Anticipatory%20Care

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Anticipatory Care

• ..Behold the Throne of Chaos and with him
• Sable-vested Night The consort of his Reign..
• Adrian Baker
• Paul Leak
• Simon Steer

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Use of resources matters

• Lowest EEA (gt65)
• Save 1,787 admissions
• 28,141 bed days saved
• 7.335 M Saved

• Highest EEA (gt65)
• An extra 3,542 Admissions
• 59,264 extra bed days
• 16, 017 M extra costs

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ANTICIPATING
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MINORITY REPORT
THEY ARE ADMITTED
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The Nairn Anticipatory Care Pilot

• Origins
• NHS Highland Delayed Discharges Dec 2005
• DDs 90 EEAs
• Case finder algorithm using Primary Care data
• MIXING
• -Age / sex/ LTCs / OPDs / Inpatient episodes
• (SPARRA Development -Primary Care Data)

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A WILLING PRACTICE ?
Long haired lilac, orange and white satin Peruvian
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A WILLING PRACTICE ?
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The Nairn Case Finder
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The Nairn Anticipatory Care Pilot

• Target top 5
• Non Recurrent Investment 125k
• To pay for
• -1.2 WTE Case Manager(Nurse/OT/SW)
• -1 WTE Junior Physio
• -0.75 WTE Senior OT
• -2 WTE Care Assistants
• -GP time?
• Breakeven reduction in bed days15
• ..and targeted use of existing Resource

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Measures

• Outcomes
• EQ-5D
• ACP was it followed?
• eSSAs
• Preferred Place of Care. Did we deliver?

• Quantifiable
• Occ bed days
• DD days
• LOS
• Admission rate
• Re admission rate
• 5 Risk score
• 7. 5 Health Status

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The Anticipatory Care Plan (ACP)

• Carer or Cared for status, what happens ?
• Acute medical problem
• Acute surgical problem
• Discussion of condition by professional
• Preferred Place of Care
• Resuscitation status

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Dr Baker discusses options for the Anticipatory
Care Plan
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The go anywhere eSSA?With the ACP within it
and accessible 24/7.Consent and jointly signed
by assessor and patientData sharing with other
agencies
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The eSSA in practice
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The Review Cycle
Patient
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Case Manager

• Overview of the SP 500
• Ensure eSSA and ACP are completed
• Complete EQ-5D
• Who, where, how, what, why, when
• Case conference for long-stay patients
• Care plan updates for SAS and PCEC
• Coordinating and reviewing role
• Initially tasked on Nursing Residential

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Generic Care Assistants

• Out there with the patients
• Providing hands on care
• Coached and educated by
• Nurses, CMHT, Physio, OT, Dietetics, SALT, GPs,
  social services
• Prevent nutrition problems, falls, early warning,
  gritting paths, income maximisation, enhancing
  safety

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The Nairn Anticipatory Care Pilot Update

• Staff
• -Case managers January
• -AHPs June
• -Care Assistants June
• TeleHealth
• Mini Lab
• Preparatory work
• -eSSA ACP for top 5
• -SAS Fridges?
• -Establish Data flows
• -Gather Baseline data

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The Nairn Anticipatory Care Pilot

• Practicalities
• Re-calculate Risk scores monthly
• Alerts
• -Case managers informed of Admissions from 5
  Cohort-weekly
• -Patient Admission System Flag Admission ward
  staff Consult eSSA and Anticipatory Care plan.
• Bed day use reports
• NSD Data Warehouse/System watch-Jill Smith

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Year to date Bed Days Used by Top 5
134 Patients Admitted to 03/12/2006 from top 5
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Nairn Emergency Cost Curve
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LTCs Cumulative Excess Cost1.3m
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Nairn Pilot MatrixTop 5
Social Work Unknown
Social Work Known
52
NHS Known
45
100
347
NHS Unknown
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Focus on this

• 3am, 80 years old, sore leg
• Can I...
• Assess and keep at home with appropriate input?
• Admit to Community Hospital?
• Admit to a Consultant bed?

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Risk Scoring in reality
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To Prevent This