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Frailty Concept/ Hospital without Walls Professor Pradeep Khanna MBE Chief of Staff, Community Services Aneurin Bevan Health Board.

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Presentation on theme: "Frailty Concept/ Hospital without Walls Professor Pradeep Khanna MBE Chief of Staff, Community Services Aneurin Bevan Health Board."— Presentation transcript:

1 Frailty Concept/ Hospital without Walls Professor Pradeep Khanna MBE Chief of Staff, Community Services Aneurin Bevan Health Board

2 Commissioning & Care Planning Strategic Planning Specify Outcomes Develop Business Case Procure Services Manage Demand Maintain Performance

3 CASE FOR CHANGE Demand will always beat supply Pressure on cost is remorseless NHS can not provide a comprehensive service on current assumptions after 2011 (Kings fund and the Institute of Fiscal Studies – IFS)


5 Some Facts Nearly 33% of inpatients could safely be cared for in another setting than in an acute hospital [Kings fund audit 1992; DOH 2000] 29% of patients in acute hospital beds are medically stable [43% in elderly wards] [Barbara Vaughan; Gill Withers 2002] In Wales, higher proportion of chronic long term conditions (23%) compared to England (18%); Northern Ireland (20%) Audit of 5 GP Practices in Swansea revealed 3% of population with 2 comorbidities + emergency admission accounted for 59% of hospital admissions [Ref = WAG 2007 – Designed to improve health …chronic conditions Wales] Conclusion: A focused integrated approach of Health and Social Care, Housing and Transport is recommended


7 Drivers For Change 1.Wanless Report: Hard hitting facts about Health Services in Wales 2.Designed for life: Strategic framework: Health & Social Care Services in Wales 3.Fulfilled lives, Supportive Communities: Emphasis on Social Care 4.Making the connections [Public involvement & redesign services around the needs of the users] 5.Primary Care & Community Services Strategy (Chris Jones)



10 Hospital-at-Home: definition……… HaH = “….a service that provides active treatment by health care professionals, in the patient’s home, of a condition that would otherwise require acute hospital in- patient care, always for a limited period.” Cochrane definition, 2005 Combination of personal support & rehabilitation care Hospital care but delivered in the person’s own home !!!

11 Admission Avoidance Hospital at Home/Inpatient Care (Review) [Systematic Review & Meta Analysis] 1.Mortality at 3 months NS (P= 0.15) 2.Mortality at 6 months Significant (P=0.005) 3.Readmission Rates NS (P=0.08) (within 3 months) 4.Functional Ability (12 months) i. Quality of Life ii. Physical abilities iii. Cognitive Status NS Reference: Sheppard S, Doll H, Etal: The Cochrane Library 2009: Issue 3

12 Hospital at Home 1.CLINICAL OUTCOME: (Adverse Events & Medical Complications) a. Bowel Complications = 22.5% (96% C.I = 34% to 10.82) b. Urinary Complications = 14.4% (95% C.I = 25.4% to 3.3%) c. Antipsychotic Prescribing = 14% (95% C.I = 28% to 0.3%) in Dementia Patients d. COPD = Antibiotic = 18% (95% = 34.6% to 1.4%) 2.PATIENT SATISFACTION : Significant (P < 0.0001) 3. ECONOMIC ANALYSIS: (Co Morbidity: Older Group) Costs = Per episode $2011; 95% C.I (= $2800 to $1222) = Per day $293; 95% C.I (= $318 to $268) 4.CONCLUSION: Admission Avoidance Hospital at home can provide an effective alternative for selected group of Patients (Outcome Similar)

13 Early Supported Discharge Teams Vs Conventional Care 11 Trials (6 countries) OutcomePatients randomisedSummary result (95% CI) P Values Patients’ outcomes Death or dependency15970.79 (0.64 to 0.97)0.02 Death or institution13980.74 (0.56 to 0.96)0.02 Extended ADL Score10510.12 (0 to0.25)0.05 Satisfied with outpatient services 5131.60 (1.08 to 2.38)0.02 Carer outcomes Subjective health status score 6130 (-0.25 to 0.24)0.97 Satisfied with outpatient services 2791.56 (0.87 to 2.81)0.14 Resource outcomes Length of hospital stay1015-7.7 (-10.7 to - 4.2)<0.0001 Readmission to hospital6331.14 (0.80 to 1.63)0.48 Conclusion: “Appropriately Resourced and Co-ordinated Services” in clearly defined Target Groups has clear potential benefits Langhorne P, et al - Lancet 2005;365;501-506

14 THE EVIDENCE-BASE FOR INTERMEDIATE CARE RCTs HOSPITAL-AT-HOME 22 DAY HOSPITAL12 NURSE-LED UNITS 10 COM. REHAB.TEAMS 2 CARE HOME REHAB. 1 COMMUNITY HOSPITAL 1 Message: (a) Target people with greatest clinical need (Frailty) (b) Integrate I.C with Mainstream Services   Very expensive Shifts costs to social care Expensive 

15 Messages From Research Develop closer integration between IC and Mainstream Services Target Patients with greatest clinical need: Frailty Place stronger focus on Admission Avoidance Scheme (Health & Social Care) (Closer liaison with Ambulance Service, 3 rd Sector, A&E, Mental Health) VANTAGE POINT Reablement: More Research/Evaluation needed

16 Clinical Futures: Gwent NewportCaerphillyTorfaen Blaenau Gwent MonmouthPowysOtherAll Gwent medical11712196827717501 surgical21212108 total 11912298837917509 383931262502162 places at-home818367575415347 total places 11912298837917509 Intermediate Care and/or Non-acute Non-acute beds and places required by LHB 2014-15 with new MoC NHS etc beds Provided as

17 Joint Partnership Sub-Group 5 LHB CEOs, Trust CEO and 5 LA CEOs Aims: to develop better services along whole patient journey through closer working. To find better way of supporting people who end up needing Continuing Care Frailty Pathway chosen Gwent wide multi-agency, multi-professional workshop held April Task and Finish Groups to expand /develop ideas.

18 Frailty Programme Board Membership –Chair – Alison Ward, CEO, Torfaen LA –LA reps (social care) –LHB reps –Trust Corporate and Divisional reps –Voluntary sector –GP –Ambulance Work Streams –Independent Living and Reablement –Urgent Response and Intervention –Capacity and Financial Modelling

19 Frailty Syndrome Frailty = (Dependency x vulnerability x co-morbidity) + (Environmental x social factors)

20 What is it? Physical characteristics Multidimensional Weakness Slowness Poor endurance Weight loss Physical inactivity Socio-demographic Biomedical Functional Effective and cognitive components



23 Age 65-6970-7475-7980-8485+ %Frailty 18.321.732.132.548.8 Estimated numbers of frail elderly people by Local Authority Estimated Total Blaenau Gwent 6046218385636463275 Caerphilly 139914021816115412317002 Monmouthshire 78482510436958644211 Newport 112712221472108511566062 Torfaen 79784411056837124141 Total by age band 4177491462744180460924154 Prevalence of Frailty 3 or more of the outcome Source: Census 2001

24 Happily Independent

25 What we stand for: Principles & Values The underpinning principle of the Gwent Frailty Programme is to provide: ‘ Help when you need it to keep you independent’ The mantra for those delivering services is to provide help that is Sustaining independence.

26 Outcomes: What frail people tell us they want Be able to remain living in their own home with support Receive services in their home Be listened to by people who are responsible for providing services to assist them Have their health and social care problems solved quickly and considered as a whole rather than individually.

27 Specialist Health Care Skills Social Care Skills Health Care Skills Specialist Social Care Skills Generic Worker Skills Frail Elderly Workforce Skills Matrix

28 Generalist as the New Specialist (Intermediate Care) GP’s Changing Roles Geriatrician Changing Roles AHP’s Changing Roles Training In The Community

29 Community Nursing Service Based on Nursing Strategy: Wales (Coordination of care) 24 hour Nursing cover in each locality Overnight on call nursing service including Twilight nursing Key role in early identification & proactive care of frail clients

30 Common Service Characteristics (I.C) Urgent Response & InterventionReablement & Independent Living ACCESSVia locality Single Point of Access HOURS OF OPERATION7 days a week 365 days a year 8am to 10pm7 days a week 365 days a year 8am to 8pm RESPONSE TIME2-4 hours (for both health and social care components) 24 hours ASSESSMENTComprehensive Needs & Frailty Index Assessment Agreed shared assessment document SERVICE PROVISIONManagement/Hospital @ Home upto 14 daysApproximately 6 weeks reabilitation and reablement support No charge to user for first 6 weeks ACCESS TO‘Hot Clinics’ for rapid access to specialist and diagnostic support (Monday to Friday) Specialists including psychology, dietetics, pharmacy, speech & language therapy, podiatry, EMI teams. Rapid access to equipment and adaptations. WORKFORCEFlexible Health & Social Care Workforces

31 Components of Comprehensive Needs Assessment Components 1Medical assessment 2Assessment of functioning 3Psychological assessment 4Social assessment 5Environmental assessment Elements Co-morbid conditions Medication review Nutritional status Activities of daily living Gait and balance Mental status Assessment of needs, assets and resource eligibility Home safety, transportation and tele-health

32 Proposed Locality Structure Joint Chair:Director of Social Services Locality Manager (Health) Members:Project Manager Human Resource Finance Intermediate Care Consultant General Practitioner Lead Nurse Voluntary Sector Co-opted Members:Pharmacist, Mental Health, Therapies, CHC

33 Urgent Response & Intervention Comprises of three key elements: Urgent Comprehensive Assessment (Health & Social Care) Rapid Response Intervention (health) Social Care Crisis Intervention

34 Proposed Capacity Model (Crisis Management) Aims –Better management at home or in a community setting. –Engagement with care homes and the independent sector. –Management of patients in Accident & Emergency –Patients handed over to DN teams on discharge from service Main Functions –Assessment of 200 new patients per month for acute exacerbations of chronic conditions and associated disorders. –Follow-up of 200 patients per month. –7-day presence in A & E and MAU to assess patients and prevent admissions, pulling them back into the community, as required. –Daily Hot Clinics for each borough, run by ACAT/RRT for the provision of advice for GPs. –Formal links with other specialties, including General Medicine, Falls, Trauma & Orthopaedics. –On-going management of patients at home for a 5 – 7 day length of stay (care package) –The Gwent-wide combined team of ACAT, Rapid Response and PATH to provide around 70 virtual beds across Gwent.

35 Staffing Model (Crisis Management) Based on population of 70-90k –1 wte Consultant Specialist –2 wte Staff Grades or GPswSI (salaried GPs) –4 wte Band 7 –10 wte Band 6 –3 wte Band 4 Reablement Officers –1 wte Band 6 OT for Reablement –1 wte Social Worker –Approx 50 wte generic Health & Social Care Support Workers, and/or Rapid Access to Immediate Home Care –1 wte Secretarial Staff and 2 wte Typists shared with the Reablement Team

36 Independent Living & Reablement Approximately 6 weeks coordinated review and reablement to sustain independence Rapid access to equipment and minor adaptations Care & Wellbeing Workers able to work across the different elements of the integrated locality team

37 Proposed Capacity Model for Locality Reablement Teams (1) Based on 70-90k population 5 WTE Occupational Therapists (able to work across ACAT, PATH and Reablement) 5 WTE Physiotherapists 50 Band 3 Generic Support Workers* 2 WTE Case Managers (role needs to be clarified) 2 WTE Social Workers * Proportion of generic support workers up-skilled to perform some functional assessments? Shared resources: IT officer Training and Development officer Administrative Support Hot clinics for Falls, Gen Med and Orthopaedics

38 Proposed Capacity Model for Locality Reablement Teams (2) Sessional support from: 2 WTE Dieticians 2 WTE Speech and Language Therapists 2 WTE Psychiatric Liaison Nurse (1 for older people, 1 for younger people) Podiatrist – unable to quantify because many clients using private 1 WTE Community Pharmacologist attached to PATH and Reablement

39 Implementation Workstreams Communication & Stakeholder Engagement Workforce Planning Governance & Structure Outcome Indicators, Performance and Continuous Improvement Information sharing & Single Point of Access Locality Planning (including longer-term care and interfaces with other services) Financial Modelling/ Building the Business Case

40 Communication & Stakeholder Engagement Workstream lead: Dr Liam Taylor Development of a communication strategy for all key stakeholders Specific programmes of work – a. Stakeholder Briefings b. Staff Communication c. Public Engagement d. Power Brokers (Politicians and Executive Key Members)

41 Financial Planning Workstream lead: Nigel Stephens Use the outputs from the other workstreams to: confirm demand map capacity identify the resource gaps calculate the financial requirements Set up pooled budget arrangements

42 Locality Planning (including longer-term care and interfaces with other services) Workstream lead: Jo Williams Support planning for preventative services and delivery at locality level Ensure that core standards are met and outcomes achieved. Key Aims: a. Each locality sharing innovation b. Joint problem solving c. Work through operational challenges d. accessing expertise

43 Information Sharing & Single Point of Access Workstream lead: Jayne Griffiths Single Point of access Information System and Develop agreed information sharing protocols Develop safe means of electronic transfer

44 Outcome Indicators, Performance & Continuous Improvement Workstream lead: Angela Jones Use the Outcomes-Based Approach. Happily Independent:(5 key elements) 1.Be able to remain living in their own home with support 2.Receive services in their home 3.Be listened to by people who are responsible for providing services to assist them 4.Have their health and social care problems (holistically) solve quickly 5.Have a general good health

45 Governance & Structures Workstream Lead: Bobby Bolt Agreed standards and protocols 3 Groups of work: a. Clinical accountability b. Operational issues c. Clear lines of management (professional and regulatory issues)

46 Workforce Planning Workstream lead: Kevin Barber Challenges: To Integrate - a. 6 organisations b. 9 professional groups Key Aims: a. Harmonising the structure (extremelly complex) b. Managing the transition c. Managing multi-agency staff groups (responsibility, accountability, training and development)

47 Next Steps Service Model Capacity Plan Workforce Plan Service Model Capacity Plan Workforce Plan Financial Plan


49 Resource Package 1.Wanless funds (WAG) – Approx £5million:2004 2.Public Service Committee (Chaired by Finance Minister – Wales): £60million over 2009/10 and 2010/11 (Scheme: Invest To Save) 3. Transitional cash required: £20million (Fund new teams and manage additional capacity) 4.Over time: ●Shifting of resources from Secondary to Primary Care ●? Nursing and Residential Purchasing Budgets ●Continuing Care Budget

50 Current Situation 1 LocalityFrailty care model (DGH) Co-located teams Single point of referral Community Consultant Caerphilly +---+ Newport +- -+ Torfaen +-+-+ Blaenau Gwent +--- Monmouthshire +---

51 Current Situation 2 *Referral criteria variable in all 5 localities. LocalityConsultant operational team Primary and secondary interface Rapid response ACATReablement team Formal GP involvement Caerphilly +-++-+- Newport +- +-+ Torfaen +- +++ Blaenau Gwent +- +-+- Monmouthshire --+--+-


53 Performance Indicators As per Frailty Programme Work stream and including: Pre-crisis Assessment (CGA): 100% offered within 28 days An episode of crisis requiring hospitalisation should normally require no more than 72 hours in hospital Service responses will be delivered within agreed time limits 50% of frail older people will be managed in the community during an episode of crisis 80% of frail older people with a social crisis will be maintained at home 75 % of rehabilitation services for frail older people will be based and delivered in the community. Assessment of equipment needs delivered within 24 hours Equipment provided within 72 hours of assessment


55 Paul Williams Director General, Health & Social Services Chief Executive, NHS Wales I want the service to focus on: Changing behaviour not structures; Collaboration not confrontation; Planning not commissioning; Whole systems not hospitals; Clinical engagement; Partnership working; and Wellness not illness (1 st October 2009)

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