Unique Care: Converting Unplanned Crisis into Planned Care

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Unique Care Converting Unplanned Crisis into
Planned Care

• Ruth Adam
• Philip Lewer

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An acute hospital admission is a failure of the
Health System.

• The real challenge to the NHS is how to manage
  chronic disease better

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The trick is to convert unplanned care into
planned.

• Adopt a multi-skilled, multi-agency approach to
  ensure effective care co-ordination

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Unique Care

• Integrate Health and Social Care
• Deal with current referrals
• Joint assessment joint working (SAP)
• Tailored packages of care
• Hospital In-reach
• Get the 20 on the radar

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Unique Care

• Same day assessment 97 of time
• Utilisation of primary care team, CPNs Practice
  nurses, etc.
• Involvement of Voluntary Sector
• Better use of other Health Professionals,
  including pharmacists, rehab, OT, rapid response
  teams
• Effective use of social services resources

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Over 65s Admissions per 1,000 Population
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Over 65s Average Length of Stay
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Over 65s Bed Days per 1,000 Population
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Other Effects

• District Nurse Team didnt need backfill
• GPs home visits fell by 30
• Social Services budget made small saving in
  Castlefields but overspent in Borough
• Use of intermediate care remained stable within
  expected for population
• 48 cases admissions fell from 123 to 2 and only
  three went into long term care

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Money released for re-investment

• Practice Population 12,000
• Saves 210,000 (US 408,281) per year on
  admissions

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Over 65s Acute AdmissionsCastlefields Health
Centre
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Unique Care 5 Key Principles

• Create a Unique Care team between health and
  social services
• Create and maintain a practice based register of
  patients with complex needs
• Case find patients at risk of admission
• Establish hospital in-reach
• Create a bespoke plan with each patient

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Which patients benefit most from Unique Care?
Level 3 Highly Complex Patients
Case Management
Unique Care
Professional Care
Level 2 High Risk Patients
Unique Care
Disease Management
Self Care
Level 1 70-80 of an LTC population
Supported Self Care
Unique Care
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Which patients benefit most from Unique Care?

• Multiple Crisis Multiple LTCs, complex
  medical social needs, frequent admissions to
  hospital / AE attendance / OOH Service
• Not attended for screening / OPAs
• Experienced major life changes e.g. bereavement,
  deterioration in health, self neglect
• An older person about whom you have concerns

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The Pareto principle

• 20 of supermarket products account for 80 of
  sales
• 20 of criminals account for 80 of the value of
  crime
• 20 of people who marry account for 80 of
  divorce statistics
• 20 of your carpet gets 80 of the wear
• 20 of the clothes in your wardrobe get worn 80
  of the time

Source Koch 1998
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The 20 of Patients who need 80 of the Care

• Older People
• Decreased Functional Ability
• Revolving Door Admissions
• COPD Heart Failure
• End of Life
• Psychological Social Support
• Packages of care tailored to the individual

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Postal Questionnaire

• 20 questions Yes/No answers only
• One sheet of paper
• Coloured ink large font
• Invitation signed by own GP
• Helpline
• First second reminders

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Response

• All practices in PCT recruited
• 3999 identified as potential participants
• 350 ruled out by cross-checking with the
  practices
• 3649 sent questionnaire
• 302 declined to participate
• 305 failed to respond
• 3048 positive response (83.5)

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12 month summary

• Diabetes 1.3
• Lung problems 1.7
• Heart problems 1.7
• Stroke 1.7
• Cancer 1.2
• Depression 1.6
• Bladder problems 1.6
• Leg ulcers 2.2
• Lives alone 1.0
• Help if ill 1.1

• Help to get out 0.4
• Bath without help 0.4
• Eyesight 1.7
• Memory problems 1.9
• Flu Vacc 0.9
• 4 medicines 2.0
• Previous admission 2.9
• Fall 1.8
• Bereavement 1.2
• General health 0.4

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12 month summary

• Diabetes 1.3
• Lung problems 1.7
• Heart problems 1.7
• Stroke 1.7
• Cancer 1.2
• Depression 1.6
• Bladder problems 1.6
• Leg ulcers 2.2
• Lives alone 1.0
• Help if ill 1.1

• Help to get out 0.4
• Bath without help 0.4
• Eyesight 1.7
• Memory problems 1.9
• Flu Vacc 0.9
• 4 medicines 2.0
• Previous admission 2.9
• Fall 1.8
• Bereavement 1.2
• General health 0.4

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Identifying At RiskStart with 10, then if Yes

• Do you have heart problems? 3
• Do you have leg ulcers? 4
• Can you get out of the house without help? -5
• Do you have problems with your memory and get
  confused? 4
• Have you been admitted to hospital for an
  emergency in the last 12 months? 8
• Would you say the general state of your health is
  good? -4

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Identifying High Risk

• Tools only go so far, so dont be rigid
• Look out for repeat admittees
• Severe COPD
• Heart Failure
• More holistic assessment
• Packages of care according to need
• Regular review

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Has this worked elsewhere?
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Enfield Practice Population 3,600

• Emergency Admissions Reduction 50
• (12 in comparator practice)
• Occupied Bed Days Reduction 70
• (10 in comparator)
• Excess Bed Days Value Reduction 98
• (23 in comparator)
• Spells Value Reduction 49
• (5.6 in comparator)
• Total Budget Savings 67
• (8 in comparator)
• Total budget savings over 5 months 99,000
• Estimate over 1 year 237,000

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Results
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Avoiding one admission per week

• If all 13 Durham Dales practices avoided one
  admission per week, this would release money for
  re-investment to the tune of
• 642,876
  
• 1.2 million US
• (951 2005/6 Durham Dales)

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Feedback from sites

• Unique Care has had the benefit of reducing the
  number of referrals to social servicesthe team
  have helped older people to understand better
  what the statutory services can provide for them
• Jenny Goodall Director, Brent Social Services
•  This approach has reduced my workload a lot.
  Quality of care for complex housebound patients
  has improved immensely
• GP, Derbyshire Dales South Derbyshire PCT
• Unique Care makes life easier for people with
  complex needs in many cases its the simplest
  things that have made a big difference.
• Gwyneth Oates Care Co-ordinator
• "Its a good feeling knowing that capable and
  caring people are there to support you if
  problems arise"
• Patient, Durham Dales PCT

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And more importantly..

• The hospital said that I wasnt fit to be on my
  own really..after further consideration I
  decided I didnt want to go there (residential
  home), after all here I can do what I like, I can
  get up in the night, imagine what it would be
  like living in somebody elses place!
• Patient, Brent 2005.
• Its very hard with angina. You get frightened
  and you just dont know where to turn. I was able
  to talk to you and I know I have somebody there
  and its nice to have somebody. I did what you
  told me taking my spray and not get to excited
  about it all and it saved me from the phoning the
  ambulance.
• Patient, Oldham 2005.

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Health and Social Care Perspective

• Challenges
• Opportunities
• Coming together

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Health and Social Care Perspective

• Those that use our services, want /deserve /need
  services that meet their needs, they also want to
  make informed choices about their lives.
• Emphasis on choice and self determination for the
  individual.

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Health and Social Care Perspective

• The need to work together to tackle the growing
  numbers of people with chronic illness and long
  term conditions
• The need for local providers and purchases to
  develop services through the market place and
  contestability

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Health and Social Care Perspective

• We are both struggling with our finances.
  Patients / citizens want more choice and better
  services we are tempted to cost shunt rather
  than see the commissioning gap!

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We can if we want to

• Challenge existing cultures
• Ensure the empowerment of people to take expert
  control of their conditions
• Delivering high quality care

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What has worked

• Scrap the eligibility criteria for low level
  services such as
• Careline (telephone response / pendant service )
• Meals on wheels ( frozen meals service )
• My Mum

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Conclusion

• There is a willingness to work together
  especially with GPs so that we can jointly
  commission new and preventative services
• We want to create new care pathways and community
  based services so that we can manage demand and
  expectation together.

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• So what are you going to do when you go back to
  work
• How will you make a difference?
• How will your patients know?

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We can rise to the challenge!

• Philip Lewer
• Tel [phone]
• philip.lewer_at_btinternet.com

Ruth Adam Tel [phone] ruth.adam_at_btinterne
t.com
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Dont React Panic

• Anticipate Plan

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Dont React Panic

• Anticipate Plan

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References

• Practice-based commissioning, a toolkit primary
  care contracting
• www.primarycarecontracting.nhs.uk 2006
• Developing effective joint commissioning for
  adult services lessons from history and future
  prospects
• Nick Goodwin, Care Services Improvement
  Partnership 2006
• The future of health and adult social care a
  partnership approach for wellbeing
• Local Government Association 2006
• Human dimensions for change (ppt) taken from
  Google
• Susy Cook, Gill Husband, Margaret McQuade
• NHS Improvement Alliance, South Tees Hospital NHS
  Trust
• White paper- Strong and prosperous communities
  (chap 7) /-Our health our care our say
• A whole system working a guide and discussion
  paper CSIP
• Commissioning framework for health and well
  being