Long term Conditions Event

1. Long term Conditions Event Atlantic Quay 17 November 2011

2. Improving Risk Prediction 1. Risk stratification user interface SPARRA STACCATO

3. Targeting care through the application of Risk StratificationNHS Tayside/NHS Grampian

4. What are we trying to achieve? • More targeted and co-ordinated care at a local level • An objective and smart way of managing data to assist in day to day business • To demonstrate the applicability of the model developed in Tayside to another Board area where IT systems differ

5. Why are we trying to achieve this? • Future challenges of changing demographics • Need for high quality, safe,efficient and effective service delivery • Objective, user friendly way of managing populations and monitoring caseloads

6. Where have we got to? • 11 practices agreed to take part • Revised timescales applied to PID • Aim to move forward and pilot from January • Completing final arrangements with Tayside, environment now ready • Data Sharing Protocol going through sign-off • Good buy in and enthusiasm to progress

7. Improving Risk Prediction Risk stratification user interface 2. SPARRA STACCATO

8. Enhanced SPARRA Predictive Model & SPARRA Patient Alerts Risk prediction and service development Kathleen McGuire – Long Term Conditions Manager Ehealth LTC Workshop November 2011

9. Aim Integrated systems and communications Expand the cohort of patients for whom a risk score can be calculated over and above the current SPARRA “All Ages” (Version 2) algorithm Improve the predictive power of the algorithm Provide the board with a risk prediction tool which will identify patients for referral to Community Wards

10. Scope Feasibility of a model which included GP/Primary Care, Social Care, Accident and Emergency and Prescribing data. Any other potentially useful sources which may serve as a predictor for emergency hospitalisation, including falls and IoRN. Producing a linked data set Improved data links to and from Primary and Secondary Care

11. Deliverables Data extract specification Predictive risk model (with technical report and recommendations) Reporting and implementation scoping requirements (report) Prototype reporting tool (with user manual) Final report (with conclusions and recommendations) Post project evaluation (report )

12. Lessons learned will inform the national development of SPARRA, predictive risk modelling, related tools GP SCI Gateway referral message integrated into ADASTRA

13. How we have taken forward Appointed a Data Analyst Appointed a Project Manager Gained strategic organisational commitment- eHealth programme Gained buy in by utilising other national SPARRA developments & improvements Integrated the project with service development of Community Hubs Expansion of current LES

14. SPARRA Prediction & Tools Accident &Emergency Information Tool LOTS Social Services SPARRA Navigator LES I SPARRA Nursing Homes ADOC Patients/Carers

15. Community Hubs SECONDARY CARE Acutely illPatient NHS 24 Intermediate Care & Enablement Teams Chronicallyill Patient PRIMARY CARE TEAM AHPs Pharmacy OT Specialist Nurse Geriatric ANPs SOCIAL SERVICES SPOC Social Care Liaison HUB GP Multiple/Complex Social-needs Patient Practice Nurse District Nurse Community Wards Enhanced SPARRA CPM AYRSHIRE HOSPICE ADOC CARERS (Kinship / Professional)

16. What we have learned so far Project needs to be integrated with other development Requires stakeholder buy in Differing views around data specification Quality and coding of data Informed consent and data sharing

17. What we have learned so far Time, expertise and partnership required IT systems used in out of hours setting suffer from poor demographics and duplicates Integrating Primary Care systems with the out of hours service requires a primary data cleansing task

18. Our wish To use the principles of risk adjustment to evaluate the pathways of complex community-based interventions to reduce avoidable hospitalisation, eg testing the cost effectiveness of Community Wards and Telehealth To link large datasets at an individual level pseudonymously through our partnership arrangements and relationships Predict future costs of health and social care

19. Our wish To exploit new Clinical Portal technology to help distribute electronic information to the point of care. Successful procurement of a new community wide IT system (currently in progress) to support collection of data and distribution.

20. Requirements & Next Steps National Support and continuation CHI Seeding, time & expertise Integrated IT systems within and across organisations Go live with model 1st April Extend roll out and testing of CPM Further integrate SPARRA & IRF

21. Improving Risk Prediction Risk stratification user interface SPARRA 3. STACCATO

22. STACCATOStow Anticipatory Care Community Assessment Tool Dr Paul Cormie Sandra Pratt NHS Borders

23. What is it? • Computer based assessment tool for comprehensive functional and social assessment in patient’s home • 3 scenarios: • Current situation • Patient unwell • Carer unavailable • Risk prediction • Decision support software to enable consistency in addressing unmet need and anticipatory care planning • Information directory individual to each patient

24. The aims … • Preventing crises: • falls, • carer stress, • nutrition, • aspiration (pneumonia & UTI) • Preventing admission if a crisis arises: • Predict problems likely to arise if patient or their carer becomes unwell – logical approach to anticipatory care planning

25. The aims … • Improving discharge planning should admission be necessary – the next step: • Detailed information on functional and social status prior to the problem resulting in admission • Optimal use of health care professionals in hospital • Discharge planning starting within 24 hours of admission • Communication tool with primary care

26. Progress so far… • Rolled out as LES across NHS Borders – all GP practices opted in • Full Social Work engagement – adapted their IT system to host assessments & collect evaluation data • Out of Hours – storing assessments on shared folder in hospital & noting availability on NHS24 record • Voluntary Organisations fully involved – Neighbourhood Links, PRTC, BIAS

27. Funding….. • eHealth LTC funding: • 13 laptops for use by primary care teams in NHS Borders to carry out the patient assessments in their own home. • Provide backfill for the District Nurse on the project team to carry out training on the use of the tool in each of the primary care teams in NHS Borders • Enable a quantitative evaluation of the effectiveness of the tool

28. Other Funding … • NHS Borders: • Anticipatory Care Local Enhanced Service (GPs) & additional resource for district nurses • Change Fund: • additional social care including Bordercare, voluntary organisations, • Scottish Govt: • qualitative evaluation through University of Edinburgh 2012 • Endless amounts of Paul’s time….

29. Challenges …. • IM&T: configuration of laptops; information sharing with OOHs and Social Work; • DN access to Social Work IT system – practicalities • Communication– making sure everyone is in the loop, engages & understands • Managing anxiety about: • potential impact on DN capacity • competency with use of IT • Changing working practice

30. Evaluation … • Number of ACPs in place • Number of plans activated; times activated & outcomes • Numbers admitted / readmitted (longer timescale) • Identification of unmet need & additional care / services needed to support at home • Related referrals to voluntary organisations • Feedback from DNs: use of assessment tool & process; activation of ACPs • Patient & carer feedback • Longer term qualitative evaluation (Edinburgh University)

31. Future developments • More detailed social care planning section • Hospital discharge planning section • Care Home assessment • Tentative plans for a polypharmacy risk assessment section

32. Key Information Summary (KIS) LTC eHealth Event 17 November 2011

33. Agenda National Overview Progress Next Steps Local Project Feedback NHS Greater Glasgow and Clyde NHS Forth Valley NHS Highland / NHS Grampian NHS Tayside Q+A

34. KIS Overview Extension of ECS – not a new system Aims to replace paper based faxing of “Special Notes” from GP Practices More generic version of ePCS Support for: electronic Anticipatory Care Plans (eACP) Long Term Conditions Mental Health Utilise existing ECS infrastructure and process Expecting 500,000 patients to have KIS information in place

35. 4 Sections on KIS Form Section 1 – “Special Note” Free text field of 2048 Characters Expiry Date Patient and Carer details Other demographics (Next of Kin) Section 2 – Current Situation Medical History ACP / Self Management Plan agreement Home Oxygen

36. 4 Sections on KIS Form Section 3 – Care and Support details Homecare support Incapacity / Guardianship Power of Attorney Section 4 – Resuscitation DNACPR CYPADM (Children Resuscitation) Current and Preferred Place of Care

37. Progress to Date GP Systems Specifications complete Testing to start next week Demonstrations held for EMIS Central ECS Live and ready for KIS End user systems progressing Patient Communication LTCAS engagement FAQ’s / Clinical Guidance

38. Next Steps Pilots! February for EMIS / Vision Testing Several phases based on development from suppliers Complete Clinical Guidance Support LTC pilots Prepare for national rollout eHealth Strategy deliverable by 2014

39. Long Term Conditions & e-Health KEY INFORMATION SUMMARY Initial development complete, KIS displaying in test portal. Stylesheet update - November 2011 Review and approval by ECS user group Nov – Dec 2011 Portal Release – Dec 2011 Pilot practices identified – pilot February 2012 following delivery of KIS for EMIS in Jan 2012 Lessons learned reported back - March – April 2012

40. Long Term Conditions & e-Health Clinical Scenario Mr Smith, 76 yrs, Mild to moderate dementia Carer is 75 yr old frail wife Has had an SSA completed and care manager appointed by social work Has a care plan Mr Smith becomes ill on Saturday and presents to OOH GP…

41. Long Term Conditions & e-Health AT PRESENT The SSA and care plan are paper based and not easily shared. The OOH GP may have a faxed special note re the patient but may not. The OOH GP doesn’t know what services are involved, or why the patient is agitated and resistant to intervention by medical staff The patients carer appears frail, so the patient is admitted for IV fluids and antibiotics. The patient becomes more agitated and confused in the unfamiliar hospital environment and the carer is without the usual community supports Hospital staff are unaware of the patients full history or how best to manage him Patient deteriorates and carer struggles to cope leading to prolonged admission

42. Long Term Conditions & e-Health IN FUTURE… Those working with patient in the community (health and social care) will be able to see SSA and care plan from the Clinical portal GPs completes KIS, indicates is care plan, states history and diagnosis, key contacts, services available and care manager OOH GP has enough information to treat patient without admission Patient remains in familiar environment and does not become agitated Carer continues to receive support in the community If patient does require to be admitted, hospital staff can see history in portal, knows who key contacts are and can work with discharge teams for speedier supported discharge.

43. Key Information Summary NHS Forth Valley Progress to date

44. KIS / EMIS evaluation Local KIS Project Board established 11 GP practices recruited Practice Teams established Meeting of practices scheduled for 1st December Key contacts in OOH and ED established KIS progress monitored through CHP eHealth committee via monthly highlight report QI involvement to develop evaluation methodology and evaluation tools

45. KIS / EMIS evaluation Raising awareness of KIS pilot at Organisational level e.g. GP sub, ACF, LTC. Keen for FV staff to be involved in Webex demo / SEF testing etc. Developed a KIS intranet webpage Key concern – timing of Adastra implementation On track for KIS live testing Feb / March 2012

46. Improving Support in Anticipatory CareKey Information Summary (KIS) in Vision PracticesNHS Highland /NHS Grampian

47. Progress Nov 2011 • Grampian GP-sub have endorsed project • Grampian have identified the test practices • In Grampian links have been established locally with Living Well Dying Well Clinical Lead to ensure continuity with ePCS and palliative process of care

48. Progress Nov 2011 • NHS Highland Project Manager appointed • Stakeholders identified • Continued rollout of ePCS • Pilot documentation under development for distribution to practices • Work started to integrate local LES into workstream • Integration into LTC programme • Pilot practices to be identified over coming weeks

49. Next Steps • NHS Grampian/Highland joint working group to be established • Joint project plan development • Options for Adastra ACPA conversion to be identified

50. NHS Tayside update Awaiting outcome of decisions / options on MIDIS integration Suggested option that MIDIS could directly add information to KIS outside of GP Practice Links to Clinical Portal Any developments shared with all MIDIS boards Change in OOH system expected in March Support for SEF testing