whole system models of care for older people tom bowen the balance of care group orahs 2004,...
TRANSCRIPT
‘Whole System’ Models of Care
for Older People
Tom Bowen
The Balance of Care Group
ORAHS 2004, Stockholm, Sweden28 June 2004
Content
• Health status of older people
• ‘Integrated’ and ‘intermediate’ care
• Balance of Care models
• Appropriateness Evaluation Protocol surveys
• Comparison of UK local health economies
Health Status of Older People
• Manton (US) estimated disability reducing by 1.3% p.a. in over 75s
• Lagergren (Sweden) has shown that health and social care costs continue to concentrate in last two years of life
• Dixon et al (UK) show that the number of acute hospital bed days in last 3 years of life does not increase with age (2004)
• Some debate about ‘compression of morbidity’
Developing a community focus
• Kaiser Permanente– focus on chronic disease management
• Adcroft Surgery– occupied bed days reduced by 20% in local
hospitals
• South Bucks EPICS scheme– Managed population 4,200 elderly and
saved 561 bed days in first 5 months
• EverCare Project– Ten pilot PCTs in UK– 30-35% admissions from 1% of population
Intermediate Care
• Driven by wish to free up acute beds
• In-between acute hospital care and primary care
• ‘Step up’ and ‘step down’
• Could be bed or community based
• Cuts across professions, organisations and budgets
Balance of Care model
OlderPeopleIC care
Post-acuteintensive
(up to 7 days)
“slow stream rehab”(up to 42 days)
Supported discharge(up to 14 days)
Communitynurse
Care Co-ordinator
Voluntary &Independent sector
NHS
LocalAuthority
Physiotherapist
Care assistant
Occ. therapist
Speech therapist
CareOption 1
Care Option 2
CareOption 3
Rehab/ recovery(up to 28 days)
Alternative toadmission
Balance of Care Group
CareOption 4
Phase of Care Care Option Intervention Provider
Community Admission Diagnosis Treatment Discharge
Rich Picture of Process Flow
Community Admission Diagnosis Treatment Discharge
Referral detail
Admission reason
Acute care
Rehabilitation
Interim care
Investigations
Assessment
Social circs
Risk factors
Discharge planning
DA
TA
Rich Picture of Process Flow
Community Admission Diagnosis Treatment Discharge
Referral detail
Admission reason
Acute care
Rehabilitation
Interim care
Investigations
Assessment
Social circs
Risk factors
Discharge planning
Earlierdischarge
ChronicDisease
Management
Alternativetherapysettings
Alternativediagnostics
settings
Admissionavoidance
AL
TE
RN
AT
IVE
SD
AT
A
Rich Picture of Process Flow
Point Prevalence Surveys
• All inpatients in selected specialties on a single day
• Acute and elderly medicine, & orthopaedics
• Data collected from casenotes by clinical staff
• Use Appropriateness Evaluation Protocol (AEP) to identify possibly ’non-acute’ patients
• Also survey non-acute hospitals
• Follow up discharge outcomes to provide basis for demand analysis
AEP Criteria
On admission• Severity of illness
eg unconscious, unable to move (fall), acute bleeding
• Intensity of service eg surgery + gen anaesthesia, regular monitoring, IV therapy
On day of care
• Medical services
• Nursing services• Patient condition
eg acute confusion, other acute states, coma, fever
Results from Typical Acute Hospital
• 12% of all patients admitted outside AEP criteria
• 43% of all patients outside AEP criteria on day of survey
• Clinicians assess preferred alternative type and location of care
Age of patients in acute hospital
18-6425%
65-7422%
75-8432%
85+21%
No of patients by AEP status in acute hospital
0
20
40
60
80
100
120
140
160
180
18-64 65-74 75-84 85+
Age
No
of
pat
ien
ts
Outside AEP
Within AEP
AEP comparison for medical patients
Outside AEP on admission
Outside AEP on the day
East Berkshire 15% 47%
Cambridge 16% 47%
Oxfordshire 20% 49%
East Surrey 15% 50%
NW Surrey 16% 57%
Some implications
• Alternatives focussed on rehabilitation services (c50%)
• Remainder have continuing care needs, or could just go home earlier
• AEP values characterise the nature of the UK hospital service, and potential to develop
• Change to the clinical process is needed if service development to deliver benefits