1. The Balance of Care Group Alternatives to Hospital MODELS OF INTEGRATED CARE Tom Bowen www.balanceofcare.com +44 7768 123865 ORAHS 2008, Toronto, 29 July 2008

2. 2 Pre admission AdmissionDiagnosisTreatmentDischargeRe-admission Social details alone, carers, residence Risk factors: age, drugs, co- morbidities, psychiatric/ dementia, falls Preventative care Disease management Managed populations Source of referral Time Waiting time Route Decision maker Reason for admission Alternatives to admission to acute setting Admission diagnosis Inpatient diagnosis Delays in diagnosis Chronic disease Alternative access for diagnosis Delays in therapy Alternative settings for therapy (especially rehab) Discharge planning Delays in planning Delays in execution Alternative sites for discharge Revolving door Avoidable e.g. chronic disease management Alternative sites for readmission Rich picture available from process flow

3. 3 Appropriateness Evaluation Protocol (AEP) This is a validated protocol, used within the survey, to determine whether an acute admission might have been avoided, and whether there is an alternative to continued occupation of an acute bed It is not about auditing clinical decisions for the survey patients, but developing an understanding for the future potential of alternative care and treatment pathways Clinical judgement is involved

4. 4 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

5. 5 Dementia case study for National Audit Office (2006/7) To identify the number and types of people with dementia currently receiving hospital care who might potentially: –be treated elsewhere and avoid admission –required admission, but could now be treated elsewhere Point prevalence survey in Lincolnshire on 29-11-2006 –All medical and orthopaedic inpatients (667) –All intermediate care (rehab etc) inpatients (121) –All OPMH (older people with mental health issues) inpatients (75)

6. 6

7. 7

8. 8

9. 9

10. 10

11. 11

12. 12

13. 13

14. 14 Some Key Points 111 out of 863 patients surveyed (13%) had a recorded dementia diagnosis 65 were in acute hospital There may be substantial under-diagnosis or under- recording of dementia Majority of acute hospital patients with dementia were outside AEP criteria on the day of the survey Potential alternative care settings cover a wide range of services, specialist coordination may be needed Demand for rehab support for people with dementia

15. 15 Development Issues Can benchmark local service configurations from previous studies: –15 local health economies in England –All acute hospitals in Republic of Ireland (40% sample) Can apply to other cuts of the patient pathway: –Rehabilitation in non-acute bed and at home –A&E/ short stay admissions –End of Life Care Use to focus development of integrated care and associated IT Potential for more sophisticated modelling approaches?