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Elaine Mead, Chief Executive, NHS Highland and Dr Adrian Baker, a GP in NHS Highland provide the background as to why they integrated health and social care services in their area and why they concluded that a radical structural reform was the way forward. They also explain some of the pre-work that they tested, the experience they gained from elsewhere, and where they are now. They also share some of the challenges that they faced and how they dealt with those things that they did not quite anticipate. See more on the 2013 NHSScotland Event website http://www.nhsscotlandevent.com/resources/resources2013/resources
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Integrating Care in the
Highlands:
our story so far
Intro Film Clip
Integrating care in the Highlands
our story so far
Adrian Baker, GP
Elaine Mead, Chief Executive
Integrating care in the Highlands:
About a journey from 2005
NHS HIGHLAND (Highland Council and Argyll & Bute Council Areas)
Actual and projected number of people aged over 75: 1981 to 2031 Source: General Register Office for Scotland
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
45,000
50,000
Why did we need to integrate care?
• High level of delayed discharges
• Early (young) admissions to care homes
• Lack of alternatives to hospital admission
• Unnecessary and avoidable admissions
• Limited care at home access
• Lack of ‘joined-up’ services
New admissions to care home
75.4
75.9 75.7 75.8
76.3
72.5
73.2
73.7
73
73.4
70
71
72
73
74
75
76
77
2008 2009 2010 2011 2012
Average age at admission
Scotland
Highland
What do people want?
• Maintain good health
• Maintain independence
• Prevent unnecessary hospital admissions
• Support carers to care
• Stay in their own homes for as long as
possible
Cost and quality of experience
Independent
Supported self care
Care at Home
Hospital at Home
Community Hospital
Residential Care
Acute Hospital Care Better
Experi
ence In
cre
asin
g C
osts
Journey of dependence
• Home Care £6K / pt /year
• NHS 24 = NHS Direct £36.67 / call
• OOH contact £68.00
• GP in hours contact £30.00
• District nurse £40.89
• A&E £92.50
• Admission (Ave 10 days) £2,784
• Long stay care £20K to £40K+
Integrating – what?
Acute
Health
3rd Sector,
voluntary
People
Community
resilience
Health &
Social
Integrating health & social care
2005 2011-12
2020
Integrating health
2005 2011-12
2020
Unscheduled Care
Anticipatory
Polypharmacy
Whole system flow
A&E waits
• A&E waits compromised when no flow
• Medical admissions redirected through
A&E
• Trauma space compromised
• Patients waiting on trolleys
• Long minor patients waits
Actions in hospital
• Acute physician
• AMAU (assessment not admission)
• Nurse call triage
• Focus on planned date of discharge
• Reduce bed stays for tests
• Reduce medical outliers
• Maximise community hospitals
Percentage Compliance with the Four Hour Target: July 2007 to March 2013
NHS Highland and NHS Scotland
NHS Scotland
NHS Highland
88%
90%
92%
94%
96%
98%
100%
Jul-07 Jan-08 Jul-08 Jan-09 Jul-09 Jan-10 Jul-10 Jan-11 Jul-11 Jan-12 Jul-12 Jan-13
Month
Pe
rce
nta
ge
of
pa
tie
nts
sp
en
din
g le
ss t
ha
n f
ou
r
ho
urs
in
A&
E
Nairn Town and County
The Gatekeeper and the Wizard: a fairy tale. (Br Med J 1989;298:172-3)
“The wizard asked the Minister for bigger and better
crystal balls and more powerful magic potions. But it
was no good….”
Healthy Aging
Lots happening
• SPARRA
• Casefinding
• Anticipatory Care
• Polypharmacy
• Hospital at Home
• Community Hospitals
• Virtual Ward
• Unscheduled Care – Flow 5!
Nairn Case Finder 2006/07 Nairn Cumulative Emergency Bed days
5%=44%
List
Be
d D
ay
s
100%
100%
Anticipating
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
Homework
• Power of Attorney
– Welfare – who do you want to decide on this?
– Finance – who do you want to have control of your financial affairs?
• Will – do you have a will?
• Do you have a Living Will and if so who knows?
The Numbers
• Initial study 2005-8 100 patients and 100 controls
• 15-16% mortality rate in the year.
• Survivors, 42% fewer admissions (P = 0.002)
• 52% fewer bed days (P = 0.020)
• The cost of hosptialisation of the study population was reduced by 50%. (P = 0.029)
• The control population had 11 patients die in hospital, the study population had 3 deaths in hospital (P = 0.007)
At scale for >5,000 patients
• By 31st March 2011, 5,329 patients who had received ACPs, demonstrated:
– 29% reduction in emergency new admissions, and
– 47% reduction in occupied bed days.
• Patients with a SPARRA score of ≥ 50% but no ACPA in place showed:
– 59% increase in emergency new admissions,
– 63% increase in occupied bed days
Impact
• For end of life care there is more chance of dying at home rather than in hospital if a ACP is in place.
• In the practice, there are less chaotic home visits, more structured and organised times with families and less work regarding crisis guardianship cases.
Lillian – Our Highland Esther
Small tests of change
Gaining 2 beds for £3K a month DD days in Hospital and Community, Nairn, 2007 - 11
0
20
40
60
80
100
120
140
160
180
200
Apr-0
7
Aug-0
7
Dec
-07
Apr-0
8
Aug-0
8
Dec
-08
Apr-0
9
Aug-0
9
Dec
-09
Apr-1
0
Aug-1
0
Dec
-10
Apr-1
1
Aug-1
1
Date
DD
's p
er
mo
nth DD's in Hospital
Ave LOS pre 70h
Ave LOS post 70h
DD days in the community
Frailty / Dementia Trajectory
Function
Decline in ADL’s &
Memory
Death
First Acute
Problem
TIME 3-10 years
Unable to
self care
High
Low
A Highland Huddle
Dementia Film Clip
Carers
Percentage of last 6 months of life spent at home or in a community setting
2 3 4 5 6NHS Highland
SCOTLAND
89.0
89.5
90.0
90.5
91.0
91.5
92.0
92.5
93.0
93.5
2006/07 2007/08 2008/09 2009/10 2010/11
% of last six months of life spent at home or in a community setting
Trend in care home places for older people, 1999/00 to 2011/12
1999/00 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11
NHS Highland
SCOTLAND
0%
20%
40%
60%
80%
100%
120%
1999/00 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12
Care Home Places for Older People
Trend in bed days by type of admission,
Highland residents 2001 -2012
Changing Landscape
• These things had and continue to have an
impact…
BUT
It won’t be enough
to make it better for the
people of the Highlands
Commitment
Integration of Services
“Banish the artificial divide between health
and social care and involve charities,
social enterprises and community groups
more closely in service provision.”
Scottish Older Peoples Assembly, 2010
Ambition to devolve decision making to
integrated front line teams
Single management and single budget for
ALL health & social care in a locality
Lead Agency approach
• NHS Board and the Highland Council moved to explore the benefits of a lead agency model
• NHS Highland - Older adults
• The Highland Council - Children’s services
• CEOs committed to STOP if any identified detriment to adults and children as a result
• Agreement made in December 2010 with plan to go live April 2012
Statement of Intent
“We will improve the quality and reduce
the cost of service through the creation of
new, more simple organisational
arrangements that are designed to
maximise outcomes.”
The Highland Council & NHS Highland
16 December 2010
Scale of change: some numbers
• Social care staff to NHS Highland = 1,500
• Budget to NHS Highland = £90m
• Health staff to Highland Council = 250
• Budget to Highland Council = £8m
• Buildings occupied under licence to NHSH
• Partnership Agreement = 400 pages
March 2012
Partnership Agreement signed
“Merger not a take over”
NHS Highland now delivers care:
• In hospitals
• In care homes
• In the communities, and
• At home
For patients and clients across the north of
Highland
Working closely with Argyll and Bute Council
to develop a model to support integration
of adult care in this area
But our journey continues
• Working to change culture & attitudes
• Developing shared language and approaches
• Working across boundaries ……
Lots of opportunities
• RNI Community
Hospital
• Mackenzie Centre
• York Day Hospital
(Inverness)
Film clip
Working with the third
and voluntary sector
Maximise
use of
technology
Building community resilience
Integration, integration, integration
2005 2011-12
2020
Str
uctu
ral C
hange
Re-d
esig
n W
ork
…………………… R
e-d
esig
n W
ork
Re-d
esig
n W
ork
Third and voluntary sector
Community resilience
Partners in care
Inte
gra
ting H
ealth
Family &Friends
Care Home
Day Services
Acute
Hospital
Neighbours
Home
Carers
Respite
Care
Physio GP
Day
Services
Consultants
Residential
Care
Social
Workers
Pharmacy District
Nurse
OT
Voluntary
Community
Hospital Care Co-
ordinator
Communities
3rd Sector
A new model
for care and
caring
Film clip
And our last message ?
It is not hard!
It is really hard …
But it is worth it
Thank you