1. System and Service Design for Older Adults Asangaedem Akpan MPhil FRCPI FRCP(UK) Consultant in Community Geriatric Medicine & Health Foundation/Institute for Healthcare Quality Improvement Fellow 2011-12 Aintree University Hospitals/Liverpool Community Health/South Sefton CCG Liverpool, Merseyside, England

2. Conflict of interest The Health Foundation is sponsoring my conference trip

3. Acknowledgements The Health Foundation The Institute for Healthcare Improvement Aintree University Hospitals NHS FT Liverpool Community Health South Sefton CCG

4. THE TRIPLE AIM Cost Individual experience of care Population Health ‘If you can imagine it, you can achieve it’ William Ward

5. Debra 87 years old living alone Increasingly forgetful Son lives far away Trips and falls in front of her house, unable to get up Usual scenario The future

6. Fred 78 years old on a surgical ward Emergency surgery Uncomplicated First time in hospital Has osteoarthritis and stable coronary artery disease Usual scenario The future

7. Mary 75 years old recurrent admissions Chronic bronchitis Coronary artery disease with chronic heart failure Chronic kidney impairment Type 2 Diabetes Mellitus On 15 different medications 7 admissions in 12 months In hospital usually seen by all the specialists The future for Mary now………..

8. The coming together of payers and providers North Liverpool, England 330,000 population 40,000 65 years and over Clinical Commissioning Groups – South Sefton,Liverpool,Knowsley Sefton, Liverpool and Knowsley Council Aintree University Hospitals NHS FT Liverpool Community Health Voluntary agencies and groups

9. Components Rapid and Community intermediate care team Step down facilities General practice Medicines management Mental health liaison Social services An acute older persons unit in the hospital Rapid access MDT type outpatient (ambulatory) care

10. Enablers The payer agrees with providers new ways of providing care Each provider identifies a key or key individuals to lead on this One individual with the knowledge, skill and competence to take overall lead and work with identified key individuals Project management, data,measures and outcomes Aligning of finances – funds are going toflow out of secondary to primary and community care

11. Understanding flow through the healthcare system Routine data on service usage Capacity and workflow planning Modelling Queuing theory Failure mode and effects analysis Staff feedback Observation and ethnography

12. Changing the flow Reducing variation Real time management Matching capacity and demand Proactive discharge planning Pulling

13. Conclusion Whole system approach Detailed diagnostic workup Local adaptation Time and resources Engagement and training Learn from other systems

14. References Improving patient flow across organisations and pathways. The Health Foundation November 2013 Improving patient flow. The Health Foundation April 2013 The triple aim. The Institute for Healthcare Improvement

15. Thank you for your attention Asan.Akpan@Aintree.nhs.uk ‘Man cannot discover new oceans unless he has the courage to lose sight of the shore’ Andre Gide ‘Try and fail, but don’t fail to try’ Stephen Kraggwa