Successful population ageing - the challenge for acute care

Dr Ian SturgessPartner,

NHS Interim Management and SupportSenior Clinical Lead,

Emergency Care Intensive Support Team

To Cover: Some but not all:-

• I: The success story of population ageing• II: The need to focus on prevention and

anticipatory care• III: What ageing really means for health and

wellbeing – a balanced view• IV: The financial climate• V: Older people as key service users: “Older

People R US”• VI: And services for them as key to the efficiency

challenge• VII: Implications for general practice and

commissioning

A whole system perspective

Preventative/Predictive careDisease managementManaged populations

Alternatives to acute admission settings

Alternative access for diagnosis

Alternative settings for therapy

Alternative sites for discharge

Alternative sites for readmission

Health Promotion

General Practice & GP OOH

Community Support

Ambulance Service & GP

OOHA+E MAU/SAU/

Short Stay

Focus on CDM and more effective responses to urgent care needs – ACS condition management

Clear operational performance framework and integrated in to primary careImproved integration with primary care responders

Front load senior decision process incl primary care

Redesign to left shift LOS

Inpatient Wards

Optimise ambulatory emergency care

Information flow converting the unheralded to the heralded

Discharge Process

Lots of policy effort over the last 30 years to reduce the fragmentation between health and social care

Every system is perfectly designed to achieve the results it achieves

What are we trying to achieve?Getting patients better faster and safer

Safety

ReliabilityFlow

Ideal Care

Improving outcomes

• No avoidable deaths• No harm• No unnecessary pain• No waste• No delays• No feelings of helplessness• No inequality• Getting everyone on the

‘same page’

• NOT - ‘Hitting the target but missing point’

‘Data’ vs ‘Intelligence’Usefulness of ‘Delayed Transfer of Care’ measure?• Activity vs Demand : capacity analysis

– Predictive modelling• Averages vs variance• Point prevalence vs run charts/Statistical Process

Control/CUSOM Charts• Response to variance

– Special cause vs Common cause– Capability assessment

For strategic planning, monitoring impact of projects, and operational management.

Building a Cascade of Measures

L 1System

L 2Board & CEO

L 4

Outcome - system level eg admissions, death, harm, Institutionalisation etc

Process + Outcome

Process (+ Outcome)Microsystems: Units, Depts

L 5Physician & Patient Individual

Process Metrics

Adapted from Lloyd & Caldwell

L 3Service Line

I: The success story of population ageing

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Over the last 50 years, trend has moved from a ‘rectangularisation’ to an a ‘elongation’ (from “old” to “older”) Number over 80 has doubled in past two decades (See BMJ 2010 “oldest old double”)

Source: mortality.org, originally ONS

Distribution of death England 1841 - 2006

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Around 18% of all deaths were before 65 in 2006 – the same proportion as in 1991

II: The need to focus on prevention and anticipatory care

Could do better on prevention e.g. Activity (Age UK PCMD 2012)

Primary Prevention? e.g. Obesity. Men. (England)

III: What ageing really means for health and wellbeing

How older people define wellbeing:Bio-Psycho-Social.Not just medical model of “absence of disease”

• Control over daily life• Personal care and

appearance• Food and drink• Accommodation

(cleanliness and comfort)• Personal safety• Social participation• Occupation/activity• Dignity (in care) once you are acutely ill or dependent on care

Wider Determinants: Potential for multiple disadvantages. Role of local government, benefits, housing etc?

Frailty – (only around 6% of over 65s but very high proportion of service use and predicts poor outcomes and high mortality)

Fried Criteria for frailtyWeight loss, exhaustion, weakness, slow walking speed, diminished physical activity

”Frailty is a failure to integrate responses in the face of stress. This is why diseases manifest themselves as the “geriatric giants”….functions …such as staying upright, maintaining balance and walking are more likely to fail, resulting in falls, immobility, incontinence, delirium or general failure to thrive . A small insult can result in catastrophic loss of function”Rockwood Age Ageing 2004

i.e. Poor Functional Reserve

Fried 1999

Problems with traditional LTC approach. See Oliver D, Br J Gen Practice 2012)• “Cut and paste” of Kaiser Pyramid• Too much “single disease” thinking• QOF can reinforce this• In turn, drives prescribing without due regard to drug/drug

or drug/disease interaction, risk-benefit/therapeutic goals or evidence of benefit in oldest old or complex multi-morbidity

• Common conditions of ageing often neglected• Support for carers?• Where are frailty syndrome and disability?• Crisis response (24/7) and adequate access to alternatives

to hospital crucial to admission prevention.• Artificial divide between LTC pathway and acute care/social

care pathways. Fundamentally interdependent

22Source: Family Resources Survey 2007

Individuals with a disability, including

limiting long standing illness

Individuals without a disability,

including limiting long standing

illness

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Disability distribution over age

Reported prevalence of disability clearly rises with age.

V: Older people (often with complex needs) as core patients/clients

Getting their care right is key to delivering the efficiency challenge

People over 65 (England)...

• 60% adult social care spend (£9bn)– 1.25 M out of 1.7 m users

• 37% NHS Primary Care spend (£27bn)• 46% acute care spend (£ 27bn)• 12% NHS budget is on community health care

(largely older people) (c £12bn)• 66% drug budget (including GMS)• Often those interdependent on multiple services

(e.g. 60% of home care service users have been in hospital in previous year. 80% of delayed transfers are over 70)

• Population ageing means this trend will continue

Trends in hospital admissions in England, >75 years

Emergency Bed days per person per annum by age and gender

Factors driving rate of use of emergency hospital beds

Read Freakonomics and Super Freakonomics!

Provider efficiency System inefficiency

Better and more efficient care

Reduction in length of stay

More beds available

Admission threshold reduced

Lower acuity cases using costly inpatient care

Less severe cases admitted

Supply side drivers in healthcare are alive and well in our ‘service level designs’. Result = increased unintended consequences

Managing the StreamsIdentify the stream

– Short stay Sick specialty Sick frail Complex– Allocate early to teams skilled in that stream

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Length of stay (days)

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Clarity of specialty criteriaSpecialty case management plan at

Handover – no delaysGreen bed days vs red bed days

Short stay – manage to the hourMaximise ambulatory care

Complex needs – how much is decompensation?Detect early and design

simple rules for discharge

Minimise handoverDecompensation risk

Early assertive managementGreen bed days vs red bed days

Roland M BMJ 2012. Preventing Emergency Admissions – excessive focus on “frequent flyers”? Does current GP consultation model and QOF allow comprehensive assessment/anticipatory care etc in older people with complex needs?

Quality Care For Older People With Urgent & Emergency Care Needs: Silver Book

An intercollegiate body of work describing care standards for older people over the first 24 hours of an urgent care episode, with the specific remit to:• help decrease variations in practice• influence the development of appropriate services

across the urgent care system• identify and disseminate best practice• influence policy development

Silver Book Membership• Age UK• Association of Directors of Adult Social Services• British Geriatrics Society • Chartered Society of Physiotherapy• Community Hospitals Association• College of Emergency Medicine• College of Occupational Therapists• National Ambulance Service Medical Directors• Royal College of General Practitioners• Royal College of Nursing• Royal College of Physicians• Royal College of Psychiatrists• Society for Acute Medicine

Purpose Of Silver Book

• Describes the issues relating to older people accessing urgent care in the first 24 hours irrespective of provider

• Describes the competencies required to respond• Recommends urgent care standards for older people - first

24 hrs of an acute care episode• Contextualises health & social care for older people & at

the interface• Aimed to improve satisfaction and outcomes for older

people in urgent care & satisfaction amongst staff

Standards: All older people accessing urgent care should be routinely assessed for (based on priorities)

pain delirium, dementia

depression nutrition/hydration

skin sensory loss

falls & mobility activities of daily living

continence vital signs

safeguarding end of life care issues

Recommendations• Generic – across all settings in first 24 hrs; including

discharge planning• Specific – include - Primary care- Community hospitals- ED/UC/AMU- Mental health- Safeguarding- Major incident planning- Commissioning- Training and development for all staff groups

VI: Services for older people as the key to the efficiency challenge?

Ageing Population: 10 + Challenges for General Practice Oliver D. Br J Gen Practice 2012. Editorial. • 1. Address the efficiency challenge (through care of older people)• 2. Improve quality and combat discrimination• 3: Greater focus on prevention• 4. Proactive care of people with multiple LTC & age-related conditions• 5. Addressing frailty and co-morbid disability• 6. Dementia (earlier diagnosis and support)• 7. Crisis intervention and rapid response /support• 8. Prescribing and medicines management• 9. Input to nursing and residential homes• 10. Integration, continuity and system leadership• (11. Support and advice for carers)• (12. Intermediate care, step up and step down, bed based and home based.

Adequate medical and healthcare inputs and leadership. Smart use of beds and places)

• (13. What happens within acute care and around discharge and early post-discharge [transitional ] care really counts.

Critical Themes to Support Transformation1. Quality and system improvement as a core strategy2. Organizational capacities and skills to support performance

improvement3. Robust primary care teams at the centre of the delivery system4. Engaging patients in their care and in the design of care.5. Promoting professional cultures that support teamwork,

continuous improvement and patient engagement6. More effective integration of care that promotes seamless care

transitions 7. Information as a platform for guiding improvement8. Effective learning strategies and methods to test and scale up9. Leadership activities that embrace common goals and align

activities throughout the organization.10. Providing an enabling environment buffering short-term factors

that undermine success

Defining ‘Integration’• There are different, but interconnected levels of integration

• The ‘degree’ of integration varies (Leutz 1999)

Eg integrated health and social care systems (Wales,

NI)

Health and social care integration through care trusts

Eg integrated health and social care teams

SYSTEMIC (MACRO) TEAM OR SERVICE(MICRO)

ORGANISATIONAL (MESO)

Cooperation between teams & organisations (eg shared resources or

protocols)

Existing organisations working within networks/ partnership

agreements

Organisational merger or JV

LINKAGE FULL INTEGRATIONCOORDINATION IN NETWORKS

Organisational integration: Torbay care trust

• Five locality health and social care teams linked to GP practices. • Unified assessment processes • Health and social care coordinators act as a single point of contact.

• Focus on vulnerable elderly people targeted through risk prediction

• Impact• Reduced use of hospital beds (daily average number of occupied

beds fell from 750 in 1998-9 to 502 in 2009-10)• Low use of emergency bed days among people aged ≥65

(1920/1000 population compared with regional average of 2698/1000 population in 2009-10)

• Minimal delays in transfers of care

• Failing the Frail: A Chaotic Approach to Commissioning Healthcare Services for Care Homes

• Deficiencies in – Inclusion in commissioning– Specialist primary/community

healthcare services (whole range)

– Response Standards/Referral

Don’t forget Nursing and Residential Care

• Median 9 meds per resident. For each med, 10% error rate in prescribing, admin, monitoring (Barber et al CHUMS study)

• Still too many patients being admitted to hospital to die or where earlier intervention could have kept them in NH

From NHS Institute LTC in Older People. Gilmour Frew

The ChallengeFundamental change to the delivery system is needed, with greater emphasis on: • preventing illness and tackling risk factors• supporting people to live in their own homes and offering a wider

range of housing options in the community • providing high standards of primary care in all practices to enable

more services to be delivered in primary care, where appropriate • making more effective use of community health services and

related social care, and ensuring these services are available 24/7 when needed

• using acute hospitals and care homes only for those people who cannot be treated or cared for more appropriately in other settings

• integrating care around the needs of people and populations.Transforming The Delivery Of Health And Social Care The Case For Fundamental Change – King’s Fund 2012