Anticipatory Care Planning
Dr Anne Hendry
National Clinical Lead for Integrated Care
Joint Improvement Team
Anticipatory Care Planning
Self Management
LTC Collaborative
Top Ten Improvement Actions
Very
High
Acute
Risk prediction in primary care
sector
Case / Care Management
Anticipatory Care Planning
High risk
Support for Self Management
Intermediate care
Medium risk
Telehealth and Telecare
Reablement and Rehabilitation
Lower risk
Medicine reconciliation &
pharmaceutical care
Reduction in delayed discharge
Prevention and
Health Improvement
Hospital pathways for frailty and delirium
14% reduction in rate of hospital
bed days 06/07 – 10/11
SPARRA Tool
How many previous
emergency admissions
has the patient had?
How many
prescriptions?
How many outpatient
appointments?
What age is the patient?
Hospitalisation
(3 years)
What type of
outpatient
appointments did
the patient have?
Psychiatric Admission
(3 years)
Any A&E
attendances in
the past year?
Any prescriptions for e.g.
dementia drugs? Or
substance dependence?
Any previous admissions
for a long term condition
(such as epilepsy?
PRE-PREDICTION PERIOD
Outpatient
(1 year)
Emergency Department
(1 year)
Prescribing
(1 year)
Any recent admissions to
a psychiatric unit ?
Outcome Year
(1 year)
OUTCOME PERIOD
SPARRA Cohorts
Frail Elderly
Age
Alcohol/
substance
misuse
related
admissions
All cohorts
Deprivation
Prescriptions
in specific
BNF chapters
Younger ED
Emergency /
elective / daycase
admissions
LTC related
admissions
Emergency
bed days
ED
attendances
Polypharmacy
New OP
attendances
Prescriptions
for specific
groups of
drugs
New OP
attendances
for MH
LTC
Psychiatric
admissions
Prescriptions/admissions indicating
particular conditions
Deprivation
www.isdscotland.org/dhipwww.isdscotland.org/dhip
Patient Risk Trajectories 2 – Over 75
(Frail Elderly)
www.isdscotland.org/dhipwww.isdscotland.org/dhip
www.isdscotland.org/dhipwww.isdscotland.org/dhip
Patient Risk Trajectories 3 – YED
www.isdscotland.org/dhipwww.isdscotland.org/dhip
Anticipatory Care Continuum of Risk
2nd choice for
QOF ACP
SPARRA SCORE
< 20%
20- 40%
1st choice for
QOF ACP
40 - 60%
> 60%
Long Term Conditions
People with lowest risk
of emergency
admission to hospital.
Likely to need simple
information, advice and
support to help them to
stay well and manage
their conditions
People at moderate risk of
emergency admission.
Patients at highest risk of
emergency admission to hospital
Likely to attend the practice or a
nurse specialist for follow up
Likely to be receiving care or
managed by the Community Team
Their ACP is usually best
developed by the GP and the
Practice team
Many already have an ACP
Lifestyle Interventions
Their ACP is usually developed by
the Community Team or nurse
specialist involved
Electronic Key Information Summary
15,000 KIS accessed in October
Feedback from patients
Very happy to
share this
information with
relevant others
Gives
confidence when
GP surgery
closed
Excellent
idea
Would not want
some sensitive
information from
medical notes
shared with others
No problem
as long as
information is
‘secure’
Surprised that
this was not
happening
already
What GPs liked
Excellent for
sharing info
with relevant
others
Good breadth
of
information
Structured,
concise and
easy to fill in
Ability to add
descriptive
text
Easy to use
and navigate
Good design
and workflow
Users in A&E
Good that it is
not just for
palliative care
Information is
clear and
concise
Anticipatory care
information
particularly useful
Would be good if
we could also
write to KIS
rather than readonly
Some of the
KISs in pilot
were of limited
quality
This information
could
dramatically
improve the care
we provide
ACP Evaluation
1. Nairn Study: Baker, Leak et al Br J General Practice Feb 2012
RCT with a net saving of £190 per patient for the ACP cohort
2. Highland study of emergency admissions and bed days for older
people in care homes and the top 1% risk group living at home
2 cohorts matched for SPARRA risk – 1556 in each cohort
No ACP - emergency admissions and bed days ↑by 51% and 49%
ACP - emergency admissions and bed days ↓ by 38% and 49%
3. York Health Economics Report
4. Local Evaluations
Personal Outcomes
What are the
things that
matter most to
me at this point
in time?
Being treated,
cared about or
supported the
way I want to be
Being more able
to understand &
manage my
health, condition
or treatment
Maintaining
and
enjoying a
good quality
of life
Achieving
specific
changes in my
health or
wellbeing
Policy Alignment
2020 Vision
Everyone is able to live longer healthier lives at home, or in a homely setting.
> Integrated health and social care, a focus on prevention, anticipation and
supported self management.
> When hospital treatment is required, and cannot be provided in a community
setting, day case treatment will be the norm.
> Care will be provided to the highest standards of quality and safety, with the
person at the centre of all decisions.
> There will be a focus on ensuring that people get back to their home or
community as soon as appropriate, with minimal risk of re-admission.
Locality Planning - Local and Personal
Supports & Services for Older People in North Lanarkshire
Intermediate Care
Health Promotion
Voluntary Organisations and Supports
Sheltered Housing
Carers Support
Activity Programmes
Care Management
Palliative Care
Community Health
Services
Continence/Falls
Services
Intensive Home
Support
Integrated Health &
Social Care Services
Assistive Technology
Home Support
Very Sheltered
A
Housing
He cute
alt
h S Ment
erv al
ice
s
Locality Link Officers
Community
Assessment &
Rehabilitation
Respite
Community
Pharmacy
ity
un ls
m
m
ita
Co osp
H
Acute Hospital
Services
Care Homes
Community Alarms
Most people with any long term condition
have multiple conditions in Scotland
Guidelines and the current organisation of care do not reflect this reality.
Guthrie B et al, BMJ 2012;345:e6341; Hughes L et al, Age and Ageing 2013;42:62-69
Reshaping Care Pathway
CHILDREN
YOUNG
PEOPLE
FAMILIES
ADULTS
OLDER
ADULTS
PEOPLE AT
WORK
Improving
efficiency &
optimising
workforce
capacity and
capability
Developing
skills &
knowledge
through
education
Utilising
Telecare &
Telehealth
technology
Effective
Modernising
Nursing in the
community
Person-centred
Building
workforce
capacity &
capability
Utilising high
quality
clinical
outcomes
Informing
practice
with policy,
research &
evidence
Providing
choice &
care in the
right setting
Working
with clients,
carers &
patients as
partners
Using care
pathways
Strengthening
leadership &
team
working
Delivering safe, high quality care, treatment & rehabilitation
Promoting
health &
addressing
inequality
Anticipating
health needs
&
responding
earlier
Enabling
and
supporting
self care
Working with
other
agencies &
disciplines as
partners
Community Services programme
Technology Enabled Integrated Community Team
http://www.knowledge.scot.nhs.uk/chin