Keynote Session 5: Integrating Care in the Highland: Our Story So Far

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Elaine Mead, Chief Executive, NHS Highland and Dr Adrian Baker, a GP in NHS Highland provide the background as to why they integrated health and social care services in their area and why they concluded that a radical structural reform was the way forward. They also explain some of the pre-work that they tested, the experience they gained from elsewhere, and where they are now. They also share some of the challenges that they faced and how they dealt with those things that they did not quite anticipate.

See more on the 2013 NHSScotland Event website http://www.nhsscotlandevent.com/resources/resources2013/resources

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Keynote Session 5: Integrating Care in the Highland: Our Story So Far

  1. 1. Integrating Care in the Highlands: our story so far
  2. 2. Intro Film Clip
  3. 3. Integrating care in the Highlands our story so far Adrian Baker, GP Elaine Mead, Chief Executive
  4. 4. Integrating care in the Highlands: About a journey from 2005
  5. 5. NHS HIGHLAND (Highland Council and Argyll & Bute Council Areas) Actual and projected number of people aged over 75: 1981 to 2031 Source: General Register Office for Scotland 0 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000 45,000 50,000
  6. 6. Why did we need to integrate care? • High level of delayed discharges • Early (young) admissions to care homes • Lack of alternatives to hospital admission • Unnecessary and avoidable admissions • Limited care at home access • Lack of ‘joined-up’ services
  7. 7. New admissions to care home 75.4 75.9 75.7 75.8 76.3 72.5 73.2 73.7 73 73.4 70 71 72 73 74 75 76 77 2008 2009 2010 2011 2012 Average age at admission Scotland Highland
  8. 8. What do people want? • Maintain good health • Maintain independence • Prevent unnecessary hospital admissions • Support carers to care • Stay in their own homes for as long as possible
  9. 9. Cost and quality of experience Independent Supported self care Care at Home Hospital at Home Community Hospital Residential Care Acute Hospital Care BetterExperience IncreasingCosts
  10. 10. Journey of dependence • Home Care £6K / pt /year • NHS 24 = NHS Direct £36.67 / call • OOH contact £68.00 • GP in hours contact £30.00 • District nurse £40.89 • A&E £92.50 • Admission (Ave 10 days) £2,784 • Long stay care £20K to £40K+
  11. 11. Integrating – what? Acute Health 3rd Sector, voluntary People Community resilience Health & Social
  12. 12. Integrating health & social care 2005 2011-12 2020
  13. 13. Integrating health 2005 2011-12 2020 Unscheduled Care Anticipatory Polypharmacy
  14. 14. Whole system flow
  15. 15. A&E waits • A&E waits compromised when no flow • Medical admissions redirected through A&E • Trauma space compromised • Patients waiting on trolleys • Long minor patients waits
  16. 16. Actions in hospital • Acute physician • AMAU (assessment not admission) • Nurse call triage • Focus on planned date of discharge • Reduce bed stays for tests • Reduce medical outliers • Maximise community hospitals
  17. 17. Percentage Compliance with the Four Hour Target: July 2007 to March 2013 NHS Highland and NHS Scotland NHS Scotland NHS Highland 88% 90% 92% 94% 96% 98% 100% Jul-07 Jan-08 Jul-08 Jan-09 Jul-09 Jan-10 Jul-10 Jan-11 Jul-11 Jan-12 Jul-12 Jan-13 Month Percentageofpatientsspendinglessthanfour hoursinA&E
  18. 18. Nairn Town and County
  19. 19. The Gatekeeper and the Wizard: a fairy tale. (Br Med J 1989;298:172-3) “The wizard asked the Minister for bigger and better crystal balls and more powerful magic potions. But it was no good….”
  20. 20. Healthy Aging
  21. 21. Lots happening • SPARRA • Casefinding • Anticipatory Care • Polypharmacy • Hospital at Home • Community Hospitals • Virtual Ward • Unscheduled Care – Flow 5!
  22. 22. Nairn Case Finder 2006/07 Nairn Cumulative Emergency Bed days 5%=44% List BedDays 100% 100%
  23. 23. Anticipating
  24. 24. 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
  25. 25. Homework • Power of Attorney – Welfare – who do you want to decide on this? – Finance – who do you want to have control of your financial affairs? • Will – do you have a will? • Do you have a Living Will and if so who knows?
  26. 26. The Numbers • Initial study 2005-8 100 patients and 100 controls • 15-16% mortality rate in the year. • Survivors, 42% fewer admissions (P = 0.002) • 52% fewer bed days (P = 0.020) • The cost of hosptialisation of the study population was reduced by 50%. (P = 0.029) • The control population had 11 patients die in hospital, the study population had 3 deaths in hospital (P = 0.007)
  27. 27. At scale for >5,000 patients • By 31st March 2011, 5,329 patients who had received ACPs, demonstrated: – 29% reduction in emergency new admissions, and – 47% reduction in occupied bed days. • Patients with a SPARRA score of ≥ 50% but no ACPA in place showed: – 59% increase in emergency new admissions, – 63% increase in occupied bed days
  28. 28. Impact • For end of life care there is more chance of dying at home rather than in hospital if a ACP is in place. • In the practice, there are less chaotic home visits, more structured and organised times with families and less work regarding crisis guardianship cases.
  29. 29. Lillian – Our Highland Esther
  30. 30. Small tests of change Gaining 2 beds for £3K a month DD days in Hospital and Community, Nairn, 2007 - 11 0 20 40 60 80 100 120 140 160 180 200 Apr-07 Aug-07 D ec-07 Apr-08 Aug-08 D ec-08 Apr-09Aug-09 D ec-09 Apr-10 Aug-10 D ec-10 Apr-11 Aug-11 Date DD'spermonth DD's in Hospital Ave LOS pre 70h Ave LOS post 70h DD days in the community
  31. 31. Frailty / Dementia Trajectory Function Decline in ADL’s & Memory Death First Acute Problem TIME 3-10 years Unable to self care High Low
  32. 32. A Highland Huddle
  33. 33. Dementia Film Clip
  34. 34. Carers
  35. 35. Percentage of last 6 months of life spent at home or in a community setting 2 3 4 5 6 NHS Highland SCOTLAND 89.0 89.5 90.0 90.5 91.0 91.5 92.0 92.5 93.0 93.5 2006/07 2007/08 2008/09 2009/10 2010/11 % of last six months of life spent at home or in a community setting
  36. 36. Trend in care home places for older people, 1999/00 to 2011/12 1999/00 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 NHS Highland SCOTLAND 0% 20% 40% 60% 80% 100% 120% 1999/00 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 Care Home Places for Older People
  37. 37. Trend in bed days by type of admission, Highland residents 2001 -2012
  38. 38. Changing Landscape
  39. 39. • These things had and continue to have an impact… BUT It won’t be enough
  40. 40. to make it better for the people of the Highlands Commitment
  41. 41. Integration of Services “Banish the artificial divide between health and social care and involve charities, social enterprises and community groups more closely in service provision.” Scottish Older Peoples Assembly, 2010
  42. 42. Ambition to devolve decision making to integrated front line teams Single management and single budget for ALL health & social care in a locality
  43. 43. Lead Agency approach • NHS Board and the Highland Council moved to explore the benefits of a lead agency model • NHS Highland - Older adults • The Highland Council - Children’s services • CEOs committed to STOP if any identified detriment to adults and children as a result • Agreement made in December 2010 with plan to go live April 2012
  44. 44. Statement of Intent “We will improve the quality and reduce the cost of service through the creation of new, more simple organisational arrangements that are designed to maximise outcomes.” The Highland Council & NHS Highland 16 December 2010
  45. 45. Scale of change: some numbers • Social care staff to NHS Highland = 1,500 • Budget to NHS Highland = £90m • Health staff to Highland Council = 250 • Budget to Highland Council = £8m • Buildings occupied under licence to NHSH • Partnership Agreement = 400 pages
  46. 46. March 2012 Partnership Agreement signed
  47. 47. “Merger not a take over”
  48. 48. NHS Highland now delivers care: • In hospitals • In care homes • In the communities, and • At home For patients and clients across the north of Highland
  49. 49. Working closely with Argyll and Bute Council to develop a model to support integration of adult care in this area
  50. 50. But our journey continues • Working to change culture & attitudes • Developing shared language and approaches • Working across boundaries ……
  51. 51. Lots of opportunities • RNI Community Hospital • Mackenzie Centre • York Day Hospital (Inverness)
  52. 52. Film clip
  53. 53. Working with the third and voluntary sector
  54. 54. Maximise use of technology
  55. 55. Building community resilience
  56. 56. Integration, integration, integration 2005 2011-12 2020 StructuralChange Re-designWork …………………… Re-designWork Re-designWork Third and voluntary sector Community resilience Partners in care IntegratingHealth
  57. 57. Family &Friends Care Home Day Services Acute Hospital Neighbours Home Carers Respite Care Physio GP Day Services Consultants Residential Care Social Workers Pharmacy District Nurse OT Voluntary Community Hospital Care Co- ordinator Communities 3rd Sector A new model for care and caring
  58. 58. Film clip
  59. 59. And our last message ? It is not hard!
  60. 60. It is really hard …
  61. 61. But it is worth it
  62. 62. Thank you

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