Cohort Model for End of Life Care in Community Settings

Executive Briefing material

Version 2, April 2012

Background

The National Programme has sponsored the development of this tool to help address some of the strategic commissioning questions about End of Life Care services, including making a contribution to QIPP;

The tool is rooted in work undertaken in the East The tool is rooted in work undertaken in the East Midlands that involved significant clinical and professional engagement to arrive at a robust model framework and baseline assumptions;

The tool has subsequently been ‘road-tested’ through local calibrations and is now available for wider adoption.

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What does the modelling do?

Five things the tool helps with:

1. Identifying total population needs for EoLC;

2. Exploring the impact of improved early recognition;

3. Understanding trajectories of illness and cohorts of need;need;

4. Reflecting targets for reducing deaths in hospital;

5. Identifying the impact on workforce.

Supported by nine statements defining language and the underpinning principles and values.

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What are the model boundaries?

Covers the full last year of life, although it restricts the number of people who could reasonably be identified as being in the last year dependent on trajectory;

Considers care outside of hospital only, although it does reflect admissions to hospital as part of impact and financial savings;

Identifies the support needs of people where these people can Identifies the support needs of people where these people can be identified and placed on an EoLC register or equivalent. It reflects health, social care and carer input and then costs that element of the workforce that could reasonably be considered to be part of an EoLC service;

Takes a 10 year time horizon to ensure future needs are anticipated.

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Model overview

Do something

Entering EoLC

Care after death

Last days of life and

actual death

Entering EoLC

Entering EoLC

Needs sensitive to disease trajectories

1

765

2

98New cases entering

Do something more

43

5

Entering EoLC

needs (1)

Last year of life but not apparent or recognised

Mid stage but not on EoLC pathway

Early stage but not on

EoLC pathway

TriggersTriggers

Entering EoLC

needs (2)

Entering EoLC

needs (3)

1 98

Triggers

Late stage but not on EoLC pathway

Triggers

New cases entering last year of life

Needs based on five EoLC trajectories

Last year

Function

Sudden death

Last year

Function

Cancers

Function

Frailty

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Last year Last year

Last year

Function

Other terminal conditions

Last year

Function

Organ failure

Last year

Function

Populating the model - summaryUsing national projections for deaths pa 2011 to 2021;

Allocating cause of death to one of the five EoLC needs trajectories (making allowance for frailty);

Distinguishing for each trajectory the estimated time with different levels of need within the last year;with different levels of need within the last year;

Using the functional analysis to identify tasks along the pathway, making allowance for dementia needs;

Costing the workforce element with an allowance made for the mix of activity for specialist staff;

Exploring the impact of changes in population needs and an optimised EoLC service offering.

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Dynamic elements of the model

1. Underlying demographic – what is the likely future need for end of life care services?

2. Increased likelihood of early recognition of end of life care needs – what might this mean in terms of community support and the impact on achieving community support and the impact on achieving choice of place of death.

3. Increased provision of alternatives to dying in hospital coupled with increased likelihood of this being taken up due to earlier conversations.

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Health Functional Mapping Process

During the initial development work 3 engagement events were held focussing on workforce aspects of EoLC;

Functional analysis for each trajectory expressed as:Functional analysis for each trajectory expressed as:

1. Skills needed (expressed as functions);

2. Skill level needed (1 of 3);

3. Timings.

For each point of the pathway, for each of the 5 trajectories, with an allowance made for dementia in each.

Example – Other Terminal

Skill level:GenericEnhancedSpecialist

Common Core

Timings

Assumptions/notes = richness

Common Core Competences

Quality Assurance

High level of engagement from a wide range of health and social care professionals;

Common Core Competence mapping;

Additional expert input (cancer, community health services);services);

Cross-trajectory analysis;

Further refinement, questioning and clarifying -consensus workshop;

Participant evaluation.

Organising the response to needs

Do somethingCare after death

Last days of life and

actual death

7652

Do something more

43

Last days

Early Support

12

Entering EoLC

pathway (1)

actual death

TriggersTriggers

Entering EoLC

pathway (2)

Entering EoLC

pathway (3)

Pathway sensitive to disease trajectories

1 98

Triggers Triggers

Early Recognition

Last days

Characteristics of support

Early recognition – requires specialist/designated input to ensure effective planning and advice;

Early support – requires balance of support from mainstream (health and social care) staff, the carer and the ‘expert patient’ with small amount of specialist or the ‘expert patient’ with small amount of specialist or designated input;

Last days – requires a mix of:

� Specialist/designated support from EoLC team;

� Health and social care staff trained in providing EoLC;

� Support from carer.

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Cost elements within the modelUnit cost of notional community workforce calculated on the basis of PSSRU unit costs of health and social care:

� Generic based on clinical support worker @ £22K;

� Enhanced based on community physio or OT @ £35k;

� Specialist based on ANP @ £55k.� Specialist based on ANP @ £55k.

Cost of EoLC designated community support calculated as a % of the notional value taking account of input from carers and mainstream community staff;

Hospital savings generated from alternatives at end of life are netted off at a unit cost of £3,000.

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Benefits of the cohort modelExpected benefit of the cohort model:

� To provide a clear expression of EoLC needs in such a way as to help local partners to align understanding and develop a common approach to system redesign;

� To demonstrate the dynamics of this system in order to scale the opportunities likely to accrue to people with EoLC needs and the opportunities likely to accrue to people with EoLC needs and local partners before investment in detailed analysis and planning;

� To provide a framework and set of definitions that can inform the nature of local information or data collection and analysis to inform local planning and any further calibration of the framework model to local needs.

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The Cohort Model home pageExplanatory

notes

Policy switch

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Navigation buttons to assumptions and outputs for different cohorts of need

Navigation buttons to other assumptions and model outputs

Model outputs over time (2011 –

2021)

Illustrative outputsThe local calibration process enables you to identify the extent to which local population needs for end of life care might vary over time compared to an al England average:

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Illustrative outputsIt also provides a breakdown by which you can identify where needs are increasing:

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Illustrative outputsAnd provides an indication of the shift in place of death:

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Illustrative outputsAnd finally it provides an indication of the likely financial impact over time compared with a do-nothing alternative:

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What people have saidSelected comments from those involved in the early adopter programme for the Cohort Model:� “Having early adopter status has been such a massive enabler in terms

of identifying and evidencing required improvements to health outcomes, and thus influencing commissioning decisions”.

� “Being an early adopter gave me the opportunity to improve what I � “Being an early adopter gave me the opportunity to improve what I was doing, to gain evidence, and to add weight to decision making”

� “We now have a tool… a lever to change practice, with facts and figures that will evidence the basis of our requirements.”

� “The model is simple to use and helps us in our project planning. Thus we can now have greater influence which will lead to practice change. We no longer have to try and make the national picture fit – it’s like having your own crayons instead of those belonging to someone else, now being able to make decisions based on meaningful data”.

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Definitions for cohorts of needThe methodology for allocating deaths to a trajectory is explained in an accompanying workbook but is based on cause of death codes with a re-allocation from each trajectory to frailty for a proportion of deaths in the older age groups, thus reflecting co-morbidities and an individuals actual needs:

� Cancer: All cancer deaths, ave.21% based on the above methodology.� Cancer: All cancer deaths, ave.21% based on the above methodology.

� Other Terminal Illness: Parkinson's, MND, MS, Diabetes and other diseases of the nervous system; ave.4% of deaths.

� Frailty: Dementia, Alzheimers, senility plus a proportion of other causes of death increasing with age; ave.42% of deaths.

� Organ failure: IHD, COPD etc; ave.19% of deaths.

� Sudden Death: Acute myocardial infarction, stroke, pneumonia, accidents etc; ave.14% of deaths.

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Further information and contact details

For the full context and briefing materials go to www.endoflifecare-intelligence.org.uk/models

For direct access to an online version of the cohort model reflecting an average 200,000 population follow

this link

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For information about local calibration and support for using the cohort model please contact

peter.lacey@thewholesystem.co.uk

www.thewholesystem.co.uk

this link