Anticipatory Care Planning

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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

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  • Anticipatory Care Planning

    Dr Anne Hendry National Clinical Lead for Integrated CareJoint Improvement Team

    2013 European Telemedicine Conference

  • Anticipatory Care Planning Self Management

    2013 European Telemedicine Conference

  • 2013 European Telemedicine Conference

  • 14% reduction in rate of hospital bed days 06/07 10/11 LTC Collaborative

    2013 European Telemedicine Conference

  • SPARRA Tool

    2013 European Telemedicine Conference

  • SPARRA Cohorts Frail ElderlyAll cohortsYounger EDLTCAgePrescriptions in specific BNF chaptersDeprivationAlcohol/ substance misuse related admissionsPrescriptions for specific groups of drugsPsychiatric admissionsDeprivationNew OP attendancesPolypharmacyED attendancesEmergency bed daysLTC related admissionsEmergency / elective / daycase admissionsPrescriptions/admissions indicating particular conditionsNew OP attendances for MH

    2013 European Telemedicine Conference

  • Patient Risk Trajectories 2 Over 75 (Frail Elderly)

    2013 European Telemedicine Conference

  • 2013 European Telemedicine Conference

  • Patient Risk Trajectories 3 YED

    2013 European Telemedicine Conference

  • 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 ConditionsPatients at highest risk of emergency admission to hospital Likely to be receiving care or managed by the Community Team Many already have an ACPTheir ACP is usually developed by the Community Team or nurse specialist involved

    Anticipatory Care Continuum of Risk1st choice for QOF ACP2nd choice for QOF ACPPeople 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

    2013 European Telemedicine Conference

  • Electronic Key Information Summary

    2013 European Telemedicine Conference

  • 15,000 KIS accessed in October

    2013 European Telemedicine Conference

  • Feedback from patientsVery happy to share this information with relevant othersGives confidence when GP surgery closedSurprised that this was not happening alreadyNo problem as long as information is secureExcellent ideaWould not want some sensitive information from medical notes shared with others

    2013 European Telemedicine Conference

  • What GPs likedGood breadth of informationAbility to add descriptive textEasy to use and navigateGood design and workflowStructured, concise and easy to fill inExcellent for sharing info with relevant others

    2013 European Telemedicine Conference

  • Users in A&EInformation is clear and conciseWould be good if we could also write to KIS rather than read-onlySome of the KISs in pilot were of limited qualityThis information could dramatically improve the care we provideGood that it is not just for palliative careAnticipatory care information particularly useful

    2013 European Telemedicine Conference

  • 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

    2013 European Telemedicine Conference

  • What are the things that matter most to me at this point in time?Being more able to understand & manage my health, condition or treatmentPersonal Outcomes

    2013 European Telemedicine Conference

  • 2013 European Telemedicine Conference

  • Policy Alignment

    2013 European Telemedicine Conference

  • 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.

    2013 European Telemedicine Conference

  • Locality Planning - Local and Personal

    2013 European Telemedicine Conference

  • Most people with any long term condition have multiple conditions in ScotlandGuidelines 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

    2013 European Telemedicine Conference

  • Reshaping Care Pathway

    2013 European Telemedicine Conference

  • CHILDRENYOUNG PEOPLEFAMILIESADULTS OLDER ADULTS

    PEOPLE AT WORK

    Using care pathways Working with other agencies & disciplines as partnersStrengthening leadership & team workingDelivering safe, high quality care, treatment & rehabilitationImproving efficiency & optimising workforce capacity and capability Anticipating health needs & responding earlierPromoting health & addressing inequalityBuilding workforce capacity & capabilityProviding choice & care in the right settingWorking with clients, carers & patients as partnersModernising Nursing in the communityUtilising Telecare & Telehealth technologyUtilising high quality clinical outcomesInforming practice with policy, research & evidence Enabling and supporting self careDeveloping skills & knowledge through educationEffectivePerson-centred

    2013 European Telemedicine Conference

  • Community Services programme

    2013 European Telemedicine Conference

  • Technology Enabled Integrated Community Team

    2013 European Telemedicine Conference

  • http://www.knowledge.scot.nhs.uk/chin

    2013 European Telemedicine Conference

    Engagement with personal outcomes need to consider why the purpose and remit of more collaborative approaches to healthcare: What is the purpose of focusing on personal outcomes? Is it:To ensure traditional practitioner efforts are aligned with and contribute to whats important to the personTo develop insights into the need for deeper (psychological or even spiritual) or broader social processes to be worked through - by handing over the baton / referring on to a more appropriately skilled colleagueOr to expand role and in a sense redefine the purpose of healthcare by assuming responsibility for directly supporting the person to achieve a broader range of outcomes, drawing on a range of supports To make away from service-based assumptions altogether and think instead about developing individual capabilities and unleashing potential to achieve their own quality of life outcomes

    The answer to the question will depend very much on the context

    *Pick and mix approach**