Dr Brendan Walsh delivered this presentation at an ESRI conference tilted ‘Health and social care supply and resource allocation planning in Ireland' on 24 September 2019. There were two reports launched at the event. They can be read here: ‘An analysis of the effects on Irish hospital care of the supply of care inside and outside the hospital’ https://www.esri.ie/publications/an-analysis-of-the-effects-on-irish-hospital-care-of-the-supply-of-care-inside-and ‘Geographic profile of healthcare needs and non-acute healthcare supply in Ireland’ https://www.esri.ie/publications/geographic-profile-of-healthcare-needs-and-non-acute-healthcare-supply-in-ireland Photos from the conference are available to view on the ESRI website here: https://www.esri.ie/events/health-and-social-care-supply-and-resource-allocation-planning-in-ireland

1. www.esri.ie
An Analysis of the Effects on Irish
Hospital Care of the Supply of Care
Inside and Outside the Hospital
DATE
24/09/2019
VENUE
ESRI
AUTHOR
Dr Brendan Walsh

2. Aim, Context & Motivation
• Report 1
– Geographic profile of non-acute care
• Report 2
– Analyse how supply of acute & non-acute care affects utilisation
of hospital care
• Provide an overview of changes to the public hospital sector in recent
years (Reconfiguration)
• Examine association of hospital bed capacity and inpatient length of stay
• Examine association of long-term care (home care and long-term
residential care (LTRC)) and inpatient length of stay
– Recommendations for improving resource allocation in the Irish
health and social care system
2

3. 2.43
0 2 4 6 8
Mexico
UK
Isreal
Sweden
Spain
Ireland
Turkey
Denmark
Finland
Portugal
Latvia
Norway
Greece
Estonia
Switzerland
France
Luxembourg
Slovenia
Czech Rep.
Hungary
Slovakia
Poland
Belgium
Austria
Germany
Lituania
Korea
Japan
Inpatient Beds Per 1,000 Population
95%
60% 70% 80% 90% 100%
United States
Portugal
Korea
Estonia
Slovak Republic
Slovenia
Turkey
Hungary
Latvia
Luxembourg
Greece
Austria
Czech Republic
Japan
France
OECD27
Spain
Mexico
Chile
Belgium
Italy
Germany
Norway
Switzerland
UK (England)*
Canada
Israel
Ireland
Inpatient Bed Occupancy Rates
• Public hospitals in Ireland experiencing significant capacity issues
Acute Hospital Capacity
3

4. Delayed Discharges
• High occupancy rates also a consequence of inability to access
community and Delayed Discharges
• 1/16 inpatient beds filled by patients medically cleared for
discharge
• In 2017 there were 205,047 inpatient bed days from delayed discharge
– Almost all were aged 65 years and over
– 15 per cent were awaiting home care
– 30 per cent were awaiting LTRC
• Delayed discharge prevents patients returning home, receive care in
most appropriate setting, prevents bed being used for other
services such as elective care
4

5. Medium-Term Planning
• Sláintecare, HS Capacity Review, National Development Plan make
assumptions on substituting care from ‘hospital-centric’ setting
– Optimistic case based on substitution assumptions and large investments in non-
acute care supply and workforce
– Difference between Base and Optimistic equivalent to 7 St Vincent’s Hospitals
5
10,500
11,500
12,500
13,500
14,500
15,500
16,500
2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031
Inpatient Bed Supply Projections – Health Service Capacity Review
Base Case Optimistic Case Actual (Open Beds Report, April 2019)

6. Can Long-Term Care Substitute for Hospital Care?
• This report focused on acute care and long-term care (Home Care
and LTRC beds):
1. Older patients use a large proportion of health and social care services
2. Almost all delayed discharges aged 65+, with half awaiting long-term care
services
3. International evidence provided us with a modelling methodology template
to examine substitution of acute and long-term care services
4. Data Availability! Similar analyses not possible for other services examined in
Smith et al. (2019)
6

7. Data: 2012 - 2015
Public Hospitals – Hospital In-Patient Enquiry (HIPE) Data
– Captures 99%+ of public hospital discharges. Info on: date of
admission/discharge; disease classification; procedure; age; sex; DRG.
– Residence ID (county, Dublin postcode) of each discharge
– BIU HSE information on hospital bed supply by month (‘push’ factor)
Home Care – HSE Social Care Division Data
– Number of HH hours and HCPs by LHO by month
Long-Term Residential Care – HIQA Bed Register + Monitoring &
Compliance Reports; Long-Stay Activity Statistics, Nursing Homes Ireland
– Comprehensive list of LTRC beds by 28 counties
Population Data – ESRI Estimates
– Broken down by county, age, sex
7

8. Outcome Variables
Hospital Use
• Emergency Inpatient Length of Stay (LOS)
– Due to lack of Individual Health Identifier (IHI), difficult to examine overall
hospital use, readmissions, patient outcomes
– Due to lack of data on private hospitals, difficult to examine elective LOS
– >300,000 discharges arriving from home
• Delayed Discharges
– Delayed Discharges not captured in HIPE data → long LOS (90th percentile)
used as a proxy for delayed discharges
8

9. Supply Variables of Interest
• Home Care: County-Level Home Care Hours per capita aged 65+
• LTRC: County-Level LTRC beds per capita aged 65+
– Beds included: Long-stay beds for elderly; limited-stay or intermediate care
beds; respite beds; rehab beds; condition-specific beds (dementia care beds)
• Modelling methodology
– Linear and negative binomial regressions used to examine associations
between long-term care supply and average hospital LOS
– Unconditional Quantile Regressions used to examine associations between
long-term care supply for longer LOS (delayed discharges)
– Are effects larger for some groups (i.e. delayed discharges; stroke, hip fracture,
Alzheimer's/dementia patients; females, sicker patients)
9

10. Identifying Long-Term Care Supply Effects
10
• Strategy takes advantage of patients from different
counties using the same hospital
• UHL patients from Clare, Lim., Tipp N, Tipp S
• Patients have different levels of long-term care
supply depending upon their address & year
• Hospital & patient-level factors controlled for

11. DESCRIPTIVE RESULTS

12. Descriptive Statistics: 2012-2015
12
Number of discharges
Emergency inpatient discharges 333,928
Length of stay 10.51 days
Age 77.36 years
Medical card 0.78
Number of diagnoses 5.27
Discharge destination
Home 0.80
Long stay 0.11
Transfer/Other 0.18
Length of stay by discharge Destination
Home 8.00 days
Long stay 26.28 days
Transfer/Other 13.70 days
Stroke 0.03
Hip fracture 0.03
Alzheimer’s/dementia 0.05

13. Length of Stay and Inpatient Bed Days
13
0
500,000
1,000,000
1,500,000
2,000,000
2,500,000
3,000,000
3,500,000
Cumulativeinpatientbeddays
Length of Stay
90th LOS percentile
47.6% of inpatient bed days

14. Annual Home Care Hours per capita aged 65+
14
0
5
10
15
20
25
30
35
40
2012 2013 2014 2015

15. Annual LTRC beds per capita aged 65+
15
0
10
20
30
40
50
60
70
80
2012 2013 2014 2015

16. SUBSTITUTION RESULTS

17. Home Care – Average LOS
17
All 65+ Dublin North* Stroke Hip Fracture
Average LOS -1.75% -2.7% -2.7% -1.6%
Illustration of effects grossed-up to national level
Bed Days -14,700 -40,000*
Beds -40 -110*
• Results interpreted in terms of a 10% increase in Home Care Hours
(1.5m hours)
• Not all patients amenable to home care to reduce their LOS
* Grossed to National Value

18. Home Care – Delayed Discharges
18
• Results interpreted in terms of a 10% increase in Home Care Hours
(1.5m hours)
• Dublin North: 10% increase in Home Care associated with 2 days less in
hospital in 90th percentile
-0.12 -0.11 -0.19 -0.24 -0.45 -0.70 -1.04
-2.93
-5.93
-15
-12
-9
-6
-3
0
0.2
(2 days)
0.3
(3 days)
0.4
(4 days)
0.5
(5 days)
0.6
(7 days)
0.7
(9 days)
0.8
(13 days)
0.9
(21 days)
0.95
(34 days)
Length of stay quantile
Ireland
-0.35 -0.14 -1.72 -2.04 -2.64 -3.52
-8.87
-21.05
-52.49
-100
-90
-80
-70
-60
-50
-40
-30
-20
-10
0
0.2
(2 days)
0.3
(3 days)
0.4
(5 days)
0.5
(6 days)
0.6
(8 days)
0.7
(11 days)
0.8
(16 days)
0.9
(29 days)
0.95
(50 days)
Length of stay quantile
Dublin North

19. Emergency Inpatient Length of Stay
Quantiles: 2012 & 2015
19
Ireland Dublin North
Quantile
2012
(n=77,452)
2015
(n=76,433)
2012
(n=9,117)
2015
(n=9,098)
<20th n/a n/a n/a n/a
20th 2 days 2 days 2 days 2 days
30th 3 3 3 3
40th 4 4 5 5
50th 5 6 6 6
60th 7 7 8 8
70th 9 9 11 11
80th 12 13 17 16
90th 21 22 31 28
95th 33 35 56 45

20. LTRC Beds – Average LOS
20
• Results interpreted in terms of a 10% increase in LTRC beds (2,965
beds)
• Not all patients amenable to LTRC to reduce their LOS
All 65+ Long-Stay
Discharge
Hip Fracture Alzheimer’s/
Dementia 85+
Average LOS -2.2% -3.9% -2.5% -5%
Illustration of effects grossed-up to national level
Bed Days -19,000 -9,720
Beds -53 -27

21. LTRC Beds – Delayed Discharges
21
• Results interpreted in terms of a 10% increase in LTRC beds (2,965 beds)
• Discharged to LTRC: 10% increase in LTRC associated with 3.3 days less
in hospital in 90th percentile
-0.05 -0.13 -0.39 -0.58 -0.96 -1.38 -1.94
-5.02
-12.25
-18
-15
-12
-9
-6
-3
0
0.2
(2 days)
0.3
(3 days)
0.4
(4 days)
0.5
(6 days)
0.6
(7 days)
0.7
(9 days)
0.8
(13 days)
0.9
(22 days)
0.95
(35 days)
Length of stay quantile
All Discharges
-1.62 -1.72 -2.32 -3.06 -5.02 -7.69
-14.43
-34.38
-70.95
-100
-80
-60
-40
-20
0
0.2
(6 days)
0.3
(8 days)
0.4
(10 days)
0.5
(13 days)
0.6
(17 days)
0.7
(23 days)
0.8
(34 days)
0.9
(62 days)
0.95
(97 days)
Length of stay quantile
Discharges to Long-Stay

22. Overview of Report 2 Results
22
• Home Care and LTRC supply associated with shorter inpatient LOS
for older patients admitted from home
• Results larger for those groups most amenable to LTC
– Stoke, Hip Fracture, Delayed Discharges, Discharge to LTRC
• Other analyses from the report highlight the importance of hospital
bed capacity, and imply that home care supply may also reduce
discharge to LTRC facility – further research required
• NB: while increases in home care and LTRC are required, so too is
additional hospital capacity

23. POLICY RECOMMENDATIONS FOR RESOURCE
ALLOCATION

24. Resource Allocation Mechanism
24
• Many of the recommendations in Chapter 8 of Report 2 build on
ideas put forward previously
– “Resource allocation and financing in the health sector” (Brick et al., 2010)
– “Towards the development of a resource allocation model for primary,
continuing and community care in the health services” (Vega et al., 2010)
• there is no single correct way to allocate resources, and there is no perfect model
• Better resource planning requires:
1. Data
2. Substitution and Integration
3. Workforce Planning
4. Equity across Geographic Regions
5. Planning for Demographic Change

25. Health System Data
25
• Gathering appropriate data and undertaking necessary research vital
to make informed decisions about how best to allocate resources
• Current data, and data infrastructure, in Ireland makes efficient
allocation of resources difficult
• Lack of information on demand, supply, and unit-costs
• Considerable data gaps in private health and social care
– Private Hospitals provide 31% of day cases, 15% if inpatient bed days
• Little information on patients, resources, workforce, salaries, outcomes
– Private physios provide over 50% of community physio supply
– Publicly-funded Home Care and LTRC now largely privately provided
• >75% LTRC beds in private facilities
• >55% home care hours provided by non-HSE staff

26. Substitution and Integration
26
• Health and social care should be provided at the most appropriate
level, at lowest level of complexity, and as close to home as possible
• Lack of IHI makes it difficult to follow patients across the services
• Regional Integrated Care Organisations (RICOs) should provide the
template to better integrate care across services
– NB: Activity-Based Funding being rolled out across hospitals. Without
integration of services, are hospitals being punished for poor social
care supply in their area?
• Further research on substitution across services (GP care,
community therapy) required

27. Workforce Planning
27
• The provision of quality and efficient healthcare services depends
upon having workforce numbers at the national and regional levels
• Planning requires understanding of current workforce, the ability to
recruit and retain workers and the necessary level of newly trained
personnel to meet future demand requirements
• Unrealistic assumptions about the ability to substitute care into the
community may lead to further resourcing issues in acute system
• Information on private providers also required: both public and
private providers ‘fishing from the same pool’ of talent

28. Equity across Geographic Regions
• Lack of allocation mechanism has resulted
in regional inequalities in supply
• Supply differences not related to
population need differences
• Allocation mechanism would allow for
supply to follow population increases, age
difference, disability, deprivation etc.
(Sláintecare)

29. Demographic Change
29
• Population is growing, especially at older ages
– Economic health and population health has improved
– Between 2015-2030 overall pop. to increase by up to 1.08millon
– Population aged 65+ to increase by up to 63%
• Ensuring those areas and population groups that will see largest
increase are matched with sufficient health and social care supply
– Health and social care supply should be matched with population
need

30. ESRI HIPPOCRATES Model (Wren et al., 2017)
Macro-simulation model, single year of age, M/F
Rates of use
of health
services
2015
xPopulation
2015-2030
Costsx
Healthcare
Expenditure
=
Healthcare
Demand
2015-2030
Scope to expand Hippocrates:
1) Capacity (Keegan et al., 2018)
2) Workforce Planning
3) Regional Demographics
4) Implications of substitution

31. THANK YOU