PACT Patient experience and Anticipatory Care Planning Team. Dr Eleanor Halloran Consultant Liaison Psychiatrist Edinburgh

Transcription

1 PACT Patient experience and Anticipatory Care Planning Team Dr Eleanor Halloran Consultant Liaison Psychiatrist Edinburgh

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4 Project proposers Dr David Caesar Dr Carl Bickler Clinical Director GP Clinical Lead: Long Term Emergency Medicine Conditions, ECHP Dr Robby Steel Dr Lisa Carter Consultant Liaison Psychiatrist Primary Care Physician Royal Infirmary of Edinburgh Emergency Department, RIE

5 The Team RIE: Wojtek Wojcik- Liaison psychiatrist Michele Open ED consultant Annette Cosgrove Senior charge Nurse ED Catherine Moar Alcohol liaison nurse Joyce Follan- Lead Mental health Nurse Jim Marple G.P WGH: Eleanor Halloran Liaison Psychiatrist Werner Pretorius Liaison Psychiatrist -Diabetes Janine Ferguson Mental health nurse - Diabetes Medical secretary Michelle Daly Data manager Chris Cooper Patient Level Costings and Financial analysis -Christine.mcgregor@scot.gov

6 What We Do: Anticipatory Care Planning Patients identified using risk stratification data High risk of unplanned admission or emergency department attendance to acute hospitals.

7 PACT AIMS To optimize patient care To incorporate patient experience / improve self management To reduce ED attendance To reduce admissions

8 ANTICIPATORY CARE PLANS Widespread recognition of the potential benefits of ACPs Using locally for clinician referred ED patients- can involve case management / brief intervention /treatment Few studies looking at patient outcomes and cost effectiveness of ACPs.

9 PACT Cohort reviewed after 1 year Database to evaluate outcomes

10 Plan for this talk How cohort is identified - Risk stratification PACT Intervention groups Examples of care planning Reflections from patients /clinicians Prelim analysis

11 SPARRA Scottish Patients At Risk of Readmission and Admission SPARRA is an algorithm for predicting a patient s risk of emergency inpatient admission to an acute hospital in a particular year

12 SPARRA Age, Sex, Deprivation Number of previous emergency and elective admissions Total bed days accumulated in the 3 years Time since last emergency admission Principal diagnosis Number of diagnostic groups ( co-morbidity) Emergency admission rate ( standardised) for Gp practice

13 High resource Scotland Hospital based and GP Prescribing Resource 102, 628 (2%) consume 2.6bn the other 4,322,546 consume 2.6bn 100% 90% 80% 70% 60% 98% 4,322,546 Consume 2.6bn 50% 0.8bn other 40% 30% 20% 2% 1.8bn 102, bn Unplanned Consume admissions 10% 0%

14 From TRAK From SPARRA From Clinicians Emergency Department 80% risk of unscheduled placing or at imminent risk of From SAS From Frequent Attender hospital admission in placing a high demand upon frequent readmissions 10 ED attendances in year the next 12 months unscheduled care services and callers project or 5 in 3 months likely to benefit from this approach revolving (N.B. 200 patients in both) door patients c.700 c ? incorporate ED very high pre-emptive in future?incorporate Frequent admission referrals in future Attenders risk NHS LOTHIAN VERY HIGH RISK COHORT 1,500-2,000 patients, membership reviewed at 12 months Algorithm run monthly Younger Emergency Long Term Frail Department Conditions Elderly SJH RIE? other COPD Diabetes Generic LTC COMPASS REACT YED YED specialist patient psychological team (Edinburgh) (West Lothian) team team LTC services pathway medicine in the future project service

15 Scottish patients by category and SPARRA score % 100.0% 14.6% 12.3% 10.8% 9.9% 7.2% 80.0% 40.5% 60.0% 52.8% 45.6% 42.1% 39.6% 81.6% Younger ED Long Term Condition Frail Elderly 40.0% 45.8% 20.0% 32.6% 42.0% 47.0% 50.5% 0.0% 13.7% 11.2%

16 Younger ED cohort - presentations 1% 2% 1% 9% 2% Alcohol Abdominal Pain Mental Health 32% alcohol 2% 3% 32% Injuries Substance Misuse Chest Pain Self Harm 18% self harm 18% Seizures Learning Disability 10% subs misuse 7% abd pain 4% 10% 5% 4% 7% Abcess Cellulitis Pelvic Pain Pain Other 4% Primary mental health reason

17 LTC COHORT MAIN PRESENTATIONS 8% Abdominal Pain COPD 20% Asthma 18% COPD 12% DIABETES 8% ABDOMINAL PAIN 4% ASTHMA 2% 4% 5% 8% 3% 5% 3% 2% 4% 12% 18% 2% 4% ALD Diabetes Urology C.V.S Chronic Pain Renal Epilepsy / Seizures Cardiac conditions Colorectal MS Mental health Other

18 PACT 1. Algorithm identifies high risk cohort 2. Patients triaged according to clinical picture 3. Suitably trained keyworker allocated

19 4. Keyworker + patient + key clinicians agree individualised anticipatory care plan 5. Care plan shared with patient, hospital / Gp

20 Engagement challenges Appointment sent with explanatory letter Opt in letter Opportunistic Specially written software to allow staff to identify, in real time, which patients from the cohort are in hospital and where

21 Patient details GP Other contacts Diagnosis Medication: as per ECS Blank care plan

22 Background Guidance during consultation Patient experience Who to contact on discharge Please note this care plan is a guide only, and its contents should be overridden when in the best interests of the patient. Always seek real time ED physician advice when there are management difficulties. It is good practice to always check current accuracy of information with patient, GP letter, KIS and hospital medical notes. DATE FOR REVIEW

23 Some younger ED care plans are focused on risk management - consistency of care Some involve using the mental health nurses skills in brief interventions to enable patients to engage in self care and engage with services that may benefit them.

24 Example from Younger ED group 12 Professional meetings and case conferences s Regular updates and review of care plan Currently on version 15 of care plan Now has consistency of approach

25 Risks If not admitted how does the patient cope with their distress Options- increase input from appropriate community or outpatient resources PACT team input in ED Liaison Psychiatric input 3 rd sector- Cyrenians, Samaritans etc

26 LTC GROUP COPD - anticipatory care planning and augmented out-of-hospital management Diabetic psychiatry service LTC general

27 Patient experience Individual guidance / experience Lack of continuity / mixed messages Challenges of changes in service delivery Feedback to A&E or ward teams on what goes well or not

28 Clinician reflections Seeing patients who would not otherwise be referred - undiagnosed psychiatric disorder / adjustment issues / MUS/SSD Getting an view of the patient s perspective

29 Proposed Evaluation 1. Financial modelling: acute hospitals 2. Impact upon other services: GP, SW 3. Patient satisfaction /experience 4. Referrer/collaborator satisfaction

30 Early evaluation of ACPs Hospital based activity was extracted for ACP cohort for 6 and 12 months pre and post ACP plan Activity data costed using patient level costing by Scottish Government.

31 Early evaluation of ACPs 6 months Positive findings 6 months pre and post : Based on 400 patients. A&E attendance declined by 31%, resource use fell by 76k. Emergency inpatients admissions fell by 33% and occupied bed days by 17%. Corresponding resource use fell by 468,000.

32 Early evaluation of ACPs 12 months Positive findings 12 months pre and post: Based on 205 patients. A&E attendances declined by 34% and resource use by 79k Emergency inpatient admissions fell by 43% and occupied bed days by 32%. Corresponding resource use fell by 810k.

33 6 reduction in clinical demand for every 1 invested. ED reduced demand + Reduced admissions = 78, ,412 = 889,265 for 205 patients = 4,338 per patient PACT has completed and uploaded care plans for 577 patients, hence annual saving = 577 x 4,338 = 2.5million for an investment of 400k

34 This is prelim analysis Need to compare with robust control group to attribute impact to Pact

35 Cautiously optimistic Decline in emergency inpatient specialities are those which cohort would tend to use frequently toxicology. Decline has been maintained over 12 months for sample cohort.

36 Updates next year..