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Helping vulnerable patients to become more independent

Those working in primary care know there are patients who, through their many chronic illnesses and healthcare needs, reach a level of dependency that requires a huge amount of input from highly skilled staff. These are the patients for whom GPs and district nurses spend enormous amounts of time, sometimes daily, trying to firefight problems that seem infinite and never improving.

Despite best intentions, there is a lack of time, facilities and support to make any real impact in helping people self-manage and become more independent – weaning them off the high-level healthcare they require because, for whatever reason, their condition is getting the better of them.

For several years, Age UK in Cornwall and Isles of Scilly has been developing different types of service for vulnerable older people but on a small scale, such as falls prevention and dementia support, in specific locations. We know such services improve outcomes and keep people out of hospital but the challenge now is how do we offer these services in a more coordinated way with health and social services?

The plan

Age UK, Kernow CCG, the community health provider and the local authority, are looking at how we can develop these services into a bundle using risk stratification to identify the most vulnerable population and then offering them the appropriate support for their specific needs.

We hope to achieve integration of voluntary-sector-led preventive approaches tied in with clinical and specialist responses in 2013. Ultimately we want to build a portfolio of services based on the combined functions of local providers to reduce patients’ dependency.

Two key workers, funded by Age UK central office and managed by Age UK Cornwall, act as the link between the individual and the various services they may need to support them in becoming more independent.

We believe this will improve health outcomes, reduce the burden on acute care through fewer unplanned hospital admissions and save money through preventing ‘crises’ rather than trying to manage them when they happen. And we are carefully measuring every aspect of what we are doing to ensure the evidence base is as strong as it can be, before we roll out further.

The next 12 months

From now until the end of 2013, we are running a pilot programme with 100 participants identified from two practices covering 22,000 patients in Newquay. We have identified high-risk individuals over the age of 60 with a 90% chance of hospital admission through the UnitedHealth risk stratification tool.

Those eligible must also have at least two long-term conditions that have the potential of being managed in the community. A clinician then reviews the candidates to omit those who may have a medical need for a regular admission.

So far we have identified about 60 individuals who fall within the 0.5% of the population who have a very high relative risk of admission to hospital and would benefit from a case management approach. The remaining 40 people we identify will have a lower risk but will still fall within the top 5% of patients likely to be admitted to hospital.

They have access to a co-ordinated team of people who can offer a personal, coordinated and flexible response at the centre of which sit the Promoting Independence in People (PIP) key workers. Age UK Cornwall already provides six of these throughout the county funded by Cornwall Council.

The PIP key workers visit every participant and talk to them about their goals and ambitions for managing their condition and gaining more independence. This differs hugely from person to person. It might be being able to walk the dog, do their own shopping, travelling to spend more time with family members, or getting their hair done.

This guided conversation is about learning how someone deals with their own condition, what makes a good day and what makes a bad day, and getting a sense of family and social support and connections. Through this and discussions with relevant health professionals, the PIP worker helps to create a personal living plan and anticipatory care plan.

The individual also receives a mental health wellbeing assessment that is repeated every six weeks. This helps the team to understand how the patient feels about their condition. Initial visits also involve offers of help with benefit claims and home safety checks.

The key worker, who is supported by Age UK volunteers, is based within the community hospital alongside the district nursing and adult social care teams and acts as a link, offering a coordinated and flexible response, pulling in clinical or social expertise whenever it is required. They are also the portal for connecting the patient to voluntary and community sector groups such as carer or peer support, day services and local activities.

We are also testing the idea of a ‘virtual ward’ manned by volunteers, PIP key workers and clinicians to support individuals in their home. This will have protocols in place on what has to happen next, if the person’s needs increase so everyone understands when a case needs to be escalated.

Initial findings

Feedback so far suggests the first 60 patients identified have needed around 7–10 hours in the first couple of weeks to develop the shared management plan. We would expect this time to lessen as shared planning is implemented, but we will be measuring the input needed from different teams over time.

Our robust evaluation involves looking at 50 measures across three areas – individual health outcomes, integrated working, and financial savings. A vital aspect is the close monitoring of spending patterns to ensure that costs are not simply being shunted to different services and we have 35 measures specifically looking at the financial impact.

Some initial findings show a 13.2% improvement in mental wellbeing as measured with the Short Warwick-Edinburgh Mental Wellbeing Scale.

We have also seen at this early point – presented with the caveat that this is very early data – that acute admissions to hospital appear to be lower than in previous years and the number of limited admissions experienced and the length of stay appears to be shorter than in previous years for people with similar long-term conditions.

Anecdotal feedback from staff suggests the programme has been well received and the PIP workers and volunteers have integrated well into existing teams. We are testing job satisfaction levels across all sectors but GPs and district nurses say patients are being offered something different and it feels like progress is possible, even for those considered most dependent.

One key bit of learning is that the highest risk patients, because of their complex needs, have well-established dependencies on mainstream NHS and social care services, so encouraging the move to self care is more difficult to achieve. It requires more intensive one-to- one and peer support to regain confidence and life skills and to increase individual expectations.

Social impact bonds

We are confident that the pathfinder will identify both outcome and financial benefits from putting PIPs into community nursing and adult care and support teams but at the moment it is not clear how a full roll-out might be funded. This could be through the CCG and Cornwall Council or some other blended commissioning programme.

Another option for funding a scaled-up project is social impact bonds – a contract with the public sector in which it commits to pay for improved social outcomes. Funding is attracted through external socially motivated investment.

The idea is that if social outcomes improve, the investor receives a financial return, which is dependent on the degree to which outcome improves.

This potential approach is one reason we are so closely monitoring the outcome of the project – investors would want to see evidence that the programme works.

It is anticipated that further decisions about which cash-flow mechanism best suits an extension of this programme will be made by all partners after the initial evaluation.   

Future expansion

We have overloaded ourselves with performance measures because we want to be absolutely clear that there are cost savings to the whole system, not just an impact on one area. We will be assessing continuously as we go along but Age UK is in discussion with the Nuffield Trust to provide independent validation of results.

One of the things we are trying to understand is whether by focusing on the very high-dependency group of people, those savings could be reinvested into the next level down to ultimately change the whole graph of dependency. Can you completely change the nature and risk of dependency?

Should the pathfinder prove successful we would not be able to simply parachute the programme into other areas of Cornwall. The infrastructure needs to be in place. We already had the perfect set-up in Newquay, with two practices supported by a community hospital and district nursing team, but across the whole of Cornwall there are 72 practices and it would be impossible to scale up in that manner.

Our plan, should we prove effective, is to then do a larger-scale pilot of around 1,000 patients to further prove the financial and demand impact on acute hospital services. The timescale would be to establish that extended pilot towards the end of 2013.

Tracey Roose, is chief executive of Age UK Cornwall and the Isles of Scilly and Dr Tamsyn Anderson  is a GP and member of Kernow CCG


60-second summary

⦁ Initiative A pathway programme to help patients with multiple problems become more independent with an intensive review of all their needs, including social and mental health needs.  The pathway is being closely measured to create a strong evidence base before further roll-out

⦁ Staffing Two Promoting Independence in People (PIP) workers funded by Age UK.

The PIP workers carry out the review of patients’ needs and then coordinate a personal living plan and anticipatory care plan assisted by Age UK volunteers.

⦁ Early outcomesImproved mental health scores, signs admissions have reduced

⦁ Contact

Case study: The model in action

Mrs N is a 74-year-old who lives alone with a small dog. She has poorly managed diabetes and is very breathless, the cause of which has not been diagnosed, causing considerable anxiety. She had a stroke a while ago leaving a lot of pain in her right arm. She is also partially sighted and as a result of her medical conditions is highly dependent on services and daily carers. After a period of confidence-building she recently went on an organised shopping trip and now attends a ladies’ coffee morning with other individuals on the Pathfinder programme. Telehealth support has been put in place to help manage her diabetes and she has had a functional assessment for an exercise buddy;  this involved a volunteer visiting her first at home and then as part of a group, to encourage and support her through an exercise programme.