Download Integrated CQUIN 2013 - Lincolnshire East CCG

Integrated CQUIN 2013/2014
Suggested Impact and Measures
The Context
• National Benchmarking data shows that
the CCGs who are the main users of
ULHT have
– a higher than average rate of non-elective
admission for their populations
– A higher than average rate of A&E Attendance
Source: NHS Comparators
The Challenge
• To Reduce the Rate of Inappropriate
Medical Admissions to Lincolnshire Acute
Hospitals via A&E.
• Commissioner Proposed measure:
– Reduce Conversion Rate by 5%
The Response
• The Three Trusts will work together to
deliver a CQUIN that encourages
integration of approaches and delivers:
– A reduction in inappropriate medical
admissions through A&E
but
– The parameters for success of a CQUIN
scheme require further definition
The Detail
• In 2012/13 there were a total of 143,637 attendances at
ULHT A&E Departments. This was a slight reduction
from 2011/2012 (145,087)
• Of these 41,266 were admitted
• A Conversion rate of 28.73%
• Commissioners have indicated an aim of reducing this
by 5% - a reduction of 7,180 admissions against the
same number of attendances
Refining the detail
• Remove non-medical attendances (surgery,
trauma and injury)
• Remove Commissioned Pathways
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Stroke
MI
Paediatrics
Maternity
Best Practice tariff
• Remove Patients staying more than two days
The Final Cohort
• In 2012/13 there were a total of 26951 medical attendances at
ULHT A&E Departments
• Of these 19301 were admitted
• A Conversion rate of 71.6%
• However only 5295 people admitted with a ‘medical’ condition
stayed in hospital more than 2 days
• Assumption: if people are in hospital for more than 2 days, they are
‘ill’.
Of these admissions, a proportion will be inappropriate –
These are the people we need to focus on
Data Weaknesses
• Biggest cohort of A&E Diagnoses is ‘other’
• Therefore we attached the admitted spells data
to refine what people were treated for following
admission.
• Only one diagnosis used therefore other
reasons e.g. dementia may be hidden by
physical symptom in the dataset
Hypotheses of impact can be tested by detailed
audit
Accepted Wisdom
• People attend A&E as there’s no obvious alternative
• GPs send people to A&E without assessment
• Community services are not responsive and only react
following a crisis
• Admission is a ‘bad’ thing
• Resources are aligned to early discharge rather than
stopping admission.
• Hospitals admit to stop 4 hour breaches
• All patients are from Lincolnshire
• All of these can be challenged…
What the numbers say
• If you are admitted for any reason for 2 days or
less and attended A&E in an ambulance, but
weren’t in a care home and you don’t die (5604
people) you will usually (98%, 5495 people) be
admitted.
• Assumption: If ambulances have alternative
access routes to Out of Hospital services, less
people would be admitted.
What the numbers say
• If you attend A&E from a Nursing Home
(usually by ambulance), you will normally
be admitted (98%)
• Assumption: better support for Nursing
Homes can reduce 999 calls
What the numbers say
• Of Patients admitted to medical specialities for
short stays (less than 2 days) who don’t arrive
by ambulance (2436) and don’t die, 80%
(1946) are in the following HRGs:
• 42 people are admitted from A&E because of
Social Issues
• Assumption: activity in Bold HRGs is more likely
to be inappropriate. This only represents 10.4%
of the total (202)
Appropriate or Inappropriate?
• Many admissions through A&E require hospital
intervention as there is no other service
available – e.g. chest pain, head injury,
poisoning, ante-natal observation, TIA.
• A small proportion of these will be picked up
through better Complex Case Management.
• Assumption: activity in Bold HRGs is more likely
to be an inappropriate admission. This only
represents 10.4% of the total (202)
What the numbers say?
• 208 people attend A&E and die without
Admission
• 294 people are admitted from A&E and die
within 2 days
• Assumption: a proportion can be better
supported outside of hospital
How can we make an impact?
• Reduce Attendances
– Stop People getting to A&E
• Reduce Inappropriate Admissions
– Discharge direct from A&E
• Improve Quality of Admission
– Manage admissions according to best
practice tariff protocols
– Discharge patients following short stay
ambulatory intervention
Reducing Attendances
Better Case Management and more reactive community provision
•How?
Ensure Primary and Community Teams work together and are clear of
communication routes – rapid acceptance of referral
Enable ambulance crew access to community services
Review Rapid Response Service Specification
Work with Nursing and Care Homes to support their residents better and provide inreach where appropriate
Communicate alternative routes to care to the public
Ensure DOS is fully utilised
Assure Access to Primary Care in an urgent situation
Palliative Care – ensure rapid response incl.
St Barnabas
•Current Weaknesses
in-hours services only;
Specialist community resources resourced mainly for planned care and advice;
default can still be 999
Nursing home responsibilities can be unclear
Reduce Inappropriate Admissions
from A&E
Early identification of patients requiring support to be discharged in A&E
Rapid Communication to Community Support Network
• How?
– Focus Assertive In-reach services on A&E
– Develop RAPA alert system for more conditions
– Enhance RAID provision to enable rapid discharge of people with mental health
issues Develop PACT approach with third sector for immediate support
– Work with Social Care to implement immediate packages from A&E
– Develop ‘Trusted Assessor’ roles
– Expand Integrated Living Team approach
– Assess to Admit rather than admit to assess
– Access to urgent Outpatient appointments
– Senior Clinical Assessment ‘at the front door’
•
Current weaknesses
– Coverage different across sites
– Wider Community support mechanisms less developed outside of Lincoln
– Complex Case Management Capacity not always available within small time
window
– Focus on A&E may have impact on flow through EAU
Improve Quality of Admission
Only admit those who need to be in hospital
Use Best Practice to assess and start treatment in
ambulatory model to the same level as the top quartile of
Trusts
•How?
– Further develop pathways and protocols with Primary Care to
complete assessments before requesting hospital intervention
– Senior Clinical Assessment ‘at the front door’
– Rapid Access for Community Staff to advice from senior
clinicians
– Assess for discharge on admission and aim to discharge within
12 hours
• Weaknesses
– Capacity in Primary Care to receive discharges
Measures
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Attendance Numbers (reduce/maintain in line with national trends)
Medical Admissions (number not rate)- reduce total, increase best practice, assure
short stay assessment admissions.
Conversion rate attendance to admission (for ‘medical’ admissions) – (may increase if
we can tackle attendance totals)
Best Practice Tariff Performance – improve to top quartile
Number of People discharged from A&E with support (maintain or increase)
Number of people case managed (increase)
Admissions of people on community complex case load through A&E (set baseline
and reduce)
Admissions of people on community complex case load through EAU (increase)
Admissions through EAU to ambulatory care model (increase)
Average length of stay (increase by taking out EAU)
Assessment of ‘avoided admissions’ through action in the community (anecdotal but
should increase)
People discharged following short stay ambulatory admission with and without
support (increase)
Audit of people admitted for less than two days but not on ambulatory pathway (prove
quality of care and appropriateness of admission)
Admission and attendance rates by GP practice
ALL FIGURES SHOWN AS ANNUAL NUMBERS
Suggested Targets –
Reducing Attendances
• 2.5% of people attending by ambulance can be
diverted to alternative care (140 atts) prior to arrival
• 20% of people sent to A&E from Nursing Homes can
be supported to stay where they are (98 people)
• 10% of people who die on attendance can be
supported ‘at home’ (26 attendances)
• Suggested Owners LCHST, LPFT, St Barnabas
Suggested Targets –
Reducing Admissions
• of people attending by ambulance 98% continue to be admitted (138 less
admissions due to reduction in attendances)
• 20% of people admitted via A&E from Nursing Homes can be supported to
stay where they are and reduce admissions (98 people)
• 10% of people who are admitted and die within 2 days can be supported ‘at
home’ (26 attendances)
• 50% of people identified as being admitted for social issues can be diverted
elsewhere (21)
• 50% of people whose admission is potentially inappropriate are diverted
(115)
• 10% of patients attending and admitted under ‘appropriate’ HRG can be
turned around within 4 hours (560)
• Suggested Owners – ULHT, LCHST, LPFT, St Barnabas
Suggested Targets –
Improved Admissions
• Of patients admitted under the same HRG
as Best Practice Tariff for less than 7 days,
but not classified as BPT, convert 20% to
BPT (400)
• Suggested Owner - ULHT
Next Steps
• Meet CCGs to critique information analysis
• Agree Individual Organisation Targets
• Develop Action Plans
Schedules to be agreed
• Trajectory for delivery
• 2 year CQUIN?
• Appropriate measures for each Trust
Conclusion
• Multi-faceted actions required to deliver
‘simple’ impact on patient flow.
• Difficult to measure achievements.