1. Daring to Ask “..Behold the Throne of Chaos and with him Sable-vested Night The consort of his Reign..” Paradise Lost Dr Adrian Baker Paul Leak Simon Steer

2. Public health; health Improvement; health education Lower risk: supported self-care (70-80%) High risk: disease Management (15-20%) MIU, A&E, emergency admissions Interventions Outcomes Individuals with complex needs: case management (3-5%) Delivering for Health Information Programme Long-term conditions + interface with acute care 2 Unscheduled Care Flows 3 4 5 1

3. Nairn Case Finder

6. ANTICIPATING

7. MINORITY REPORT THEY ARE ADMITTED

8. Models of Care Biomedical Biomedical Cure Cure Specialist role Specialist role Disease / Illness Disease / Illness Compliance Compliance Intensive Intensive Palliative Chemo Palliative Chemo Biosocial Biosocial Care Care Holistic Holistic Patient Autonomy Patient Autonomy Concordance Concordance Time / Choices Time / Choices Community Based Community Based

9. Locality Total £/head

10. The Nairn Anticipatory Care Pilot Non Recurrent Investment £125k To pay for New Post To pay for New Post 1.2 WTE Case Manager (Nurse/OT/SW); 1.2 WTE Case Manager (Nurse/OT/SW); Gaps in Primary Care Infrastructure Gaps in Primary Care Infrastructure 1 Physiotherapist; 1 Physiotherapist; 0.75 OT; 0.75 OT; Equipment budget; Equipment budget; Gaps In Local Authority Provision Gaps In Local Authority Provision 2 WTE Care Assistants / Emergency Home Care 2 WTE Care Assistants / Emergency Home Care

11. Case Manager eSSA & ACP eSSA & ACP Complete EQ-5D Complete EQ-5D Who, where, how, what, why, when Who, where, how, what, why, when Coordinating and reviewing role Coordinating and reviewing role

12. The Anticipatory Care Plan (ACP) Carer or Cared for status, what happens ? Carer or Cared for status, what happens ? Acute medical problem Acute medical problem Acute surgical problem Acute surgical problem Discussion of condition by professional Discussion of condition by professional Preferred Place of Care Preferred Place of Care Resuscitation status Resuscitation status

13. Heart Failure / COPD Function Second Hospitalisation Death First Acute admission TIME Final Illness High Low

14. Frailty / Dementia Trajectory Function Decline in ADL’s & Memory Death First Acute Problem TIME 3-10 years Unable to self care High Low

15. Care Assistants Hands on care Hands on care Coached & educated by Coached & educated by Nurses, CMHT, Physio, OT, Dietetics, SALT, GP’s Nurses, CMHT, Physio, OT, Dietetics, SALT, GP’s Nutrition problems, falls, Nutrition problems, falls, Income maximisation (CAB) Income maximisation (CAB) Enhancing safety Enhancing safety Social Services Substitution Social Services Substitution

16. Measures Outcomes 1. Health Status: EQ-5D 2. ACP was it followed? 3. Preferred Place of Care. Did we deliver? 4. Qualitative: Interviews Outputs 1. Bed Day rate 2. Admitted rate 3. Admission rate 4. Re-admission rate 5. Delayed Discharges

17. ACP Cohort: Age Profile Age

18. Change in Community Hospital use over 2005-2008

19. Change in Bed Day Rates in Raigmore 2005-2008

20. ALOS in Raigmore 2005-2008

21. Qualitative Evaluation University of Stirling, CCRC University of Stirling, CCRC June 2008 after 1 st year June 2008 after 1 st year Acknowledged benefit to patients, carers and families Acknowledged benefit to patients, carers and families Staff empowered, committed and focused on providing care locally Staff empowered, committed and focused on providing care locally Anticipatory and Reactive elements Anticipatory and Reactive elements

22. eSSA

23. 80 Yr Old Non-Smoking Unmarried Female with a Stroke Living In a Care Home BeforeAfter 2005/06 & 2006/07: 13 Admissions in Raigmore 13 Admissions in Raigmore 24 Bed Days in Raigmore 24 Bed Days in Raigmore 10 Months 2007/08: 4 Admissions in Raigmore 4 Admissions in Raigmore 3 Bed Days in Raigmore 3 Bed Days in Raigmore

24. Work in Progress A 74 year old female who missed the ACP Chronic Renal Failure – Stage 5 Chronic Renal Failure – Stage 5 On dialysis 3 years On dialysis 3 years Admitted to Nursing Home, deteriorating condition Admitted to Nursing Home, deteriorating condition GP discussion with family, all considering and wanting to cease dialysis GP discussion with family, all considering and wanting to cease dialysis Admitted for 3 weeks – June 08 Admitted for 3 weeks – June 08 Returned to Nursing home Returned to Nursing home Dialysis continued Dialysis continued Arrested on Unit – 11 August 08 Arrested on Unit – 11 August 08 Crash team call and resus attempted, patient intubated, unsuccessful. Crash team call and resus attempted, patient intubated, unsuccessful.

25. 78 Yr Old Married Male Smoker with Hypertension, CHD, Diabetes, Heart Failure & Stroke Living at Home BeforeAfter 2005/06 & 2006/07: 3 Admissions in Raigmore 3 Admissions in Raigmore 44 Bed Days in Raigmore 44 Bed Days in Raigmore 1 Admission & 1 Transfer to Nairn 1 Admission & 1 Transfer to Nairn 39 Bed Days in Nairn 39 Bed Days in Nairn 6 Months 2007/08: 1 Admission to Raigmore 1 Admission to Raigmore 1 Bed Day in Raigmore 1 Bed Day in Raigmore

26. Opportunities Dovetails with LTC and Mental Health Dovetails with LTC and Mental Health Increase patient autonomy / choice Increase patient autonomy / choice Gold standard palliative Home care including complex care packages Gold standard palliative Home care including complex care packages Gold Standard palliative Nursing home care Gold Standard palliative Nursing home care Extended Community Hospital care Extended Community Hospital care Disease specific consultant care Disease specific consultant care Single patient record for Health and Social Care Single patient record for Health and Social Care

27. Does culture change work? Emphasis on group affiliation, teamwork, coordination Emphasis on group affiliation, teamwork, coordination More likely to be associated with implementation of quality improvement More likely to be associated with implementation of quality improvement Emphasis on formal structure, regulation, and reporting arrangements Emphasis on formal structure, regulation, and reporting arrangements Negatively associated with quality improvement Negatively associated with quality improvement

28. Threats More Middle Management More Middle Management Spending Crisis from historic work patterns, but business as usual Spending Crisis from historic work patterns, but business as usual Cuts to frontline AHP and Nursing posts in Community. Cuts to frontline AHP and Nursing posts in Community. Cut Marie Curie Availability and Funding Cut Marie Curie Availability and Funding “No money to continue projects” “No money to continue projects” £165 / patient at Board level in “Corporate Services” £165 / patient at Board level in “Corporate Services” £50M in NHS Highland

29. Conclusion Anticipating and planning works Anticipating and planning works Deserved and appreciated by Patients, Carers and Families Deserved and appreciated by Patients, Carers and Families The community health and social care team delivering current best practice to the individual are the only people who can fulfil this role The community health and social care team delivering current best practice to the individual are the only people who can fulfil this role