Long term Conditions Event

Atlantic Quay

17 November 2011

Improving Risk Prediction

1. Risk stratification user interface

SPARRA

STACCATO

Targeting care through the application of Risk Stratification

NHS Tayside/NHS Grampian

• More targeted and co-ordinated care at a local level

• An objective and smart way of managing data to assist in day to day business

• To demonstrate the applicability of the model developed in Tayside to another Board area where IT systems differ

What are we trying to achieve?

• Future challenges of changing demographics

• Need for high quality, safe,efficient and effective service delivery

• Objective, user friendly way of managing populations and monitoring caseloads

Why are we trying to achieve this?

Where have we got to?

• 11 practices agreed to take part• Revised timescales applied to PID• Aim to move forward and pilot from January• Completing final arrangements with

Tayside, environment now ready• Data Sharing Protocol going through sign-

off• Good buy in and enthusiasm to progress

Improving Risk Prediction

Risk stratification user interface

2. SPARRA

STACCATO

Enhanced SPARRA Predictive Model & SPARRA Patient Alerts

Risk prediction and service development

Kathleen McGuire – Long Term Conditions Manager

Ehealth LTC Workshop

November 2011

Aim

• Integrated systems and communications

• Expand the cohort of patients for whom a risk score can be calculated over and above the current SPARRA “All Ages” (Version 2) algorithm

• Improve the predictive power of the algorithm

• Provide the board with a risk prediction tool which will identify patients for referral to Community Wards

Scope

• Feasibility of a model which included GP/Primary Care, Social Care, Accident and Emergency and Prescribing data. Any other potentially useful sources which may serve as a predictor for emergency hospitalisation, including falls and IoRN.

• Producing a linked data set

• Improved data links to and from Primary and Secondary Care

Deliverables

• Data extract specification

• Predictive risk model (with technical report and recommendations)

• Reporting and implementation scoping requirements (report)

• Prototype reporting tool (with user manual)

• Final report (with conclusions and recommendations)

• Post project evaluation (report )

• Lessons learned will inform the national development of SPARRA, predictive risk modelling, related tools

• GP SCI Gateway referral message integrated into ADASTRA

How we have taken forward

• Appointed a Data Analyst

• Appointed a Project Manager

• Gained strategic organisational commitment- eHealth programme

• Gained buy in by utilising other national SPARRA developments & improvements

• Integrated the project with service development of Community Hubs

• Expansion of current LES

SPARRA Prediction & Tools

SPARRA

Accident & Emergency

Patients/Carers

Social S

ervices

Nursing

Hom

es

ADOC

LOTS

LES

Information Tool

Navigator

I SPARRA

Community Hubs

HUB

SECONDARY CARE

CARERS (Kinship / Professional)

SO

CIA

L SE

RV

ICE

S

Chronically ill Patient

Acutely ill Patient

Multiple/Complex Social-needs

Patient

Enhanced SPARRA

CPM

PRIMARY CARE TEAM

Intermediate Care &

Enablement TeamsAHPs

PharmacyOTSpecialist NurseGeriatric ANPs

Community Wards

Social Care Liaison

Practice Nurse

District Nurse

SPOC

GP

AYRSHIRE

HOSPICEADOC

NHS 24

What we have learned so far

• Project needs to be integrated with other development

• Requires stakeholder buy in

• Differing views around data specification

• Quality and coding of data

• Informed consent and data sharing

What we have learned so far

• Time, expertise and partnership required

• IT systems used in out of hours setting suffer from poor demographics and duplicates

• Integrating Primary Care systems with the out of hours service requires a primary data cleansing task

Our wish

• To use the principles of risk adjustment to evaluate the pathways of complex community-based interventions to reduce avoidable hospitalisation, eg testing the cost effectiveness of Community Wards and Telehealth

• To link large datasets at an individual level pseudonymously through our partnership arrangements and relationships

• Predict future costs of health and social care

Our wish

• To exploit new Clinical Portal technology to help distribute electronic information to the point of care.

• Successful procurement of a new community wide IT system (currently in progress) to support collection of data and distribution.

Requirements & Next Steps

• National Support and continuation

• CHI Seeding, time & expertise

• Integrated IT systems within and across organisations

• Go live with model 1st April

• Extend roll out and testing of CPM

• Further integrate SPARRA & IRF

Improving Risk Prediction

Risk stratification user interface

SPARRA

3. STACCATO

STACCATOSTACCATOStow Anticipatory Care Community Stow Anticipatory Care Community Assessment ToolAssessment Tool

Dr Paul CormieDr Paul Cormie

Sandra PrattSandra Pratt

NHS BordersNHS Borders

What is it?What is it?

Computer based assessment tool for Computer based assessment tool for comprehensive functional and social comprehensive functional and social assessment in patient’s homeassessment in patient’s home

3 scenarios:3 scenarios:– Current situationCurrent situation– Patient unwellPatient unwell– Carer unavailableCarer unavailable

Risk predictionRisk prediction Decision support software to enable Decision support software to enable

consistency in addressing unmet need and consistency in addressing unmet need and anticipatory care planninganticipatory care planning

Information directory individual to each Information directory individual to each patientpatient

The aims …The aims …

1.1. Preventing crises: Preventing crises: falls, falls, carer stress, carer stress, nutrition, nutrition, aspiration (pneumonia & UTI)aspiration (pneumonia & UTI)

2.2. Preventing admission if a crisis Preventing admission if a crisis arises:arises:

Predict problems likely to arise if patient Predict problems likely to arise if patient or their carer becomes unwell – logical or their carer becomes unwell – logical approach to anticipatory care planning approach to anticipatory care planning

The aims …The aims …

3.3. Improving discharge planning should Improving discharge planning should admission be necessary – the next admission be necessary – the next step: step:

Detailed information on functional and Detailed information on functional and social status prior to the problem social status prior to the problem resulting in admission resulting in admission

Optimal use of health care professionals Optimal use of health care professionals in hospital in hospital

Discharge planning starting within 24 Discharge planning starting within 24 hours of admissionhours of admission

Communication tool with primary careCommunication tool with primary care

Progress so far…Progress so far…

Rolled out as LES across NHS Borders – all GP Rolled out as LES across NHS Borders – all GP practices opted inpractices opted in

Full Social Work engagement – adapted their Full Social Work engagement – adapted their IT system to host assessments & collect IT system to host assessments & collect evaluation dataevaluation data

Out of Hours – storing assessments on shared Out of Hours – storing assessments on shared folder in hospital & noting availability on folder in hospital & noting availability on NHS24 recordNHS24 record

Voluntary Organisations fully involved – Voluntary Organisations fully involved – Neighbourhood Links, PRTC, BIASNeighbourhood Links, PRTC, BIAS

Funding…..Funding…..

eHealth LTC fundingeHealth LTC funding::– 13 laptops for use by primary care teams in NHS 13 laptops for use by primary care teams in NHS

Borders to carry out the patient assessments in Borders to carry out the patient assessments in their own home.their own home.

– Provide backfill for the District Nurse on the project Provide backfill for the District Nurse on the project team to carry out training on the use of the tool in team to carry out training on the use of the tool in each of the primary care teams in NHS Borderseach of the primary care teams in NHS Borders

– Enable a quantitative evaluation of the Enable a quantitative evaluation of the effectiveness of the tooleffectiveness of the tool

Other Funding …Other Funding …

NHS Borders: NHS Borders: – Anticipatory Care Local Enhanced Service Anticipatory Care Local Enhanced Service

(GPs) & additional resource for district (GPs) & additional resource for district nursesnurses

Change Fund:Change Fund:– additional social care including Bordercare, additional social care including Bordercare,

voluntary organisations, voluntary organisations, Scottish Govt:Scottish Govt:

– qualitative evaluation through University of qualitative evaluation through University of Edinburgh 2012Edinburgh 2012

Endless amounts of Paul’s time….Endless amounts of Paul’s time….

Challenges ….Challenges ….

IM&T: configuration of laptops; information IM&T: configuration of laptops; information sharing with OOHs and Social Work; sharing with OOHs and Social Work;

DN access to Social Work IT system – DN access to Social Work IT system – practicalitiespracticalities

Communication– making sure everyone is in Communication– making sure everyone is in the loop, engages & understands the loop, engages & understands

Managing anxiety about:Managing anxiety about:– potential impact on DN capacitypotential impact on DN capacity– competency with use of ITcompetency with use of IT– Changing working practiceChanging working practice

Evaluation …Evaluation …

Number of ACPs in place Number of ACPs in place Number of plans activated; times activated & Number of plans activated; times activated &

outcomesoutcomes Numbers admitted / readmitted (longer timescale)Numbers admitted / readmitted (longer timescale) Identification of unmet need & additional care / Identification of unmet need & additional care /

services needed to support at homeservices needed to support at home Related referrals to voluntary organisationsRelated referrals to voluntary organisations Feedback from DNs: use of assessment tool & Feedback from DNs: use of assessment tool &

process; activation of ACPsprocess; activation of ACPs Patient & carer feedbackPatient & carer feedback Longer term qualitative evaluation (Edinburgh Longer term qualitative evaluation (Edinburgh

University)University)

Future developments Future developments

More detailed social care planning More detailed social care planning sectionsection

Hospital discharge planning Hospital discharge planning sectionsection

Care Home assessmentCare Home assessment Tentative plans for a polypharmacy Tentative plans for a polypharmacy

risk assessment sectionrisk assessment section

Key Information Summary (KIS)

LTC eHealth Event17 November 2011

Agenda

• National– Overview– Progress– Next Steps

• Local Project Feedback– NHS Greater Glasgow and Clyde– NHS Forth Valley– NHS Highland / NHS Grampian– NHS Tayside

• Q+A

KIS Overview

• Extension of ECS – not a new system• Aims to replace paper based faxing of

“Special Notes” from GP Practices• More generic version of ePCS• Support for:

– electronic Anticipatory Care Plans (eACP)– Long Term Conditions– Mental Health

• Utilise existing ECS infrastructure and process

• Expecting 500,000 patients to have KIS information in place

4 Sections on KIS Form

• Section 1 – “Special Note”– Free text field of 2048 Characters– Expiry Date– Patient and Carer details– Other demographics (Next of Kin)

• Section 2 – Current Situation– Medical History– ACP / Self Management Plan

agreement– Home Oxygen

4 Sections on KIS Form

• Section 3 – Care and Support details– Homecare support– Incapacity / Guardianship– Power of Attorney

• Section 4 – Resuscitation– DNACPR– CYPADM (Children Resuscitation)– Current and Preferred Place of Care

Progress to Date

• GP Systems– Specifications complete– Testing to start next week– Demonstrations held for EMIS

• Central ECS– Live and ready for KIS

• End user systems progressing• Patient Communication

– LTCAS engagement• FAQ’s / Clinical Guidance

Next Steps

• Pilots!– February for EMIS / Vision

• Testing – Several phases based on development

from suppliers• Complete Clinical Guidance• Support LTC pilots• Prepare for national rollout

– eHealth Strategy deliverable by 2014

Long Term Conditions & e-Health

KEY INFORMATION SUMMARY

• Initial development complete, KIS displaying in test portal.

• Stylesheet update - November 2011• Review and approval by ECS user group Nov – Dec 2011• Portal Release – Dec 2011• Pilot practices identified – pilot February 2012 following

delivery of KIS for EMIS in Jan 2012• Lessons learned reported back - March – April 2012

Long Term Conditions & e-Health

Clinical Scenario

• Mr Smith, 76 yrs, Mild to moderate dementia• Carer is 75 yr old frail wife• Has had an SSA completed and care manager

appointed by social work • Has a care plan

• Mr Smith becomes ill on Saturday and presents to OOH GP…

Long Term Conditions & e-Health

AT PRESENT

• The SSA and care plan are paper based and not easily shared. • The OOH GP may have a faxed special note re the patient but

may not. • The OOH GP doesn’t know what services are involved, or why

the patient is agitated and resistant to intervention by medical staff

• The patients carer appears frail, so the patient is admitted for IV fluids and antibiotics.

• The patient becomes more agitated and confused in the unfamiliar hospital environment and the carer is without the usual community supports

• Hospital staff are unaware of the patients full history or how best to manage him

• Patient deteriorates and carer struggles to cope leading to prolonged admission

Long Term Conditions & e-Health

IN FUTURE…• Those working with patient in the community (health and

social care) will be able to see SSA and care plan from the Clinical portal

• GPs completes KIS, indicates is care plan, states history and diagnosis, key contacts, services available and care manager

• OOH GP has enough information to treat patient without admission

• Patient remains in familiar environment and does not become agitated

• Carer continues to receive support in the community • If patient does require to be admitted, hospital staff can see

history in portal, knows who key contacts are and can work with discharge teams for speedier supported discharge.

Key Information Summary

NHS Forth ValleyProgress to date

KIS / EMIS evaluation

• Local KIS Project Board established • 11 GP practices recruited

– Practice Teams established– Meeting of practices scheduled for 1st

December• Key contacts in OOH and ED established• KIS progress monitored through CHP eHealth

committee via monthly highlight report• QI involvement to develop evaluation

methodology and evaluation tools

KIS / EMIS evaluation

• Raising awareness of KIS pilot at Organisational level e.g. GP sub, ACF, LTC.

• Keen for FV staff to be involved in Webex demo / SEF testing etc.

• Developed a KIS intranet webpage • Key concern – timing of Adastra

implementation• On track for KIS live testing Feb / March

2012

Improving Support in Anticipatory Care

Key Information Summary (KIS) in Vision Practices

NHS Highland /NHS Grampian

• Grampian GP-sub have endorsed project

• Grampian have identified the test practices

• In Grampian links have been established locally with Living Well Dying Well Clinical Lead to ensure continuity with ePCS and palliative process of care

Progress Nov 2011

• NHS Highland Project Manager appointed• Stakeholders identified• Continued rollout of ePCS• Pilot documentation under development

for distribution to practices• Work started to integrate local LES into

workstream• Integration into LTC programme• Pilot practices to be identified over

coming weeks

Progress Nov 2011

• NHS Grampian/Highland joint working group to be established

• Joint project plan development

• Options for Adastra ACPA conversion to be identified

Next Steps

NHS Tayside update

• Awaiting outcome of decisions / options on MIDIS integration– Suggested option that MIDIS could

directly add information to KIS outside of GP Practice

– Links to Clinical Portal– Any developments shared with all MIDIS

boards• Change in OOH system expected in March• Support for SEF testing

Questions + Answers

More information:www.ecs.scot.nhs.uk/kis

jcameron2@nhs.net

Realising the quality and efficiency benefits

eHEALTH in support of LONG TERM CONDITIONS

17 November 2011

Susan Bishop, QuEST

We’re aiming to understand the quality and efficiency benefits?

• There’s variation, waste and harm in services for people with long term conditions

• Each Board’s striving to be more efficient and

give better outcomes and experience, but may not be aware of what more they can achieve and at what cost

Outpatients, Primary and Community Care

• Manage demand & capacity - pace of Lean in community, PGP• Translate local into national gains - scale & spread anticipatory care•Transform demand on secondary care - new and return outpatients• Think differently about 4 Primary Care contracts -cross contract opportunity

NHS Board Lead:Elaine Mead

SGHD Lead: Graeme Dickson

QuEST Support: Susan Bishop

What are we expecting to see?

• Transformed acute, community, primary and self care demand

• Improved utilisation of existing resources

• Over a 12 month period

• Learning about what didn’t work

What approaches can we use to

determining benefits and costs?

Return on investment calculation

• Benefit Cost Ratio = Benefits/Costs• Example: 1000/500 = 2• ROI = Net Programme Benefits/Program

Costs X 100• Example: (1000-500)/500 x100 = 100%• Second shows the return clearly on

initial investment (cost).

Full benefits logic

Service Improvements

PatientImprovements

StaffImprovements

Efficacy & productivity

Efficiencies (cashable)

Capacity increase

PatientCentred

Clinical quality & safety

StaffExperience

Clinical community “buy in”

Standardise assessment process

Reduce unnecessary time

at Hosp.

Learn (clinically) as a system

Transfer approach to other LTCs

Access the right care first time

Understand what success looks like

Benefit Drivers Benefit Areas

System can cope with pathway

changes

Understand current (whole) pathway

Simplify out of hospital assessment

Clinical Decision Support

Understand activity & clinical profile

Opportunity Areas

Pre –hospital falls pathway

Cost Consequence Analysis

1. Non-recurrent costs of making change

2. Recurrent costs/savings of making change

3. Non-financial impacts of change – both positive and negative - just state

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