Improve frail elderly care with evidence, not intuition

Improving the health and quality of life for frail and elderly people in Camden, north London, and improving primary care services are two of five health priorities identified by Camden Clinical Commissioning Group. The CCG found that elderly people with the most complex health and social care needs frequently experienced fragmented services that were difficult for them and their carers to navigate.

This poorly coordinated care also increased the clinical risks in handovers and led to a high rate of admissions and readmissions to hospital that are costly with limited improvement in outcomes.

The CCG’s aim is to deliver integrated services to all patients with complex and chronic mental and physical problems, including the frail and elderly, which improve the coordination and continuity of care for patients.

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‘The number of days spent at home was seen as particularly important by elderly patients’

To achieve this the CCG supported patients, carers and professionals to come together to define a range of outcomes – now used as system measures of success – and develop the model of care in partnership with us.

Camden developed and implemented multidisciplinary teams integrated across secondary, primary and community health and social care providers to coordinate and plan care for the borough’s most vulnerable elderly patients.

Risk stratification

This group of patients are identified through the use of a risk stratification tool that assesses those who would benefit most from this approach. A care plan for each patient is then formulated.

Those patients with less complex needs are discussed at team meetings in the GP surgeries, while those with complex needs are referred to a weekly borough-wide multidisciplinary meeting.

Team members at the borough-wide meetings are led by a geriatrician and GP, and include hospital and community based nurses and allied health professionals, social workers and mental health professionals. This joint working is supported by a shared IT system that allows information to be captured and disseminated electronically across the health and social care system.

The new approach aims to increase the amount of time people spend at home through early intervention, prevention and recovery, and as a result reduce the amount of time the most vulnerable elderly people spend in hospital.

When patients, carers, clinicians, providers and the CCG jointly developed the outcomes to measure the success of the multidisciplinary teams, the number of days spent at home was seen as particularly important by elderly patients.

Reducing admissions

One patient who has benefited from this approach had multiple hospital admissions as a result of her long term condition. Assessment and care planning by the team stabilised her condition. As a result she has not been to hospital since the care plan was initiated and the cost of her care has reduced from £9,100 a year to £3,600.

The borough-wide team has supported about 250 patients in its first year. Current results from 93 patients show an increase of 7 per cent in the number of days they were able to spend at home in the six months after receiving support.

The impact of this has been:

• a 51.8 per cent reduction in emergency bed days;
• a 47.7 per cent reduction in accident and emergency attendances; and
• a 32.9 per cent reduction in first and follow up outpatients’ appointments.

Further data suggests the benefits of collaborative working (professional relationships and IT support) through the multidisciplinary team have a wider impact and lead to cultural shifts, which extend to those patients who are vulnerable but have less highly complex needs, with reductions in emergency admissions across the 64-75 year population.

‘The CCG has moved its decision making process from one based on intuition to one based on intelligence’

The focus is now on expanding the care team and the CCG is working closely with GP practices to increase the numbers of elderly patients identified.

Another focus for Camden CCG in its first year was improving the quality of primary care services throughout the borough. GPs and practices, as independent contractors, have often worked in isolation with marked variability in the quality, range and accessibility of services offered.

While not commissioners of primary care, CCGs are responsible for continuous improvement in the quality of primary care with a unique role for clinical commissioners to influence colleagues.

The CCG has worked with its three localities to encourage peer review, reducing variability between practices and sharing successes.

As a result, Camden improved and achieved the best antibiotic prescribing rates in primary care in London at 4 per cent - 1:25 of the population - and agreed quality measures for primary care.

Practice development plans

Each practice has a profile to help them put together a practice development plan to improve those areas of weaker performance.

The practices have also been involved in data capture exercises to understand the demand and capacity across Camden’s system for unscheduled care. Evidence collected from a borough-wide audit of demand for urgent care on 9 September 2013 demonstrated that of all 1,812 patients seeking urgent care, 85 per cent were managed in general practice.

Further evidence from the data segmented the population attending A&E into four cohorts:

• under-5s;
• 19-44 year olds mainly registered with a GP but who did not try to access them;
• 55-70 year olds with long term conditions including mental health problems; and
• Over 75s, who are a relatively small number but the highest risk of admission.

In order to reduce A&E attendances, the CCG used this data to inform how demand and capacity within practices need to be met and how each of these different groups’ needs might be met. The practices have worked with the CCG – incentivised through an innovation fund – to implement and evaluate a range of pilot schemes to reduce the numbers of these groups attending A&E.

The CCG’s primary care mandate sets out a three-year programme to federate practices to further increase access and improve quality and equity of services delivered in primary care.

A holistic digital view

The transformation of services for the frail and elderly and across primary care would not have been possible without new technology, both to enable the changes and provide analytical capacity to measure and monitor outcomes.

The CCG has driven the creation of the Camden Integrated Digital Record, with the necessary data sharing agreements in place, that brings together data held in the disparate health and social care systems in the area to support a holistic view of the each patient’s care.

‘Breaking down barriers across organisations to ensure the patient is at the heart of services is not culturally or contractually easy’

This provides the care community with the ability to view care records (with the patients’ consent) through the use of a platform for an integrated care process without organisations having to be moved onto common platforms. The use of data and analytics to provide insight into the issues and identify the potential for sustainable transformational change has underpinned the CCG’s approach.

A small, highly skilled analytical team, supported by powerful flexible data management and analytic tools, has allowed the CCG to move its decision making process from one based on intuition to one based on intelligence.

The CCG found that working collaboratively is easy in theory but more difficult in reality and breaking down the barriers across organisations to ensure the patient is at the heart of services is not easy, culturally or contractually.

CCGs need to build confidence among their patients and clinicians by using evidence to show there is a need to deliver services in new ways and settings, and that these services will deliver improved quality, safety and effectiveness.

Dr Caz Sayer is chair of Camden CCG and a local GP