Innovation Forum, Hampshire

1
ICN Conference 20th January 2005

• Innovation Forum, Hampshire
• Claire Foreman and David Browning

2
The Innovation Forum

• Hampshire was one of 22 authorities ranked
  excellent under the first Comprehensive
  Performance Assessment
• These 22 authorities got together to form the
  Innovation Forum for developing new ways of
  working for local government starting with four
  major projects
• One project the Health Project involves 10
  local authorities working with their health
  partners

3
The Health Project (April 2004)

• The aim is to promote the well-being of older
  people reducing their need for emergency hospital
  admissions.
• Hampshire has set up local projects in individual
  primary care practices, involving nurses and
  social workers working together proactively
• These projects focus on frail older people with
  multiple problems (both social and clinical) who
  make high use of emergency services.

4
Method of working

• Working with four (of seven) PCTs initially
• Developing our approach through action
  research, adapting our methodology as we go
  along
• Monitoring arrangements in place from the start

5
The project was based initially on the
Castlefields Project

• Castlefields Health Centre in Runcorn
• A nurse and a social worker work closely together
  with people over 65 who meet three of the
  following criteria
• Four or more active long-term conditions
• Four or more medicines, prescribed for six months
  or more
• Two or more hospital admissions, not necessarily
  as an emergency, in the past twelve months
• Two or more AE attendances in the past 12
  months
• Significant impairment in one or more activity of
  daily living
• Older people in the top 3 of frequent visitors
  to the practiceolder people who have had two or
  more outpatient appointments
• Older people whose total stay in hospital
  exceeded four weeks in a year
• Older people whose social work contact exceeded
  four assessment visits in each three month
  period and
• Older people whose prescribing costs exceeded
  100 per month.

See Supporting People with Long Term Conditions
(DH Jan 2005) page 15
6
Case finding strategy 1Search the records for
suitable people

• This approach encountered a lot of problems
• Information was held in different places on
  different systems
• It was very difficult to get at
• It required a lot of work after it arrived
• Much of it was incomplete
• Many of the people identified were either already
  well catered for or not interested
• Overall this strategy was frustrating and
  inefficient

7
Case finding strategy 2Ask people for
nominations

• This approach also had its difficulties
• People in primary care and elsewhere didnt know
  what we wanted
• There were risks that people would be nominated
  that no-one knows what to do with
• People not known to the system would be missed
• There were risks that expectations would be
  raised
• BUT, nevertheless, it has given us a start, and
  confidence has grown on both sides with growing
  experience

8
As we got going, other big issues started to
appear

• Who were we actually looking for?
• Why?
• What were we planning to do with them?

9
Level 3 in the DH Triangle?
Level 3 high complexity
Level 3
Level 2 disease specific with high risk
Level 2
Level 1 70 80 of the LTC population
self-support and management
Level 1
See Supporting People with Long Term Conditions
(DH Jan 2005) page 10
10
People at level 3 are of two sorts
Not known No active involvement
Known Active involvement
Level 3
Level 2
Level 1
11
The people we are focusing on

• No active involvement
• Not currently in crisis
• Not accessing support
• With a number of complex problems although not
  diagnosis specific
• Tottering

12
Typical interventions 1

• A very full assessment usually over two or more
  visits taking much more time than usual
• Winning peoples trust and getting under the
  surface is crucial
• Care and contingency plans are then developed
• Care plans use a wide range of activities
  preferably using community resources wherever
  possible
• Commitment by the person is critical

13
Typical interventions 2

• Befriending
• Bereavement
• Decorating
• Finances
• Heating
• Respite
• Transport
• Wristcare

• Blood pressure
• Continence
• Falls service
• Flu jab
• Fluid intake
• Health advice
• Medication
• OT

14
Links with other services
GPs and practice staff
Care managers and social services
Nurse
Social worker
Specialist Nurses, OTs physios
Finance, housing, transport
District nurses
Voluntary Sector
15
Case finding strategy 3Look for key trigger
events that indicate instability

• Examples include
• People whose pattern of attendance at GP
  practices starts to change
• People who experience an event a fall or
  attendance at AE but who are discharged
• People who make repeated calls to Social Services

16
Possible future case finding strategies

• Postal surveys using validated screening tools
  (following the successes of the London
  Development Programme)
• Targeting people over 75 who have not been in
  contact with health or social services for at
  least a year (in effect, the old over-75 check)

17
Strategy adopted by one PCT

• Identify all people admitted to hospital twice or
  more in the last year
• Screen and rank high, moderate or low risk
• Follow up people with high risks, keep in touch
  by telephone with people of moderate risk and
  give telephone number to people at low risk
• Demonstrate use of hospital has reduced

18
Monitoring

• Assessing well-being
• Recording circumstances and actions taken for
  each person
• Comparing patterns of emergency admissions to
  hospital across practices and PCTs

19
Early Results from one PCT

• 6 Month Review
• 2 Practices / 141 People seen

20
Comparisons
21
Innovations forum project Case finding no one
reliable method has emerged will include
SAP More time SW Nurse together and
separately no new methods but synergy more
than the sum of its parts medication reviews
SWs report greater acceptance of help and Nurse
report that are given more information by
patients Joint care planning Assistive
technology Vivatech
Information
Referral initial contact
Assessment
Care planning
Monitoring
Review
22
Moving Forward

• The Project
• targeting the right people
• developing new ways of working
• linking with other services
• building up the evidence base

23
Moving Forward

• The context
• project fit with managed care
• sustainability
• shifting the workforce profile
• LPSA2 and target setting