Transcript Slide 1

2nd National Transition Care Forum 2009
Tuesday 24 November 2009
National Convention Centre Canberra
Transition Care from an International Perspective
Stuart Parker
University of Sheffield
UK
Doctor Routinely Receives Reminders for
Guideline-Based Interventions or Screening Tests
Percent
100
Yes, using a manual system
75
73
6
Yes, using a computerized system
72
10
54
50
49
4
27
67
47
39
16
62
19
25
45
31
27
17
20
0
AUS
UK
FR
NZ
ITA
27
US
21
16
16
12
7
9
9
7
GER
NET
NOR
10
9
CAN
Percentages may not sum to totals because of rounding.
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
10
6
4
SWE
6
Practice Routinely Sends Patients Reminders
for Preventive or Follow-Up Care
Percent
100
97
4
97
Yes, using a manual system
89
21
7
Yes, using a computerized system
80
75
31
60
51
50
92
76
35
82
47
33
25
32
29
25
48
24
24
26
18
15
9
17
ITA
GER
0
NZ
UK
AUS
NET
FR
SWE
US
Percentages may not sum to totals because of rounding.
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
31
21
15
10
12
3
CAN
NOR
7
Practices with Advanced Electronic
Health Information Capacity
Percent reporting at least 9 of 14 clinical IT functions*
100
92
91
89
75
66
54
50
49
36
26
19
25
15
14
FR
CAN
0
NZ
AUS
UK
ITA
NET
SWE
GER
US
NOR
* Count of 14 functions includes: electronic medical record; electronic prescribing and ordering of tests; electronic access test
results, Rx alerts, clinical notes; computerized system for tracking lab tests, guidelines, alerts to provide patients with test
results, preventive/follow-up care reminders; and computerized list of patients by diagnosis, medications, due for tests or
preventive care.
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
8
Transition Care
(Recent advances)
Stuart Parker
University of Sheffield
UK
King's Fund Intermediate Care Reading List
10
9
8
7
6
5
4
3
2
1
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
King's Fund Intermediate Care Reading List
10
9
8
7
6
5
4
3
2
1
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Web Of Knowledge
Geriatrics and Gerontology
140
120
Citations
100
80
Intermediate
60
40
20
0
1998
2000
2002
2004
Year
2006
2008
2010
Web Of Knowledge
Geriatrics and Gerontology
140
120
Citations
100
Intermediate
80
Transition
60
40
20
0
1998
2000
2002
2004
Year
2006
2008
2010
Web Of Knowledge
Geriatrics and Gerontology
300
250
Citations
200
Intermediate
Transition
150
Community
100
50
0
1998
2000
2002
2004
Year
2006
2008
2010
Pathways of care for frail older
people including acute, intermediate
and primary care.
NHS Institute for Innovation and Improvement 2006
16
•
•
•
•
•
•
•
•
Better access to primary care
Faster access to drugs and treatment
Improved access to urgent care
Better care closer to home
Personalised care
Choice and control
Improving the patient experience
Improving patient safety.
Pathways of care for frail older
people including acute, intermediate
and primary care.
NHS Institute for Innovation and Improvement 2006
28
Cochrane reviews
Suggest they can provide a satisfactory alternative to treatment in an acute hospital (10 RCTs 850
patients, Sheppard et al, 2008; 2009) .
Early discharge hospital at home - Despite increasing interest in the potential of early discharge
hospital at home services as a cheaper alternative to in-patient care, this review provides
insufficient objective evidence of economic benefit or improved health outcomes.
COPD – home treatment by respiratory nurse as effective as hospital, but only 1 in 4 patients
suitable (Ram et al, 2003).
Rehabilitation setting. A comparison of rehabilitation in hospitals, care homes and people’s own
homes (Ward et al, 2008) …
27,840 titles
1586
154
5
0
abstracts
papers
reviews
met inclusion criteria
•RCT - 490 patients needing rehabilitation after an acute illness (Young et al, 2007)
•Patients assigned to community hospitals (7) or acute hospitals (5).
•The community hospital group had slightly better function (bigger change in NEADL
scores) at 6 months follow up
•Cost-effectiveness analysis found the resource use to be similar in both groups and
there was a small, non-significant difference in the quality-adjusted life years,
favouring the community hospital group (O’Reilly et al, 2008).
• Limited but generally positive evidence for the benefits of community rehabilitation
teams, including specialist services for people recovering from stroke.
• Two studies of nurse-led units indicated that these could provide appropriate care
for certain patients, but often led to an increased length of stay.
• The evidence for the effectiveness of nursing home based IC is also limited.
• Day hospital care that provides comprehensive intervention and care appears to be
as effective as other forms of care for older people.
Day hospital and home rehabilitation costs. Sensitivity analysis
Total costs
30
Mean costs (£000)
25
20
DHR (3 months)
HBR (-) (3 months)
HBR (+) (3 months)
15
DHR (12 months)
HBR (-) (12 months)
10
HBR (+) (12 months)
Linear (DHR (3 months))
5
0
100
150
200
Overheads/transport (£)
250
Day hospital and home rehabilitation costs. Sensitivity analysis.
Public sector costs.
10
Mean costs (£000)
9
8
7
DHR (3 months)
6
HBR (-) (3 months)
5
HBR (+) (3 months)
4
HBR (-) (12 months)
3
HBR (+) (12 months)
DHR (12 months)
Linear (DHR (3 months))
2
1
0
100
150
200
Overheads/transport (£)
250
Readmission at 6 months
Study name
Months
Statistics for each study
Odds ratio and 95% CI
Odds Lower Upper
ratio
limit
limit Z-Value p-Value
Young 1992
6.000
0.600
0.137
2.628
-0.678
0.498
Crotty 2008
6.000
1.872
1.098
3.191
2.305
0.021
Parker 2008
6.000
1.788
0.750
4.261
1.311
0.190
Roderick 2001 6.000
1.200
0.561
2.567
0.470
0.638
1.545
1.059
2.252
2.259
0.024
0.1
0.2
0.5
Fav ours DHR
1
2
5
Fav ours HBR
10
Evidence to inform the most effective ways to deliver
intermediate care
Study of workforce variations
Community and intermediate care services for older people
~200 services were included in a survey and
20 services studied in depth,
~2,000 patients and
4 in-depth case studies of teams with innovative roles.
The impact of workforce flexibility on the costs
and outcomes of older peoples' services
Report for the National Co-ordinating Centre for NHS Service Delivery
and Organisation R&D (NCCSDO), July, 2008
Susan A Nancarrow, Anna M Moran, Pamela Enderby, Stuart Parker, Simon Dixon, Caroline
Mitchell, Michael Bradburn, Alex McClimens, Clare Gibson, Alex John, Alan Borthwick,
James Buchan.
The impact of workforce flexibility on the costs
and outcomes of older peoples' services
•A detailed policy and literature review
•A cross sectional survey of 186 older peoples‘ community based
services, which captured details about the staffing and service
configurations as well as the completion of the Workforce
Dynamics Questionnaire by 327 staff from 36 teams
•A prospective study of 20 older peoples ‘ community based
services to examine, in depth specific hypotheses relating to
workforce variations on service costs
•Qualitative data collection involving focus groups with a selection
of the teams involved in the prospective study
•A discrete choice experiment to explore service user preferences
around staffing, service setting and frequency
•Case studies of 4 teams which have introduced novel or extended
roles
The impact of workforce flexibility on the costs and outcomes of older
peoples' services
Key messages for clinicians and service managers
Patients prefer to receive care in their own home.
However, if they need to be cared for in an institution, the preferred setting is
hospital.
Good team working is important.
Small teams are nice to work in.
Big teams can work well for patients.
Think carefully about skill mix and adjust to match the needs of the patient.
Tools to help with matching needs to skills and demonstrating outcomes are
becoming available and may be useful in this regard.
16/07/2015
© The University of Sheffield
44
The impact of workforce flexibility on the costs and outcomes of older
peoples' services
Highly variable service specifications
•Most teams included nurses, physiotherapists, OTs, therapy assistants, support
workers, social care staff and voluntary sector workers.
•Most teams provided services in several locations including own home and other
residential / inpatient settings.
Better patient outcomes associated with:
•Teams that included a higher proportion of support workers
•Teams where the patients saw fewer different types of practitioners.
•Fewer senior staff,
•Larger teams.
Higher costs were associated with
•Teams with a higher proportion of support workers.
The impact of workforce flexibility on the costs and outcomes of older
peoples' services
Reduced length of stay in the service was associated with
•Greater access to technology and equipment
Staff satisfaction was associated with
•Smaller team size
•Weekly (as opposed to less frequent) team meetings
•Having a single team manager
•A high level of team working and integration.
Effect of skills mix on cost per patient
400
Cost per patient (£)
350
300
250
All patients
200
Client needs slow stream rehabilitation
150
Client needs regular rehabilitation
100
50
0
0.2
0.3
0.4
0.5
0.6
0.7
0.8
Proportion of contacts made by qualified staff
0.9
Effect of number of professions on cost per
patient across all teams
900
800
Cost per patient (£)
700
600
500
400
300
200
100
0
1
2
3
4
5
6
7
Number of different professions involved in care
8
The impact of workforce flexibility on the costs and outcomes of older
peoples' services
Key messages for clinicians and service managers
Patients prefer to receive care in their own home.
However, if they need to be cared for in an institution, the preferred setting is
hospital.
Good team working is important.
Small teams are nice to work in.
Big teams can work well for patients.
Think carefully about skill mix and adjust to match the needs of the patient.
Tools to help with matching needs to skills and demonstrating outcomes are
becoming available and may be useful in this regard.
16/07/2015
© The University of Sheffield
49
National Institute for Health Research
NIHR Collaborative Leadership in Applied
Health Research and Care for South Yorkshire.
Professor Sue Mawson
Director
Professor Stuart Parker
Associated Director
Doncaster
Barnsley
Sheffield
Rotherham
Doncaster
Barnsley
Sheffield
f
Self-management
and self-care of
long term conditions
User-centred
Healthcare
Design
Knowledge
into
action
Intelligent
commissioning
Achieving translation
Inequalities
in
health
Rotherham
National Institute for Health Research
NIHR Collaborative Leadership in Applied
Health Research and Care for South Yorkshire.
Professor Sue Mawson
Director
Professor Stuart Parker
Associated Director
http://clahrc-sy.nihr.ac.uk/
Doncaster
Barnsley
Sheffield
Rotherham