Professor John Young
National Clinical Director for Integration & the Frail Elderly
nhsManagers.net
Integration and Older People with Frailty
John Young
Dept. Elderly Care Medicine
Bradford Hospitals Trust
& University of Leeds
National Clinical Director for Integration & Frail
Elderly, NHS England
Integration and Older People with
Frailty
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What’s the problem?
How does integration fit in?
What’s the evidence?
What’s the plan?
PERFECT STORM:
• Increasingly clumsy health & social care system
• Changing population:
simple needs
highly complex (frailty)
• The Austerity years
Health & Social Care System
needs to be fit for purpose
By 2030, the number of people over 80 will have doubled…
Emergency hospital admissions by age band
700,000
600,000
Number of admissions
Over the last decade, some 40%
of the increase in emergency
admissions is from over 65s
85+
80-84
500,000
75-79
400,000
70-74
65-69
300,000
200,000
100,000
-
The rate of emergency readmissions
has also grown faster for older people
In 2008, there were 1.9 million
people with more than one long
term condition. By 2026, 3 million
people will have three long term
conditions
Population estimates for frailty:
65-69
=
4%
70-74
=
7%
75-79
=
9%
80-84
=
16%
Over 85
=
26%
Multimorbidity in Scotland
(Scottish School of Primary Care Barnett et al Lancet May 2012)
– The majority of over-65s have 2 or more conditions, and the
majority of over-75s have 3 or more conditions
– More people have 2 or more conditions than only have 1
Frailty is loss of physiological reserve
Frailty syndromes present in crisis
FUNCTIONAL ABILITIES
“Minor illness” eg
UTI
Independent
Dependent
Hyper-acute
Frailty syndromes:
• Immobility
• Falls
• Delirium
• Fluctuating
disability
• Incontinence
(Clegg, Young, Rockwood Lancet 2013)
STRUCTURAL, RELATIONAL & CULTURAL FRAGMENTATION
(SILOS OF PROVISION)
HOSPITALS
PRIMARY CARE
SOCIAL CARE
(LG funded & means tested)
COMMUNITY
HEALTH
SERVICES
NURSING &
CARE HOMES
COMMUNITY
NURSING
MENTAL
HEALTH
SERVICES
PHARMACY
AMBULANCE
SERVICES
VOLUNTARY
SECTOR
HOSPITAL-AT-HOME; “VIRTUAL WARDS; COMMUNITY HOSPITALS; HOME
THERAPY TEAMS; COMMUNITY MATRONS; SPECIALIST NURSES; CARE HOME
REHAB; PALLIATIVE CARE; “ENABLEMENT” SERVICES, etc, etc…
Does anybody want my patient?
Rapid Access Clinic = “Too
ill”
Care home rehab = “Not ill
enough”
Com hosp = “We’re full till
Monday”
HaH = “You mean she’s got
dementia!”
L.A. Enablement Service = “Send her
along!”
We have a fundamental whole system failure
The Wrong Type of Patients:
“If we design services for people with one thing wrong at
once but people with many things wrong turn up, the
fault lies not with the users but with the service, yet all
too often these patients are labelled as inappropriate and
presented as a problem”
Prof Rockwood 2005
The Wrong Type of System:
“Systems designed to treat occasional episodes of care
for normally healthy younger people are being used to
deliver care for people who have multiple, complex and
long term conditions. The result is often that they are
passed from silo to silo without the system having
ability to co-ordinate different providers”
Rt Hon Stephen Dorrell MP 2011
Integration and Older People with
Frailty
•
•
•
•
What’s the problem?
How does integration fit in?
What’s the evidence?
What’s the plan?
NATIONAL VOICES (www.nationalvoices.org.uk)
A national coalition of health and social care charities in England
Voice of patients, service users, carers, their families
Over 150 members organisations
Connects with the experiences of millions of people
“We are sick of falling through gaps. We are tired of organisational
barriers and boundaries that delay or prevent access to care. We do
not accept being discharged from a service into a void. We want
services to be seamless and care to be continuous”
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NATIONAL VOICES: What do we mean
by “integration”?
Integration and Older People with
Frailty
•
•
•
•
What’s the problem?
How does integration fit in?
What’s the evidence?
What’s the plan?
Preventing admission of older people to hospital
(D’Souza & Guptha BMJ 2013)
Emergency hospital admissions by age band
700,000
Number of admissions
600,000
85+
80-84
500,000
75-79
400,000
70-74
65-69
300,000
200,000
Mostly based on experimental RCTs
100,000
-
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And yet………………
Case management
Community matrons
Integrated community teams
Targeted, specialist services
Torbay and S. Devon Health Care Trust
Acclaimed service integration work:
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Bed use reduced 33%
Emergency bed use >85y reduced 32%
Delayed transfers of care “negligible”
LTC use reduced
Home care use increased
“I have seen the future. It is Torbay”
David Nicholson NHS Chief Executive
Torbay and S. Devon Health Care Trust
• Work started 2004
• Pilot work: joint care manager and joint health and
social care team
• Narrative: “Mrs Smith” (see BMJ March 2012)
• Performance metrics: early successes
• Staff: better experience
• Service users: better experience
Preventing admission of older people to hospital
(D’Souza & Guptha BMJ 2013)
Mostly based on experimental RCTs
•
•
•
•
Case management
Community matrons
Integrated community teams
Targeted, specialist services
• Experimental control of one (albeit complex)
thing
• Short time-horizon of experimenters
WHOLE SYSTEMS THINKING
National Evaluation of (16) Integrated Care Pilots
RAND Europe; Ernst &Young 2012
Identified several “integrating activities”
http://www.youtube.com/watch?v=ecanqQmJq-0
Can you identify some “integrating
activities” from this video?
National Evaluation of (16) Integrated Care Pilots
RAND Europe; Ernst &Young 2012
“Integrating activities” included:
• Narrative/collective vision; strong leadership
• Developing relationships & trust
• Process improvements: care planning; new roles; MDT working
• Locality based teams & co-location
• Shared IT/ care records
• Governance and performance management
• Financial systems and incentives
What did they find?
National Evaluation of (16) Integrated Care Pilots
RAND Europe; Ernst &Young 2012
Headline findings:
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Patient experience unchanged
Unexpected increase in acute admissions
Unexpected decrease in elective care
Changes more complex & took longer
• Integration work not complete or mature
• Mostly horizontal (not vertical)
integration
Integrated
What are characteristics
of bestCare:
integrated systems (1)?
What are the characteristics of best integrated systems (1)?
• Strong clinical leadership across sectors and disciplines,
e.g. Grouphealth (US), Jonkoping (Sweden)
• Use of data-driven processes to guide quality
improvement, e.g. Intermountain (US), Virginia Mason
(US), CCNC (US), GRIPA (US)
• Multi-disciplinary team around primary care practitioners,
e.g. Kaiser (US), Dudley (UK), Torbay (UK), CCNC (US)
• Strong investment in preventative services to improve
self-management, e.g. Kaiser (US), Leeds (UK), On Lok
(US)
• Use of risk stratification and proactive assessment/ care
planning, e.g. Tri-boroughs (UK), Kent (UK), North
Lanarkshire (UK), Grouphealth (US)
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Integrated Care:
What
ofofbest
integrated
systems
(2)?
What
areare
thecharacteristics
characteristics
best
integrated
systems
(2)?
• During crisis episodes, care co-ordination starts in A&E,
including social care, right through to discharge e.g. Kaiser
(US), Dudley (UK)
• Seamless transfer between acute and community setting,
backed up by continuous dialogue between GP & hospital
consultant, e.g. RHZ (Netherlands), VHA (US)
• Single electronic care record with patient access/interaction,
e.g. RHZ (Netherlands), Kaiser (US)
• Integration between physical and mental health services,
with same access standards, e.g. United (US), Beacon (US)
• Same incentives across system – outcomes, process, user
experience, VFM; e.g. Intermountain (US)
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Kings Fund Integrated Care 2011
• “Organisational integration appears to be neither
necessary nor sufficient to deliver the benefits of
integrated care.”
• “No single ‘best practice’ model of integrated care exists.
What matters most is clinical and service-level
integration that focuses on how care can be better
provided around the needs of individuals, especially
where this care is being given by a number of different
professionals and organisations Moreover, integrated
care is not needed for all service users or all forms of care
but must be targeted at those who stand to benefit
most.”
Integration and Older People with
Frailty
•
•
•
•
What’s the problem?
How does integration fit in?
What’s the evidence?
What’s the plan(s)?
The National Collaboration for Integration
National Partners: a major commitment
25 February 2013
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Integrated Care and Support: Our Shared Commitment
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Launched by MS(CS)14 May 2013
Sets out policy background
National Voices narrative prioritised
Call for ‘pioneers’
Sense of urgency within the
system to integrate
Information sharing
Accelerated learning across the system
National support to reduce/ eliminate
barriers
No national blueprint – local innovation
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Integration and Older People with Frailty:
Policy and Plans
Focus is on:
• Whole systems
• Older people with multiple co-morbidities/frailty
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Vulnerable Older People Plan
- (Urgent care, primary care, integration)
Urgent and Emergency Care Review
Integrated Care Pioneers
“Year of Care” Pilots
Integration Transformation Fund (£3.8 billion)