Download Most people with any long term condition have

Role of Risk Prediction
in achieving our 2020 Vision
Dr Anne Hendry
National Clinical Lead for Quality
JIT Associate
Headline Projections
• 21% rise in 65+ from 2006 – 2016
62% rise by 2031
• 38% rise in 85+ by 2016
• 144% rise by 2031
• 1 in 3 aged 75+ have two or more
Long Term Conditions
LTC Prevalence by Age
People reporting a chronic condition (by age)
80
70
% of sample
60
0-4y
50
5-15y
16-44y
40
45-64y
65-74y
30
75+
20
10
0
1972
1975
1981
1985
1991
1995
1996
1998
1998
2000
2001
Year (note: data from1998 is w eighted)
2002
Most people with any long term condition have multiple
conditions in Scotland – Scottish School of Primary Care
Projected Demand for Health and Social Care,
All Ages, 2008/09 prices.
Health and Social Care Demand Projections, £ mn, 2008/09 prices
15,000
14,000
13,000
Cost £mn
12,000
11,000
10,000
9,000
HLE constant
8,000
Change HLE = 0.5 change LE
7,000
Change HLE = Change LE
6,000
5,000
2010
2015
2020
Year
2025
2030
20
09
/1
0
20
10
/1
1
20
11
/1
2
20
12
/1
3
20
13
/1
4
20
14
/1
5
20
15
/1
6
20
16
/1
7
20
17
/1
8
20
18
/1
9
20
19
/2
0
20
20
/2
1
20
21
/2
2
20
22
/2
3
20
23
/2
4
20
24
/2
5
20
25
/2
6
20
26
/2
7
£ Millions (2010-11 Prices)
Projected Scottish Government spending
32,000
2009-10
16 years
2025-26
30,000
£42 billion
28,000
26,000
24,000
22,000
20,000
Sustainable Quality
A 2020 Vision
• Integrated primary and social care, and more effective working with
the Voluntary sector
• A focus on prevention, anticipation and supported self management
in order that everyone can live longer healthier lives at home, or in
the community as long as possible.
• When hospital treatment is required, and cannot be provided in a
community setting, day case treatment should be the norm and it
should be provided in the place which can guarantee highest quality,
safety and a good experience.
• A focus on ensuring that people get back into their home or
community environment as soon as appropriate, with minimal risk of
re-admission.
Reshaping Care Pathway
Population model
Care
Management
Level 3
Pr
Disease
Management
Supported
Self Care
of
es
Complex coco-morbidity
3 – 5%
si
Se
M lf
an
ag
e
m
on
al
Level 2
Poorly controlled single
disease 15 – 20%
Ca
r
e
en
t
Population Wide Prevention, Health Improvement &
Health Promotion
Level 1
Well controlled
(70(70-80% of LTC
population)
Anticipatory Care and Self Management
Integrated Locality Team
Day Care and
Respite
Residential
Care
Tele Health
Tele Care
Primary Care
Team & Care
Managers
Care and
support at
Home
Integrated
Locality Team
Hub
Rehabilitation /
reablement
Third Sector
capacity
Meals
Laundry
Extra Care
Housing
support
Telehealthcare
Anticipatory Care Planning
Anticipatory Care Plans
Highland
• Cohort with ACP in place
34% reduction in emergency new admissions
and a 57% reduction in emergency OBDs
compared to previous year
• No ACP but SPARRA risk > 50% (control)
56% increase in emergency new admissions and
an 83% increase in emergency OBDs compared
to previous year
Complex Polypharmacy
Chronic Medication Service
1. Registration of Patients
81,100 by 1224 community pharmacists
2. Pharmaceutical care Planning
3. Therapeutic Partnership to generate serial
prescription 24-48 weeks
Serial Dispensing Early Adopters
• 42 GP practices and 84 Community
Pharmacists across 12 NHS boards
• 3000 serial prescriptions for 5500
medicines for approx. 1000 patients
• SG working with Health Boards to extend
this to all by April 2013
NHS Scotland Rate per 1,000 Attendance at Emergency
Departments and Admissions for Females by Age Group Attendance
from Rate
0ct 2010 to Sep 2011
Admission Rate
450
400
350
250
200
150
100
age
80-84
75-79
70-74
65-69
60-64
55-59
50-54
45-49
40-44
35-39
30-34
25-29
20-24
15-19
10-14
5-9
-
85+
50
0-4
rate
300