Stuart Cumming, National Clinical Lead

Janette Barrie, National Clinical Lead

Living Well in Communities part of the

Overview of this session

• Recognise and share where we are

• Describe the Anticipatory Care Planning (ACP) National Action Plan in Scotland

• Deliver change using improvement methodology

• Challenge of implementing sustainable spread of ACP by enabling culture change and review of models of care

What is Anticipatory Care Planning?

“Thinking ahead" Working with people and those close to them ..... to set and achieve common goals in an ongoing process ... Person-centred care and ownership Quality and consistency To ensure ....the right thing is being done at the right time by the right person(s) with the right outcome

Who should have an Anticipatory Care Plan?

Consider ACP approach for 5-6% of population Appropriately early intervention to - improve quality of life optimise outcomes ACP from recognition of complex needs to end of life care 2% of population use 77% of bed days (90% are unplanned admissions!) use 50% of prescribing costs

Background

ACP Task and Finish Group

National Action Plan for ACP

National Action Plan for ACP : Primary Drivers

1. Raise awareness and profile of ACP and embed principles within each locality to help those with multiple morbidities

2. Share Information • Supporting people to develop their plan Design ACP material for individuals

• Supporting professionals to work together Increase access to the Key Information Summary (KIS) 3. Work to ensure carer support aligned with ACP Ensure delivery of ACP for all who would benefit

An ACP for

Scotland

Current Landscape

National AHP Action

Plan

Primary Care Transformation

Out of Hours Review

Dementia Strategy

Health & Social Care Integration

National Clinical

Strategy

Palliative Care

Nursing Review

GMS Contract

Prescription for

Excellence

Integration

Intermediate Care

Self Directed Support

Carers Act

Person Centred

Care

Time to bring jigsaw together..........

ACP Primary Drivers

Case Management

Rehabilitation and Reablement

Who should have an Anticipatory Care Plan? ACP Triggers

An ACP for

Scotland

Situation Condition

Assessment

ACP Triggers: Situation “

• Elderly and living alone

• Long term housebound

• Complex care package, living in a care home or in receipt of respite care

• Unplanned hospital admission

• Frequent unscheduled contacts

• Carer stress

ACP Triggers: Condition

• Deteriorating long term condition(s)

• Requiring specialist nurse, multidisciplinary team input • Placed on disease registers e.g. palliative care dementia learning disability mental health register

ACP Triggers: Assessment

Formal

• SPARRA or other risk prediction tools e.g. Activities of Living

• Polypharmacy review

• Falls assessment

Informal

Recognised as vulnerable

• Clinical judgement

• Local intelligence

General population growth 12.5%

In 2015 1 in 6 of the population aged over 65

By 2035: 1 in 4 aged over 65

In 2015: 1 in 14 aged over 75 By 2035 : 1 in 8 aged over 75

The need for change......

Acute Access

HAI

Front Door

WORKFORCE WORKFORCE

Admission avoidance

ACP

LTC/MM

and getting the balance right

Lifestyle

Refocussing the model of care…

Along with evidence....

Bit of blue sky thinking and a leap of faith

END STAGE

HIGH COMPLEXITY SEVERITY OR IMPACT

Integrated structured care provided by PHC

interdisciplinary team in collaboration with Specialists. Clients case managed

within General practice

MODERATE COMPLEXITY, SEVERITY OR IMPACT Co-ordinated structured care provided by a responsive PHC

interdisciplinary team. Clients case managed

within general practice

DIAGNOSED: MILD COMPLICATIONS OR IMPACT. CLIENTS CLINICAL INDICATORS ARE WITHIN ACCEPTABLE RANGE

Primary care, predominantly general practice based with referral to other PHC providers

WELL/AT RISK POPULATION Health promotion and prevention, early detection and intervention,

diagnosis and treatment

FROM POPULATION HEALTH TO LAST DAYS OF LIFE

Integrated palliative care

Based remodelling on need

DIAGNOSED: MILD COMPLICATIONS OR IMPACT. CLIENTS CLINICAL INDICATORS ARE NOT WITHIN ACCEPTABLE RANGE AND/OR THERE IS EVIDENCE THAT THE CLIENT IS NOT SELF

MANAGING EFFECTIVELY Predominantly general practice based with referral to other PHC providers.

3

2

4

1

5

6

ASH rate (Ambulatory Sensitive Hospitalisations) rate for conditions where appropriate ambulatory (Primary) health care prevents or

reduces the need for admission to hospital. People over age 75 are not categorised as ASH as age is then the major admission driver

Supporting ACP in New Zealand

Having a KIS significantly

reduces chance of hospital admission

In Scotland we have 11% reduction in the hospital

admission for the over 75s

Enabling and spreading change -

Awareness raising and improvement

Baseline scoping:

• Local leads within Boards/Partnerships

• National ACP Programme Board

Focussed improvement: work to inform future spread • Development of Logic Models

Tests of change

• Triggers

• Risk predictors

• Test ACP documentation

Measuring change:

Proposed measures:

• Number of ACPs and KISs

• Admission/readmission

• Bed days and delayed discharge

• Percentage of last 6 months of life spent in hospital

• Workforce engagement

• Patient experience

Measure change through Contribution Analysis

Growth and Change

• Learning Needs Analysis to develop education

programme

• Communication programme

• Raise public awareness and engagement

• Link with Technology Enabled Care

Improvement Programme

• Mobile technology (Apps)

• Improve use of eKIS (Key Information summary)

2395

2757

3284

3903

4645 5006

5343

5793 6088

6526

6995

2013/14, 7263

7427 7652

8135

8584 8816

9144 9627

9880 10220

10706 10843

2014/15, 11407

11667

11903 12117

12337 12521

12713 12927

13148 13377

13557 13805

2016/16, 14048

0

2000

4000

6000

8000

10000

12000

14000

16000

April May June July August September October November December January February March

KIS/EPC Uploads

2013/14 2014/15 2015/16

0

10

20

30

40

50

60 Th

ou

san

ds

of

AC

P

Number of ACPs in Scotland

2015

2016

8.17%

3.76%

4.22%

5.06%

4.17% 3.69%

3.31%

6.88%

5.37%

3.85%

4.94% 4.31%

5.52% 4.32%

Current % of ACPs per population

Sharing Information with each other:

Use of eKIS

0

500000

1000000

1500000

2000000

2500000

3000000

3500000

Other Accesses

OOH Accesses

A&E Accesses

KIS WS Accesses

Palliative WS Accesses

Clinical WS Accesses

KIS App Accesses

Palliative App Accesses

Clinical App Accesses

Demog App Accesses

eKIS accesses for one year to March 2016

Public Awareness

Jean experienced pathway 1

Margaret experienced pathway 2

Meet Jean and Margaret

July August September October November December

Hospital admission 1

Social Care Assessment

Hospital admission 2

Social Care Assessment

Hospital admission 3

Death

Outpatient Consultant

Clinic

Jean’s Pathway 1. Total cost including GP prescribing £ 18,000

Admission 1. 32 days Admission 2. 16 days Admission 3. 3 days Care Home 39 days

May June July August September October

Hospital admission

Social Care assessment

P Care

Domiciliary Visit

Social Care assessment 2

Death in Care home

Margaret’s Pathway 2. Total costs including GP prescribing £7, 100

Admission 1. 4 days Care home 73 days

Courtesy of M Muirhead, ISD, NSS

Versus

Pathway illustration

Self Directed Support

Supported Self Mix

Family &

Community

Anticipatory Care Planning

CORE LOCALITY NETWORK Enabling Integrated Team Development

OOH (24/7Health & Social Care)

Individual

Older Peoples Services & Children's Services

Hospital & Home

including: AHP weekend

support, Overnight Care, Rehab at Home

Community Hospital &

Intermediate Beds Model

Telecare

Responsive Social Care Services

Employability

Rehabilitation / Early Intervention

REACH

• General Practice and Nursing Teams • Community

Pharmacy

Mental Health & Learning Disability Support

Third Sector

Other Community Services: Police, Education / Care Homes

EXTENDED LOCALITY NETWORK

Specialist Mental Health

Services

Specialist Learning Disability Service

Complex Care Services

REACH & Specialist

Rehab

Specialist Nursing

Workforce

Secondary Care

Tertiary Care

Reshaping Care for Older People

Integrated Care

Pathway

Daycare Redesign

e.g. Acute, Hospital Liaison

Ambulatory Care including:

AAU, CAU, ED Review

Enhanced Carer Support

SAS – See & Treat

Enhanced Discharge &

Discharge Planning

Management Plans, LOS, Ward Reconfiguration

Carer Support & Training

Diagnostic Services

ACUTE SERVICES NETWORK

Whole System Whole Person

Whole Team

Additional focus needed on

• Technology

• From early intervention to end of life care

• Carers • Workforce and cultural change

• Value of Collaboration

• Health Economics- Pathway

The time is right....

Right action, Right person, Right place,

right time..

Improve KIS

Communication and

Information

Increased

public awareness

Carer Support

Improved interfaces

Single ACP Accurate,

timely hand-held

Identify most

vulnerable

Community capability

and capacity

See Change?

Think ACP

An ACP for

Scotland