Evidencing Pennine Care s impact High level summary report August 2015
Treatment of long-term conditions will be at the centre of the debate 1. Long term conditions constitute the bulk of patients and NHS spend 30% people in England have a long-term condition. 70% of health and social care spend is on longterm conditions 2. Mental health is a significant component of long term conditions 2x as many people with physical long-term conditions also have mental health problems compared to the rest of the population, in addition to being a long term condition in its own right. 3bn is spent each year across the country on treating Medically Unexplained Symptoms which are associated with inadequate care of mental health disorders. 3. And the funding is in the wrong place 65% 20% or more of all secondary care could be of the NHS spent is on secondary care rather than primary and community where long term conditions could be more effectively tackled. saved if long-term conditions were cared for more extensively in the primary and community setting, our literature review suggests. 2 Frontier Economics
Greater Manchester Devolution presents an important opportunity to implement new models of care 12 CCGs to set out their healthcare needs 6bn budget for health and social care in Greater Manchester 15 NHS providers to compete for the health spend PCFT can both help shape and play a central role in the new system 10 Local authorities to share the budget 3 Frontier Economics
PCFT is already implementing many desired changes Manchester Devolution challenge I. Saving money 1. Investment in care earlier in the pathway 2. Release patients from acute care earlier 3. Self-management II. Developing new models of care 1. Better collaboration in step-up/step-down 2. Integration of mental and physical health 3. Innovative self-care and patient education 4. Focus on particular patient groups III. Placing patients at the centre 1. Fewer, shorter hospital visits 2. Patient participation 3. Care closer to home PCFT s whole person care model 4 Frontier Economics
PCFT has implemented several interventions to deflect patients from acute settings we have assessed: Psychiatry Liaison (RAID) Based in hospitals to support the diagnosis, assessment and management of people with mental health issues Saffron Ward Provides intermediate care for older patients who have mental health conditions, mainly delirium, as a comorbidity Butler Green An enhanced intermediate care facility providing enhanced recovery and rehabilitation to avoid being admitted to hospital, or to avoid a prolonged stay. My Health My Community Portfolio of tools, information, guidance and education about long term conditions to encourage and support self-care. 5 Frontier Economics
Case 1: Psychiatry Liaison (RAID) Overview Pennine Care provides psychiatry liaison services into four acute hospital sites. It is based on Birmingham s Rapid Assessment Interface and Discharge (RAID) model. The service comprises three separate teams older people s liaison, A&E liaison and alcohol liaison who support the diagnosis, assessment and management of people with mental health issues within an acute setting. It is available 24/7 to anyone aged over 16 years old. A further important role for the team is to educate and train general hospital staff in how to diagnose and treat common psychiatric, psychological and emotional problems. This requires intensive work with a small number of patients to develop care and discharge planning advice, assisting patients to eat and drink properly and providing support to families and carers of RAID patients. Staffing The RAID teams include qualified mental health practitioners and nurses, as well as Consultant Psychiatrists. Objectives RAID aims to: i. Deflect patients from A&E ii. Prevent a patient s mental heath condition prolonging their hospital stay unnecessarily iii. Deflect admissions (or re-admissions) from acute healthcare iv. Facilitate the efficient allocation of resources by better identifying mental health conditions v. To train up acute care staff to better identify and manage mental health conditions Outcomes Pennine Care has demonstrated that its psychiatry liaison services significantly improves outcomes for patients, is cost effective and promotes parity of esteem for mental health. In 2014, more than 2,200 referrals were received for the Older People s RAID service alone. An evaluation by the University of Chester found that 99% of patients and carers rated their overall experience with RAID as excellent or good. The study also found that 93% of acute staff reported that the involvement of RAID improved the quality of care provided. 6 Frontier Economics
RAID findings Inputs Resources for older people s liaison team Resources for A&E liaison team Resources for alcohol liaison team Resources for existing acute hospitals to have their staff trained by RAID teams Indirect costs (including overheads) Activities Outputs Outcomes Impacts RAID teams work in wards and A&E (depending on the focus of their team) Deliver training sessions to acute staff to better manage those with mental health conditions Carry out a number of joint assessments with acute staff Intensive work with a small number of patients to develop care and discharge planning advice Supporting daily living activities; timely access to diagnostics; medication compliance; appropriate anti-psychotic prescribing Providing support to families and carers of RAID patients. Patients receive appropriate care and discharge plan Appropriate onward referral to treat delirium e.g. to Saffron ward Advice and support delivered to patients to eat properly Training delivered to acute staff to better manage patients with mental health conditions Advice and support delivered to families and carers Reduction in length of stay of patients with mental health conditions Reduction in A&E attendance and admissions attributable to mental health (target frequent fliers) Having both physical health and mental health needs met in an integrated way Reduction in admissions and readmissions to acute wards Acute staff feel more confident dealing with patients with mental health problems Better care for patients (improved clinical outcomes and patient satisfaction) Parity of esteem between mental health and physical health Savings for the healthcare system from delivering more appropriate care We found: 11,219 patients had been seen in 2014/15 1,649 estimated bed days have been saved from shortening acute ward length of stay Around 1,511 deflections have been achieved from each of A&E and ward admissions Benefits exceed costs by an estimated 0.5 million for 2014/15 Please note this is a cautious assumption, based on data available at the time. External factors such as readmission rates, reduced ambulance call outs and reduced long term care have not been factored in. 7 Frontier Economics
Case 2: Saffron ward for older people with delirium Overview Saffron ward is a 20-bed unit that provides specialist mental health care for people over the age of 65 who are experiencing delirium. It has been operating for just under one year. The ward accepts patients as a step-down from acute physical health to provide the right care for their needs. Whilst a physical health condition can often be treated with ease, an ongoing confused state means older patients are too mentally unwell to return home, leading to an extended stay on a hospital ward. Saffron provides a viable alternative to this. The Trust s Psychiatry Liaison (RAID) team in-reaches into the acute wards to identify suitable patients who can be transferred to Safford ward, helping to reduce acute length of stay and pressures. Staffing Saffron ward is staffed by an expert multi-disciplinary team including a GP, registered mental health nurses and general nurses, physiotherapists, occupational therapists and social workers, all with mental health experience. Objectives: i. Identify and provide appropriate treatment for patients with delirium ii. Reduce the length of stay in acute hospitals iii. Reduce readmissions to acute hospitals Outcomes Through the development of the Saffron ward model, Pennine Care has demonstrated that although this group of patients has relatively easily identified and treated physical medial conditions, they often remain in the most expensive part of the care system due to the complication of their continued confusion. An intermediate community care model, consisting of an integrated multidisciplinary team with mental health experience and specialism, is ideal for managing this patient cohort in a cost effective way that achieves improved outcomes. It costs the NHS approximately 1,000 less per week for a patient to be on Saffron Ward than in hospital. 8 Frontier Economics
Saffron ward findings Inputs Activities Outputs Outcomes Impacts Resources for 15 beds on substantive funding and a further 5 beds as part of winter resilience. Resources for the PFI building Delirium appropriately identified and treated Close working with the RAID team to be able to admit older patients in need of care to the ward Delivery of care and discharge plans for patients Trained team able to identify appropriate care and make suitable onward referrals as appropriate Reduction in acute hospital length of stay Avoid re-admissions to the acute hospital Better care for patients (improved clinical outcomes and patient experience) Staff: GP Psychiatrists Occupational therapists Social worker Nurses Physiotherapists Any indirect costs Trained medical team to be able to administer the appropriate care for the patients Communal eating encourages adequate dietary intake Development of discharge plans to ensure safety Reduction in acute security staff (that keep watch over patients with delirium) Beds available to take in patients who have delirium (and a number of other comorbidities) Multidisciplinary team able to identify and design appropriate package of care for the patient More appropriate care pathways as a result of multidisciplinary medical teams Fewer inappropriate onward referrals e.g. to ill-suited care homes Better focus on mental health given referral mainly come via RAID teams Savings for the local health economy from reduced long term costs We found: Saffron has a 92% reported occupancy rate with 15 beds April October 2014 and 20 beds from November 2014 March 2015 Around 5,700 bed days have been deflected from acute wards over 2014/15 Benefits exceeded costs by around 0.3 million in 2014/15 Please note this is a cautious assumption, based on data available at the time. External factors such as readmission rates, recovery rates and reduced long term care have not been factored in. 9 Frontier Economics
Case 3: Butler Green enhanced intermediate care Overview Butler Green is an enhanced intermediate care facility in Oldham. It provides enhanced recovery and rehabilitation to help local people avoid being admitted to hospital, or to reduce acute length of stay. It provides both step up and step down care meaning primary care and acute care staff can refer patients. It has 28 beds comprising 20 nursing beds and 8 clinical enhanced beds. In addition to a bed-base, Butler Green provides a comprehensive blend of nursing and therapeutic interventions. The service also operates an ambulatory IV therapy clinic, urgent response to patients at home, A&E therapy in-reach and a GP helpline. All staff are trained in mental health brief interventions. Staffing Butler Green is delivered by a multi-disciplinary team of health and social care professionals, including nurses, physiotherapists, occupational therapists, social care workers and GPs. Objectives: i. Reduce admissions to acute hospitals by being a step up facility ii. Reduce the length of stay in acute hospitals by being a step down facility iii. Avoid admissions for IV therapy by providing ambulatory and domiciliary IV therapy iv. Avoid A&E presentations by offering an urgent care service Outcomes Pennine Care has developed and enhanced the Butler Green service in Oldham to establish a flagship model for delivering effective intermediate care in the community, as a viable alternative to hospital: The national average referral to admission time is 78 hours, at Butler Green it s 24 hours The average length of stay has reduced from 45 days to 16 days 96% of patients would recommend Butler Green to their family and friends 10 Frontier Economics
Butler Green findings Inputs Activities Outputs Outcomes Impacts Resources for staff: 2.39 admin 9.5 allied health professionals 0.6 medical IV therapy : - Domiciliary - To clinically enhanced patients within Butler Green - In an ambulatory clinic Butler Green clinically enhanced beds and standard beds able to provide a step up and a step down service A&E admissions deflected as a result of the urgent care response team Better care for patients (patient satisfaction and improved quality of life) 33.6 nurses (all grades) Resources for 8 clinically enhanced beds 20 nursing beds Resources for premises Indirect costs Nursing care: - Holistic assessments of patients including medication assessments - Enhanced treatment to patients in Butler Green - Community nursing Physio/ occupational therapy: - Assessments in own home and for inpatients - Follow ups with patients after discharge Urgent care response team Urgent care response team able to attend to patients without the need for them to attend A&E Ambulatory clinics available for IV therapy patients Multi-disciplinary team that works together to develop the most appropriate form of care for patients at home or in Butler Green Acute ward admissions deflected as a result of step up service Acute care length of stay reductions as a result of step down service Acute ward admissions deflected as a result of ambulatory and domiciliary IV therapy Savings for the local health economy from reduced long term costs We found: 1,235 patients were seen in 2014/15 Around 977 deflections from acute ward admissions via A&E Around 5,268 deflected bed days from acute care via step down service (including IV therapy) Benefits exceed costs by around 0.94 million Please note this is a cautious assumption, based on data available at the time. External factors such as readmission rates, reduced ambulance call outs and reduced long term care have not been factored in. 11 Frontier Economics
Case 4: My Health My Community Overview My Health My Community (MHMC) is a portfolio of tools, information, guidance and education delivered through various accessible channels including online, face to face and mobile apps. All elements of MHMC are intended to educate and upskill individuals about long term conditions and how they can be managed effectively at home while avoiding having to go to hospital. By being an up to date, credible and trusted resource for communities, MHMC aims to support individuals and their families and carers to manage their long term conditions and build community resilience. The long term conditions MHMC focuses on are dementia; diabetes; stroke; asthma; COPD; cardiac disease; and end of life care. For the purposes of this evaluation, we have looked closely at three key elements of the programme Sugar 3 a resource for children with Type 1 diabetes, Puffin a resource in development for children with asthma and deflection of community nursing activity. Objectives: MHMC has several key aims: i. To support communities by building knowledge and awareness of health topics (such as managing long term conditions) ii. To provide accessible support and education through various means such as face to face and online iii. Promote self-management by building patients confidence and self-care skills iv. To act as an enabler to support the healthcare integration agenda v. To improve and increase service efficiency Promoting self-care is likely to therefore lower the need for these individuals to attend A&E; reduce hospital admissions; reduce primary care contact; and reduce calls upon community services. 12 Frontier Economics
Sugar³ for children s type 1 diabetes This is a portfolio of educational modules, advice, tools, trackers and interactive activities for children with type 1 diabetes. It intends to help young people manage their diabetes, self care and improve their health. Data suggest that the number of children in the boroughs with diabetes (in Bury, HMR and Oldham) is approximately 1,200. We found that: Sugar³ needs to deflect 55 patients from A&E and 55 from acute ward admissions per year to break even (i.e. deliver benefits at least as great as costs) Over a 5-year period, deflecting 55 patients from each of A&E and ward admissions would result in net benefits of 163,730 (in present values) to break even including the upfront investment costs Puffin for children with asthma This is a portfolio of educational modules, advice, tools, trackers and interactive activities for children asthma. It intends to help young people manage their asthma, self care and improve their health. It is worth nothing that Asthma UK estimates that 75% of all asthma induced hospital admissions are avoidable. We found that: Puffin needs to deflect 39 patients from A&E and 39 from acute ward admissions per year to break even (i.e. deliver benefits at least as great as costs) Over a 5-year period, deflecting 39 patients from each of A&E and ward admissions would result in net benefits of 112,667 to break even including the upfront investment costs Community nursing deflection If patients are activated to self-manage their long term conditions, activity can be deflected from the community nursing teams, enabling the nurses to dedicate more time to complex care. MHMC supports individuals to self-care through its website, face-to-face classes and a range of other educational activities. Where patients are able to self-care, this deflects activity from the nurses, acute settings, and also primary and community care. We found that: Deflecting 1% of community nursing activity means the benefits of this intervention outweigh the costs. 13 Frontier Economics
Key observations for PCFT 1 PCFT has successfully implemented new and innovative interventions 2 The PCFT case study interventions deliver benefits significantly greater than costs Targeting high value high deflection services delivers high returns 3 4 Interventions that promote patient activation for self-care offer significant potential to be costeffective Further evidence is required to make the case for these interventions even stronger 14 Frontier Economics
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