holistic hospital care at home - rhetoric to reality professor bim bhowmick obe dl md frcp
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HOLISTIC HOSPITAL CARE AT HOME -RHETORIC TO REALITY
Professor Bim Bhowmick OBE DL MD FRCP
NHS : Do we need change? YES & WE MUST
WHY? (67 years old & chronically disabled & rattling)
The NHS must CHANGE or Die
Hospitals on the Edge? Time for Action
Professor Bim Bhowmick OBE DL MD FRCP
Royal college of Physicians October 2012
BMJ July 2012
So how do we do it?“The gap between hospital & home is unsustainable and, for the sake of our frailest and most vulnerable patients it
must be closed”BMJ 24 November 2012
Professor Bim Bhowmick OBE DL MD FRCP
A novel & radical approach:
specialist in out-of-hospital settingsKings fund October 2014
Bhowmick Innovative Model(BIM)
Academy of rhetorics
• Privacy and dignity, compassion and respect must be maintained
• Care must be patient centred • Primary care, secondary care and
Community Care-joined up• Resources must be transferred from acute
services to the community sector.
Professor Bim Bhowmick OBE DL MD FRCP
Bhowmick Innovative Model(BIM)Academy of rhetorics
• Care to be provided at home• Care to be provided near home• Early intervention• Prevent Hospital admission• Integrated service• Whole system delivery
Professor Bim Bhowmick OBE DL MD FRCP
BIM
Some facts:• Wales has the highest elderly population
compared to other countries in the U.K• Over 75s will increase by 75% in two decades• Hospitals are full to bursting• 70% of beds are occupied by patients with
chronic diseases especially Elderly• 70 pence of an NHS pound is spent for the
elderly.
Professor Bim Bhowmick OBE DL MD FRCP
NHS SYSTEM IN CRISIS
• 4-hour WAITS in A&E ↑ 50% in 2014-2015 compared with 2013-2014
• Delays in getting patients into A&E ↑ 63%
• 12-hour trolley wait ↑ 700% in a year
• Delays in discharge ↑ 29% than 1 year ago.
Professor Bim Bhowmick OBE DL MD FRCP
(BMJ 2015)
Bed Crisis
• “Emergency patients occupy elective beds.• Patients requiring social care occupy emergency
beds.• Ordinary patients occupy Intensive care beds.• Intensive care patients occupy Theatre
Recovery .• Gridlock occurs when there is NOWHERE LEFT
TO DISPLACE.”
Professor Bim Bhowmick OBE DL MD FRCP
Unscheduled Emergency Care:The Way Forward
BHOWMICK INNOVATIVE MODEL (BIM)
Torfaen
Ynys Mon/ Anglesey
PROFESSOR BIM BHOWMICK OBE DL MD FRCP
CONSULTANT COMMUNITY PHYSICIAN
Unscheduled Emergency Admissions‘Minus Ten Bed Syndrome’
Professor Bim Bhowmick OBE DL MD FRCP
2000 beds(2006-2012)
Creation of virtual beds and ward in the Community
Increasing
emergency
admission
Elderly
DTOC
Delayed
discharge
(old and very old)
“Blocked Beds”
PRESSURES ON NHSPRESSURES ON NHS
Delivery of Clinical Futures
(Reduction of acute beds)
Professor Bim Bhowmick OBE DL MD FRCP
Silver tsunami
Primary Care Secondary Care
Voluntary
Professor Bim Bhowmick OBE DL MD FRCP
Social Care
TRIBALISMTRIBALISM
Patient and Carer
WHOLE SYSTEM APPROACHLOCAL INTEGRATED PLANNING/COMMISSIONING/EVALUATION
Patient and Carer
Primary Care Secondary Care
Voluntary
Professor Bim Bhowmick OBE DL MD FRCP
Social Care
BIMINTEGRATED CARE
BIMINTEGRATED CARE
SECONDARY CARE
Physicians
A&E
MAU
SERVICE DEPARTMENTS
Biochemistry, Haematology, Radiology.LEADER
Forming the teamVOLUNTARY
ALLIANCE
CARERS GROUP
CARE HOMES -Proprietors
SOCIAL SERVICES
Chief Exec. Officer, Director, Head of Adult Services, Councilors,
CHC
AMBULANCE SERVICE FALLS TRANSPORT
COMMUNITY PHARMACIST
GENERAL PRACTITIONERS
Mon Enhanced Care (MEC) / TORFAEN
GROUNDWORK TO LINK UP SERVICES
Patch MDT
Old Age Psychiatry
Palliative Care
Professor Bim Bhowmick OBE DL MD FRCP
District Nursing
CARE & REPAIR
GOING
GOING
GONE
Normally just able Off to HOSPITAL
Time away from carers and social network
Care package interrupted or withdrawn
Ward admission
Reduced confidence
Disorientation, loss of routine
Reduced mobility
Increased confusion
MDT review
‘Unsafe for discharge’
DTOC
Bed blocking
Earliest InterventionThe ‘3G’ Syndrome
Professor Bim Bhowmick OBE DL MD FRCP
Prevent admission
Reduce DTOC
Prevent premature admission to care homes
VIRTUAL WARD
Resident at own home, care homes or sheltered housing
Diagnostics
SINGLE POINT OF ACCESS
Health Care Assistants,
Nurse Assessors, Consultant.
REFERRING BODIESHealth practitioners,
Step up to Admit Community Hospital
EMI
Specialist Nurses
COPD Stroke
Heart Failure
General Practitioner
Patch Reablement
Team Emergency
Social CareVoluntary
ServicesAmbulance
Professor Bim Bhowmick OBE DL MD FRCP
Out of hours service
Palliative Care
Minor Injury Unit
Hospital at Home (MEC/TORFAEN)
Integrated Care
General Practitioner
• Time response – 2 hours
• Community Equipment
Types of Emergency Admissions in the Elderly
ITU Critically Ill
UTI Urinary Tract Infection
TUI Totally unnecessary inpatient
TIU To inform the undertaker
Professor Bim Bhowmick OBE DL MD FRCP
Types of Emergency Admissions in the Elderly
ITU Critically Ill
UTI Urinary Tract Infection
TUI Totally unnecessary inpatient
TIU To inform the undertaker
Professor Bim Bhowmick OBE DL MD FRCP
Integrated Management Team
Hospital Admission Avoidance Scheme
MINDING THE GAP/ WORKING TOGETHER (BIM)MINDING THE GAP/ WORKING TOGETHER (BIM)
GP, Social Services, Matron, Consultant.
JOINT CO-ORDINATOR
• Large Multi-Disciplinary Group
Steering Board
MEC
Steering Board
Torfaen
Intermediate Care Directorate
(Clinical Director, Business Manager, Locality Manager).
LHB’s, Trust, Social Services, GP’s, Consultants & Voluntary Bodies
Professor Bim Bhowmick OBE DL MD FRCP
MEC CASE STUDY 1
• 86 year old retired Anaesthetist.• PMH: AF, PPM, CKD Stage II, hypertension, progressively
slowed down, recurrent chest infections• Fell in bathroom at night• Partner noticed noisy chest and commenced abx as per
previous advice from GP.• GP visited next morning, sleepy ++. Diagnosed chest
infection. Referred to MEC.• Lab results satisfactory. Undiagnosed PD. Aspiration
pnuemonia right side.
Professor Bim Bhowmick OBE DL MD FRCP
MEC CASE STUDY 1
• Managed at home with significant improvement. ANP visited daily for 5 days, then once weekly for 3/52.
• Consultant visit x 2• Mobilising easily, discharged from MEC back to
GP.• No further admissions last 7 months
Professor Bim Bhowmick OBE DL MD FRCP
MEC CASE STUDY 2• GW – 84, Female, lives alone, manages with home care.
• Recently Fractured Neck of Femur. Discharged 3 weeks ago.
• PMH: Breast Ca 5 yrs ago with mets to spine. Uterine cancer with daily PV bleeds (on tranexamic acid), CKD stage III, hypertension, chronic anaemia.
• 2nd June 2012 sudden onset of acute pain, left axilliary region and became breathless.
• GP referred to MEC
• Provisional clinical diagnosis – Pulmonary embolism
Professor Bim Bhowmick OBE DL MD FRCP
MEC CASE STUDY 2• Commenced appropriate treatment at home and
arranged CTPA next morning confirming the diagnosis.
• GP & ANP continued to manage her at home with increased support from Social Services and family.
Professor Bim Bhowmick OBE DL MD FRCP
MEC CASE STUDY 3
• Nov 2012 93 year old female in a residential home.
• GP referral to MEC• Fall; Slurred speech; Weak right side; Gone off
legs; Diarrhoea for 2 Days; ? AF.• PMH: CCF; HTN; CKD stage 3; Hypothyroidism;
Diverticular disease.• MEC Diagnoses• Rapid AF (heart rate 124pm); T.I.A. (resolving);• Diarrhoea due to faecal impaction
Professor Bim Bhowmick OBE DL MD FRCP
MEC Case Study 3 cont’d
• Blood Results: Hypokalaemia(2.7mmol);• Osteomalacia (low Ca++: low phosphate:
raised alkaline phos).• Managed at the residential home with
Physiotherapy.• Repeat Bloods/ Repeat visits: All well.• Discharged back to GP in 2 weeks.
Professor Bim Bhowmick OBE DL MD FRCP
MEC RESULTS
Volume of activities Total Referrals Total Visits Admission/Attendance Avoided
July 2012 -December 2012 127 595 121
REFERRALS TOSOCIAL SERVICE
12
Professor Bim Bhowmick OBE DL MD FRCP
Torfaen OutcomesVolume of activities Total Referrals Total Visits Admission/Attendance
Avoided
Jan 2007-Dec 2007 744 1569 578
Jan 2008-Dec 2008 1369 4111 1124
Emergency Admission/attendance
Delayed Transfers of Care
Daytime admissions from care homes
Admission to Care Homes from the Community AND
Social services underspent for first time
Approximately 2million pounds savings (Audit Commission 2009
Professor Bim Bhowmick OBE DL MD FRCP
The Model Delivers the Changes we Need
• Older persons do not want hospital admission. We provided a choice.
• We changed the culture of patients and carers automatically wanting hospital admission.
• We changed the culture of GPs – ‘one size fits all’ by supporting them at the point of need. with urgent diagnostics and secondary care opinion.
Professor Bim Bhowmick OBE DL MD FRCP
The Model Delivers the Changes we Need
• We broke down barriers between the ‘tribes’.
• Professional boundaries - medics, nurses, therapists, social workers - broken down (teams without walls)
• Mental health partnership very important• Voluntary sector and independent sector
must be inclusive
Professor Bim Bhowmick OBE DL MD FRCP
Finally.....To Succeed...
• Strong & Persuasive CLINICAL leadership.
• Focused vision.• Passion, Persistence, Pennies.• Dedicated team.
Professor Bim Bhowmick OBE DL MD FRCP
BIMVIRTUAL WARD IN THE COMMUNITY
Rhetoric to Reality
• Privacy & Dignity YES• Pts choice YES• Alternative to acute admission YES• Continuity of Care YES• No boarding out YES• Pt & Carers Satisfaction YES
Professor Bim Bhowmick OBE DL MD FRCP
BIMVIRTUAL WARD IN THE COMMUNITY
Rhetoric to Reality
• Treat & manage at home • Treat & manage in the
Community Hospital• Urgent intervention• Urgent Investigation• Cost Effective• Hard Work• “Thick Skinned”
YES
YES
YES
YES
YES
YES
YES
Professor Bim Bhowmick OBE DL MD FRCP
BIMVIRTUAL WARD IN THE COMMUNITY
Rhetoric to Reality
INTEGRATION
Working Together WithG.P.’sSocial ServicesDistrict NursesVoluntary AllianceE.M.I.Palliative CareAmbulanceCare Homes
YES
Professor Bim Bhowmick OBE DL MD FRCP
BIM
• Bevan commission 2013 recommended to the Health Minister that BIM is adapted as the basis for a national standard for NHS Wales.
Professor Bim Bhowmick OBE DL MD FRCP
BIM
VIRTUAL WARD IN THE COMMUNITYRhetoric to Reality
Finally Hospital ceases to be “somewhere” it becomes
everywhere.
YES
Professor Bim Bhowmick OBE DL MD FRCP
BIM
• Further information can be found at the following websites –
www.bimbhowmick.co.uk
www.bevancommission.org
Professor Bim Bhowmick OBE DL MD FRCP
Grateful thanks to MEC Team
Dr Stephen McVicar – General Practitioner
Mr Stephen Sloss – Interim Director of Social Services.
Mrs Annwen Davies – Head of Adult Social Services.
Mrs Kate Thomas – Locality Matron
Mrs Cheryl Hindle – Joint MEC Co-ordinator
Advanced Nurse Practitioners – Ann, Karen, Bryona,
Health Care Workers
• “I can honestly say that the way this initiative is working under the inspirational leadership of Prof. Bhowmick is the most innovative and best of any model of care that I have ever seen.” - Chair of the Voluntary Alliance
• “I write on behalf of the Elected Members, Senior Officers and all staff in Adult Services at the Isle of Anglesey County Council to thank you most sincerely for your efforts, drive and immense success on the Island over the past year…” Head of Adult Social Services
• “You have built up a team from nothing and have engendered in the nurses a definite ‘spirit de corps’. You have managed to obtain services from the secondary sector through your negotiating skills.” – GP
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