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