • Engaging citizens

What People Tell Us

• Being active, staying healthy and contributing

• Continuing to learn

• Friends and community – being valued and belonging

• The importance of family and relationships

• Valuing diversity

• Approachable local services

• Having choices, taking risks

How can care co-ordination be achieved?

Social Prescribing

Telephone and/or Visit Establish need / want and further information, create Age UK paperwork and input on Charity Log

Stage 1

Stage 2

Referral to Age UK Worker If more complex case that requires action.

Referral to other third sector organisation / Agency Alzheimer's, Cruise, West Cumbria Carers, University of the Third Age

Referral to other Age UK Service: MoneyWise, Handyperson, Help at Home, Fit as a Fiddle, social groups and community activities

Referral for Volunteering Opportunities for volunteering with Age UK projects / services, other organisations services or local community projects looking for volunteers. Important to utilise people’s skills as assets in the community.

GPs Health Professionals Other

Health

Third sector post as referral/signposting hub Bridges gap between health, third sector and assets in the community

Underlying philosophies

• Asset Based Community Development • Co-Production and Co-Design (informing

future commissioning of services) • Partnership between Third Sector and

NHS • Can do

One number

Knowledge of Materials and community Information Hub Information Independent Living Volunteers Events Signposting Targeted information Services Activities

• Can be accessed electronically on GP computers

• Referral is emailed to practice manager or reception staff

• Centre for the Third Age Coordinator collects forms from reception on a daily basis

Referral form

Can this be evidenced?

Using 5 ways as a Framework

• Connect - with others, at home, at work, in your community • Be Active – an active lifestyle not only keeps our bodies healthy, but

makes us feel good as well • Keep Learning – trying something new can help keep our minds and

our lives active • Give – giving to others makes us feel better, and 2010 could not

have happened without the generosity of the people of Liverpool • Take Notice – It’s easy to rush through our busy lives without

pausing for thought

Star Outcomes

• Picture • Focus on person’s issue

• Deal with complexity • Encourages self management • Measure progress

Target Wellbeing

1%

12%

38% 31%

18%

Pre TWB None of the time

Rarely

Some of the time

Often

1%

2%

7%

66%

24%

Post TWB None of the time

Rarely

Some of the time

Often

I have been joining in social activities’

‘There are social activities available to me’

5%

9%

43% 28%

15%

Pre TWB None of the time

Rarely

Some of the time

Often

1% 2%

27%

53%

17%

Post TWB None of the time

Rarely

Some of the time

Often

‘I have good relationships with others’

0% 1%

16%

57%

26%

Pre TWB None of the time

Rarely

Some of the time

0% 1%

15%

63%

21%

Post TWB None of the time

Rarely

Some of the time

Often

All of the time

Moneywise

40.00

45.00

50.00

55.00

60.00

65.00

70.00

75.00

80.00

85.00

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Female claimants vs claimant age range

Claimants Aged 80 and Over Claimants Aged 70-79 Claimants Aged 60-69 Female

Moneywise (cont)

0.00

5.00

10.00

15.00

20.00

25.00

30.00

35.00

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

All

Sain

ts

Asp

atri

a

Bolto

ns

Brou

ghto

n St

Bri

dget

's

Chri

stch

urch

Clift

on

Crum

moc

k

Dal

ton

Der

wen

t Val

ley

Elle

n

Elle

nbor

ough

Ewan

rigg

Flim

by

Har

ring

ton

Hol

me

Kesw

ick

Mar

sh

Moo

rclo

se

Mos

s Ba

y

Net

herh

all

St Jo

hn's

St M

icha

el's

Seat

on

Sillo

th

Solw

ay

Stai

nbur

n

Wam

pool

War

nell

Wav

er

Wha

rrel

s

Wig

ton

90 and over 85-89 80-84

75-79 70-74 64-69

% over 65 on AA

WEMWBS

WEMWBS (cont)

Number % Number %Very Poor 0 0.00% Very Difficult 1 0.68%

Poor 0 0.00% Quite Difficult 2 1.35%

Alright 5 3.38% Alright 30 20.27%

Very Good 40 27.03% Quite Easy 68 45.95%

Excellent 103 69.59% Very Easy 47 31.76%

30.57%

85.98%

55.41%Percentage increase in Clients Awareness

Clients Percentage Awareness of Age UK/Concerns Services Before Contact

Clients Percentage Awareness of Age UK/Concerns Services After Contact

Questionnaire 2 Supplimental Data Analysis

Age UK/Concern Service Rating Contacting the Right Help

In the first 3 months after opening C3A there were 141 fewer hospital admissions than the comparable quarter the year before (but a large number of admission avoidance activities are working together to achieve this).

Impact Assessments

Case Studies

• Mr L (£799) v Mr T (£10,319) • Mrs G (£4,385) v Mrs S (£38,484)

• Mr P (£1874) v Mr A (£8503) • Mrs D (-£164) v Mrs K (£5532)

Using a volunteer model? The financial value of volunteering averages around £700,000 per year in Hospital Trusts, £500,000 per year in Mental Health Trusts and £250,000 per year in a Primary Care Trust. Each £1 investment in a volunteering programme yielded an average return of between £3.38 and £10.46 - with these returns shared between organisation, service users , volunteers and the wider community (Teadale 2008) In 2012, work undertaken by NEF and published by the British Red Cross estimated that the money saved was typically at least 3.5 times greater than the cost of the services provided.

What £30,000 has bought in 12 months (10K Pop) Objective: Clinical / improved Care 325 patients signposted/referred to the activities/services of Third Sector organisations 8 sustainable activities which support health and wellbeing set up in the community 250 people attending wellbeing events - e.g. falls awareness, winter warmth 3 sustainable activities to support patients to live well with a long-term condition/dementia Objective: Efficiencies 19 named patients had reduced frequency of GP attendances 36 supported discharges from GP managed beds 38 patients provided with exit strategies from rehabilitation, podiatry etc 38 identified patients who may be at risk were visited, with a comprehensive preventative, holistic assessment 90% of patients attending flu clinics provided with additional wellbeing information

The way forward

What can you do as a person ?

The way forward... Question the notion of ageing; in society, in ourselves Ignore the calendar; chronological age is progressively less

relevant Develop services and products which are appropriate to the

‘third’ and fourth ages’ Think about how we can

– enable life and living – enhance the quality of life – simplify life

What can you do as a Clinician

• Think about the pathway

• Where does the person get “lost” ?

• What could be saved to be re-invented ? • Think about Age UK as a quality partner