Transcript System Reform for Older People Project Falls and

System Reform for Older People
The role of commissioning to
develop effective services for falls
and fractures patients
BGS Commissioning Workshop
London
November 25th 2009
Dr Finbarr C Martin
Geriatrician at Guys and St Thomas’
Acting National Clinical Director, Older People
Department of Health
System Reform for Older People
Clinical background
• >60,000 people fell and fractured hip in England in 2007/8
- biggest cause of trauma bed days
- high mortality, morbidity, and cost
• 200,000 + other fragility fractures – wrist, pelvis, upper arm
• Costs of fragility fracture care is over £2 billion yearly
• Falls affect 30% of people over 65 and 50% over 80/year
- major reason for hospital attendance and admission
- ambulance call out and admission to long term care
System Reform for Older People
For a typical 300K PCT :
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> 15,000 will fall each year, >6000 twice or more
Most will not call for help
>70/week will attend A&E or the MIU
A similar number will call the ambulance service
350 hip fractures/year
~1000 other fragility fractures)
Average PCT & council costs on falls are £50m per annum
Ageing demography means all this will increase 50% by 2020
Fragility fractures as a long term condition
System Reform for Older People
Increasing
falls rate
Additional
morbidity
from fragility
fractures
Morbidity
from other
causes
“Hip fracture is all too often the final destination of a 30 year journey
fuelled by decreasing bone strength and increasing falls risk”2
1. J Endocrinol Invest 1999;30:583-588 Kanis JA & Johnell
2. Osteoporosis Review. 2009;17(1):14-16 Mitchell PJ
Efforts to tackle the problem with policy and guidance etc
System Reform for Older People
NSF
NICE
falls
NICE
20 prevention
RCP audit ------------------------------------I
NHFD ------------------------I
?
increasing incidence of fragility fractures
2001
2011
System Reform for Older People
•We have guidelines and standards, but…………
• Care and outcomes show massive variation
• The NHS is NOT delivering adequate care
System Reform for Older People
RCP national audits 2005 to 2011
Clinical Audit 2006/7
• Individual patient level data
• Patients attending Emergency Departments with
– Non-hip fractures (40) - radius, ulna, humerus, pelvis or
vertebra
– Hip fractures (20)
• Total scores calculated from all domains of acute care and
secondary prevention of falls and fractures
System Reform for Older People
No SHA has got it sorted - non hips
November 2007
Secondary prevention (antiresorptive therapy) for
osteoporosis and falls
assessments are effective in
reducing further fragility fractures
and must be an integral part of
the fracture care.
PCTs should commission
patient care pathways and risk
assessments
PCTs and local providers
should audit and share
information
Efforts to tackle the problem with policy and guidance etc
System Reform for Older People
NSF
NICE
falls
NICE
20 prevention
RCP audit ------------------------------------I
NHFD ------------------------I
Toolkit
PbR best practice
?
increasing incidence of fragility fractures
2001
2011
DH Systematic approach to falls and fracture
care & prevention: four key objectives
Stepwise
implementation
Hip
fracture
patients
System Reform for Older People
Non-hip fragility
fracture patients
Individuals at high risk
of 1st fragility fracture
or other injurious falls
Objective 1: Improve outcomes and
improve efficiency of care after hip
fractures – by following the 6 “Blue
Book” standards
Objective 2: Respond to the first
fracture, prevent the second – through
Fracture Liaison Services in
acute and primary care
Objective 3: Early intervention to restore
independence – through falls care
pathway linking acute and urgent
care services to secondary falls
prevention
Objective 4: Prevent frailty, preserve
bone health, reduce accidents –
Older people
07 July 2015
through preserving physical
activity, healthy lifestyles and
reducing environmental hazards
DH Systematic approach to falls and fracture
care & prevention: four key objectives
System Reform for Older People
NSF, TA161, CG21,
Blue Book & NHFD
NSF, TA161, CG21
& Blue Book
NSF, TA160
& CG21
NSF, LTC
programmes
Social care
Hip
fracture
patients
Non-hip fragility
fracture patients
Individuals at high risk
of 1st fragility fracture
or other injurious falls
Objective 1: Improve outcomes and
improve efficiency of care after hip
fractures – by following the 6 “Blue
Book” standards
Objective 2: Respond to the first
fracture, prevent the second – through
Fracture Liaison Services in
acute and primary care
Objective 3: Early intervention to restore
independence – through falls care
pathway linking acute and urgent
care services to secondary falls
prevention
Objective 4: Prevent frailty, preserve
bone health, reduce accidents –
Older people
through preserving physical
activity, healthy lifestyles and
reducing environmental hazards
DH Systematic approach to falls and fracture
care & prevention: four key objectives
Hip
fracture
Hip
patients
System Reform for Older People
fracture
patients
Non-hip fragility
fracture patients
Objective 1: Improve outcomes and
improve efficiency of care after hip
fractures – “Blue Book” standards
Objective 2: Respond to the first
fracture, prevent the second – through
Fracture Liaison Services in
acute and primary care
Improve the care, experience
through falls care
Individuals at high risk
and outcomes
after
hip
fracture
pathway linking acute and urgent
of 1 fragility fracture
Objective 3: Early intervention to restore
independence –
st
or other injurious falls
care services to secondary falls
prevention
Objective 4: Prevent frailty, preserve
bone health, reduce accidents –
Older people
07 July 2015
through preserving physical
activity, healthy lifestyles and
reducing environmental hazards
Professional consensus
Hip fracture patients
should be admitted
within 4 hours to an
appropriate clinical
ward area with
nursing, orthogeriatric
medicine and surgical
expertise appropriate
for this often frail
patient group
So what levers will be available?
Hip
fracture
patients
System Reform for Older People
• Quality Commissioning PbR
– Best Practice Tariff
• HQIP: National Hip Fracture Database
• CQUIN data collection, local incentives on pathway elements
• NICE – Guidelines Development Group – late 2010
• QOF: Next review (? osteoporosis)
• Demonstrate the cost-efficacious case
15
Using PbR best practice tariffs for incentives
Hip
fracture
patients
People
for OlderFRACTURES
System ReformFRAGILITY
What should be the best practice measures?
1.
2.
Time to surgery
Quality of care
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36 hours
OrthoGeriatric Medicine
Admit with joint protocols
Peri-operative care – seen within 3 days by
orthogeriatrician
Rehabilitation – OG led multidisciplinary care
Fracture prevention – falls and fracture
prevention plan
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0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
19-Apr-08
05-Apr-08
03-May-08
19-Apr-08
17-May-08
03-May-08
17-May-08
31-May-08
31-May-08
14-Jun-08
14-Jun-08
28-Jun-08
28-Jun-08
12-Jul-08
12-Jul-08
26-Jul-08
09-Aug-08
26-Jul-08
23-Aug-08
09-Aug-08
06-Sep-08
23-Aug-08
20-Sep-08
04-Oct-08
06-Sep-08
18-Oct-08
20-Sep-08
01-Nov-08
15-Nov-08
04-Oct-08
29-Nov-08
18-Oct-08
13-Dec-08
27-Dec-08
01-Nov-08
10-Jan-09
15-Nov-08
24-Jan-09
29-Nov-08
07-Feb-09
21-Feb-09
13-Dec-08
07-Mar-09
27-Dec-08
21-Mar-09
04-Apr-09
10-Jan-09
18-Apr-09
24-Jan-09
02-May-09
16-May-09
07-Feb-09
30-May-09
21-Feb-09
13-Jun-09
07-Mar-09
27-Jun-09
11-Jul-09
21-Mar-09
25-Jul-09
04-Apr-09
08-Aug-09
18-Apr-09
02-May-09
16-May-09
% of Patients
Reform for Older People
System
05-Apr-08
Patients with Fractured Neck of Femur operated on within 48 hours.
Hip
Patients with Fractured
Neck
of
Femur
operated
on
within
48
hours.
fracture
JR & HGH
patients
JR & HGH
What can be achieved ?
In Week %
In Week %
QTD %
Schedule 3pt4 Target
CQUIN Target
QTD %
Schedule 3pt4 Target
500 hip fracture hospital
Weekly Date
Weekly Date
CQUIN Target
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
2 more dedicated lists
0.6wte orthogeriatrician
30-day mortality
(%) mortality
What can be achieved?
30 day
Hip
fracture
patients
12%
System Reform for Older People
10%
10% to 7%
8%
6%
2007
2008
2003-2007
2009
2008
2009
4%
2%
0%
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Days post-op
DH Systematic approach to falls and fracture
care & prevention: four key objectives
Stepwise
implementation
Hip
fracture
patients
System Reform for Older People
Respond to the first
Non-hip fragility
fracture,
the
fractureprevent
patients
second
Individuals at high risk
of 1st fragility fracture
or other injurious falls
Objective 1: Improve outcomes and
improve efficiency of care after hip
fractures – by following the 6 “Blue
Book” standards
Objective 2: Respond to the first
fracture, prevent the second – through
Fracture Liaison Services in
acute and primary care
Objective 3: Early intervention to restore
independence – through falls care
pathway linking acute and urgent
care services to secondary falls
prevention
Objective 4: Prevent frailty, preserve
bone health, reduce accidents –
Older people
07 July 2015
through preserving physical
activity, healthy lifestyles and
reducing environmental hazards
Objective 2: Respond to the first fracture, prevent the second
System Reform for Older People
How is this achieved?
• Fracture Liaison Services
– Case finding in A&E, MIUs and hospital fracture services
– Apply NICE guidance care pathways
– Link straight to falls services
– Monitor and maintain medication adherence
• Case find for those with previous fractures
• Agree who needs specialist investigations and services from local
Osteoporosis experts
What do the NHS and local councils need to do?
• Commission
a Fracture Liaison Service from the acute hospital
• Appoint an Osteoporosis champion in primary care
• Implement the DES for Osteoporosis
• Broker the local service level agreements
Consider a PCT population of 300,000
System Reform for Older People
Post-menopausal
women with new
fracture each year
Post-menopausal
women with prior
fracture history
900
6,900
Post-menopausal
women with
osteoporosis
17,400
Post-menopausal
women
55,000
Fracture Liaison:
Acute-care based
Fracture Liaison:
Primary-care
based
GP case-finding
stratified by risk
+ Direct Access
DXA Services
1. http://www.statistics.gov.uk/pdfdir/popest0808.pdf
2. (Adapted from) Curr Med Res Opin 2005;21:4:475-482 Brankin E et al
System Reform for Older People
Newcastle hospital and primary care fracture liaison service
Proposal
To establish a full time Fracture Risk Assessment Service
at the Fracture Clinic, Newcastle General Hospital
(Appendix 1).
To establish a targeted Fracture Prevention Service in
primary care, initially concentrating on care homes and
patients on oral glucocorticoids (Appendix 2) .
Objectives
To meet several criteria included in the NHS plan:
Development and design of new services around the
needs of people
Improvement of access to services and outcomes in
older people
Reduction in demand on secondary care with increased
care in the community
Extend the roles of nursing
Decrease in health inequalities
System Reform for Older People
Projected Costs
Capital Expenditure
GE Lunar Bravo BMD equipment (including VAT)
£35,000
Recurrent Expenditure
1 WTE H grade Nurse
Clerical Support A&C 3 Grade 12 hours/week
Database Support
Production and postage of reports and questionnaires
Support literature
BMD equipment service contract
BMD equipment depreciation/replacement costs
Fracture Clinic room charges
Total Recurrent Costs
£53,625
£36,916
£ 5,389
£ 600
£ 2,800
£ 500
£ 2,000
£ 5,000
£ 420
Objective 3: Early intervention
To restore independence
System Reform for Older People
How is this achieved?
• Fallers who are unsteady need a falls risk assessment
– Medical conditions, Gait & balance, Vision, Medication review
• Fear of falling and restricting activity leads to further falls
– Re-enablement and rehabilitation
– Increase opportunities for social participation
• Successful programmes are multidisciplinary BUT coordinated
• Exercise to improving strength and balance is the most powerful part
What do the NHS and local councils need to do?
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Review the local falls pathway with the community and acute providers
Agree who does what? Who attends specialist clinics?
Build falls prevention into mainstream services and intermediate care
Commission effective exercise programmes
Consider using the leisure services and voluntary sector
Objective 4: Prevent frailty, preserve bone
health, reduce accidents
System Reform for Older People
How is this achieved?
• Promote healthy ageing and preserve bone health
– Physical activity (as per the NHS physical activity strategy)
30minutes x 5 per week
– Maintain optimal weight
– Quit smoking
– Alcohol only in moderation
• Targeted home assessments and Telecare
• Medications reviews
• Safe environments for promoting social participation
What do the NHS and local councils need to do?
• Use
JSNA and develop local strategies
• Involve the local population
System Reform for Older People
System Reform for Older People
System Reform for Older People
System Reform for Older People
Greenwich action plan includes commissioning new posts
System Reform for Older People
What is in the DH falls & fractures
commissioning toolkit 2009
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Overview guide and narrative slide set
Economic evaluation
Joint Strategic Needs Assessment advice note
Web based care pathways
– for acute care of fragility fractures from presentation to
secondary prevention
– for primary care and community services based on long
term conditions model
• Business planning tool for Fracture Liaison
• Good practice examples
• Exercise for fall and fractures: advice note
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/DH_103146
System Reform for Older People
Strategies to promote change
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Top down pressure
Create inter-specialty collaboration
Clinical performance data in routine services
Guidance for commissioners
Better metrics
Financial incentives
System Reform for Older People
Top down pressure
• National audits
– Government obliged to respond to national results
– Used for trusts assessment by the national quality
inspections
Create inter-specialty collaboration
System Reform for Older People
Memorandum of
Understanding
BOA and BGS
The Blue Bookes
Use clinical performance data in routine services
System Reform for Older People
Six standards in the Blue Book
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Admission within 4 hours
Surgery within 48 hours
Management of pressure
Orthogeriatric medicine
Treatment to prevent
osteoporotic fractures
Falls prevention
National Hip Fracture
Database
Commissioning
Stepwise
implementation
Hip
fracture
patients
System Reform for Older People
Non-hip fragility
fracture patients
Individuals at high risk
of 1st fragility fracture
or other injurious falls
Objective 1: Improve outcomes and
improve efficiency of care after hip
fractures – by following the 6 “Blue
Book” standards
Objective 2: Respond to the first
fracture, prevent the second – through
Fracture Liaison Services in
acute and primary care
Objective 3: Early intervention to restore
independence – through falls care
pathway linking acute and urgent
care services to secondary falls
prevention
Objective 4: Prevent frailty, preserve
bone health, reduce accidents –
Older people
07 July 2015
through preserving physical
activity, healthy lifestyles and
reducing environmental hazards
Better metrics and Financial incentives
System Reform for Older People
Information Centre for Health & Social Care
– Dashboard of service and outcome data to benchmark local
performance
Commissioning costs linked to service quality
– Best Practice tariff for Hip Fractures –April 2010
Support knowledge transfer
– Map of Medicine