Daring to AskDaring to Ask

““..Behold the Throne of Chaos and ..Behold the Throne of Chaos and with him Sable-vested Night The with him Sable-vested Night The

consort of his Reignconsort of his Reign..”..”Paradise LostParadise Lost

Dr Adrian BakerDr Adrian BakerPaul LeakPaul Leak

Simon SteerSimon Steer

Public health; healthImprovement; health education

Lower risk:supported self-care

(70-80%)

High risk:disease

Management(15-20%)

MIU

, A&

E,

em

erg

ency

adm

issions

Inte

rventio

nsO

utco

mes

Individuals withcomplex needs: case management(3-5%)

Delivering for Health Information ProgrammeLong-term conditions + interface with acute care

2

Unscheduled Care Flows

34

5

1

Nairn Case FinderNairn Case Finder2006/07 Nairn Cumulative Emergency Bed days

5%=44%

List

Bed

Day

s

100%

100%

N a ir n s h ir e p o p u la t io nC u r r e n t a n d p r o j e c t e d t o 2 0 2 4

750 500 250 0 250 500 750

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

Number

Male

Projected 2024

Female

Projected 2024

Location of Death 1996-2000

Mental Health1%

Raigmore Hospital

20%Other Hospital

2%

Home26%

Nairn Town and County Hospital

27%

Highland Hospice

2%Nursing/

Residential Home22%

Nursing/ResidentialHome

Home

Other Hospital

Raigmore Hospital

Mental Health

Nairn Town and CountyHospital

Highland Hospice

ANTICIPATINGANTICIPATING

MINORITY REPORTMINORITY REPORT

THEY ARE ADMITTED

Models of CareModels of Care

BiomedicalBiomedical CureCure Specialist roleSpecialist role Disease / Illness Disease / Illness ComplianceCompliance IntensiveIntensive Palliative ChemoPalliative Chemo

BiosocialBiosocial CareCare HolisticHolistic Patient Autonomy Patient Autonomy ConcordanceConcordance Time / ChoicesTime / Choices Community BasedCommunity Based

Locality Total £/headLocality Total £/head

1,300.00

1,350.00

1,400.00

1,450.00

1,500.00

1,550.00

1,600.00

1,650.00

1,700.00

1,750.00

Inverness Locality

CaithnessLocality

Badenoch &S

trathspeyLocality

Lochaber Locality

North W

estS

utherlandLocality

Argyll &

Bute

East S

utherlandLocality

Skye &

LochalshLocality

Nairn &

Ardersier

Locality

Ross &

Crom

artyLocality

The Nairn Anticipatory Care The Nairn Anticipatory Care PilotPilot

Non Recurrent Investment £125kNon Recurrent Investment £125k

To pay for New PostTo pay for New Post 1.2 WTE Case Manager (Nurse/OT/SW);1.2 WTE Case Manager (Nurse/OT/SW);

Gaps in Primary Care InfrastructurGaps in Primary Care Infrastructuree 1 Physiotherapist;1 Physiotherapist; 0.75 OT;0.75 OT; Equipment budget;Equipment budget;

Gaps In Local Authority ProvisionGaps In Local Authority Provision 2 WTE Care Assistants / Emergency Home Care2 WTE Care Assistants / Emergency Home Care

Case Manager Case Manager

eSSA & ACP eSSA & ACP

Complete EQ-5DComplete EQ-5D

Who, where, how, what, why, whenWho, where, how, what, why, when

Coordinating and reviewing roleCoordinating and reviewing role

The Anticipatory Care Plan The Anticipatory Care Plan (ACP)(ACP)

Carer or Cared for status, what Carer or Cared for status, what happens ?happens ?

Acute medical problemAcute medical problem Acute surgical problemAcute surgical problem Discussion of condition by professionalDiscussion of condition by professional Preferred Place of CarePreferred Place of Care Resuscitation statusResuscitation status

Heart Failure / COPDHeart Failure / COPDFunctionFunction

Second Hospitalisation

Death

First Acute admission

TIME

Final Illness

High

Low

Frailty / Dementia Frailty / Dementia TrajectoryTrajectory

FunctionFunction

Decline in ADL’s & Memory

Death

First Acute Problem

TIME 3-10 years

Unable to self care

High

Low

Care AssistantsCare Assistants

Hands on careHands on care Coached & educated byCoached & educated by

Nurses, CMHT, Physio, OT, Dietetics, SALT, GP’sNurses, CMHT, Physio, OT, Dietetics, SALT, GP’s

Nutrition problems, falls, Nutrition problems, falls, Income maximisation (CAB) Income maximisation (CAB) Enhancing safety Enhancing safety Social Services SubstitutionSocial Services Substitution

MeasuresMeasuresOutcomesOutcomes

1.1. Health Status: EQ-5DHealth Status: EQ-5D

2.2. ACP was it followed?ACP was it followed?

3.3. Preferred Place of Preferred Place of Care. Did we deliver?Care. Did we deliver?

4.4. Qualitative: Qualitative: InterviewsInterviews

OutputsOutputs

1.1. Bed Day rateBed Day rate

2.2. Admitted rateAdmitted rate

3.3. Admission rateAdmission rate

4.4. Re-admission rateRe-admission rate

5.5. Delayed Delayed DischargesDischarges

ACP Cohort: Age ProfileACP Cohort: Age Profile

0

20

40

60

80

100

120Age

Change in Community Change in Community Hospital use over 2005-Hospital use over 2005-

20082008

0.00

2000.00

4000.00

6000.00

8000.00

10000.00

12000.00

14000.00

Control SE>80 Years Nairn

OB

D/1

000

Av 05/06-06/07 07/08

Change in Bed Day Rates in Change in Bed Day Rates in Raigmore 2005-2008Raigmore 2005-2008

0.0

1,000.0

2,000.0

3,000.0

4,000.0

5,000.0

6,000.0

Control SE>80 Years Nairn

OB

D/1

00

0

Av 05/06-06/07 07/08

ALOS in Raigmore 2005-ALOS in Raigmore 2005-20082008

0.00

2.00

4.00

6.00

8.00

10.00

12.00

Control SE>80 Years Nairn

AL

OS

(D

ay

s)

Av 05/06-06/07 07/08

Qualitative EvaluationQualitative Evaluation

University of Stirling, CCRCUniversity of Stirling, CCRC June 2008 after 1June 2008 after 1stst year year Acknowledged benefit to patients, Acknowledged benefit to patients,

carers and familiescarers and families Staff empowered, committed and Staff empowered, committed and

focused on providing care locallyfocused on providing care locally Anticipatory and Reactive elementsAnticipatory and Reactive elements

eSSAeSSA

80 Yr Old Non-Smoking Unmarried 80 Yr Old Non-Smoking Unmarried Female with a Stroke Living In a Care Female with a Stroke Living In a Care

Home Home BeforeBefore AfterAfter

2005/06 & 2006/07:2005/06 & 2006/07:

13 Admissions in 13 Admissions in RaigmoreRaigmore

24 Bed Days in 24 Bed Days in RaigmoreRaigmore

10 Months 2007/08:10 Months 2007/08:

4 Admissions in 4 Admissions in RaigmoreRaigmore

3 Bed Days in 3 Bed Days in RaigmoreRaigmore

Work in ProgressWork in ProgressA 74 year old female who missed A 74 year old female who missed

the ACPthe ACP Chronic Renal Failure – Stage 5Chronic Renal Failure – Stage 5 On dialysis 3 yearsOn dialysis 3 years Admitted to Nursing Home, deteriorating conditionAdmitted to Nursing Home, deteriorating condition GP discussion with family, all considering and GP discussion with family, all considering and

wanting to cease dialysiswanting to cease dialysis Admitted for 3 weeks – June 08Admitted for 3 weeks – June 08 Returned to Nursing homeReturned to Nursing home Dialysis continuedDialysis continued Arrested on Unit – 11 August 08Arrested on Unit – 11 August 08 Crash team call and resus attempted, patient Crash team call and resus attempted, patient

intubated, unsuccessful. intubated, unsuccessful.

78 Yr Old Married Male Smoker with78 Yr Old Married Male Smoker withHypertension, CHD, Diabetes, Heart Hypertension, CHD, Diabetes, Heart

Failure & Stroke Living at HomeFailure & Stroke Living at Home

BeforeBefore AfterAfter2005/06 & 2006/07:2005/06 & 2006/07: 3 Admissions in 3 Admissions in

RaigmoreRaigmore 44 Bed Days in 44 Bed Days in

RaigmoreRaigmore 1 Admission & 1 1 Admission & 1

Transfer to NairnTransfer to Nairn 39 Bed Days in Nairn39 Bed Days in Nairn

6 Months 2007/08:6 Months 2007/08: 1 Admission to 1 Admission to

RaigmoreRaigmore 1 Bed Day in 1 Bed Day in

RaigmoreRaigmore

OpportunitiesOpportunities Dovetails with LTC and Mental HealthDovetails with LTC and Mental Health Increase patient autonomy / choiceIncrease patient autonomy / choice Gold standard palliative Home care Gold standard palliative Home care

including complex care packages including complex care packages Gold Standard palliative Nursing home care Gold Standard palliative Nursing home care Extended Community Hospital careExtended Community Hospital care Disease specific consultant careDisease specific consultant care Single patient record for Health and Social Single patient record for Health and Social

CareCare

Does culture change work?Does culture change work?

Emphasis on group affiliation, Emphasis on group affiliation, teamwork, coordinationteamwork, coordination More likely to be associated with More likely to be associated with

implementation of quality improvementimplementation of quality improvement

Emphasis on formal structure, Emphasis on formal structure, regulation, and reporting regulation, and reporting arrangementsarrangements Negatively associated with quality Negatively associated with quality

improvementimprovement

ThreatsThreats More Middle ManagementMore Middle Management Spending Crisis from historic work Spending Crisis from historic work

patterns, but business as usualpatterns, but business as usual Cuts to frontline AHP and Nursing Cuts to frontline AHP and Nursing

posts in Community. posts in Community. Cut Marie Curie Availability and Cut Marie Curie Availability and

FundingFunding ““No money to continue projects”No money to continue projects” £165 / patient at Board level in £165 / patient at Board level in

“Corporate Services” “Corporate Services” £50M in NHS Highland£50M in NHS Highland

ConclusionConclusion Anticipating and planning worksAnticipating and planning works

Deserved and appreciated by Deserved and appreciated by Patients, Carers and FamiliesPatients, Carers and Families

The community health and social The community health and social care team delivering current best care team delivering current best practice to the individual are the only practice to the individual are the only people who can fulfil this rolepeople who can fulfil this role