‘Whole System’ Models of Care for Older People Tom Bowen The Balance of Care Group ORAHS 2004, Stockholm, Sweden 28 Jun

1. ‘Whole System’ Models of Care for Older People Tom Bowen The Balance of Care Group ORAHS 2004, Stockholm, Sweden28 June 2004

2. Content • Health status of older people • ‘Integrated’ and ‘intermediate’ care • Balance of Care models • Appropriateness Evaluation Protocol surveys • Comparison of UK local health economies

3. Health Status of Older People • Manton (US) estimated disability reducing by 1.3% p.a. in over 75s • Lagergren (Sweden) has shown that health and social care costs continue to concentrate in last two years of life • Dixon et al (UK) show that the number of acute hospital bed days in last 3 years of life does not increase with age (2004) • Some debate about ‘compression of morbidity’

4. Developing a community focus • Kaiser Permanente • focus on chronic disease management • Adcroft Surgery • occupied bed days reduced by 20% in local hospitals • South Bucks EPICS scheme • Managed population 4,200 elderly and saved 561 bed days in first 5 months • EverCare Project • Ten pilot PCTs in UK • 30-35% admissions from 1% of population

5. Intermediate Care • Driven by wish to free up acute beds • In-between acute hospital care and primary care • ‘Step up’ and ‘step down’ • Could be bed or community based • Cuts across professions, organisations and budgets

6. Balance of Care model Phase of Care Care Option Intervention Provider Alternative to admission Community nurse NHS Post-acute intensive (up to 7 days) Care Co-ordinator Care Option 1 Physiotherapist Older People IC care Supported discharge (up to 14 days) Care Option 2 Speech therapist Care Option 3 Local Authority Rehab/ recovery (up to 28 days) Occ. therapist Care assistant Care Option 4 Voluntary & Independent sector “slow stream rehab” (up to 42 days)  Balance of Care Group

10. Point Prevalence Surveys • All inpatients in selected specialties on a single day • Acute and elderly medicine, & orthopaedics • Data collected from casenotes by clinical staff • Use Appropriateness Evaluation Protocol (AEP) to identify possibly ’non-acute’ patients • Also survey non-acute hospitals • Follow up discharge outcomes to provide basis for demand analysis

11. AEP Criteria On admission • Severity of illness eg unconscious, unable to move (fall), acute bleeding • Intensity of service eg surgery + gen anaesthesia, regular monitoring, IV therapy On day of care • Medical services • Nursing services • Patient conditioneg acute confusion, other acute states, coma, fever

12. Results from Typical Acute Hospital • 12% of all patients admitted outside AEP criteria • 43% of all patients outside AEP criteria on day of survey • Clinicians assess preferred alternative type and location of care

14. AEP comparison for medical patients

15. Some implications • Alternatives focussed on rehabilitation services (c50%) • Remainder have continuing care needs, or could just go home earlier • AEP values characterise the nature of the UK hospital service, and potential to develop • Change to the clinical process is needed if service development to deliver benefits