1. Whole System Models of Care for Older People Tom Bowen The Balance of Care Group ORAHS 2004, Stockholm, Sweden 28 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 Older People IC care Post-acute intensive (up to 7 days) slow stream rehab (up to 42 days) Supported discharge (up to 14 days) Community nurse Care Co-ordinator Voluntary & Independent sector NHS Local Authority Physiotherapist Care assistant Occ. therapist Speech therapist Care Option 1 Care Option 2 Care Option 3 Rehab/ recovery (up to 28 days) Alternative to admission Balance of Care Group Care Option 4 Phase of CareCare OptionInterventionProvider

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 condition eg 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