National Audit of Intermediate Care

National ConferenceBirmingham, Sept 12th 2012

Professor Finbarr C. MARTIN Geriatrician

Guys and St Thomas’ Hospitals & King’s College LondonPresident, British Geriatrics Society

Intro

Well done !

• Starting data informed discussion is good• Linking organisational and patient level

data is good• This was a vital first step

How did we get here?(and what might we have lost sight of on route?)

• Damon has given the policy context and aspiration

• The aspirations are at many levels

– Improved experience for patients

– ?? For carers

– Better outcomes for patient?

– More sustainable public services (ie efficiency)

– Reducing inequity and inequalities

• Being integrated or even being the glue in the system is proving a challenge

• Are the 10, 20 and social care building blocks the problem?

Key considerations

What service problem are we trying to solve ?

- a system level diagnosis is needed JSNA

What is the clinical nature of the work ?

- necessary to define the skills needed

Who are the right patients/users ?

- need evidence of ability to benefit

How is it done best

- dearth of evidence on this

What are the success parameters ?

- at system and individual levels

What are JSNA may wish to consider(From DH guidance)

● the number and occupancy of beds in acute and community

● incidence rates of emergency admissions for people over 75

● the average length of stay for certain index conditions

● the rates of new admissions to care homes

● the pattern of repeat admissions

● discharge locations from acute care eg. of people over 75

● the locations of people 3 and 12 months after leaving IC

● the number of people receiving intensive home care.

Key considerations

What service problem are we trying to solve ?

- a system level diagnosis is needed JSNA

What is the clinical nature of the work ?

- necessary to define the skills needed

Who are the right patients/users ?

- need evidence of ability to benefit

How is it done best

- dearth of evidence on this

What are the success parameters ?

- at system and individual levels

Some Clinical issues

• Criteria for acceptance

– Medically stable

– Ability to benefit from rehab

– Needing significant mental health input

• Does it matter that geriatricians were hardly involved in this service largely for older people?

• Should post acute care be an opportunity for systematic CGA based care?

• What is in the black box (ie patients as well as the interventions!)

Illness, recovery and interdisciplinary inputs

intensity

Time from onset of disabling illness

nursing

medicine

physio

occupational therapy

socialwork

(adapted from HAS Thematic review 1997)

Timely hospital discharge

Vicious Cycle of Dependency

Incomplete recovery

Readmissions and LTC increased dependency

Vulnerable to change

This is what IC is trying to impact

Some Clinical issues

• Criteria for acceptance

– Medically stable

– Ability to benefit from rehab

– Needing significant mental health input

• Does it matter that geriatricians were hardly involved in this service largely for older people?

• Should post acute care be an opportunity for systematic CGA based care?

• What is in the black box (ie patients as well as the interventions!)

Does the evidence from RCTs help ?

RCTs can clarify causality,

ie treatment x given to patient y produces outcome z(more commonly than chance or placebo, but not

always)-------------------------------------------------so what is treatment x ?and who is patient y ?what is the importance of the context ?what else affects outcome and individual variation ?

Who is patient y

eg. Supported discharge teams

Lambeth Gloucester

Bartel 15 (11-18) 16 (15 -17)

Cognitive impairment mild/moderate nil/mild

morale low low

functional change slight slight

Controls at home 40% 66%(at 6 months) Impact of intervention significant not significant

What does success imply?

Low morale or high discharge related anxiety may :– predict those most likely to benefit– predict those with higher rate of adverse

outcomes

Δ Risk adverse schemes miss the point !!

What is treatment x ? –eg duration

Supported/Early discharge teams costs

Kettering (acute) orthopaedic 4-6 days same or less

West London (rehab) orthopaedic 9 days more

Kettering (acute) chest disease etc 9 days same or less

Bristol (mixed rehab) 15 days same

Lambeth (mixed older people) 22 days less

Nottingham (mixed older people ) less

So we need to know the nature of the problem to be solved, and for whom, to interpret the LOS and resources etc

How might audit help?

• Later presentations make good suggestions

• Encourage commissioners to be strategic• Encourage services to combine clinical

governance across sectors

• Encourage clarity of purposes • Be holistic rather than functional