Frailty Concept/ Hospital without Walls

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Frailty Concept/ Hospital without Walls

• Professor Pradeep Khanna MBE
• Chief of Staff, Community Services
• Aneurin Bevan Health Board

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Commissioning Care Planning

• Strategic Planning
• Specify Outcomes
• Develop Business Case
• Procure Services
• Manage Demand
• Maintain Performance

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CASE FOR CHANGE

• Demand will always beat supply
• Pressure on cost is remorseless
• NHS can not provide a comprehensive service on
  current assumptions after 2011
• (Kings fund and the Institute of Fiscal Studies
  IFS)

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Some Facts

• Nearly 33 of inpatients could safely be cared
  for in another setting than in an acute hospital
  Kings fund audit 1992 DOH 2000
• 29 of patients in acute hospital beds are
  medically stable 43 in elderly wards Barbara
  Vaughan Gill Withers 2002
• In Wales, higher proportion of chronic long term
  conditions (23) compared to England (18)
  Northern Ireland (20)
• Audit of 5 GP Practices in Swansea revealed 3 of
  population with 2 comorbidities emergency
  admission accounted for 59 of hospital
  admissions Ref WAG 2007 Designed to improve
  health chronic conditions Wales
• Conclusion A focused integrated approach of
  Health and Social Care, Housing and Transport is
  recommended

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Drivers For Change

• Wanless Report Hard hitting facts about Health
  Services in Wales
• Designed for life Strategic framework Health
  Social Care Services in Wales
• Fulfilled lives, Supportive Communities Emphasis
  on Social Care
• Making the connections Public involvement
  redesign services around the needs of the users
• 5. Primary Care Community Services Strategy
  (Chris Jones)

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Current System of Care Push System full of Black
Holes
Local government
COM NURS E TMS
FRAGMENTED AND DISORGANISED COMMMUNITY BASED CARE
HEALTH
SOCIAL
HOSPITAL BASED CARE
PRIMARY CARE
DISCHARGE
FRAIL
DEPENDENT
NH
RH
OOH
AE
FIT
INDEPENDENT
NHSD
PARA MED
Patient journey
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Hospital-at-Home definition
Hospital care but delivered in the persons own
home !!!
HaH .a service that provides active treatment
by health care professionals, in the patients
home, of a condition that would otherwise require
acute hospital in-patient care, always for a
limited period. Cochrane definition, 2005
Combination of personal support rehabilitation
care
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Admission AvoidanceHospital at Home/Inpatient
Care(Review)

• Systematic Review Meta Analysis
• Mortality at 3 months
  NS (P 0.15)
• Mortality at 6 months
  Significant (P0.005)
• Readmission Rates
  NS (P0.08)
• (within 3 months)
• Functional Ability (12 months)
  
• i. Quality of Life
• ii. Physical abilities
• iii. Cognitive Status
  NS
• Reference Sheppard S, Doll H, Etal The Cochrane
  Library 2009 Issue 3

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Hospital at Home

• CLINICAL OUTCOME (Adverse Events
  Medical Complications)
• Bowel Complications 22.5
  (96 C.I 34 to 10.82)
• Urinary Complications 14.4
  (95 C.I 25.4 to 3.3)
• c. Antipsychotic Prescribing
  14 (95 C.I 28 to 0.3)
• in Dementia Patients
• COPD Antibiotic 18
  (95 34.6 to 1.4)
• PATIENT SATISFACTION
  Significant
  (P lt 0.0001)
• 3. ECONOMIC ANALYSIS
• (Co Morbidity Older Group)
  Costs Per episode 2011 95 C.I ( 2800 to
  1222)
• 
  Per day 293 95 C.I ( 318 to 268)
• CONCLUSION Admission Avoidance Hospital at
  home can provide an effective
• 
  alternative for selected group of Patients
  (Outcome Similar)

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Early Supported Discharge Teams Vs Conventional
Care11 Trials (6 countries)
Outcome Patients randomised Summary result (95 CI) P Values
Patients outcomes
Death or dependency 1597 0.79 (0.64 to 0.97) 0.02
Death or institution 1398 0.74 (0.56 to 0.96) 0.02
Extended ADL Score 1051 0.12 (0 to0.25) 0.05
Satisfied with outpatient services 513 1.60 (1.08 to 2.38) 0.02
Carer outcomes
Subjective health status score 613 0 (-0.25 to 0.24) 0.97
Satisfied with outpatient services 279 1.56 (0.87 to 2.81) 0.14
Resource outcomes
Length of hospital stay 1015 -7.7 (-10.7 to - 4.2) lt0.0001
Readmission to hospital 633 1.14 (0.80 to 1.63) 0.48
Conclusion Appropriately Resourced and
Co-ordinated Services in clearly
defined Target Groups has clear potential
benefits Langhorne P, et al - Lancet
2005365501-506
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THE EVIDENCE-BASE FOR INTERMEDIATE CARE

• RCTs
• HOSPITAL-AT-HOME 22
• DAY HOSPITAL 12
• NURSE-LED UNITS 10
• COM. REHAB.TEAMS 2
• CARE HOME REHAB. 1
• COMMUNITY HOSPITAL 1
• Message (a) Target people with greatest
  clinical
• need (Frailty)

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Expensive
Very expensive
?
Shifts costs to social care
?
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Messages From Research

• Develop closer integration between IC and
  Mainstream Services
• Target Patients with greatest clinical need
  Frailty
• Place stronger focus on Admission Avoidance
  Scheme (Health Social Care)
• (Closer liaison with Ambulance Service, 3rd
  Sector, AE, Mental Health)
• VANTAGE POINT
• Reablement
• More Research/Evaluation needed

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Clinical Futures Gwent
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Joint Partnership Sub-Group

• 5 LHB CEOs, Trust CEO and 5 LA CEOs
• Aims to develop better services along whole
  patient journey through closer working. To find
  better way of supporting people who end up
  needing Continuing Care
• Frailty Pathway chosen
• Gwent wide multi-agency, multi-professional
  workshop held April
• Task and Finish Groups to expand /develop ideas.

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Frailty Programme Board

• Membership
• Chair Alison Ward, CEO, Torfaen LA
• LA reps (social care)
• LHB reps
• Trust Corporate and Divisional reps
• Voluntary sector
• GP
• Ambulance

• Work Streams
• Independent Living and Reablement
• Urgent Response and Intervention
• Capacity and Financial Modelling

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Frailty Syndrome

• Frailty (Dependency x vulnerability x
• co-morbidity)
• (Environmental x social factors)

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What is it?

• Physical characteristics

• Multidimensional

• Weakness
• Slowness
• Poor endurance
• Weight loss
• Physical inactivity

• Socio-demographic
• Biomedical
• Functional
• Effective and cognitive components

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PREVENT/ DELAY ADVERSE OUTCOMES PROVIDE CARE
PREVENT FRAILITY
DELAY FRAILTY
FRAILTY
MODIFIERS Biological Psychological Social
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Prevalence of Frailty 3 or more of the outcome
Age 65-69 70-74 75-79 80-84 85
Frailty 18.3 21.7 32.1 32.5 48.8
Estimated numbers of frail elderly people by Local Authority Estimated numbers of frail elderly people by Local Authority Estimated numbers of frail elderly people by Local Authority Estimated numbers of frail elderly people by Local Authority Estimated numbers of frail elderly people by Local Authority Estimated numbers of frail elderly people by Local Authority Estimated Total
Blaenau Gwent 604 621 838 563 646 3275
Caerphilly 1399 1402 1816 1154 1231 7002
Monmouthshire 784 825 1043 695 864 4211
Newport 1127 1222 1472 1085 1156 6062
Torfaen 797 844 1105 683 712 4141
Total by age band 4177 4914 6274 4180 4609 24154
Source Census 2001
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Happily Independent
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What we stand forPrinciples Values

• The underpinning principle of the Gwent Frailty
  Programme is to provide
• Help when you need it to keep you independent
• The mantra for those delivering services is to
  provide help that is
• Sustaining independence.

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OutcomesWhat frail people tell us they want

• Be able to remain living in their own home with
  support
• Receive services in their home
• Be listened to by people who are responsible for
  providing services to assist them
• Have their health and social care problems solved
  quickly and considered as a whole rather than
  individually.

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Frail Elderly Workforce Skills Matrix
Specialist Health Care Skills
Social Care Skills
Health Care Skills
Generic Worker Skills
Specialist Social Care Skills
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Generalist as the New Specialist(Intermediate
Care)

• GPs Changing Roles
• Geriatrician Changing Roles
• AHPs Changing Roles
• Training In The Community

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Community Nursing Service

• Based on Nursing Strategy Wales
• (Coordination of care)
• 24 hour Nursing cover in each locality
• Overnight on call nursing service including
  Twilight nursing
• Key role in early identification proactive care
  of frail clients

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Common Service Characteristics (I.C)
Urgent Response Intervention Reablement Independent Living
ACCESS Via locality Single Point of Access Via locality Single Point of Access
HOURS OF OPERATION 7 days a week 365 days a year 8am to 10pm 7 days a week 365 days a year 8am to 8pm
RESPONSE TIME 2-4 hours (for both health and social care components) 24 hours
ASSESSMENT Comprehensive Needs Frailty Index Assessment Agreed shared assessment document
SERVICE PROVISION Management/Hospital _at_ Home upto 14 days Approximately 6 weeks reabilitation and reablement support No charge to user for first 6 weeks
ACCESS TO Hot Clinics for rapid access to specialist and diagnostic support (Monday to Friday) Specialists including psychology, dietetics, pharmacy, speech language therapy, podiatry, EMI teams. Rapid access to equipment and adaptations.
WORKFORCE Flexible Health Social Care Workforces Flexible Health Social Care Workforces
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Components of Comprehensive Needs Assessment

• Components
• 1 Medical assessment
• 2 Assessment of functioning
• 3 Psychological assessment
• Social assessment
• Environmental assessment

• Elements
• Co-morbid conditions
• Medication review
• Nutritional status
• Activities of daily living
• Gait and balance
• Mental status
• Assessment of needs, assets
• and resource eligibility
• Home safety, transportation and
• tele-health

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Proposed Locality Structure

• Joint Chair Director of Social Services
• Locality Manager (Health)
• Members Project Manager
• Human Resource
• Finance
• Intermediate Care Consultant
• General Practitioner
• Lead Nurse
• Voluntary Sector
• Co-opted Members Pharmacist, Mental Health,
  Therapies, CHC

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Urgent Response Intervention

• Comprises of three key elements
• Urgent Comprehensive Assessment (Health Social
  Care)
• Rapid Response Intervention (health)
• Social Care Crisis Intervention

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Proposed Capacity Model (Crisis Management)

• Aims
• Better management at home or in a community
  setting.
• Engagement with care homes and the independent
  sector.
• Management of patients in Accident Emergency
• Patients handed over to DN teams on discharge
  from service
• Main Functions
• Assessment of 200 new patients per month for
  acute exacerbations of chronic conditions and
  associated disorders.
• Follow-up of 200 patients per month.
• 7-day presence in A E and MAU to assess
  patients and prevent admissions, pulling them
  back into the community, as required.
• Daily Hot Clinics for each borough, run by
  ACAT/RRT for the provision of advice for GPs.
• Formal links with other specialties, including
  General Medicine, Falls, Trauma Orthopaedics.
• On-going management of patients at home for a 5
  7 day length of stay (care package)
• The Gwent-wide combined team of ACAT, Rapid
  Response and PATH to provide around 70 virtual
  beds across Gwent.

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Staffing Model(Crisis Management)

• Based on population of 70-90k
• 1 wte Consultant Specialist
• 2 wte Staff Grades or GPswSI (salaried GPs)
• 4 wte Band 7
• 10 wte Band 6
• 3 wte Band 4 Reablement Officers
• 1 wte Band 6 OT for Reablement
• 1 wte Social Worker
• Approx 50 wte generic Health Social Care
  Support Workers, and/or Rapid Access to Immediate
  Home Care
• 1 wte Secretarial Staff and 2 wte Typists shared
  with the Reablement Team

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Independent Living Reablement

• Approximately 6 weeks coordinated review and
  reablement to sustain independence
• Rapid access to equipment and minor adaptations
• Care Wellbeing Workers able to work across the
  different elements of the integrated locality team

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Proposed Capacity Model for Locality Reablement
Teams (1)

• Based on 70-90k population
• 5 WTE Occupational Therapists (able to work
  across ACAT, PATH and Reablement)
• 5 WTE Physiotherapists
• 50 Band 3 Generic Support Workers
• 2 WTE Case Managers (role needs to be clarified)
• 2 WTE Social Workers
• Proportion of generic support workers
  up-skilled to perform some functional
  assessments?
• Shared resources
• IT officer
• Training and Development officer
• Administrative Support
• Hot clinics for Falls, Gen Med and Orthopaedics

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Proposed Capacity Model for Locality Reablement
Teams (2)

• Sessional support from
• 2 WTE Dieticians
• 2 WTE Speech and Language Therapists
• 2 WTE Psychiatric Liaison Nurse (1 for older
  people, 1 for younger people)
• Podiatrist unable to quantify because many
  clients using private
• 1 WTE Community Pharmacologist attached to PATH
  and Reablement

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Implementation Workstreams

• Communication Stakeholder Engagement
• Workforce Planning
• Governance Structure
• Outcome Indicators, Performance and Continuous
  Improvement
• Information sharing Single Point of Access
• Locality Planning (including longer-term care and
  interfaces with other services)
• Financial Modelling/ Building the Business Case

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Communication Stakeholder Engagement

• Workstream lead Dr Liam Taylor
• Development of a communication strategy for all
  key stakeholders
• Specific programmes of work
• a. Stakeholder Briefings
• b. Staff Communication
• c. Public Engagement
• d. Power Brokers (Politicians and
  Executive Key Members)

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Financial Planning

• Workstream lead Nigel Stephens
• Use the outputs from the other workstreams to
• confirm demand
• map capacity
• identify the resource gaps
• calculate the financial requirements
• Set up pooled budget arrangements

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Locality Planning

• (including longer-term care and interfaces with
  other services)
• Workstream lead Jo Williams
• Support planning for preventative services and
  delivery at locality level
• Ensure that core standards are met and outcomes
  achieved.
• Key Aims
• a. Each locality
  sharing innovation
• b. Joint problem solving
• c. Work through operational
  challenges
• d. accessing expertise

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Information Sharing Single Point of Access

• Workstream lead Jayne Griffiths
• Single Point of access
• Information System and Develop agreed information
  sharing protocols
• Develop safe means of electronic transfer

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Outcome Indicators, Performance Continuous
Improvement

• Workstream lead Angela Jones
• Use the Outcomes-Based Approach.
• Happily Independent(5 key elements)
• Be able to remain living in their own home with
  support
• Receive services in their home
• Be listened to by people who are responsible for
  providing services to assist them
• Have their health and social care problems
  (holistically) solve quickly
• Have a general good health

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Governance Structures

• Workstream Lead Bobby Bolt
• Agreed standards and protocols
• 3 Groups of work
• a. Clinical accountability
• b. Operational issues
• c. Clear lines of management
  (professional and regulatory issues)

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Workforce Planning

• Workstream lead Kevin Barber
• Challenges To Integrate -
• a. 6 organisations
• b. 9 professional groups
• Key Aims
• a. Harmonising the structure
  (extremelly complex)
• b. Managing the transition
• c. Managing multi-agency staff
  groups (responsibility, accountability,
  training and development)

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Next Steps
Capacity Plan
Service Model
Financial Plan
Workforce Plan
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Resource Package

• Wanless funds (WAG) Approx 5million2004
• Public Service Committee (Chaired by Finance
  Minister Wales) 60million over 2009/10 and
  2010/11
• (Scheme Invest To Save)
• 3. Transitional cash required 20million
• (Fund new teams and manage additional
  capacity)
• 4. Over time
• ? Shifting of resources from Secondary to Primary
  Care
• ? ? Nursing and Residential Purchasing Budgets
• ? Continuing Care Budget

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Current Situation 1
Locality Frailty care model (DGH) Co-located teams Single point of referral Community Consultant
Caerphilly - - -
Newport - - -
Torfaen - -
Blaenau Gwent - - -
Monmouthshire - - -
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Current Situation 2Referral criteria variable
in all 5 localities.
Locality Consultant operational team Primary and secondary interface Rapid response ACAT Reablement team Formal GP involvement
Caerphilly - - -
Newport - - - -
Torfaen - - -
Blaenau Gwent - - - -
Monmouthshire - - - - -
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Performance Indicators

• As per Frailty Programme Work stream and
  including
• Pre-crisis Assessment (CGA) 100 offered within
  28 days
• An episode of crisis requiring hospitalisation
  should normally require no more than 72 hours in
  hospital
• Service responses will be delivered within agreed
  time limits
• 50 of frail older people will be managed in the
  community during an episode of crisis
• 80 of frail older people with a social crisis
  will be maintained at home
• 75 of rehabilitation services for frail older
  people will be based and delivered in the
  community.
• Assessment of equipment needs delivered within 24
  hours
• Equipment provided within 72 hours of assessment

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Paul WilliamsDirector General, Health Social
ServicesChief Executive, NHS Wales

• I want the service to focus on
• Changing behaviour not structures
• Collaboration not confrontation
• Planning not commissioning
• Whole systems not hospitals
• Clinical engagement
• Partnership working and
• Wellness not illness
• (1st October 2009)