Unique Care Harmonising Health

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Unique CareHarmonising Health Social Care for
Older People

• Dr David Lyon
• GP Castlefields
• Affiliate to Improvement Foundation

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Change Principles

• Establish a system for creating, validating and
  updating a Register
• Be systematic and pro-active in maintaining care
• Involve patients in developing and delivering
  their care
• Adopt a multi-skilled, multi-agency approach to
  ensure effective care co-ordination

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An acute hospital admission is a failure of the
Health System.

• The real challenge to the NHS is how to manage
  chronic disease better

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The Pareto principle

• 20 of supermarket products account for 80 of
  sales
• 20 of criminals account for 80 of the value of
  crime
• 20 of people who marry account for 80 of
  divorce statistics
• 20 of your carpet gets 80 of the wear
• 20 of the clothes in your wardrobe get worn 80
  of the time

Source Koch 1998
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The 20 of Patients who need 80 of the Care

• Older People
• Decreased Functional Ability
• Revolving Door Admissions
• COPD Heart Failure
• End of Life
• Psychological Social Support
• Packages of care tailored to the individual

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Patient Pathway
Long-term condition Low functional ability
Develop new disease
Bereavement
Supported care at home
Death
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Integrated Teams

• Built around practice populations
• Brings PHCT DNs together
• Formally involves Social Services
• Linkage with care homes
• Flexible caseloads
• Importance of home care
• Rehabilitation Intermediate Care
• Dont forget the specialists

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Care Co-ordinator

• A co-pilot through the system
• Great inter-personal skills
• Able to engage all types of clinicians
  professionals
• Understands locally available services
• Takes responsibility for review
• Nurse of varying types, GP, social worker, care
  home supervisor

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Key Worker

• Most important person to the patient
• Most involved in patient care
• Most likely to know if things are going wrong
• More valuable than the Care Co-ordinator
• Relative, neighbour, home carer, nurse, GP etc

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Involve Patients

• Patient education
• Individual management plans
• Peer Education
• Self help groups
• Expert patients
• PCT groups

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Unique Care

• Integrate Health and Social Care
• Deal with current referrals
• Joint assessment joint working (SAP)
• Tailored packages of care
• Hospital In-reach
• Get the 20 on the radar

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Over 65s Admissions per 1,000 Population
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Over 65s Average Length of Stay
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Over 65s Bed Days per 1,000 Population
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Workload

• 253 referred 245 assessed same day
• 151 hospital in-reach
• 43 already known to team
• 48 proactive case management
• 409 people in total out of 1300 over 65s

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Other Effects

• District Nurse Team didnt need backfill
• GPs home visits fell by 30
• Social Services budget made small saving in
  Castlefields but overspent in Borough
• Use of intermediate care remained stable within
  expected for population
• 48 cases admissions fell from 123 to 2 and only
  three went into long term care

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Number of Admissions Over 65sBracknell Forest
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Durham Dales Number of Acute Admissions All Over
65s
over a rolling 12 months period
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Over 65s Acute AdmissionsCastlefields Health
Centre
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Managing Long-term Conditions

• Long-term commitment
• Systematic approach
• Opportunistic interventions
• Co-pilot through the local system
• Bring together sectors agencies
• Contingency plans out-of-hours
• Aim to prevent crises

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Dont React Panic

• Anticipate Plan

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Dont React Panic

• Anticipate Plan

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Identifying At RiskStart with 10, then if Yes

• Do you have heart problems? 3
• Do you have leg ulcers? 4
• Can you get out of the house without help? -5
• Do you have problems with your memory and get
  confused? 4
• Have you been admitted to hospital for an
  emergency in the last 12 months? 8
• Would you say the general state of your health is
  good? -4

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