Unique Care: Converting Unplanned Crisis into Planned
Care
Ruth Adam& Philip Lewer
An acute hospital admission is a failure of the Health System.
The real challenge to the NHS is how to manage chronic
disease better
The trick is to convert unplanned care into planned.
Adopt a multi-skilled, multi-agency approach to ensure effective care co-ordination
Unique Care
• Integrate Health and Social Care• Deal with current referrals• Joint assessment & joint working (SAP)• Tailored packages of care• Hospital In-reach• Get the 20% on the radar
Unique Care
• Same day assessment 97% of time • Utilisation of primary care team, CPNs
Practice nurses, etc.• Involvement of Voluntary Sector• Better use of other Health
Professionals, including pharmacists, rehab, OT, rapid response teams
• Effective use of social services’ resources
Over 65s Admissions per 1,000 Population
0
50
100
150
200
250
300
350
Castlefields Runcorn
Year Pre-project Project Year
Over 65s Average Length of Stay
0
1
2
3
4
5
6
7
8
Castlefields Runcorn
Year Pre-Project Project Year
Over 65s Bed Days per 1,000 Population
0
500
1000
1500
2000
2500
Castlefields Runcorn
Year Pre-Project Project Year
Other Effects
• District Nurse Team didn’t need backfill• GPs’ home visits fell by 30%• Social Services budget made small saving in
Castlefields but overspent in Borough• Use of intermediate care remained stable &
within expected for population• 48 cases; admissions fell from 123 to 2 and
only three went into long term care
Money released for re-investment
Practice Population: 12,000
Saves £210,000 (US$ 408,281) per year on admissions
Over 65s Acute AdmissionsCastlefields Health Centre
0
50
100
150
200
250
300
350
1999 2000 2001 2002 2003 2004 2005
Unique Care – 5 Key Principles
1. Create a Unique Care team between health and social services
2. Create and maintain a practice based register of patients with complex needs
3. Case find patients at risk of admission
4. Establish hospital in-reach 5. Create a bespoke plan with each patient
Which patients benefit most from Unique Care?
Supported Self Care
Disease Management
Case
Management
Level 1
70-80% of an LTC population
Level 2
High Risk Patients
Level 3
Highly Complex PatientsProfessional CareSelf Care
Unique Care
Unique Care
Unique Care
• Multiple Crisis – Multiple LTC’s, complex medical & social needs, frequent admissions to hospital / A&E attendance / OOH Service
• Not attended for screening / OPA’s • Experienced major life changes e.g. bereavement,
deterioration in health, self neglect
• An older person about whom you have concerns
Which patients benefit most from Unique Care?
The Pareto principle
• 20% of supermarket products account for 80% of sales
• 20% of criminals account for 80% of the value of crime
• 20% of people who marry account for 80% of divorce statistics
• 20% of your carpet gets 80% of the wear• 20% of the clothes in your wardrobe get worn
80% of the time
Source: Koch 1998
The 20% of Patients who need 80% of the Care
• Older People• Decreased Functional Ability• Revolving Door Admissions• COPD & Heart Failure• End of Life• Psychological & Social Support• Packages of care tailored to the
individual
Postal Questionnaire
• 20 questions Yes/No answers only• One sheet of paper• Coloured ink & large font• Invitation signed by own GP• Helpline• First & second reminders
Response
• All practices in PCT recruited• 3999 identified as potential participants• 350 ruled out by cross-checking with the
practices • 3649 sent questionnaire• 302 declined to participate• 305 failed to respond• 3048 positive response (83.5%)
12 month summary• Diabetes 1.3• Lung problems 1.7• Heart problems 1.7• Stroke 1.7• Cancer 1.2• Depression 1.6• Bladder problems 1.6• Leg ulcers 2.2• Lives alone 1.0• Help if ill 1.1
• Help to get out 0.4• Bath without help 0.4• Eyesight 1.7• Memory problems 1.9• Flu Vacc 0.9• 4+ medicines 2.0• Previous admission 2.9• Fall 1.8• Bereavement 1.2• General health 0.4
12 month summary• Diabetes 1.3• Lung problems 1.7• Heart problems 1.7• Stroke 1.7• Cancer 1.2• Depression 1.6• Bladder problems 1.6• Leg ulcers 2.2• Lives alone 1.0• Help if ill 1.1
• Help to get out 0.4• Bath without help 0.4• Eyesight 1.7• Memory problems 1.9• Flu Vacc 0.9• 4+ medicines 2.0• Previous admission 2.9• Fall 1.8• Bereavement 1.2• General health 0.4
Identifying At RiskStart with 10, then if ‘Yes’
• Do you have heart problems? +3• Do you have leg ulcers? +4• Can you get out of the house without
help? -5• Do you have problems with your
memory and get confused? +4• Have you been admitted to hospital for
an emergency in the last 12 months? +8• Would you say the general state of your
health is good? -4
SCORE % Pop Identified
Chance of Admission
20+ 6% 55%
15-20 7.5% 47%
10-15 11.5% 30%
<10 75% 17%
Identifying High Risk
• Tools only go so far, so don’t be rigid• Look out for repeat admittees• Severe COPD• Heart Failure• More holistic assessment • Packages of care according to need• Regular review
Has this worked elsewhere?
Enfield – Practice Population 3,600
• Emergency Admissions Reduction 50% • (12% in comparator practice) • Occupied Bed Days Reduction 70% • (10% in comparator)• Excess Bed Days Value Reduction 98% • (23% in comparator)• Spells Value Reduction 49% • (5.6% in comparator)• Total Budget Savings 67%• (8% in comparator)• Total budget savings over 5 months = £99,000• Estimate over 1 year = £237,000
ResultsReduction in admissions
Reduction in bed days
Castlefields 15% 40%
Bracknell Forest 20% 40%
Durham Dales 15% 20%
Oldham 25% 20%
Enfield 53% (12%) 70% (10%)
Avoiding one admission per week• If all 13 Durham Dales practices avoided one
admission per week, this would release money for re-investment to the tune of:
************************£642,876********************
1.2 million US$
(£951 2005/6 Durham Dales)
Feedback from sites“Unique Care has had the benefit of reducing the number of referrals to social
services……the team have helped older people to understand better what the statutory services can provide for them”
Jenny Goodall: Director, Brent Social Services
“This approach has reduced my workload a lot. Quality of care for complex housebound patients has improved immensely”
GP, Derbyshire Dales & South Derbyshire PCT
“Unique Care makes life easier for people with complex needs in many cases it’s the simplest things that have made a big difference.”
Gwyneth Oates: Care Co-ordinator
"Its a good feeling knowing that capable and caring people are there to support you if problems arise"
Patient, Durham Dales PCT
And more importantly…………..“The hospital said that I wasn’t fit to be on my own really…..after further
consideration I decided I didn’t want to go there (residential home), after all here I can do what I like, I can get up in the night, imagine
what it would be like living in somebody else’s place!”
Patient, Brent 2005.
“It’s very hard with angina. You get frightened and you just don’t know where to turn. I was able to talk to you and I know I have somebody there and it’s nice to have somebody. I did what you told me taking
my spray and not get to excited about it all and it saved me from the
phoning the ambulance”. Patient, Oldham 2005.
Health and Social Care Perspective
• Challenges
• Opportunities
• Coming together
Health and Social Care Perspective
• Those that use our services, want /deserve /need services that meet their needs, they also want to make informed choices about their lives.
• Emphasis on choice and self determination for the individual.
Health and Social Care Perspective
• The need to work together to tackle the growing numbers of people with chronic illness and long term conditions
• The need for local providers and purchases to develop services through the market place and contestability
Health and Social Care Perspective
• We are both struggling with our finances. Patients / citizens want more choice and better services – we are tempted to cost shunt rather than see the commissioning gap!
We can if we want to
• Challenge existing cultures
• Ensure the empowerment of people to take expert control of their conditions
• Delivering high quality care
What has worked
• Scrap the eligibility criteria for low level services such as – Careline (telephone response / pendant
service )– Meals on wheels ( frozen meals service )
• My Mum
Conclusion
• There is a willingness to work together especially with GPs so that we can jointly commission new and preventative services
• We want to create new care pathways and community based services so that we can manage demand and expectation together.
So what are you going to do when you go back to work……
How will you make a difference?
How will your patients know?
We can rise to the challenge…!
Philip Lewer
Tel: (07918) 600795
Ruth AdamTel: (0161) 236 [email protected]
Don’t React & Panic
Anticipate & Plan
Don’t React & Panic
Anticipate & Plan
References
• Practice-based commissioning, a toolkit – primary care contractingwww.primarycarecontracting.nhs.uk 2006
• Developing effective joint commissioning for adult services: lessons from history and future prospects
Nick Goodwin, Care Services Improvement Partnership 2006• The future of health and adult social care: a partnership approach for wellbeing
Local Government Association 2006• Human dimensions for change (ppt) taken from Google
Susy Cook, Gill Husband, Margaret McQuadeNHS Improvement Alliance, South Tees Hospital NHS Trust
White paper- Strong and prosperous communities (chap 7) /-Our health our care our say A whole system working a guide and discussion paper CSIP
Commissioning framework for health and well being