Frailty Concept/ Hospital without Walls

Professor Pradeep Khanna MBEChief of Staff, Community Services

Aneurin Bevan Health Board

Commissioning & Care Planning

• Strategic Planning

• Specify Outcomes

• Develop Business Case

• Procure Services

• Manage Demand

• Maintain Performance

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)

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

WHO has identified that chronic conditions will be the leading cause of disability and death by 2020

Targets

Reduce number of emergency bed days by 5%

• Analysis of NHS use indicates that effective chronic disease management presents significant scope to reduce avoidable hospital admissions

• For patients with more than one condition the costs are six times higher than people with only one

Drivers For Change

1. Wanless Report: Hard hitting facts about Health Services in Wales

2. Designed for life: Strategic framework: Health & Social Care Services in Wales

3. Fulfilled lives, Supportive Communities: Emphasis on Social Care

4. Making the connections [Public involvement & redesign services around the needs of the users]

5. Primary Care & Community Services Strategy (Chris Jones)

HOSPITALBASED CARE

PRIMARY CARE

OOH

FRAGMENTED AND DISORGANISED COMMMUNITY BASED CARE

PUSH

PUSH

Current System of Care “Push System full of Black Holes”

AE

DISCHARGE

INCREASING DEPENDENCY

INCREASING COMPLEXITY

DECREASING FUNCTIONALITY

Patient journey

NH RH

NHSDPARA MED

Local government

FIT

FRAILDEPENDENT

INDEPENDENT

HEALTH SOCIAL

COM

NURSE

TMS

HOSPITALBASED CARE

AS

SE

SS

DIR

EC

T

PRIMARY CARE

OOH

ORGANISED SYSTEM OF INTERGRATED COMMUNITY SERVICES

PULL

PULLPULL

PULL

SHARED INFORMATION BASED ON GP RECORD

Future System of Care “Seamless Pull System with Integrated Access to Information”

Locnet

Patient journey

COMSHUB

Resourceteam

Primary Care Support Unit

COM

NURSE

TMS

Hospital-at-Home: definition………

HaH = “….a service that provides active treatment by health care professionals, in the patient’s 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

Hospital care but delivered in the person’s own home !!!

Admission AvoidanceHospital at Home/Inpatient Care

(Review)

[Systematic Review & Meta Analysis]

1. Mortality at 3 months NS (P= 0.15)2. Mortality at 6 months Significant (P=0.005)3. Readmission Rates NS (P=0.08) (within 3 months)4. 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

Hospital at Home

1. CLINICAL OUTCOME: (Adverse Events & Medical Complications)

a. Bowel Complications = 22.5% (96% C.I = 34% to 10.82)

b. 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

d. COPD = Antibiotic = 18% (95% = 34.6% to 1.4%)

2. PATIENT SATISFACTION: Significant (P < 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)

4. CONCLUSION: Admission Avoidance Hospital at home can provide an effective

alternative for selected group of Patients (Outcome Similar)

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) <0.0001

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 2005;365;501-506

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)

(b) Integrate I.C with Mainstream Services

Very expensive

Shifts costs to social care

Expensive

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, A&E, Mental Health) VANTAGE POINT

• Reablement:

• More Research/Evaluation needed

Clinical Futures: Gwent

Newport Caerphilly Torfaen

Blaenau

Gwent

Monmouth Powys Other All Gwent

medical 117 121 96 82 77 1 7 501

surgical 2 1 2 1 2 1 0 8

total 119 122 98 83 79 1 7 509

38 39 31 26 25 0 2 162

places at-home 81 83 67 57 54 1 5 347

total places 119 122 98 83 79 1 7 509

Intermediate

Care and/or

Non-acute

Non-acute beds and

places required by LHB

2014-15 with new MoC

NHS etc beds

Provided as

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.

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

Frailty Syndrome

• Frailty = (Dependency x vulnerability x

co-morbidity)

+

(Environmental x social factors)

What is it?

Physical characteristics Multidimensional

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

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

components

PREVENT

FRAILITY

DELAY FRAILT

Y

PREVENT/ DELAYADVERSE OUTCOMESPROVIDE CARE

MODIFIERSBiological

PsychologicalSocial

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 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

Prevalence of Frailty 3 or more of the outcome

Source: Census 2001

Happily Independent

What we stand for:Principles & 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.

Outcomes:What 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.

Specialist Health Care Skills

Social Care Skills

Health Care Skills

Specialist Social Care Skills

Generic WorkerSkills

Frail Elderly Workforce Skills Matrix

Generalist as the New Specialist(Intermediate Care)

• GP’s Changing Roles

• Geriatrician Changing Roles

• AHP’s Changing Roles

• Training In The Community

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

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 @ 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

Components of Comprehensive Needs Assessment Components 1 Medical assessment

2 Assessment of functioning

3 Psychological assessment

4 Social assessment

5 Environmental assessment

ElementsCo-morbid conditionsMedication reviewNutritional status Activities of daily livingGait and balance

Mental status

Assessment of needs, assetsand resource eligibility

Home safety, transportation and tele-health

Proposed Locality StructureJoint Chair: Director of Social Services

Locality Manager (Health)

Members: Project ManagerHuman ResourceFinanceIntermediate Care ConsultantGeneral PractitionerLead NurseVoluntary Sector

Co-opted Members: Pharmacist, Mental Health, Therapies, CHC

Urgent Response & Intervention

Comprises of three key elements:

Urgent Comprehensive Assessment (Health & Social Care)

Rapid Response Intervention (health)

Social Care Crisis Intervention

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.

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

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

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

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

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

Communication & Stakeholder Engagement

Workstream lead: Dr Liam Taylor

• Development of a communication strategy for all key stakeholders

Specific programmes of work –a. Stakeholder Briefingsb. Staff Communicationc. Public Engagementd. Power Brokers (Politicians and Executive Key Members)

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

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

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

Outcome Indicators, Performance & Continuous

ImprovementWorkstream lead: Angela Jones

Use the Outcomes-Based Approach.Happily Independent:(5 key elements)1. Be able to remain living in their own home with

support2. Receive services in their home3. Be listened to by people who are responsible for

providing services to assist them 4. Have their health and social care problems

(holistically) solve quickly5. Have a general good health

Governance & Structures

Workstream Lead: Bobby Bolt

• Agreed standards and protocols• 3 Groups of work:

a. Clinical accountabilityb. Operational issuesc. Clear lines of management

(professional and regulatory issues)

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)

Next Steps

Service Model

Capacity Plan

WorkforcePlan

Plan

Service Model

Capacity Plan

WorkforcePlan

FinancialPlan

Key Milestones

Business case submitted by October 2009

Groundwork from workstreams completed by end of March 2010

First locality ready for roll out April/May 2010

Implemented in all localities by end of March 2011

Resource Package1. Wanless funds (WAG) – Approx £5million:2004

2. 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

Current Situation 1

Locality Frailty care model

(DGH)

Co-located teams

Single point of referral

Community Consultant

Caerphilly +- - - +Newport +- +- - +Torfaen +- + - +Blaenau Gwent + - - -Monmouthshire + - - -

Current Situation 2*Referral 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 - - +- - + -

Activity Figures: Non Elective: Adult Medicine (Since 1999 till 2008 = 53% increase)

6.5

6.3

5.7

5.2

7.1

8.2

8.0

8.4

7351

9261

10728

11336

(+54%)

Since 2000.

12902

14053

14046

13615

(+5.5%)

Since 2000.

1999-2000

2002-2003

2005-2006

2007-2008

LOS NHHLOS RGHNHHRGH

Reduction Of 90 Community Hospital Beds

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

Locality Steering Board (tri-partite)Health, social services, LHBs, voluntary sector

Operational Team (Operational Clinical Team)+

Consultant Doctor, Consultant Nurse, Senior Social WorkerConsultant Rehabilatationist

Single point of referral

= Prevention of admission

= Early supported discharge

= Chronic long terms conditions mgt

Integrated Intermediate Care (frailty) Model (Gwent)

Generic Support Workers (Multi-disciplinary)

Path ContinenceCardiac failure

1. Chronic disease mgt-

Joint daycare

Palliative care

Wound mgtStroke

COPD

Neuro degenerative

Rapid response

Chronic conditions specialists

ACAT

Reablement2. Chronic

conditions mgt-

Mental Health

(dementia)

Expert patient scheme

District nursing (generalist role)

Community hospitals

Frailty care model

Pan-Gwent Intermediate Care (frailty) Steering BoardChief Executives- Trust, LHB, LAs

Mental Health Teams

Care support/ respite care

Self care

Assistive technology/

smart houses

= Independent living within the community

Roles-1) Standard setting2) Uniformity of service

across Gwent3) Performance

management4) Financial

management

= Continuing care + transport

Social crisis mgt

Co

ntin

uin

g care

Tran

spo

rt

Paul WilliamsDirector General, Health & Social Services

Chief 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)