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									Intermediate Care In Wales
       April 2008!
Dr Pradeep B Khanna MBE MB FRCP-
 Consultant Physician/Chief of Staff,
 Community Services & COTE/ Lead
        Clinician Stroke Care
Intermediate Care in England

        Prof JOHN YOUNG
   Head, Academic Unit of Elderly
       Care & Rehabilitation
     Bradford Hospitals & Leeds
           University, UK

      Why do we need intermediate care ?
• Provide high quality service with better outcomes

• Too many older people

• Too many older people in hospital

• Too many of the wrong sorts of older people in hospital

• Demand to contain or reduce hospital costs = reduce
                             length of stay

   An opportunity to design better services for
                      older people

            “I’m going to keep my
              eyes tightly closed
              until this nasty
              intermediate care
              thing has blown
 Welsh Definition of Intermediate Care
  STANDARD – Intermediate Care is established as a mainstream,
  integrated system of health and social care which:

• Enables older people to maintain their health, independence and
  home life;
• Promptly identifies and respond to older peoples health and social
  care needs, helping to avoid crisis management and unnecessary
  hospital or care home admission;
• Enables timely discharge or transfer, promoting effective
  rehabilitation and independence.

  National Service Framework for Older People in Wales.
  (March 2006)
1. Responding to, or averting, a crisis
                                          Admission prevention
2. Active rehabilitation following an acute hospital stay
                                               Early discharge
3. Where long-term care is being considered
                                 Prevention of long term care
4. Chronic long term Conditions Management.
Expert patient programme and assistive technology
Service Characteristics of Welsh
       Intermediate Care
• Integrated approach to local planning, commissioning, delivery
  and evaluation
• Early discharge or admission prevention
• Actions based on rapid comprehensive unified assessment and
• Maximises independence with force on rehabilitation
• Multi-agency working –integrated teams supported by sound,
  network and governance

All components needed
   Development of Intermediate Care

                     1999      2004

Intermediate care    4,442     8,697

People receiving    132,000   331,721
intermediate care

Intermediate care    7,149    17,339
                   I.C. CAPACITY
Needs assessment survey in Medway & Swale (pop=372,000)

Census of pts in DGH+CHs+DH+rehab centre+IC services

N=871 pts…. of whom 395 (45%) in need of an IC service

 Clinical futures (gwent)

  • inpatients 634/2082 (30.45%)
  • I.C – 35% NHS facilities; 65% community

  45% is a very big number!

     BUT, although size matters

 It’s NOT the only thing that matters
        Summary of RCT Evidence for
       Intermediate Care Service Models
                    (*Cochrane Reviews)
•Nurse-led Units*    10 trials        ? Increase mortality
                     (n=1,896)        Increase overall LOS

•Day hospital*       12 trials        Effective but expensive

•Care homes          1 trial          Shift costs to social care

•Community Hosp      1 trial          Cost effective

•Hosp-at-home*       >20 trials       3 separate Cochrane reviews
Hospital-at-Home: definition………

Hospital care but delivered in the person’s own
home !!!

HaH = “….a service that provides active treatment by
health care professionals, in the patient’s home, of a
condition that would otherwise require acute hospital in-
patient care, always for a limited period.”
                                Cochrane definition, 2005

 Combination of personal support &
 rehabilitation care
  Hospital-at-Home v In-patient Care (RCTs)
 Reduction in hospital stay (days) for elderly medical patients

Early Discharge Services               Control HaH Diff
Bristol, UK         n=241     3mth     50       39     -11(-22%)
Gloucester, UK      n=60      6mth     11        5     -6   (-55%)

Oxford, UK          n=96      3mth     13.2     12.8   -0.4 (-3%)
London, UK          n=54      12mth    35       14     -21(-60%)
Nottingham, UK      n=370     12mth    21       12     -9   (-43%)

 But does this mean we are going to save money?
Hospital-at-Home Intermediate Care:
Three conclusions……………………….

1. Limited RCT evidence base

2. Flexible type of service:
   •Different patients groups
   •Early discharge and admission avoidance

3. Can reduce hospital bed use improve outcome (better
ADL’s, reduce whole system costs and be cost-effective
system of care
BUT….              not always……….
  Evaluation of Leeds city-wide I.C. service:
“Before” & “After” study (n=1,648)
Frail patients: acute E.C. admissions with “geriatric giants”
Only 29% pts received I.C. over 12 months
       NEADL                 I.C. pts      Controls
    score changes            (n=246)       (n=246)
       3months:              -2.44         -1.39
       6months:              -2.63         -1.92
       12months:             -3.26         -2.79

  Beds days used over 12 months = +8 days for I.C. group

                        Young et al. Age & Ageing 2005; 34: 577
Bradford, UK Community Hospital Study

Single centre RCT (n=220) of CH v Acute Hospital Geriatric
Dept care for patients with “Geriatric Syndromes”
CH was locality-based (population of 92,000)
CH provided I.C. as an early discharge service

 • Greater functional independence at six months

• Improved patient experience of hospital care
 • Cost-effective
                            Brit Med Journal 2005 & 2006
      Early discharge service using a community
             hospital: the sooner the better?
• Secondary, pre-planed analysis (n=220)
• Changes in Nottingham extended ADL baseline to 6 months

                       Early transfer    Late transfer      Gen Hosp
    NEADL                < 2 days          >2 days
    SCORES                [n=73]           [n=49]            [n=69]
    Median (IQR)         32 (17-42)       31 (20-43)        36 (21-46)
    Mean (SD) score      -7.2 (16.1)      -12.1 (13.8)     -14.2 (13.5)
                                           P < 0.05
  Main reason for transfer delays was administrative
  Observed trial treatment effect largely due to early transfer group of
   Multi-centre RCT of post-acute care in
   community hospitals
                 (5 Gen Hosp; 7 CHs; n = 490)

1. Rehabilitation in the CHs was associated with a
   statistically significant improvement in medium term (6
   month) independence outcomes – better EADL
2. CH associated with trends to fewer “poor” outcomes
3. Patient/carer experiences favour CH
4. Affordable cost……yes; £17,000 per (QALY)
Young et al; JAGS 2007; 55; 1995
O’Reilly et al; Age Ageing (in press)
Economic study        Com Hosp          Gen Hosp
6 month results
                      Societal perspective for health care
                      affordability in England is responsibility of
Median LOS (IQR)       22 (11-45) 20 for Health
                      the National Institute (10-34) and
                      Clinical Effectiveness (NICE)
% readmissions             28%              23%
                      Health care systems and technologies
                      considered affordable when ICER less
Median QALY value     than 0.27
                           £30,000        0.20      P=0.17

Mean (SD) cost per       £8,946          £8,226        P=0.26
                      Therefore in English NHS……..community
patient                                   rehabilitation care
                      hospital post-acute(7,453)
                      would be considered cost-effective
Incremental cost        £17,192               /
effectiveness ratio   (£ per QALY)
                      Integrated Intermediate Care Model (Gwent)

                                           Steering Board (tri-partite)
                                              Health, social services, LHBs

                                Operational Team (Operational Manager)
= Admission avoidance                             +
                               Consultant Doctor, Consultant Nurse, Senior Social Worker
= Early supported discharge                  Consultant Rehabilatationist

= Chronic long terms conditions mgt
                                                 Single point of
= Independent living within the community            referral

                                                     1. Chronic           2. Chronic        Expert patient
     Rapid response           Reablement                                conditions mgt-
                                                    disease mgt-                              scheme

 Chronic conditions              Path              Cardiac failure            Continence        District
     specialists                                                                                nursing
                               Joint day                                  Palliative care      Assistive
         ACAT                    care                   COPD                                 technology/
                                                                                            smart houses
                               hospitals                                      Wound mgt

                              Frailty care                                      Mental
                                model                  Neuro                    Health
                                                    degenerative              (dementia)

                               Generic Support Workers (Multi-disciplinary)
                                 Level 1 services model - process

                                  Primary, secondary, social services, ambulance

                                             Single point of
= Admission avoidance
= Early supported discharge

= Chronic long terms conditions mgt              Unified
= Independent living within the community

                                                  1. Chronic          2. Chronic       Expert patient
     Rapid response           Reablement                            conditions mgt-
                                                 disease mgt-                            scheme

 Chronic conditions              Path           Cardiac failure        Continence          District
     specialists                                                                           nursing
                               Joint day                             Palliative care      Assistive
         ACAT                    care                COPD                               technology/
                                                                                       smart houses
                               Hospitals                               Wound mgt

                              Frailty care                               Mental
                                                    Neuro                Health
                                model            degenerative          (dementia)

                               Generic Support Workers (Multi-disciplinary)
                            Gwent Schemes (I.C)
Early Discharge Schemes         Months   Numbers          Bed Days Saved                Differential in
(a)    Reablement Scheme:       12       555              N = 8325                      £2,497,500
       Blaina Gwent (Budget =                             (Av. Bed per day 15 days)     (£300 per day in
       £39800)                                                                          hospital)
                                                          N = 1416
(b)     Mardy Park Rehab        12       N=118            30 - 18 = 12 days             £167,088
        Service                                           served                        (£150 per day)
      (Budget = £26300)                                   ↓      ↓
                                                          (Community (In this Scheme)
Admission Prevention Sch.
(a)    Rapid Response Scheme:   12       N= 574           518 x 7 days                  £1087,800
       Blaina Gwent                      518 Prevented.   (3626)                        (£300 per day in
       (Budget = £247,014)               (90.24%)                                       hospital)

(a)    ACAT + Rapid response             N = 965
       (Torfaen)                12       876 Prevented.   876 x 7 days                  £1,839,600
       (Budget = £455,690)               (90.77%)         (6132 days saved)             (£300 per day in
   Activity Figures: Non Elective: Adult Medicine
        (Since 1999 till 2008 = 53% increase)

              RGH           NHH         LOS RGH    LOS NHH

1999-2000        12902          7351         7.1        6.5
2002-2003        14053          9261         8.2        6.3
2005-2006        14046         10728         8.0        5.7
2007-2008        13615         13615         8.4        5.2

               (+7.0%)        (+46%)
            Since 2000.   Since 2000.

Reduction Of 90 Community Hospital Beds
Evidence-base for Intermediate Care:

1. Limited RCT evidence base

2. Most evidence for early discharge form of I.C.

3. Evidence for HaH and CH intermediate care encouraging

                    organisational factors are critical
 BUT….              to success & clinical governance
                    systems are needed to monitor

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