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Anticipatory Care Planning. Dr Anne Hendry National Clinical Lead for Integrated Care Joint Improvement Team. Anticipatory Care Planning Self Management. Acute. Very. Emergency. High. sector. admissions. High risk. Medium risk. Lower risk. Prevention and. Health Improvement.
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Anticipatory Care Planning Dr Anne Hendry National Clinical Lead for Integrated Care Joint Improvement Team
Acute Very Emergency High sector admissions High risk Medium risk Lower risk Prevention and Health Improvement LTC Collaborative 14% reduction in rate of hospital bed days 06/07 – 10/11
SPARRA Cohorts Frail Elderly Younger ED Alcohol/ substance misuse related admissions Age All cohorts Deprivation Emergency / elective / daycase admissions Prescriptions in specific BNF chapters Prescriptions for specific groups of drugs LTC related admissions ED attendances New OP attendances for MH Emergency bed days New OP attendances Polypharmacy LTC Psychiatric admissions Prescriptions/admissions indicating particular conditions Deprivation www.isdscotland.org/dhipwww.isdscotland.org/dhip
Patient Risk Trajectories 2 – Over 75 (Frail Elderly) www.isdscotland.org/dhipwww.isdscotland.org/dhip
Patient Risk Trajectories 3 – YED www.isdscotland.org/dhipwww.isdscotland.org/dhip
Anticipatory Care Continuum of Risk 2nd choice for QOF ACP 1st choice for QOF ACP SPARRA SCORE < 20% > 60% 20- 40% 40 - 60% Long Term Conditions People with lowest risk of emergency admission to hospital. Likely to need simple information, advice and support to help them to stay well and manage their conditions People at moderate risk of emergency admission. Likely to attend the practice or a nurse specialist for follow up Their ACP is usually best developed by the GP and the Practice team Patients at highest risk of emergency admission to hospital Likely to be receiving care or managed by the Community Team Many already have an ACP Their ACP is usually developed by the Community Team or nurse specialist involved Lifestyle Interventions
Feedback from patients Excellent idea Very happy to share this information with relevant others Would not want some sensitive information from medical notes shared with others No problem as long as information is ‘secure’ Gives confidence when GP surgery closed Surprised that this was not happening already
What GPs liked Excellent for sharing info with relevant others Good breadth of information Structured, concise and easy to fill in Ability to add descriptive text Good design and workflow Easy to use and navigate
Users in A&E Good that it is not just for palliative care Information is clear and concise Anticipatory care information particularly useful This information could dramatically improve the care we provide Would be good if we could also write to KIS rather than read-only Some of the KISs in pilot were of limited quality
ACP Evaluation 1. Nairn Study: Baker, Leak et al Br J General Practice Feb 2012 RCT with a net saving of £190 per patient for the ACP cohort 2. Highland study of emergency admissions and bed days for older people in care homes and the top 1% risk group living at home 2 cohorts matched for SPARRA risk – 1556 in each cohort No ACP - emergency admissions and bed days ↑by 51% and 49% ACP - emergency admissions and bed days ↓ by 38% and 49% 3. York Health Economics Report 4. Local Evaluations
Personal Outcomes Maintaining and enjoying a good quality of life Achieving specific changes in my health or wellbeing Being treated, cared about or supported the wayI want to be What are the things that matter most to me at this point in time? Being more able to understand & manage my health, condition or treatment
2020 Vision Everyone is able to live longer healthier lives at home, or in a homely setting. Integrated health and social care, a focus on prevention, anticipation and supported self management. When hospital treatment is required, and cannot be provided in a community setting, day case treatment will be the norm. Care will be provided to the highest standards of quality and safety, with the person at the centre of all decisions. There will be a focus on ensuring that people get back to their home or community as soon as appropriate, with minimal risk of re-admission.
Most people with any long term condition have multiple conditions in Scotland Guidelines and the current organisation of care do not reflect this reality. Guthrie B et al, BMJ 2012;345:e6341; Hughes L et al, Age and Ageing 2013;42:62-69
Modernising Nursing in the community CHILDREN YOUNG PEOPLE FAMILIES Improving efficiency & optimising workforce capacity and capability Effective Building workforce capacity & capability Providing choice & care in the right setting Person-centred ADULTS OLDER ADULTS Developing skills & knowledge through education Informing practice with policy, research & evidence Anticipating health needs & responding earlier Utilising high quality clinical outcomes Working with clients, carers & patients as partners PEOPLE AT WORK Utilising Telecare & Telehealth technology Using care pathways Enabling and supporting self care Promoting health & addressing inequality Strengthening leadership & team working Working with other agencies & disciplines as partners Delivering safe, high quality care, treatment & rehabilitation
