‘Whole System’ Models of Care for Older People

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• Whole System Models of Care for Older People
• Tom Bowen
• The Balance of Care Group
• ORAHS 2004, Stockholm, Sweden28 June 2004

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Content

• Health status of older people
• Integrated and intermediate care
• Balance of Care models
• Appropriateness Evaluation Protocol surveys
• Comparison of UK local health economies

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Health Status of Older People

• Manton (US) estimated disability reducing by
  1.3 p.a. in over 75s
• Lagergren (Sweden) has shown that health and
  social care costs continue to concentrate in last
  two years of life
• Dixon et al (UK) show that the number of acute
  hospital bed days in last 3 years of life does
  not increase with age (2004)
• Some debate about compression of morbidity

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Developing a community focus

• Kaiser Permanente
• focus on chronic disease management
• Adcroft Surgery
• occupied bed days reduced by 20 in local
  hospitals
• South Bucks EPICS scheme
• Managed population 4,200 elderly and saved 561
  bed days in first 5 months
• EverCare Project
• Ten pilot PCTs in UK
• 30-35 admissions from 1 of population

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Intermediate Care

• Driven by wish to free up acute beds
• In-between acute hospital care and primary care
• Step up and step down
• Could be bed or community based
• Cuts across professions, organisations and
  budgets

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Balance of Care model
Phase of Care
Care Option
Intervention
Provider
Alternative to admission
Community nurse
NHS
Post-acute intensive (up to 7 days)
Care Co-ordinator
Care Option 1
Physiotherapist
Older People IC care
Supported discharge (up to 14 days)
Care Option 2
Speech therapist
Care Option 3
Local Authority
Rehab/ recovery (up to 28 days)
Occ. therapist
Care assistant
Care Option 4
Voluntary Independent sector
slow stream rehab (up to 42 days)
? Balance of Care Group
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Point Prevalence Surveys

• All inpatients in selected specialties on a
  single day
• Acute and elderly medicine, orthopaedics
• Data collected from casenotes by clinical staff
• Use Appropriateness Evaluation Protocol (AEP) to
  identify possibly non-acute patients
• Also survey non-acute hospitals
• Follow up discharge outcomes to provide basis for
  demand analysis

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AEP Criteria

• On admission
• Severity of illness eg unconscious, unable to
  move (fall), acute bleeding
• Intensity of service eg surgery gen
  anaesthesia, regular monitoring, IV therapy
• On day of care
• Medical services
• Nursing services
• Patient conditioneg acute confusion, other acute
  states, coma, fever

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Results from Typical Acute Hospital

• 12 of all patients admitted outside AEP criteria
• 43 of all patients outside AEP criteria on day
  of survey
• Clinicians assess preferred alternative type and
  location of care

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AEP comparison for medical patients
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Some implications

• Alternatives focussed on rehabilitation services
  (c50)
• Remainder have continuing care needs, or could
  just go home earlier
• AEP values characterise the nature of the UK
  hospital service, and potential to develop
• Change to the clinical process is needed if
  service development to deliver benefits