Over 75's Plan
I want to introduce you to our plan for over75 care for Bridlington. It is a redesign of services for patients over 75 and is based on Brid Inc, the network of Bridlington GP practices working together with the other health, social and voluntary sector organisations in the town
It is based on real need.
· Bridlington is in the most deprived fifth of areas in England, and in East Riding.
· 30% of our 42,000 residents are over 65 (13% over 75).
· Between 2010 and 2030 the over 65s will increase by 51%.
· 60% of these people have 2 or more LTCs;
· dementia will increase by 8% per year for the next 30 years.
· The care needs of older people will increase by 61% within 30 years.
· 50% all GP appts taken up with patients with LTCs.
· To manage the ageing population, GP appointments will have to grow by 2.5% pa just to stand still.
National recruitment problems are worsening for GP, nurses and social work staff. Shortages especially felt in areas such as Bridlington
With deprivation levels here amongst the highest in the county and country, the impact of an aging population with co-morbidities will have a disproportionate effect on local health, social and voluntary sector services.
The East Riding of Yorkshire CCG Community Care Strategy identified key themes from a local community forum. They included:
o No time to work with patients. Too busy filling in forms to refer them to someone else for something simple
o Look at services from patients perspective. There are lots of lonely people who struggle to access services
o Patients are being admitted to hospital who don’t necessarily need inpatient care
The same exercise revealed that the local community said:
o Need for therapy services – physio, psychology, addiction services
o Waiting times for services are too long – they frustrate patients and staff
o Need to provide better support to elderly people – longer consulation times- better integrating the GPs and NCTs would help to support this
o Increase the community workforce – would support us in providing more holistic care to housebound patients
o Better IT infrastructure – reduce admin burden
The Health & Wellbeing Strategy ((ERYC, CCG, Health Watch) 2013-16 outlined 2 key strategies –
o Effectively manage the increasing health demands due to ageing population
o Effectively manage the challenge of increasing numbers of patients with dementia
Actions identified included:
o Adopting personal care plans for patients with LTCs
o Increasing the number of people feeling confident to manage their own health
o Effective partnership working to ensure services are aligned and integrated across health & social care resulting in seamless outcomes for people
o Better and more appropriate use of community hospitals through step-up/down resources
· Reducing unplanned admissions through effective partnership working, targeting those most at risk and those with LTCs. Ensure people are supported in terms of EOLC decisions
· Develop a range of low level support services to promote independent living and encourage older people to adopt healthier lifestyles.
The emphasis on developing a local care service model for patients is of particular interest to us; providing early and accurate diagnosis and information, improving carer support and patient involvement in end of life care, and providing intensive treatment services to help care home providers manage short term challenging behaviours with a resultant reduction in unplanned admissions and an improvement in the quality of life for dementia sufferers.
Our CCG ‘s operational & strategic plan 2014-19 provides the basis for implementing the health & wellbeing board strategy by outlining key areas including:
o Individuals taking greater ownership of their own health & well being
o Services are delivered mainly in the community
o Integration of health & social care, focussed on service delivery hubs
o Clarifying the remit of community hospitals so that the added value and expertise is clearly understood and integrated into local care pathways
In response to these strategies we have produced a model of elderly care provision, articulated it in a business case, that seeks to translate the vision, aspirations and targets of the strategy documents into meaningful actions that deliver real interventions and improvements to patient care & co-ordination.
The proposed model is based on evidence and principles gathered from relevant health systems and research conducted in the UK & internationally. It emphasises the centrality of integrated working and collaboration with health, social and voluntary sector providers to deliver real improvements in the health and wellbeing of our elderly population.
Some examples of best practice are:
West Cheshire – see slide
Buurtzorg – Dutch NCTs based on teams of 12 nurses supporting 10,000 patients. They are autonomous, have frequent interactions with their patients and are local. They have reduced costs by 40% (2bn euro)
Wellmed – Texas based primary healthcare organisation for 160,000 older people covered by medicare (state rather than private insurance). Reduced mortality by 50%
Nuka – Alaskan primary care based system seen as best in the world. Team approach to healthcare & care co-ordination, emphasis on relationships & co-ownership with patients and disinvestment in hospital care. Resulted in 40% decline in use of urgent and emergency services, 30% decrease in hospital days and 20% decrease in use of primary care services. Positives – increase from 35% to 95% of people registered with primary care provider, routine appointments now same day (in person, phone, email) down from 4 weeks, staff turnover ¼ compared with 5 yr ago, 25% increase in childhood vaccinations, customer satisfaction 94%.
Torbay – Mrs Smith 2004
Robin Lane Wellbeing Centre, Pudsey.
MODEL:
Our model retains the General Practice list at its core, given patients’ affinity with their practice. It provides the vehicle for achieving continuity of care and adherence to clinical pathways. However, to achieve the benefits of integrated care working, we propose a team approach to the care of the elderly, bringing together primary care, hospital care, community services and social services. The key individuals would function as a fully integrated team.
Whilst the GP would retain contractual responsibility, the purpose of the model would enable shared accountability (team approach) for patients, both curative and preventative health & social care. This would be delivered by the GP, the geriatrician (securing integration with the hospital), the matron (securing integration with community services) and the social worker (securing integration with social services). The four coordinators would be jointly responsible for providing and arranging care, and creating and updating a single integrated care plan.
In addition, a clinical pharmacist would assume responsibility for overseeing important medicines management functions such as auctioning discharge advice, discharge resolution queries, and ensuring high quality medicines management and adherence to medication regimes. This week’s BMJ editorial emphasised the need for personalised therapeutic regimes especially for older patients to minimise harm & maximise benefit.
In order to maximise continuity, coordination and the benefits of the therapeutic relationship, each patient would have a dedicated navigator whom they would contact for primary and social care advice and intervention. The navigator would be the patient’s first port of call and function not dissimilar to both a receptionist and a healthcare assistant, would take ownership of the actions and processes surrounding patient care, whether initiated by the service or by the patient (see appendix 1 for the model).
We are focussing on the over 75’s as co-morbidities and risk of admission is linked with age. This model, in addition to delivering for patients most at risk of hospitalisation, would also focus on patients who are well in order to keep them well, active and healthier for longer. If the focus is exclusively on patients most at risk, this may well reduce admissions and costs in the very short term, but the improved health benefits will likely lead to the unwell patient living longer and thus creating an overall net cost to the health & social care system – in effect making the problem worse. Therefore the model seeks to deliver benefits to those most at risk, funded out of short term reductions in hospital admissions and A&E attendances, but with a view of a longer-term funding model by reducing the number of at risk patients in the future through early detection and intervention to keep the fit and well, fit and well for longer.
The intended outcomes for this model include:
· Reducing avoidable admissions & A&E attendances through a team approach, delivering interventions, a single integrated plan, and coordinating and arranging care according to individual expertise.
· Reducing length of stay when people do have hospital admission: facilitated by a dedicated geriatrician enabling in reach and out-reach, assurance to the hospital for early discharge, and providing intervention in the community
· Improving health related quality of life for people with long term conditions, achieved through addressing social determinants, coordinated by the matron and social worker
· Patients being more involved in their own care through co-production of the care plan
· Reducing permanent admissions to care homes through early detection and prevention, facilitated by annual reviews for patients who are fit & healthy, and regular reviews for patients with co-morbidities
· More people dying in the place of their choice, achieved through co-produced care plans and end of life plans, providing 100% coverage for all over 75 yr patients.
· Increase the dementia diagnosis rate (improved access to early diagnosis and treatment) achieved through comprehensive total care for the older population.
The costs of our scheme to set up are around 10% of the total health spend on the over75’s, therefore needing a 10% cost saving to break even. This calculation does not include the potential social care cost savings. The Kings’ Fund projects savings of 8-18% with such a scheme, whilst the Nuka organisation achieved 40% savings. All current financial calculations are dwarfed by the massive increases due to the increases in ageing and disease prevalence if the current system persists throughout the next 5-10 years. It is described as a demographic time-bomb causing financial un-sustainability. So we have to do something.
Conclusion
So, I hope that the need for change is now well understood & accepted. We cannot continue as we have done for the past few decades, as our population is ageing, becoming more unwell and more expensive to look after. Experience from other parts of the UK and the world suggest that an integrated model of health & social care, focussing on rapid response to illness, personal care plans agreed in advance of crisis being reached, utilising the full extent of our community resources, and ending the silo-culture that exists between primary & secondary care, doctors and nurses, health & social care, voluntary & statutory bodies, may be the way to avert the impending crisis. We are using our colleagues’ experience, local knowledge and expertise to help us adapt this model into a practical solution that will work for Bridlington and perhaps enable other areas to progress in a similar fashion.
It is based on real need.
· Bridlington is in the most deprived fifth of areas in England, and in East Riding.
· 30% of our 42,000 residents are over 65 (13% over 75).
· Between 2010 and 2030 the over 65s will increase by 51%.
· 60% of these people have 2 or more LTCs;
· dementia will increase by 8% per year for the next 30 years.
· The care needs of older people will increase by 61% within 30 years.
· 50% all GP appts taken up with patients with LTCs.
· To manage the ageing population, GP appointments will have to grow by 2.5% pa just to stand still.
National recruitment problems are worsening for GP, nurses and social work staff. Shortages especially felt in areas such as Bridlington
With deprivation levels here amongst the highest in the county and country, the impact of an aging population with co-morbidities will have a disproportionate effect on local health, social and voluntary sector services.
The East Riding of Yorkshire CCG Community Care Strategy identified key themes from a local community forum. They included:
o No time to work with patients. Too busy filling in forms to refer them to someone else for something simple
o Look at services from patients perspective. There are lots of lonely people who struggle to access services
o Patients are being admitted to hospital who don’t necessarily need inpatient care
The same exercise revealed that the local community said:
o Need for therapy services – physio, psychology, addiction services
o Waiting times for services are too long – they frustrate patients and staff
o Need to provide better support to elderly people – longer consulation times- better integrating the GPs and NCTs would help to support this
o Increase the community workforce – would support us in providing more holistic care to housebound patients
o Better IT infrastructure – reduce admin burden
The Health & Wellbeing Strategy ((ERYC, CCG, Health Watch) 2013-16 outlined 2 key strategies –
o Effectively manage the increasing health demands due to ageing population
o Effectively manage the challenge of increasing numbers of patients with dementia
Actions identified included:
o Adopting personal care plans for patients with LTCs
o Increasing the number of people feeling confident to manage their own health
o Effective partnership working to ensure services are aligned and integrated across health & social care resulting in seamless outcomes for people
o Better and more appropriate use of community hospitals through step-up/down resources
· Reducing unplanned admissions through effective partnership working, targeting those most at risk and those with LTCs. Ensure people are supported in terms of EOLC decisions
· Develop a range of low level support services to promote independent living and encourage older people to adopt healthier lifestyles.
The emphasis on developing a local care service model for patients is of particular interest to us; providing early and accurate diagnosis and information, improving carer support and patient involvement in end of life care, and providing intensive treatment services to help care home providers manage short term challenging behaviours with a resultant reduction in unplanned admissions and an improvement in the quality of life for dementia sufferers.
Our CCG ‘s operational & strategic plan 2014-19 provides the basis for implementing the health & wellbeing board strategy by outlining key areas including:
o Individuals taking greater ownership of their own health & well being
o Services are delivered mainly in the community
o Integration of health & social care, focussed on service delivery hubs
o Clarifying the remit of community hospitals so that the added value and expertise is clearly understood and integrated into local care pathways
In response to these strategies we have produced a model of elderly care provision, articulated it in a business case, that seeks to translate the vision, aspirations and targets of the strategy documents into meaningful actions that deliver real interventions and improvements to patient care & co-ordination.
The proposed model is based on evidence and principles gathered from relevant health systems and research conducted in the UK & internationally. It emphasises the centrality of integrated working and collaboration with health, social and voluntary sector providers to deliver real improvements in the health and wellbeing of our elderly population.
Some examples of best practice are:
West Cheshire – see slide
Buurtzorg – Dutch NCTs based on teams of 12 nurses supporting 10,000 patients. They are autonomous, have frequent interactions with their patients and are local. They have reduced costs by 40% (2bn euro)
Wellmed – Texas based primary healthcare organisation for 160,000 older people covered by medicare (state rather than private insurance). Reduced mortality by 50%
Nuka – Alaskan primary care based system seen as best in the world. Team approach to healthcare & care co-ordination, emphasis on relationships & co-ownership with patients and disinvestment in hospital care. Resulted in 40% decline in use of urgent and emergency services, 30% decrease in hospital days and 20% decrease in use of primary care services. Positives – increase from 35% to 95% of people registered with primary care provider, routine appointments now same day (in person, phone, email) down from 4 weeks, staff turnover ¼ compared with 5 yr ago, 25% increase in childhood vaccinations, customer satisfaction 94%.
Torbay – Mrs Smith 2004
Robin Lane Wellbeing Centre, Pudsey.
MODEL:
Our model retains the General Practice list at its core, given patients’ affinity with their practice. It provides the vehicle for achieving continuity of care and adherence to clinical pathways. However, to achieve the benefits of integrated care working, we propose a team approach to the care of the elderly, bringing together primary care, hospital care, community services and social services. The key individuals would function as a fully integrated team.
Whilst the GP would retain contractual responsibility, the purpose of the model would enable shared accountability (team approach) for patients, both curative and preventative health & social care. This would be delivered by the GP, the geriatrician (securing integration with the hospital), the matron (securing integration with community services) and the social worker (securing integration with social services). The four coordinators would be jointly responsible for providing and arranging care, and creating and updating a single integrated care plan.
In addition, a clinical pharmacist would assume responsibility for overseeing important medicines management functions such as auctioning discharge advice, discharge resolution queries, and ensuring high quality medicines management and adherence to medication regimes. This week’s BMJ editorial emphasised the need for personalised therapeutic regimes especially for older patients to minimise harm & maximise benefit.
In order to maximise continuity, coordination and the benefits of the therapeutic relationship, each patient would have a dedicated navigator whom they would contact for primary and social care advice and intervention. The navigator would be the patient’s first port of call and function not dissimilar to both a receptionist and a healthcare assistant, would take ownership of the actions and processes surrounding patient care, whether initiated by the service or by the patient (see appendix 1 for the model).
We are focussing on the over 75’s as co-morbidities and risk of admission is linked with age. This model, in addition to delivering for patients most at risk of hospitalisation, would also focus on patients who are well in order to keep them well, active and healthier for longer. If the focus is exclusively on patients most at risk, this may well reduce admissions and costs in the very short term, but the improved health benefits will likely lead to the unwell patient living longer and thus creating an overall net cost to the health & social care system – in effect making the problem worse. Therefore the model seeks to deliver benefits to those most at risk, funded out of short term reductions in hospital admissions and A&E attendances, but with a view of a longer-term funding model by reducing the number of at risk patients in the future through early detection and intervention to keep the fit and well, fit and well for longer.
The intended outcomes for this model include:
· Reducing avoidable admissions & A&E attendances through a team approach, delivering interventions, a single integrated plan, and coordinating and arranging care according to individual expertise.
· Reducing length of stay when people do have hospital admission: facilitated by a dedicated geriatrician enabling in reach and out-reach, assurance to the hospital for early discharge, and providing intervention in the community
· Improving health related quality of life for people with long term conditions, achieved through addressing social determinants, coordinated by the matron and social worker
· Patients being more involved in their own care through co-production of the care plan
· Reducing permanent admissions to care homes through early detection and prevention, facilitated by annual reviews for patients who are fit & healthy, and regular reviews for patients with co-morbidities
· More people dying in the place of their choice, achieved through co-produced care plans and end of life plans, providing 100% coverage for all over 75 yr patients.
· Increase the dementia diagnosis rate (improved access to early diagnosis and treatment) achieved through comprehensive total care for the older population.
The costs of our scheme to set up are around 10% of the total health spend on the over75’s, therefore needing a 10% cost saving to break even. This calculation does not include the potential social care cost savings. The Kings’ Fund projects savings of 8-18% with such a scheme, whilst the Nuka organisation achieved 40% savings. All current financial calculations are dwarfed by the massive increases due to the increases in ageing and disease prevalence if the current system persists throughout the next 5-10 years. It is described as a demographic time-bomb causing financial un-sustainability. So we have to do something.
Conclusion
So, I hope that the need for change is now well understood & accepted. We cannot continue as we have done for the past few decades, as our population is ageing, becoming more unwell and more expensive to look after. Experience from other parts of the UK and the world suggest that an integrated model of health & social care, focussing on rapid response to illness, personal care plans agreed in advance of crisis being reached, utilising the full extent of our community resources, and ending the silo-culture that exists between primary & secondary care, doctors and nurses, health & social care, voluntary & statutory bodies, may be the way to avert the impending crisis. We are using our colleagues’ experience, local knowledge and expertise to help us adapt this model into a practical solution that will work for Bridlington and perhaps enable other areas to progress in a similar fashion.
