Anticipatory Care Planning

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Anticipatory Care Planning Dr Anne Hendry National Clinical Lead for Integrated Care Joint Improvement Team

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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. - PowerPoint PPT Presentation

Transcript of Anticipatory Care Planning

Page 1: Anticipatory Care Planning

Anticipatory Care Planning

Dr Anne Hendry National Clinical Lead for Integrated CareJoint Improvement Team

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Anticipatory Care Planning Self Management

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Top Ten Improvement Actions

Risk prediction in primary care

Case / Care Management

Anticipatory Care Planning

Support for Self Management

Intermediate care

Telehealth and Telecare

Reablement and Rehabilitation

Medicine reconciliation & pharmaceutical care

Reduction in delayed discharge

Hospital pathways for frailty and delirium

14% reduction in rate of hospital bed days 06/07 – 10/11

Prevention and Health Improvement

Emergency

admissions

Acute

sectorVery High

Lower risk

Medium risk

High risk

LTC Collaborative

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SPARRA Tool

Outpatient(1 year)

Emergency Department(1 year)

Prescribing (1 year)

Outcome Year(1 year)

OUTCOME PERIOD

Hospitalisation(3 years)

PRE-PREDICTION PERIOD

Psychiatric Admission(3 years)

Any recent admissions to a psychiatric unit ?

Any A&E attendances in the past year?

What type of outpatient

appointments did the patient have?

Any prescriptions for e.g. dementia drugs? Or

substance dependence?

How many outpatient appointments?

What age is the patient?

How many previous emergency admissions

has the patient had?

How many prescriptions?

Any previous admissions for a long term condition

(such as epilepsy?

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www.isdscotland.org/dhipwww.isdscotland.org/dhip

SPARRA Cohorts

Frail Elderly

All cohorts

Younger ED

LTC

Age

Prescriptions in specific BNF chapters

Deprivation

Alcohol/ substance misuse related admissions

Prescriptions for specific groups of drugs

Psychiatric admissions Deprivation

New OP attendancesPolypharmacy

ED attendances

Emergency bed days

LTC related admissions

Emergency / elective / daycase admissions

Prescriptions/admissions indicating particular conditions

New OP attendances for MH

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www.isdscotland.org/dhipwww.isdscotland.org/dhip

Patient Risk Trajectories 2 – Over 75 (Frail Elderly)

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www.isdscotland.org/dhipwww.isdscotland.org/dhip

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www.isdscotland.org/dhipwww.isdscotland.org/dhip

Patient Risk Trajectories 3 – YED

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Lifestyle Interventions

> 60%40 - 60%20- 40%

SPARRA SCORE < 20%

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

Long Term Conditions

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

Anticipatory Care Continuum of Risk

1st choice for QOF ACP

2nd choice for QOF ACP

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

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Electronic Key Information Summary

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15,000 KIS accessed in October

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Feedback from patients

Very happy to share this information with relevant others

Gives confidence when GP surgery closed

Surprised that this was not happening already

No problem as long as information is ‘secure’

Excellent idea

Would not want some sensitive information from medical notes shared with others

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What GPs liked

Good breadth of information

Ability to add descriptive text

Easy to use and navigate

Good design and workflow

Structured, concise and easy to fill in

Excellent for sharing info with relevant others

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Users in A&E

Information is clear and concise

Would be good if we could also write to KIS rather than read-only

Some of the KISs in pilot were of limited quality

This information could dramatically improve the care we provide

Good that it is not just for palliative care

Anticipatory care information particularly useful

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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

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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

Being more able to understand &

manage my health, condition

or treatment

Personal Outcomes Maintaining and

enjoying a good

quality of life

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Policy Alignment

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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.

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Intermediate Care

Ca

re H

om

es

Community Assessment & Rehabilitation

Respite

Intensive Home Support

Very Sheltered Housing

Assistive Technology

Community Alarms

Home Support

Care Management

Community Health Services

Palliative Care

Continence/Falls Services

Ac

ute

Ho

sp

ital

Servic

es

Community Pharmacy

Carers Support

Integrated Health & Social Care Services

Health Promotion

Sheltered Housing

Locality Link Officers

Activity Programmes

Voluntary Organisations and Supports

Supports & Services for Older People in North Lanarkshire

Locality Planning - Local and Personal

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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

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Reshaping Care Pathway

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CHILDRENYOUNG PEOPLE

FAMILIES

ADULTS OLDER

ADULTS

PEOPLE AT WORK

Using care pathways

Working with other agencies & disciplines as partners

Strengthening leadership

& team working

Delivering safe, high quality care, treatment & rehabilitation

Improving efficiency & optimising workforce

capacity and capability

Anticipating health

needs & responding

earlier

Promoting health &

addressing inequality

Building workforce capacity & capability

Providing choice &

care in the right

setting

Working with

clients, carers &

patients as partners

Modernising Nursing in the

community

Utilising Telecare & Telehealth technology

Utilising high quality

clinical outcomes

Informing practice

with policy, research & evidence

Enabling and

supporting self care

Developing skills &

knowledge through

education

Effective

Person-centred

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Community Services programme

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Technology Enabled Integrated Community Team