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Professor John YoungNational Clinical Director for Integration & the Frail Elderly

John Young

Dept. Elderly Care MedicineBradford Hospitals Trust

& University of LeedsNational Clinical Director for Integration & Frail Elderly,

NHS England

Integration and Older People with Frailty

Integration and Older People with Frailty

• What’s the problem?• How does integration fit in?• What’s the evidence?• What’s the plan?

PERFECT STORM:

• Increasingly clumsy health & social care system• Changing population:

simple needs highly complex (frailty)• The Austerity years

Health & Social Care System

needs to be fit for purpose

2001/02

2002/03

2003/04

2004/05

2005/06

2006/07

2007/08

2008/09

2009/10

2010/11

2011/12

-

100,000

200,000

300,000

400,000

500,000

600,000

700,000

Emergency hospital admissions by age band

85+80-8475-7970-7465-69

Num

ber

of a

dmis

sion

sOver the last decade, some 40% of the increase in emergency admissions is from over 65s

By 2030, the number of people over 80 will have doubled…

The rate of emergency readmissions has also grown faster for older people

In 2008, there were 1.9 million people with more than one long term condition. By 2026, 3 million people will have three long term conditions

Population estimates for frailty:65-69 = 4%70-74 = 7%75-79 = 9%80-84 = 16%Over 85 = 26%

– The majority of over-65s have 2 or more conditions, and the majority of over-75s have 3 or more conditions

– More people have 2 or more conditions than only have 1

Multimorbidity in Scotland (Scottish School of Primary Care Barnett et al Lancet May 2012)

Frailty is loss of physiological reserve

FUNCTIONAL ABILITIES

Independent

Dependent

“Minor illness” eg UTI

Frailty syndromes present in crisis

Hyper-acute Frailty syndromes:

• Immobility• Falls• Delirium• Fluctuating

disability• Incontinence

(Clegg, Young, Rockwood Lancet 2013)

STRUCTURAL, RELATIONAL & CULTURAL FRAGMENTATION(SILOS OF PROVISION)

HOSPITALS PRIMARY CARE SOCIAL CARE

(LG funded & means tested)

COMMUNITY NURSING

COMMUNITY HEALTH

SERVICES

MENTAL HEALTH

SERVICES

NURSING & CARE HOMES

AMBULANCE SERVICES

PHARMACY

HOSPITAL-AT-HOME; “VIRTUAL WARDS; COMMUNITY HOSPITALS; HOME THERAPY TEAMS; COMMUNITY MATRONS; SPECIALIST NURSES; CARE HOME

REHAB; PALLIATIVE CARE; “ENABLEMENT” SERVICES, etc, etc…

VOLUNTARY SECTOR

Does anybody want my patient?Rapid Access Clinic = “Too ill”Care home rehab = “Not ill enough”

HaH = “You mean she’s got dementia!”

L.A. Enablement Service = “Send her along!”

Com hosp = “We’re full till Monday”

We have a fundamental whole system failure

The Wrong Type of Patients:“If we design services for people with one thing wrong at once but people with many things wrong turn up, the fault lies not with the users but with the service, yet all too often these patients are labelled as inappropriate and presented as a problem”

Prof Rockwood 2005

The Wrong Type of System:“Systems designed to treat occasional episodes of care for normally healthy younger people are being used to deliver care for people who have multiple, complex and long term conditions. The result is often that they are passed from silo to silo without the system having ability to co-ordinate different providers”

Rt Hon Stephen Dorrell MP 2011

Integration and Older People with Frailty

• What’s the problem?• How does integration fit in?• What’s the evidence?• What’s the plan?

NATIONAL VOICES (www.nationalvoices.org.uk)

“We are sick of falling through gaps. We are tired of organisational barriers and boundaries that delay or prevent access to care. We do not accept being discharged from a service into a void. We want services to be seamless and care to be continuous”

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A national coalition of health and social care charities in England Voice of patients, service users, carers, their families Over 150 members organisationsConnects with the experiences of millions of people

NATIONAL VOICES: What do we mean by “integration”?

Integration and Older People with Frailty

• What’s the problem?• How does integration fit in?• What’s the evidence?• What’s the plan?

Preventing admission of older people to hospital(D’Souza & Guptha BMJ 2013)

Mostly based on experimental RCTs

• Case management• Community matrons• Integrated community teams• Targeted, specialist servicesComplete failure:

Doesn’t work2001/

022002/

032003/

042004/

052005/

062006/

072007/

082008/

092009/

102010/

112011/

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-

100,000

200,000

300,000

400,000

500,000

600,000

700,000

Emergency hospital admissions by age band

85+80-8475-7970-7465-69

Num

ber

of a

dmis

sion

s

And yet………………

Torbay and S. Devon Health Care Trust

Acclaimed service integration work:

• Bed use reduced 33%• Emergency bed use >85y reduced 32%• Delayed transfers of care “negligible” • LTC use reduced• Home care use increased

“I have seen the future. It is Torbay”David Nicholson NHS Chief Executive

Torbay and S. Devon Health Care Trust

• Work started 2004• Pilot work: joint care manager and joint health and

social care team• Narrative: “Mrs Smith” (see BMJ March 2012)

• Performance metrics: early successes• Staff: better experience• Service users: better experience

Preventing admission of older people to hospital(D’Souza & Guptha BMJ 2013)

Mostly based on experimental RCTs

• Case management• Community matrons• Integrated community teams• Targeted, specialist services

• Experimental control of one (albeit complex) thing

• Short time-horizon of experimenters

WHOLE SYSTEMS THINKING

http://www.youtube.com/watch?v=ecanqQmJq-0

National Evaluation of (16) Integrated Care PilotsRAND Europe; Ernst &Young 2012

Identified several “integrating activities”

Can you identify some “integrating activities” from this video?

National Evaluation of (16) Integrated Care PilotsRAND Europe; Ernst &Young 2012

“Integrating activities” included:• Narrative/collective vision; strong leadership• Developing relationships & trust• Process improvements: care planning; new roles; MDT working• Locality based teams & co-location• Shared IT/ care records• Governance and performance management• Financial systems and incentives

What did they find?

National Evaluation of (16) Integrated Care PilotsRAND Europe; Ernst &Young 2012

• Patient experience unchanged• Unexpected increase in acute admissions • Unexpected decrease in elective care• Changes more complex & took longer

Headline findings:

• Integration work not complete or mature• Mostly horizontal (not vertical)

integration

What are characteristics of best integrated systems (1)?

• Strong clinical leadership across sectors and disciplines, e.g. Grouphealth (US), Jonkoping (Sweden)

• Use of data-driven processes to guide quality improvement, e.g. Intermountain (US), Virginia Mason (US), CCNC (US), GRIPA (US)

• Multi-disciplinary team around primary care practitioners, e.g. Kaiser (US), Dudley (UK), Torbay (UK), CCNC (US)

• Strong investment in preventative services to improve self-management, e.g. Kaiser (US), Leeds (UK), On Lok (US)

• Use of risk stratification and proactive assessment/ care planning, e.g. Tri-boroughs (UK), Kent (UK), North Lanarkshire (UK), Grouphealth (US)

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Integrated Care:What are the characteristics of best integrated systems (1)?

What are characteristics of best integrated systems (2)?

• During crisis episodes, care co-ordination starts in A&E, including social care, right through to discharge e.g. Kaiser (US), Dudley (UK)

• Seamless transfer between acute and community setting, backed up by continuous dialogue between GP & hospital consultant, e.g. RHZ (Netherlands), VHA (US)

• Single electronic care record with patient access/interaction, e.g. RHZ (Netherlands), Kaiser (US)

• Integration between physical and mental health services, with same access standards, e.g. United (US), Beacon (US)

• Same incentives across system – outcomes, process, user experience, VFM; e.g. Intermountain (US)

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Integrated Care:What are the characteristics of best integrated systems (2)?

Kings Fund Integrated Care 2011• “Organisational integration appears to be neither

necessary nor sufficient to deliver the benefits of integrated care.”

• “No single ‘best practice’ model of integrated care exists. What matters most is clinical and service-level integration that focuses on how care can be better provided around the needs of individuals, especially where this care is being given by a number of different professionals and organisations Moreover, integrated care is not needed for all service users or all forms of care but must be targeted at those who stand to benefit most.”

Integration and Older People with Frailty

• What’s the problem?• How does integration fit in?• What’s the evidence?• What’s the plan(s)?

The National Collaboration for IntegrationNational Partners: a major commitment

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25 February 2013

Integrated Care and Support: Our Shared Commitment

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• Launched by MS(CS)14 May 2013 • Sets out policy background• National Voices narrative prioritised• Call for ‘pioneers’ • Sense of urgency within the system to integrate • Information sharing• Accelerated learning across the system• National support to reduce/ eliminate

barriers• No national blueprint – local innovation

Integration and Older People with Frailty:Policy and Plans

• Vulnerable Older People Plan- (Urgent care, primary care, integration)

• Urgent and Emergency Care Review• Integrated Care Pioneers• “Year of Care” Pilots• Integration Transformation Fund (£3.8 billion)

Focus is on: • Whole systems• Older people with multiple co-morbidities/frailty