Using local evidence in service design

1
Using local evidence in service design
Oxfordshire County Councils Prevention Project

• Rachel Taylor, Research Officer
• Sara Livadeas, Assistant Head of Service,
  Strategy Transformation

2
Summary of presentation

• Rationale for the project
• Methods
• Results
• Service redesign
• Questions and discussion

3
Rationale for undertaking the project

• Promoting independence agenda preventing ill
  health and avoiding or delaying the need for
  costly services.
• Residential/nursing care per annum 46m
• 58 spent on over 85s
• Predicted increase in 85 - 2006-2031 143
• Avoidance of unnecessary care home admissions
• Evidence of what works required to justify
  investment in preventative approaches

4
Methods 1

• Worked with Institute of Public Care, Brookes
  University
• Literature review including past studies eg.
  Northamptonshires work
• File audit of care home admissions in Oxfordshire
  2008-9 (25 of admissions)
• Interviews with 21 people 7 older people, 8
  carers and 8 care managers

5
Methods 2 Issues to do with file audit

• Electronic files very difficult to read
• People auditing did not have social work
  background
• Only looked back 12 months
• Documents were the viewpoint of the care staff
• Weighting of condition/circumstance difficult to
  determine
• Health records not available

6
Methods 3 Issues to do with interviews

• Gave us the older person, carers and staff
  perspective
• Recruitment was challenging
• Mental capacity issues learning curve
• Difficult to get a clear sense of when events
  occurred
• Perceived reluctance on part of older person or
  carer to think that admission may have been
  avoidable

7
Results - literature

• Falls half of all older people who have had one
  fall will go on to have further falls.
• Continence Incontinence affects 25 of the older
  population, In care homes these figures are
  considerably higher being 30-60. Incontinence
  may contribute to premature referral for care
  home admission, as either the older person or
  their carers reach the point of no longer being
  able to manage the situation. Evidence shows that
  incontinence is often treatable in older people.
• Stroke Approximately 110,000 people in England
  suffer from a stroke each year. Caring for people
  who have had a stroke uses a significant
  proportion of inpatient hospital beds and nursing
  homes places. At present only around half of
  individuals who have experienced a stroke receive
  the rehabilitation to meet their needs in the
  first six months following discharge from
  hospital,
• Dementia Carer capacity and skills to care have
  a strong influence on the likelihood of someone
  being admitted to a care home early.

8
Results file audit 1

• Variable
  Oxfordshire Northamptonshire
• Incontinence 39 34.5
• Dementia 40 52
• Depression 25 23
• Falls 40 52
• Hospital admissions
• -in last 12/6m (OCC/NCC) 1 in 5 Over half
• Admitted from hospital 61 Over half

9
Results file audit 2

• Bereavement (not always in last year)
• Living alone (64)
• Female (71)
• Inappropriate housing (1 in 4-low estimate)
• Carer death or breakdown (10 - low estimate)
• Multiple health conditions (56-under recorded)

10
Interview findings 1

• Complexity of conditions/circumstances
• Reflected the file audit
• Mainstream services mixed picture
• Night care importance in relation to continence
• Isolation key factor conveyed in interviews
• Telecare benefits unclear
• Voluntary sector very little involvement
• Importance of carer vital importance not shown
  in the file audit

11
Interview findings 2- complexity of conditions
and circumstances

• Eg Living with consequences of health
  condition from many years ago
• He had the stroke in 95. But that limited his
  movement on his right side and you know I suppose
  getting older as well, he struggled getting
  around a bit more, then he got diagnosed with
  prostate cancerAnd he had to have a catheter
  fitted and he gets quite prone to infection and
  he had falls and things Carer

12
Interview findings 3 mainstream services

• Varied picture Social workers, PCT, hospitals
• Problems with service rather than needs-led
  provision
• Yes, that was all I wanted, just come in,
  concentrate on mum and had a 45 minute slot, but
  what would happen is if they came in with her and
  talk to her and that was as good as anything
  else. But then we had a letter saying they were
  cutting down her time because she didnt need any
  help with anything and they cut her down to a 15
  minute slot Carer

13
Interview findings 4 - incontinence

• In a lot of cases, when clients come from
  hospital to nursing homes, they come with
  catheters and all sorts of things that they quite
  possibly dont really need, but quite often they
  are given them at hospital because its easier.
  Maybe I shouldnt say that but the general
  feeling is that its easier to manage so they are
  given catheters and all sorts of things that take
  away their independence, take away their dignity
  and most of them dont want and dont actually
  need. Care Manager 7

14
Interview findings 5 - isolation

• The other big one that I find that people tend to
  go into long-term care that arent hospital
  admissions, a lot of it is isolation, is
  loneliness, is feeling vulnerable and at risk and
  especially during the winter months. Care Manager
  
• He wouldnt go out. He was frightened and so he
  got very isolated and although they had a
  community room at sheltered housing scheme,
  because of the dark nights and that, he wasnt
  going to go you know he didnt go so most days
  the only person he saw would be the warden, the
  lady who came to put him to bed, the one who came
  in the morning. So that was the only people he
  ever spoke to. Carer of ES

15
Service design

• Continence
• Turnaround what it is and where we are at
  with it.
• Support for carers of people with dementia

16
Continence redesign

• DH funding for joint PCT/SCS project to redesign
  project
• Aiming for a fully integrated service which will
  move towards prevention and rehabilitation and
  away management / containment of the problem to
  include
• Pathway redesign
• A Workforce Strategy to deliver an appropriately
  led, trained workforce in bladder and bowel
  dysfunction
• Great emphasis on educational awareness for self
  care, drawing on user experience and involvement,
  to promote universal bladder and bowel.

17
Turnaround 1
Health and Well Being
Death of a spouse
First fall
Increasing age
17
18
Turnaround 2
Health and Well Being
Reablement or restorative interventions
Increasing age
18
19
The Turnaround approach

• Interventions need to be
• Focussed on most opportune
• moment for change.
• Open ended in terms of
• time commitment .
• Delivered on the basis of
• evidence based outcomes.

Health and Well Being
Increasing age
19
20
Key factors in making it happen

• Local, national and anecdotal evidence all coming
  together
• Good partnership working already in place
• Right people willing to engage
• Opportunity with TASC money
• Still a long way to go

21
Key messages

• Use of evidence to provide knowledge based
  commissioning.
• Literature review indicated what the issues were.
• Used our own data to see what was really
  happening in Oxfordshire.
• Strong relationship between the literature and
  our own findings.
• Service response based on 2 or 3 factors that
  would make a difference.
• Needs ongoing evaluation.