Post on 11-Jul-2020
Meeting SLIC Provider Group
Date Thursday 17 December 2015
Time of Meeting 13.00 – 15.00
Paper Name Falls Business Case
Agenda Item Item 4
Paper Number Paper 5
Paper Owner Cathy Ingram
Purpose of the Paper (for information, for a
decision, for approval)
For approval
Can this paper be shared? Yes, this paper will be added to the SLIC
website
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Southwark and Lambeth Integrated Care Business Case Proposal
Falls
Mainstreaming
An Early Identification and Primary Prevention Service
Partner Lead: Cathy Ingram SLIC Lead: Fiona Martin Lead Authors: Emma Hanley ,Greg Battarbee , Corne Rossouw , Judith Hall Date: December 2015 Version: Final
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Table of Contents 1 Executive Summary .............................................................................................................. 5
2 Introduction ......................................................................................................................... 7
2.1 Vision and Aims ................................................................................................................................................. 7
2.2 Alignment with commissioner priorities ........................................................................................................... 7
2.3 The national falls picture................................................................................................................................... 9
2.4 The local falls picture ...................................................................................................................................... 10
3 Case for Change .................................................................................................................. 10
3.1 Summary of pre-existing service before test & proposed test model ............................................................ 10
4 Test models Evaluation Summary and Benefits Realisation .................................................. 14
4.1 Achievements of the test ................................................................................................................................ 15
Screening and Referral Outcome Including Exercise Prescription .......................................................................... 16
Review capacity and demand ................................................................................................................................. 16
Existing falls service capacity gap and backlog ....................................................................................................... 17
Adherence ............................................................................................................................................................... 18
Monitoring of outcomes and impact ...................................................................................................................... 20
4.2 Summary of Lessons Learnt ............................................................................................................................ 21
5 Future Commissioning intentions: Proposal to mainstream ................................................. 22
5.1 Commissioning proposal and recommendation ............................................................................................. 22
5.2 Recommended option .................................................................................................................................... 23
5.3 Description of service ...................................................................................................................................... 24
Access ...................................................................................................................................................................... 25
Triage....................................................................................................................................................................... 25
Primary prevention, the Community Exercise Classes............................................................................................ 26
Secondary prevention ............................................................................................................................................. 27
Attendance, adherence and graduate routes ......................................................................................................... 29
Support and influence the development of appropriate ‘follow-on’ community exercise options: ...................... 30
How will be programme be managed and run? ..................................................................................................... 30
Workforce development and community capital ................................................................................................... 30
5.4 Quality Assurance, Outcome and Benefit Realisation .................................................................................... 32
5.5 Projected savings: Cost impact over the next 5 years .................................................................................... 33
5.6 Financials: Direct Cost of service..................................................................................................................... 36
5.7 Interdependencies to delivery ........................................................................................................................ 38
5.8 Potential risks and Mitigation – all options .................................................................................................... 38
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Option 1 Risks and mitigation ................................................................................................................................. 38
Option 2 Risks and mitigation ................................................................................................................................. 39
Option 3 risks and mitigation .................................................................................................................................. 39
Option 4 risks and mitigation .................................................................................................................................. 40
6 Appendix 1 – modelling assumptions .................................................................................. 41
6.1 Falls business case modelling assumptions .................................................................................................... 41
Further detailed assumptions ................................................................................................................................. 43
Other assumptions used ......................................................................................................................................... 44
7 Appendix 2 - Demand, capacity and productivity existing community rehab and falls service 45
8 Appendix 3 – Health questionnaire used with clients ........................................................... 48
EuroQol Group EQ-5D ............................................................................................................................................. 48
9 Appendix 4 – FES-I .............................................................................................................. 50
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Mavis’s story: Strength and Balance
Mavis Adenekan speaks about her experience of the Strength
and Balance classes and explains the positive impact they have
had on her life.
Mavis, 74 years old, says: “I began having difficulties bending
my knees – I had to hold on to chairs for support when I was
standing up. Then last summer my knees gave up and I had to
start using a stick. It was a slippery slope from there, because I
started to develop back problems from walking differently. I
even changed my sofa, because the old sofa was too low for
me to get up from, and I thought I was going to have to move
out of my flat, because of all the stairs.
“Last year I moved to a GP in Lambeth and I was referred to
the Strength and Balance classes. I’ve been attending since last
September.
“When I first attended the class I took the walking stick with me, but the classes have now given me the confidence
and strength I need – I don’t use my stick anymore!”
Mavis, a former primary school teacher, went on to say: “Most importantly, the class instructor makes you aware
that your movements naturally change as you get older, and that it doesn’t mean you can’t keep doing things for
yourself.
“Everyone is getting older and going to need more support, but the exercises help to delay it and build muscle
strength.
“The classes made me conscious that I had started shuffling, instead of walking properly. Now I know I must pick my
feet up when I walk, so I don’t fall over again. And if I do fall, they’ve taught me how to get myself up, so I don’t have
to lie there waiting for help.
“I laugh with my friend about ‘when did we start shuffling and need help to stand up?’. I thought it was just part of
the process of getting old, but it’s in your mind. If others and you keep telling yourself that you are old and need
support, you believe it.
“Recently I went walking in Yorkshire, at one point there was a tough descent and in the past I might have fallen
down, but because I’m more confident and can process situations better, I managed to make it to the bottom.
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1 Executive Summary As can be seen from Mavis’s story, falling can have a devastating impact on a person’s life and wellbeing. It may
include loss of confidence, physical inactivity, social isolation, physical deterioration, anxiety and depression. On a
population level, the scale of the issue is catastrophic – 16,000 people in Southwark and Lambeth are at risk of falling
that is a third of the whole over 65yr population. This business case sets out a range of options for the future,
including the case to mainstream a successfully tested and evaluated primary falls prevention service operating
across Southwark and Lambeth.
The case for change
In 2012/13 there were 13,039 falls related attendances and ambulance call outs by the registered population of
Lambeth and Southwark, and 3029 admissions into a hospital bed. This amounts to a whole system cost in one year
of £8.25 million. A Briefing for NHS England set out the following in 2014;
Falls account for half of all accident related hospital admissions, and up to a quarter of ambulance callouts.
One-third of people who suffer a hip fracture die within a year – and a tenth within a month.
There is a heavy burden on social care in terms of care home admissions and dependence on domiciliary care.
The cost of a care home admission after hip fracture is estimated at £64,000
The current position, both in terms of public health, quality of care and use of resources, is unsustainable. Every
incident of a fall is a human story of pain and loss of independence, as well as wasted resource, when we have within
our skills and experience a service which can massively reduce these preventable events.
The falls service in Southwark and Lambeth provides a comprehensive range of services that meet the NICE and best
practice guidance for both primary (low risk, first falls) and secondary prevention (multiple and injurious falls).
However identification of people at risk is low. Prior to this project only 1,850 people per year were identified at risk
and referred for intervention i.e. 11.5% of the 16,000 at risk, of which only 285 (i.e. less than 2%) were offered
therapy for primary prevention. Later opportunities are missed for secondary prevention as we do not have the
capacity to manage the current levels demand for those at high risk of falls, with waiting times for one-to-one physio
of up to 20 weeks and evidence that significant numbers of people deteriorate and require urgent care such as ERR
and @home whilst waiting.
The innovative test
The intention of the project was to test and refine a method of early identification and triage for individuals at low
risk of falling. The test was funded by SLIC and implemented by GSTT Community Rehabilitation and Falls Service
(CRAFS) between June 2013 and November 2015. This included;
Re-designing the service delivery model, particularly for clinical triage and assessment
Introducing an innovative telephone triage system involving non-qualified clinicians as the decision makers
for allocation to the appropriate intervention.
Providing evidence based community exercise programmes.
Offering 1:1 physiotherapy for citizens at high risk of falls.
Creating rapid and easy access routes for the lower risk groups.
Ensuring reliable identification of citizens at lower risk of falls - for example using the Holistic Assessment
(HA) in primary care and the GP list mail outs.
Quantifying the increase in all service demand for falls prevention and treatment.
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Developing strategies for ensuring adherence and ‘graduate’ opportunities at the end of the 30 week
programme, engaging voluntary and community groups and citizens in co-production.
Developing reliable outcome measures and data collection methods.
Outcomes of the test
The test project has evaluated successfully on all outcome measures and on individual patient outcomes – increasing
people’s confidence, improving their activities of daily living and 76 % of people felt more able to be independent.
Of the 275 people triaged to be at risk of falls who have participated in the test over the 14 months of the project,
96.5% have not fallen at all, and there have been no injurious falls requiring attendance to hospital.
Options for future funding
An options analysis has been undertaken for commissioners to consider as set out below;
Option Shortlisted options Number of at risk people seen by 2019 Savings by end 2019
16/17 pickup Cost
1
Commission a year on year development of the service to deliver the transformational change required to reverse current large scale injuries and emergency care spend on falls.
3585 £7,172,879 £612,000
2
Commission the current activity level and expand at marginal rate 3050 £6,616,416 £448,000
3
Commission the SLIC activity level - remain static 1884 £5,814,148 £329,000
4 Do nothing - return to baseline
0 £64,000
wind down cost
Table 1: Options for commissioners
Our recommendation is option 1, which means to start the scale up in order to deliver the transformational change
which is required to reduce primary falls across Southwark and Lambeth. The mainstreaming of this case is an
opportunity for commissioners to make a real in year impact on falls incidence, and all their associated adverse
consequences.
Conclusion
This business case will set out our rationale for the preferred option for commissioners to consider. It will illustrate
one of the only evidenced population based interventions which can substantially reduce emergency admissions and
attendances at source, at a transformational scale.
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2 Introduction
This business case sets out the case to mainstream a successfully tested and evaluated primary falls prevention
service operating across Southwark and Lambeth. Evidence for the case is based on a test funded by SLIC and
implemented by GSTT Community Rehabilitation and Falls Service (CRAFS) between June 2013 and November 2015.
2.1 Vision and Aims The vision for this service is to provide an improved, equitable falls pathway which will ensure effective prevention opportunities for citizens at risk of falls.
This will be achieved by:
delivering a referral and triage process using non clinical staff as the primary decision makers for onward referral routes
Delivering community based falls prevention classes, working with the voluntary sector, and addressing social isolation and confidence building as much as the physical components of falls.
Developing, a range of adherence strategies, engaging with voluntary and community sector, councils and other leisure providers.
Ensuring equitable service across Southwark and Lambeth, including hard reach communities.
Increasing the falls service to meet the increased demand for falls interventions, for those at high and low risk, ensuring that care is delivered in the right place at the right time.
2.2 Alignment with commissioner priorities The falls prevention service described within this business case meets the following commissioning imperatives:
Meeting NICE Guidance - Research used by NICE (fall, assessment and prevention of falls in older people, June 2013)
to evidence the two national quality measures on falls shows that:
Specific Community based exercise is the best single intervention to prevent Falls
42% of falls can be prevented through these exercise programmes.
Everyday exercise such as walking is not enough to prevent falls
Biggest impact through frequent and sustained balance exercises
Should target general community as well as high-risk people.
NHS Outcomes Framework Domains & Indicators
The falls service has been included in the NHS Outcomes Framework for the first time in 15/16, and is relevant to the
following domains:
Domain 1 Preventing
people from dying prematurely
Domain 2 Enhancing
quality of life for people with long-term conditions
Domain 3 Helping people
to recover from episodes of ill-health or following injury
Domain 4 Ensuring
people have a positive experience of care
Domain 5 Treating and
caring for people in safe environment and protecting them from avoidable harm.
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NHS England CCG outcomes indicator set
Incidence of hip fractures is added in 2015/16 as a new indicator
Falls are also monitored through the following performance frameworks:
Adult Social Care Outcomes Framework 2015/2016 – reduction in falls incidence
Public Health Outcomes Framework 2013/2016- reduction in falls incidence
Local commisioning imperatives include:
Reducing whole system cost
Improving quality of care
Improving patient related outcomes
Local Public health analysis for Lambeth and Southwark – the ‘red box’ of high burden and increasing,
includes falls injury (older people), lower wellbeing levels and and social isolation, all of which are impacted
positively by this programme.
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Figure 3: Southwark and Lambeth health issues 2014
2.3 The national falls picture
Almost 200,000 falls could be prevented and £275 million saved each year through better access to rehabilitation and preventative therapies. The savings could be even greater because rehabilitation services can reduce the severity of a fall, should one still occur. Failing to invest in preventative rehabilitation services could see care home admissions caused by falls increase by 19 per cent by 2020 – at a cost of £124.8m annually. (These findings have been developed by the West and South Yorkshire and Bassetlaw Commissioning Support Unit to produce economic modelling that shows the dramatic impact falls prevention services can have in each clinical commissioning group area across England.)
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It is clear that falls are a priority for prevention both in terms of primary (a first time fall) and secondary (subsequent fall) events. NICE guidance on early identification of falls risk and prevention in 2013 and quality markers in 2015 reinforce support to address this need. A 2014 briefing from NHS England sets out key points below;
Falls and fall-related injuries are a common and serious problem for older people. They account for half of all
accident related hospital admissions up to a quarter of ambulance callouts.
People aged 65 and older have the highest risk of falling, with 30% of people older than 65 and 50% of
people older than 80 falling at least once a year.
One-third of people who suffer a hip fracture die within a year – and a tenth within a month
2.4 The local falls picture SLIPS (Southwark & Lambeth Integrated Care Pathway for Older People with Falls) is an integrated falls service across health, social, voluntary and leisure sectors in Southwark and Lambeth and is part of the programme of work of the Adult Therapy Rehab Team. See http://www.slips-online.co.uk/
It provides evidence based assessment and management of clients who have experienced a fall, are at risk of falls or are fearful of falling. Falls Clinics are provided at Guy’s Hospital (GSTT) and the Betty Alexander Suite, Dulwich Hospital, (KCH) and the Whittington Centre, Streatham.
Following assessment, exercise based interventions are selected as appropriate for the client dependent on their level of need and risk.
Community exercise classes are provided in community venues accessible by walking or public transport eg
Peckham Pulse; Dulwich Library and leisure centres.
Otago 1:1 exercise programme usually delivered in the client’s own home.
High risk Strength and Balance exercise groups are provided at the three Falls Clinic bases with ambulance
transport.
Clients with more complex needs require 1:1 physiotherapy: this area of work is steadily increasing, a factor that has considerable impact on therapist time and service capacity. In 2010-11 1,612 people over the age of 65 were seen by the Adult Therapy Rehab Team out a service total of 1,861 i.e. 86.6%. One of the Lambeth and Southwark CQUIN quality improvement goals (Commissioning for Quality and Improvement and Innovation) is “to reduce the incidence of falls resulting in harm in community settings across Southwark and Lambeth, streamlining falls service provision, including falls prevention, by the introduction of an evidence-based, multidisciplinary and multiagency falls pathway”.
SOURCE: Older Peoples JSNA: Factsheet 12: Living independently in later life: Needs
3 Case for Change
3.1 Summary of pre-existing service before test & proposed test model The current falls service meets all evidence for best practice in terms of the components including multifactorial
assessment and matching the appropriate exercise intervention required to the level of need. Referral flows from
health care professionals for high risk clients attending A&E, Hospital and Primary care are good, as evidenced later
in in the document. The two major constraints of the pre-existing service are:
1. A lack of capacity for primary prevention on a large scale within the population. Up to 16,000 people (30%)
of older population are at risk of falls within Southwark and Lambeth, with no reliable method of
identification (low demand), and only 7 community exercise groups available to them to prevent their first
injurious fall.
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2. Capacity for providing higher risk people with timely 1:1 physiotherapy led interventions, with inevitable
backlog and waiting times up to 20 weeks. In addition, an extensive audit of those people waiting during that
time evidences substantial use of urgent care community services with referrals to ERR and @Home (271 in
an 18 month period).
In June 2013 the SLIC Operations Board was presented with a proposal for enhancing the existing falls pathway. The
proposal was to design, test and implement a new pathway for community falls exercise targeting high volume, low
risk patients who currently are not referred to existing falls exercise interventions. This aimed to be an extension of
the existing falls pathway utilising existing resources, services and systems wherever possible.
Figure 4: Existing SLIPS Pathway (Southwark and Lambeth Integrated Pathway for falls)
The current service provides differentiation for strength and balance exercise and interventions results in four clear
cohorts. The standard agreed is that people should wait no more than 3 weeks to start exercise interventions. The
service detail is set out below;
Intervention Delivered by Venues Length/type of
intervention
Current /pre -existing
capacity
Current /pre-
existing demand
Community
exercise classes
Later life trained
exercise instructors
Community venue
such as church
halls and leisure
centres
40 weeks, 1x a
week
12 patients per
7 groups
140 patients /year
7 groups
140 patients /year
12
group
Otago 1:1 Therapy assistants Own home 5 visits average 144 patients year 144 / year
High risk
strength and
balance groups
Therapy assistants
with Physio
supervision
Health centres
with ambulance
transport
8 weeks 2 x a
week – 16
sessions
48/yr 48 /yr
Physio 1:1 Physiotherapists Own home 4 visits average 800 per yr 1500 per yr
Table 2: Services provided in Southwark and Lambeth
The community exercise class programme is based on FaME Programme exercises (components of flexibility, muscle
strengthening, balance, endurance, tai chi and practice getting up from the floor). Classes are run by postural
stability instructors who have completed the Later Life training course. Class participants attend one class a week
and exercise at home an additional 1 hour a week. The programme lasts for 30 weeks during which time exercises
are gradually progressed. Each group takes a maximum of 15 participantsThe test began by addressing the key
elements of service which needed to be in effective in order for the community exercise programme to work;
Access and referral
Adherence
Agreeing the delivery vehicle
Monitoring effectiveness of the intervention for participants.
Problems the test was aiming to address
No method for proactive identification and limited intervention of citizens at primary risk of falls
Clients needed to be assessed by physio prior to prescription of appropriate exercise programme
Limited public-facing access to community exercise classes. Most referrals by health-care professionals
Referrers required to complete 2 page referral form to access service
Multiple access points designed for HCPs but confusing for referrers
Two objective clinical outcomes were collected at the start and end of intervention. No subjective outcomes were recorded
Awareness of drop-outs during the programme, and concerns re long-term adherence to falls prevention exercise, but no capacity to explore this
Unable to meet existing demand for all Physiotherapy (1500 referrals) or community group interventions due to limited capacity
Only 7 community groups (100 people /yr) and 8 wte physiotherapists (800 new referrals) across 2 boroughs.
Table 3: Problems the test was aiming to address
The test is currently running 17 exercise classes across Southwark and Lambeth and will be running 19 by April 15.
Lambeth Southwark
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Clapham Leisure Centre (2 sessions)
Elm Court School
Ferndale Sports Centre
Streatham Ice &Leisure (2 sessions)
West Norwood Old Library (2 sessions)
Darwin Court
Dulwich Library (3 sessions)
Salmon Youth Centre
Southwark Pensioner Centre
The White Horse, Peckham Rye
Liberal Club, Peckham (2 sessions)
Table 4: Problems the test was aiming to address
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4 Test models Evaluation Summary and Benefits Realisation The following section outlines the achievements of the test to date.
Pre-existing SLIP’s service
What was needed? What have we done differently? Measures of success
Limited proactive identification and intervention of citizens at primary risk of falls
Open access Open access to triage within targeted neighbourhoods
Longitudinal reduction in falls in high risk neighbourhoods
Only 7 community exercise classes
Set up more classes Recruitment of lay instructors Suitable non health centre venues. admin systems to place and track
Reduced length of classes to 30 weeks (from 40) Increased each group to 15 attendees per session- (from 12) Planned opening of classes for locations where demand arose
12 new classes (total 19) established close to peoples own homes Well attended
Clients needed to be assessed by physio or GP prior to prescription of appropriate exercise
Fast-track access to exercise with reduced assessment cost
Clinical triage by clinical assistants rather than Physiotherapists proven accuracy and safety of onward referral with an almost 99% success rate
Appropriateness of referral from triage measured by service.
Limited public-facing access to community exercise classes. Most referrals by health-care professionals
Increased public-facing access
Strength and balance helpline launched and service advertised leading to significant volumes of self-referrals , now public facing
Number of direct referrals by citizens and non-professionals
Referrers required to complete 2 page referral form to access service
Increased ease of access for referrers
Strength and balance helpline allows referrers to refer clients over the phone giving just their name and D.O.B. Helpline staff then contact the client to complete clinical triage.
Increase in referrals
Two objective clinical outcomes were collected at the start and end of intervention. No subjective outcomes or falls incidence were recorded
Increased frequency of outcome collection and implementation of subjective outcomes to allow improved analysis of effectiveness
Collection of two objective measures at 10 week intervals throughout the programme. Collection of two subjective outcomes at the start and end of intervention, falls incidence and severity and launch collection of patient feedback.
Collection of subjective and objective outcomes and falls incidence
Awareness of drop-outs during the programme, and concerns re long-term adherence to falls prevention exercise, but no capacity to explore this
Analysis of attendance. Implementation of strategies to improve access to the programme and adherence during and after attendance. A
defined ‘graduate
programme’
Analysed and reported on attendance and drop-out rates. Liaised with attendees to garner feedback regarding attendance, drop-outs and what strategies may be helpful to reduce adherence. Created a workbook to support attendees, Created an instructional DVD, Identified where partnership, accreditation or franchise with community organisations will be beneficial. Created directory of follow on groups Funding 1-2 tests of voluntary sector support
Longitudinal reduction in falls per individuals participating in the classes. Clear exit routes to effective on-going exercise
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Unable to meet existing demand for all Physiotherapy interventions due to limited capacity
Analysis of demand versus capacity in existing service. Increased capacity to meet demand where required
An audit of caseloads identified that 88% of clients on CRAFS waiting lists have either fallen or at risk of falls. Started 9 new exercise classes, employed 1.6 WTE physiotherapists, started a second strength and balance group, Analysed demand capacity and implemented service improvement and improved productivity.
Reduction in waiting times. Defined capacity required to meet on-going demand
Multiple access points designed for HCPs but confusing for referrers
Reduction in number of access points
Introduction of strength and balance helpline. Designed plan to bring all access points to single point for triage (if mainstreamed)
Increased referrals. Fewer steps from referral to treatment.
Table 5: Changes made as a result of the test
4.1 Achievements of the test To test and refine a method of early identification and referral of clients who would potentially benefit, through the
Holistic Assessment and possibly other routes.
It had originally been hoped that a number of appropriate clients would be identified through completion of the Holistic Assessment (HA). Unfortunately, this was slow to reach momentum, but is now developing to be a valuable source of referral for primary and secondary prevention services. It was therefore necessary to identify additional routes including leaflets, posters, information pieces in bulletins and staff attending meetings and groups. These were tried over a period of months. In addition, access routes into the services were confusing and multiple. Holistic Assessment (HA) Specific falls questions were included and adapted in the evolving versions of the HA. Although slow roll out, the analysis is now showing 10-13% of people reviewed with an HA identified at falls risk and are being referred to various access points in the falls service –not necessarily the helpline as this has not been widely advertised to all GP’s. Posters and leaflets New posters and leaflets have been designed by clinical staff and distributed to a number of organisations to market the service and encourage referrals. Leaflets have also been given to practice managers from eight SE Lambeth GP practices, Age UK Lambeth, Lambeth Resolve advice centres, SLIC GP clinical lead event, Waterloo Action Centre, supermarkets, Lambeth Country Show, pharmacies and Lambeth libraries. Marketing in the early months was focused upon Lambeth residents as the bulk of early referrals were for those living in Southwark via Southwark SAIL. Further distribution and increased publicity is planned across both boroughs. Partnership working From early stages we have worked closely with Southwark and Lambeth SAIL to incorporate a falls risk identification question on their referral form. They have been one of our biggest referral sources to date, especially in the early months of the project. This is one of the tests most valuable success stories. Mail shots Three mail shots were carried out using the entire over-65 register for patients at Norwood Surgery, attendees at the Southwark Pensioners’ Centre and Sheltered Accommodation residents across Southwark and Lambeth. A total of 3343 letters and leaflets were distributed with 53 resulting in self referrals. The rate was highest as a result of the GP mail out (5% for primary prevention) and lowest from Sheltered Accommodation. GP mailshots allow geographical location of new groups to be set up in advance of receiving new referrals. Plans for further mailshots are underway. Bulletins
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Since May 2014 details of the Strength and Balance Helpline and Community Exercise Classes have been sent out to be included in the following organisations’ e-bulletins:
Lambeth CCG & Southwark CCG
Community Action Southwark (CAS)
Health watch Lambeth & Health watch Southwark
Southwark Pensioners
Age UK Lambeth
Screening and Referral Outcome Including Exercise Prescription
We tested the methods for the screening of referrals and allocation of clients to appropriate exercise classes or other intervention. The standard practice for a SLIPS referral and accepted national requirement for referrals to Exercise Classes is for this to be done (prescribed) by a physiotherapist following face-to-face assessment to ensure safety. Given the desired volumes for primary care prevention, this would not be affordable. We aimed to test the safety and effectiveness of delegating falls screening and initial assessment to Band 4 assistant staff. This rapid, low cost , high volume process has proved to be safe, cost effective, high quality and meets the need to scale up the services The Strength & Balance Helpline went live in January 2014 and has been used as the vehicle for screening referrals into the new classes. A total of 400 referrals had been received by the end of September. 212 of those had been received since June, as a result of the targeted marketing (GP mailshot). As referral numbers have increased, the screening processes have been tested and improved using Plan – Do – Study - Act methodologies in line with the model of change. The phone lines are manned Monday – Friday by Band 4 staff and there is an answerphone to leave a message if phoning out of hours.
Review capacity and demand
Referral numbers to the Strength and Balance Helpline have increased over the months. One of the issues that have been identified is that significant numbers of people calling the Helpline have needed other Falls services i.e. 1:1 physio (30%) and Strength and Balance Group for more complex clients (7%), as fig 5 shows:
Figure 5: Triage outcomes – service level demand
Triage outcomes – service level demand
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The graph above show the effect that the primary prevention initative of community exercise classes has on also identifying people who need the other more expensive interventions eg one to one Therapy sessions. However the trend shows a greatly increased proportion of primary prevention to secondary as intended demonstrating the effectiveness of the methods of identification. Community Exercise Classes From the above referral data we have established that on average 58% of referrals received are for clients appropriate for Community Exercise Class. The test started enough classes in line with the uninformed demand, but as the marketing plan develops and participants spread the word through their communities, demand has grown exponentially. Another 12 classes will be in place by April 2016 Otago 1:1 The actual activity is sits at 2% and has been absorbed into the service largely because of the productivity improvement gains. 1:1 Physio The test proposal hypothesised that 5% of referrals would require 1:1 Physio. The data from December2014 – November 2015 has shown that this figure is actually an average of 34% which is a significant increase in demand. The project data shows us that patients are seen between one and six times by a physio for a 1:1 session. On average people appropriate for the service are seen four times. High Risk Strength and Balance Group The original proposal projected that 5% of patients identified would require high-risk Strength and Balance Group. The 7.5% volume of referrals has been greater than anticipated and the demand cannot be absorbed within existing groups. An additional group was required and was set up. Falls Clinic Approximately 1% require further investigation and specialist assessment in the falls clinic – this is a specialist medical geriatrician, nursing, Physio and OT assessment in a ‘one stop shop’ . This has been absorbed into the existing service at the three falls clinic sites, Guy’s, KCH and Whittington centre. Occupational therapy There has been no increase in requirement to date as part of this test.
Existing falls service capacity gap and backlog
The current SLIPS service is only able to see approximately 10% of the at risk population- less than 7% can be seen in
a timely way.
Whilst a number of people referred to the service are able to attend the classes a significant number of complex
patients require secondary prevention involving 1-1 individual physiotherapy to meet their needs.
The number of referrals to the service and the complexity of the patients has been increasing the staffing levels of
therapists have not, therefore the service is constantly operating with a significant waiting list or backlog of clients.
Patients waiting in the back log for individual 1-1 therapy input have a greater risk of deteriorating and being
admitted to hospital or requiring rapid response due to lack of earlier intervention.
An audit by GST Community Trust examined admissions to urgent care community services for people on the 20
week waiting list. The results of the audit are set out below. As can be seen , significant numbers of people on the
waiting list are at high risk of admission. (271 in an 18 month period)
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Figure 6: Impact of 20 week waits on urgent care services
There is a significant demand/capacity mismatch and patients are breeching 18 week referral times and 3 weeks falls
service standards. The 8 wte have a capacity for 100 new referrals and receive 1500 per year.
In Southwark only 57 % of new referrals can be seen creating a constant queue for the service of the remaining 43%
of accepted new patient referrals per month. In Lambeth 60% of new patient referrals are seen with existing
capacity.
A service improvement programme has been undertaken in the mainstream service –improving Productivity and
identifying demand and capacity constraints that cannot be met within existing resources (see Appendix 2)
Productivity improvements and mobile working implementation have been taken into account and the projected
capacity gap for physiotherapy after these improvements is 4 wte and we anticipate remains static as it has in recent
years (i.e. excluding project new activity)
Adherence
To maintain and update best practice a review of the current literature, and national and local programmes relating
to falls prevention and behavioural change strategies was completed. This informed our work with citizens during
focus groups, wider citizen co-production events, questionnaire design, and the development of the adherence
strategy.
Current falls prevention evidence recommends a ‘dose’ of strength and balance exercise in excess of 50 hours, 2-3
times per week (Charters, 2013), with benefits being rapidly lost when exercise is ceased (Sherrington, 2011, Hawley,
Impact of 20 week waits on Urgent Care services
19
2009). In addition, older adults have more co-morbidity, less social support, and more disability and depression than
the general population, and these factors are associated with lower exercise adherence (Picorrelli et al, 2014).
Adherence Outcomes
Average attendance at the classes is 70%, with 70% going on to complete the programme. This is consistent with
adherence rates reported in the literature (Picorelli, 2014) of between 58 and 85%. There is scope for further
improvement
Summary of Citizen co production
The adherence strategy has looked at:
Reducing the barriers to joining the classes
o Wider promotion of the classes through partnerships with Voluntary Sector Organisations (e.g.
AgeUK Winter Wellness Packs), posters and leaflets at community sites such as local libraries,
internet presence, and direct mail-outs from GP practices and Housing Associations
o Using volunteer support or ‘Buddy schemes’ to facilitate early class attendance
o Improving our health information strategies for promoting the benefits of the service both online
and in our initial ‘welcome packs’ for participants
Supporting participants to supplement their weekly classes with additional appropriate exercise either at
home or in other community settings
o Production of a class ‘workbook’ which explores making goals, monitoring achievements, and
planning for relapses, strategies consistent with NICE guidance (2014) on behavioural change
interventions
o Telephone review following each class non-attendance
o Provision of an exercise DVD of the programme to support self-directed practice
o Exploring a volunteer programme to facilitate peer group support
Improving the transition to other community ‘follow on’ exercise activities
o Visiting and reviewing appropriate physical activity options for class ‘graduates’
o Improving our guidance for appropriate ‘follow on’ options
o Exploring volunteer support to facilitate transition to other community exercise activities
Between 45-50 people took part in the group interviews. There was a good gender mix and people from a wide
variety of ethnicities were in attendance.
We found the following:
Benefits Students like the routine and appreciate being ‘pushed’ to do the exercises at classes; while at the
same time being able to do things at their own pace and without fear of feeling intimidated or embarrassed.
As well as the benefits of better balance and strength, and avoiding a bad fall, the classes improve their
confidence, motivate them to get out of the house and do the exercises. They also meet people too. There is
a sense, with some of the classes at least, of camaraderie and mutual support.
Support They struggle with doing the exercises on their own. While there was very little interest in (or
capacity for) using the internet and text messaging, there was general support for the idea of having a DVD
they can watch at home. It would also help them in doing the exercises ‘right’. But the general view is that
these technologies are no substitute for the classes.
20
Coproduction While they wanted to continue to do something after finishing the course, and were uncertain
what that might be; for most of the students there was little interest in organising classes themselves. They
want something that is free, convenient and tailored to their needs, but felt they were too old and wouldn’t
be able to do it. There was, however, some support for a buddying approach, and perhaps building on the
moral support they were already giving each other. A few students were enthusiastic about getting together
more informally as well as running their own classes with support.
Developing community capacity The very nature of the community exercise classes, the elements that take them away from a medical model are that they are accessed directly by people who have often assessed themselves to be at risk, that they not only develop strength and balance, but have the opportunity to improve their psycho social life, over a substantial amount of time.
Monitoring of outcomes and impact
Clinical outcome data is recorded at the start of class attendance, at 10, 20 weeks, and on discharge at 30 weeks. Evaluation has been undertaken by the SLIC and Provider Project Teams, along with the participants and citizen’s
forum. The table sets out the outcomes from the project measures. Despite challenges with data capture – the
results are impressive with 96.5% of attendees not falling whilst on the programme and no injurious falls at all. This
is in a group who had fallen at least once in the previous year.
Outcome activity
Quality measures Outcome standard Actual outcome
Adherence Measures complete programme completion % Attendance over the 30 week programme -65%
75%
Clinical Outcomes
Monitors participant’s clinical outcome measures for the duration of their class participation. The outcomes measured are: ● Chair Stand Test [normal: <12 seconds] ● 180 degree Turn [normal: <5 steps] ● Timed up and go: [normal <15 seconds] Measurements are taken at the start (baseline) and then at 10 week intervals and compared against previous intervals. They are recorded as follows: ● Start Baseline ● Ten week interval ● Twenty week interval ● Programme end
50 % of participants demonstrate Improvement in one or more clinical measures
76%
PROMS (Appendix 3)
The EQ-5D-5L is a standardised validated tool to measure an individual’s quality of life as a health outcome.
70% of people had improved outcomes
75% - part way through
programme
(Appendix 4) FES-I ,Falls Efficacy Scale International A recognised, responsive, validated tool developed to measure confidence in performing a range of daily activities related to balance and walking. It can be used to predict future falls and decline in functional capacity.
70% of people had improved outcomes
70% Part way through
programme
Number of falls during programme
Have any participants fallen during the the exercise programme-and if so have they sustained an injury
No national benchmark-
estimate eg 75% do not fall 95% do not
have an injurious fall
96,5% have not fallen
No injurious falls
Improving access to
Open access to triage within targeted neighbourhoods. 5% of older people on GP register
5% from mail drop & high
volumes from
21
services non-health professionals e.g. SAIL etc
Value for money and clinically safe processes
Triage by non-qualified band 4 assistant staff, proven accuracy and safety of onward referral
99% of triaged referrals are appropriate
99%
Table 6 : The test outcomes at evaluation
4.2 Summary of Lessons Learnt
The learning from this test has shown that there is a significant demand for the early intervention Community Exercise Classes and we have seen that there are effective methods of recruiting clients with limited marketing into the programme. The most effective, manageable, quantifiable and cheapest route to recruit appropriate clients has been through the mailshot from the GP practice.
We found that the safety and effectiveness of delegating falls screening and initial assessment to Band 4
assistant staff worked 99% of the time, when the standard practice for a SLIPS referral and accepted national requirement for referrals to Community Exercise Classes is for this to be done by a physiotherapist following face-to-face assessment. This triage point also allows for swift redirection to alternative treatment if the individuals condition has changed.
The analysis of the data shows that 58% of the referrals that come to the Strength and Balance Helpline are
suitable for the Community Exercise Classes with a further 34% requiring 1:1 Physio. The GP mailshot gave a return rate of 5%. 58% go to the community classes, Physio 1:1=34%, Strength and balance group = 7.5%, Otago = 1%, Falls Clinic = 1%. The trend is for higher primary prevention and lower secondary (physiotherapy).
We have evaluated and adapted our outcome monitoring processes throughout the project. collecting a
range of clinical outcomes, subjective measures and falls incidence rates. However, this volume is not sustainable and data quality and completeness is challenging. Local clinical information systems do not support this type or level of reporting. Clinical outcome measurement is not reliable when administered by the non-clinically trained community exercise group instructors. In order to scale up the service, we plan to focus on recording falls incidence/injurious falls, and the 2 PROM’s (Patient reported outcome measures) at start and finish as we believe these will be best measures of 1. The improvement to individuals and 2. The benefits of the interventions and of the service as a whole. Individual Clinical outcomes will be collected where clinical staff are providing/leading the intervention- e.g. physio and high risk strength and balance classes
We have seen very strong results on participant reported outcomes for actual falls and confidence in
activities of daily living. Participant scores on satisfaction are also very strong, as set out in table xxx. Five attendees from the Streatham Leisure Centre were interviewed on 8 December 2014. They agreed the classes where an opportunity to …”motivate, support and look after each other”, the social benefits reinforcing the group dynamics of mutual support.
We have identified the need and resource required to increase the capacity of the whole falls service in
order to deal with the demand, and maximise the opportunities for patients and value for money.
We have understood the power of word of mouth, of community resources, and the voluntary sector that can bring added value and be developed to create opportunities for improving both individual and community resilience. The majority of referrals are from the voluntary sector are for primary prevention. This has the potential to extend to supporting or providing service provision and graduate options. We have identified that this potential requires investment in terms of time and support to develop their expertise and that accreditation and franchise options can be established.
22
5 Future Commissioning intentions: Proposal to mainstream
5.1 Commissioning proposal and recommendation We know from a strong international evidence base that our service intervention can reduce falls by up to 61%. Locally, we have demonstrated through our 15 month test that for the 275 people who have completed a 30 week course, we have a non-fall rate of 96.5%. We have seen the success of the key elements of service;
Easy ,direct community based access
Cost effective triage
Primary prevention community classes
High risk prevention therapies
Adherence and engagement with voluntary and community groups We have explored four options in order to find the one which best meets the risk profile and needs of the population of Southwark and Lambeth, the statutory obligations of commissioners and providers, and benefits the whole system resources. The detailed activity and savings analysis for all four options are set out in the finance and cost savings sections The mainstreaming of this case is an opportunity for commissioners to make a real in year impact on falls incidence, and all their associated adverse consequences. Our preferred option is to recommend option 1, which means to start the scale up in order to deliver the transformational change which is required. Overall for the service, we predict a still substantial but conservative 40% reduction in the incidence of falls, as this includes higher risk older groups. The organisational and whole systems savings are substantial through clarity of referral processes and streamlining of delivery, and these are set out in in the financial analysis section.
23
Table 7: Options for commissioning
Option Shortlisted options Quality No of at risk
people seen end of 2019
Savings by end 2019
16/17 pickup Cost
1 Commission a year on year development of the service to deliver the transformational change required to reverse current large scale injuries and emergency care spend on falls.
Service will be managed by its own service manager, developed to deliver transformational change working across community and voluntary sector.
Increased physio capacity will reduce waiting times to 3 weeks maximum avoiding deterioration and injury
Will meet quality imperatives from NHS England. CCG Outcomes indicator set 2015/16 - Hip fracture incidence included as a new measure
CQUIN reduce incidence of falls Southwark and Lambeth Adult Social Care Outcomes Framework 2015–2016 Public Health Outcomes Framework 2013–2016. NICE Guidance for Falls prevention 2013 and 2015
3585 £7,172,879 £612,000
2 Commission the current activity level and expand at marginal rate
Service will need to be managed by its own service manager
Will fail to address the scale required for maximum impact and will not have capacity to meet needs of hard to reach communities.
Current waiting times for one to one physio therapy for high risk patients may reduce to 10 or 12 weeks. Some of those waiting will experience deterioration, falls and injuries such as fractures.
3050 £6,616,416 £448,000
3 Commission the SLIC activity level - remain static
The service will not be equitable, meeting only the need of the neighbourhoods where the classes are currently placed. Without development and service management funding, the service will fail to address the needs of hard to reach communities, or those at high risk who need one to one physio to prevent falls. There will be no capacity to develop the voluntary or community sector, missing opportunities and value added resilience work.
Current waiting times for one to one physio therapy for high risk patients will remain at 20 weeks and rising. Some of those waiting will experience deterioration, falls and injuries such as fractures.
1884 £5,814,148 £329,000
4 Do nothing - return to baseline
Please see risk chart in section 5 0 0 £64,000 wind down cost
5.2 Recommended option Of the four options identified option one is the recommended option. This will provide the highest impact both in
terms of savings and prevention of falls.
24
The proposed service will include the following elements:
1. A falls prevention service which by 2020 will have provided interventions to reduce or prevent falls in 57% of
the at risk 16,000 population. This will deliver transformational change.
2. Establishment of a widely marketed permanent Falls Strength and Balance help line, and a central triage hub
providing a single point of access for members of the community and professionals, manned by band 4
Therapy assistants.
3. Incremental growth at scale in primary prevention, the Community Exercise Class, in both Southwark and
Lambeth to have capacity for over 1000 people per year.
4. Additional resource (physiotherapists and high risk strength and balance groups) to meet the demand for
the existing and the increased level of identification for secondary prevention
5. Develop voluntary and community organisation capital to augment provider options for attendance,
adherence and graduate routes after completion of the programme
Increased activity in the four exercise components – numbers of people
Figure 7: Service level activity
The management team will develop a marketing and communication plan to support this expansion.
The development of the voluntary and community sector will be specifically supported with some funding to
increase the capability, skills and capacity.
5.3 Description of service The range of strength and balance falls exercise interventions are a population based preventative service, which is
set within a whole system approach, described in fig 8 below. The service will be fully integrated within the existing
SLIPs falls service.
25
Figure 8: Contextual diagram for the service
Access
There will a central hub for all referrals for people identified at risk of falls – reducing the points of access and
confusion for referrers
The Helpline will maintain the public facing simple access point for citizens, carers, voluntary and other referrers who
have not undertaken an assessment of the person. It will be widely marketed using a variety of methods tested in
the pilot.
Health care and other professionals, who have assessed the person and are currently referring to a number of access
points, will have a single electronic point of referral within this hub.
We will support Local Care Networks and Primary care to identify at risk individuals, including a continued rollout of the over 65 maildrops that were shown to be are a very low cost and reliable method of attracting approriate self referral for 5% of the over 65 population. Demographic differences across the two boroughs may result in different response rates; Future mail outs would be coordinated with local care networks and public health advice to establish priority areas of high risk populations. The team will work closely with each group of GP practices, working on the ground with the health navigators in each practice to enable us to increase referrals from HHA’s and hard to reach groups and non-English speaking clients.
Triage
Triage by the Ban 4 Therapy Assistants to relevant exercise intervention or multifactorial assessment will be
undertaken by maintaining and developing the skilled clinical assistant roles within the hub and will triage every level
of need to the approporiate service/ intervention. This greater value for money and is scaleable.
During the test this has achieved 99% success at direction to the most appropriate falls intervention. This has proved
popular with professionals and the public alike. It also provides a route back to alternative intervention if required –
eg the person deteriorates or improves. This will reduce the steps, time and qualified physiotherapy resource
needed to safely commence the relevant exercise programme as shown in the revised flow diagram below
26
:
Figure 9: New service pathway
Primary prevention, the Community Exercise Classes
The roll out of community exercise classes in leisure and other community centres throughout Lambeth and
Southwark presents a range of operational challenges that the team are now very skilled in resolving. The rollout
plan is practical and achievable.
The classes will be delivered by instructors qualified to level 4 PSI, who are contracted with a specification which
includes the elements which can deliver our aspirations for the classes, as well as data and outcomes capture, and
recruited on a freelance basis, recruited by the Falls service manager.
A structured specialist-led group exercise element of one 1 hour session per week for 30 weeks supported by home
based physical activity, with a theraband provided at week 1 and a DVD at week 10.
27
The classes consist of essential evidence based components. Activities are specifically designed to improve balance
and strengthen specific muscle groups, not just to simply increase physical activity levels.
Venues will be chosen to take into account:
Close proximity to local residents
Easily accessible by public transport
Easy or step-free access
Spacious (a minimum of 100 sq. metres for a class of 15 participants)
Well lit, and welcoming environment
These classes have been redesigned during the pilot to be higher volume and lower cost per individual (currently
approx £220 a person for a 30 week programme or just over £5000 per year per group).
A service specification has been designed so that these can be delivered by other other organsiations on a franchise
basis under the governance of the overall falls service and this franchise model will be developed and tested in 2016-
17.
Other organsiations such as voluntary groups currently lack the expertise to provide these classes, however the
resource in the business case will help support their development to deliver these and respond to the franschise
partcularly for hard to reach communities.
We have already identified 2 popluations where this may be desirable ie the Portugese community and the project
team is working with a Mosque in the Old Kent Road area to develop a class that meets the criteria set out by the
project but will potentially be run by exercise instructors identified from their community.
Secondary prevention
The marketing of the falls helpline will help to identify unmet need, so a part of the business plan addresses the
current and predicted new capacity gap for those people who are at higher risk of falls and need more one to one
therapy led interventions.
Additional physiotherapy and high risk strength and balance groups will be recruited/ established to meet demand
and managed within existing clinical management resources.
The service will be able to achive waits of no more than three weeks from referral to offer of first appointment in
line with clinical evidence and standards.
The current cohort of people who deteriorate whilst awaiting intervention will be substabntially reduced as will the
preventable demand and cost on urgent response services such as ERR and @home (data shows this was 271 people
in an 18 month period).
The roll out plan will initially cover 4 years, and the activity schedule is set out overleaf (Table 8);
28
Number individuals Baseline14-15 Total 15-16 Total 16-17 Total 17-18 Total 18-19
Community exercise classes
140 440 640 750 1000
High risk Strength and balance group
48 96 96 120 144
Otago 1:1 144 150 154 159 164
Physio 1:1 1523 1640 1718 1816 1913
Total 1855 2326 2608 2845 3221
Table 8: Roll out plan option 1
number groups running each year -
Baseline14-15
total 15-16 total 16-17 total 17-18 total 18-19
Community exercise classes
7 19 27 37 47
High risk Strength and balance group
1 2 2 3 3
Total 8 21 29 40 50
Table 9 : Roll out plan option 1
29
Increased activity in the four exercise components – numbers of people
Fig 10: Planned activity schedule option 1
Attendance, adherence and graduate routes
Adherence during the exercise programme and long term maintenance of effective exercise is an essential
component of the service. The following strategies developed in co-production during the pilot have been identified
and will be implemented
Reducing the barriers to joining the classes
o Wider promotion of the classes through partnerships with Voluntary Sector Organisations (e.g. Age
UK Winter Wellness Packs), posters and leaflets at community sites such as local libraries, internet
presence, and direct mail-outs from GP practices and Housing Associations
o To further develop the web and social media presence. This would be particularly useful for
communicating with key stakeholders and citizens, and family members who are confident with
using the internet.
o Using volunteer support or ‘Buddy schemes’ to facilitate early class attendance
o Improving our health information strategies for promoting the benefits of the service both online
and in our initial ‘welcome packs’ for participants
Supporting participants to supplement their weekly classes with additional appropriate exercise either at
home or in other community settings
o Production of a class ‘workbook’ which explores making goals, monitoring achievements, and
planning for relapses, strategies consistent with NICE guidance (2014) on behavioural change
interventions
o Telephone review following each class non-attendance
o Provision of the exercise DVD of the programme to support self-directed practice
o The DVD can be sub-titled into different languages.
o Implement the text messaging service for those participants that would welcome use of this
communication channel.
o Developing a volunteer programme to facilitate peer group support
Improving the transition to other community ‘follow on’ exercise activities
30
o Visiting and reviewing appropriate physical activity options for class ‘graduates’ a compendium of
over 25 groups has already been created.
Support and influence the development of appropriate ‘follow-on’ community exercise options:
Develop our relationships with providers of health promotion classes such as Dance for Health in Vauxhall or
Parkour Dance in Bermondsey which have good balance and strength components. These could be become a
trusted accredited or ‘kite-marked’ as a follow-on option for clients in those localities.
To work with existing classes which do not currently have a very strong strength and balance components,
but could potentially, with some support from the project team. These could then become trusted ‘kite-
marked’ follow-on exercise options. Based on feedback from our citizens engagement work this should be
limited currently to £3-4.
Encourage Instructors from our current pool of PSI’s to set up their own ‘Pay as you go’ classes. If space can
be accessed for free or low cost through relationships with VCS’s then this would become affordable at £3-4.
Improving our guidance to individuals for appropriate ‘follow on’ options
Developing volunteer support to facilitate transition to other community exercise activities
How will be programme be managed and run?
GSTT Community teams will manage the services, and will assess and provide governance. There is resource
identified to develop the provider market in voluntary and community organsiations. The roll out programme for the
exercise classes will be fully integrated into the existing falls service.
The operational management structure is supported by a full time service manager and a clincial lead to enable the
ambitioius progreamme of expansion, francise, acdcrediation, partnership and alternative provider development.
Workforce development and community capital
The project team will be able to continue the development of a workforce of voluntary and community services and
citizens would be able to support the mainstream deployment of this early intervention pathway.
The evaluation of the test set out above demonstrates that the service is now ready to be commissioned for the
whole at risk members of our population, in order to achieve the substantial personal and whole system benefits as
specified by the SLIC Appraisal Framework is set out below
The benefits of mainstreaming the service as set out in the table below;
Benefit Impact
Population outcomes: [Life expectancy or quality of life not impacted by a fall related injury]
The fast track pathway for citizens at risk of primary falls into Community Exercise Classes allows a preventative approach to this common risk to older people’s health and wellbeing. Through early intervention and providing an appropriate designed intervention, this pathway will assist in maximising individual’s health and psycho social outcomes. The current service is only able to deliver services which reduce risk in fewer than 10% of the population. In addition to the wellbeing, financial, health and social impacts, consideration must be given to the impact on an individual who has fallen, even without major injury or hospitalisation. This impact on their quality of life is much wider and significant.
loss of confidence,
physical inactivity,
social isolation,
31
physical deterioration,
anxiety and depression
a greater dependence on family, friends
Increased demand on community health and social services.
Associated social care cost, including residential and nursing home costs. Most people who are unable to live in their own homes have suffered a fall in their past medical history.
Curbing the rise of total system cost
The physical and psycho social impact of falls in an economic context is catastrophic. The health and social care response to a person who falls and calls for assistance is at the very minimum an ambulance attendance, and can range to a 120 day stay in hospital, with discharge to a care home at £28,000 per annum. Please see the fiscal analysis in the Financial section for more detail
Patient and carer experience
This fast-track treatment pathway into Community Exercise Classes will improve patient and carer experience. Citizen engagement and partnership working has already been undertaken, with support from the SLIC Senior Engagement Officer with groups engaged have included citizens [class attendees] and the voluntary and community sector. Feedback received from citizens participating in classes includes: “I found the class hard work but very worthwhile and am sure it is the training I need to improve my balance and leg strength” Mrs N., London Two citizens from the Elm Court School class were interviewed on 5 December 2014. They stated they looked forward to their classes, finding them both useful and helping to improve their confidence when out walking and “getting on and off buses”. On 2 December 2014, five citizens at the Dulwich Library class were interviewed by the SLIC senior engagement officer. They said they enjoyed their class. They described the class as “something they needed and had waited some time for.”
Clinical improvements
76 % of the total course participants achieved at least one improved clinical marker
Has a strategic coherence taking into account other projects within the programme and the sector
Because of the significant impact that falls have across the local Health and Social economy, efforts to identify and implement effective preventative measures are high on the agenda of Southwark and Lambeth CCGs, Local Health Services and Local Authorities. This project also fits with the General Practice work aiming for early identification utilising ICMs and Holistic Health Assessments.
Organisational benefits
We will be able to demonstrate benefits to multiple agencies including Acute Hospitals [A&E attendances as well as admissions], London Ambulance Service and Southwark and Lambeth Councils [social care costs, including residential and nursing care through the following metrics;
Reduction in LAS attendance for falls against baseline 2014/15 figures
Reduction in A&E admission for falls in participant population.
Reduction in fractures as set out in our baseline metrics. The knock on benefits in acute bed usage cannot solely be attributed to this initiative, but it will play its part. Through engaging with Age UK Phase Two will help to identify how volunteers and community organisations can assist in supporting care in the community. This will help reduce overall system operational spend and improve value for the citizen due to approaches the third sector offer.
Table 10: the benefits of mainstreaming the service
32
5.4 Quality Assurance, Outcome and Benefit Realisation
The outcomes for the service will be monitored and measured with the tools set out in fig x
Outcome area Standard to be achieved Monitoring tool Outcomes per annum
Y1 Y2 Y3 Y4
Organisational We will be able to demonstrate benefits to multiple agencies including Acute Hospitals [A&E attendances as well as admissions], London Ambulance Service and Southwark and Lambeth Councils [social care costs, including residential and nursing care) Further, this initiative will support the development of voluntary sector support through the graduate programme. Specifically we can measure ;
Reduction in LAS attendance for falls against baseline 2014/15 figures
Reduction in A&E admission for falls in participant population.
Reduction in fractures as set out in our baseline metrics.
The knock on benefits in acute bed usage cannot solely be attributed to this initiative, but it will play its part.
Quarterly contract review of NICE guidance by commissioners
Satisfaction The proposed pathway has a positive impact on the following “I Statement” outcomes: I have systems in place to help at an early stage to avoid crisis I can manage my own health and wellbeing (or condition) and I am supported to do this I (am able to) live the life I want (and get the support I need to do that) 70% of participants will show an improvement
FES-I ,Falls Efficacy Scale International A
Clinical and individual outcomes
76 % of the total course participants achieved at least one improved clinical marker, and falls incidence in the participants is monitored. Monitoring the number of falls per participant during the 30 week course
Trainer records Service monitoring and commissioner review
Wellbeing 70% of participants will see an improvement on this scoring tool
The EQ-5D-5L is a standardised validated tool to measure an individual’s quality of life as a health outcome.
Activity Open access to triage within targeted neighbourhoods. Clinical triage by non-qualified staff, proven accuracy and safety of onward referral with an almost 100% success rate. Activity will be agreed with the emerging Local Care Networks and Public Health advisors, in order to target the highest risk neighbourhoods. Proposed New activity per
Monthly capacity and demand analysis - whole service
33
annum to be met.
Resources The 4 year roll out plan for this service acknowledges that the exercise class programme needs to meet demand from increasing percentages of at risk citizens per annum, and maximise the benefits set out above. Whole system cost saving will be seen against a local agreement to invest to grow this preventative service. Please see cost savings plan in section. This will be measured by ; Reduction in admissions for falls against baseline.
Quarterly review of data whole service with commissioners.
Table 11: Outcome monitoring tool
5.5 Projected savings: Cost impact over the next 5 years In order to define the cost impact, we have evaluated the following data and metrics below. Our assumptions and
analysis is set out in more detail in Appendix 1.
Our demand, defined by age and a third of each age grouping, is set out in the table below. We can see a steady rise
in year on year demand. Age is a significant marker as over the age of 80 years, falls risk doubles.
34
FY2014 FY2015 FY2016 FY2017 FY2018 FY2019 FY2020
65 to 69 4,967 5,133 5,233 5,200 5,267 5,400 5,567
70 to 74 3,767 3,733 3,767 4,000 4,133 4,267 4,400
75 to 79 3,033 3,100 3,067 3,033 3,033 3,100 3,067
80 to 84 2,133 2,133 2,200 2,200 2,233 2,300 2,367
85 to 89 1,300 1,300 1,367 1,367 1,400 1,400 1,400
Table 12: Demand for the service
Southwark and Lambeth spent £17, 183,543 in 2014 and 2015 on addressing the needs of patients who were
admitted to hospital with a fall. The breakdown is set out below;
Fig 11: Current whole system spend on falls (actual) Southwark and Lambeth
35
Savings assumptions are based on a conservative 40% decrease in falls across all risk levels, and the baseline falls
spend and programme savings from our planned activity levels set out in fig xxx are depicted below. The
conservative growth of the service reduces the savings we are able to achieve, but the trajectory of saving makes
this a very clear invest to save initiative in this first year. After this, the service pays for itself many times over.
Option 1
Fig 12 : Baseline spend and programme savings option 1
The cumulative savings against service cost are substantial and are set out below in fig 13;
Fig 13 : Cumulative programme savings option 1
36
Fig 14: Gross savings by option
The graph above illustrates the savings available from three of the options. Option 4 leaves commissioners with an
actual current spend on falls of £8.25 million a year, spent on emergency care and rehabilitation. The additional
2,000 people who would be seen in Option 1 afford additional savings of 4 million, cumulatively. As the first year is
pump primed, in order to set up the clinical and management team, the spend to set this option up is £164,000 more
than option 2, which delivers 1000 fewer participants a year. Detailed analysis is set out in Appendix 5.
5.6 Financials: Direct Cost of service The proposed enhanced services will be hosted within CRAFS - the Community Rehabilitation and Falls Service, which
provides a wide range of interventions for clients with complex rehabilitation needs.
The Total cost schedule set out below addresses the enhanced service requirement, and is set out to 2019 for Option
1 in fig 15, and Option 2 is set out in Fig 16.
37
Current SLIC project units funded Cost to run 1 group
for full year / staff
wte substantive
Groups per
year /wte
per year
Cost
substantive
Groups
/wte
Cost
substantive
Groups per
year /wte
Cost
substantive
Groups per
year /wte
Cost
substantive
Year Cost Per Unit
Community exercise group £5,313 12 £63,756 20 £106,260 30 £159,390 40.0 £212,520
High risk Strength and balance £18,924 1 £18,924 1 £18,924 1.5 £28,386 2.0 £37,848
121 Otago - (Meet through productivity gains) £30,270 0 £0 £0 £0 £0
Eliminate waits from 18-26 weeks to max 3 weeks £51,818 1 £51,818 1 £51,818 1.0 £51,818
£44,056 1 £44,056 2 £88,112 2 £88,112 2.0 £88,112
£36,559 1 £36,559 1 £36,559 1.0 £36,559
121 physio meet new referral flow (project) demand £44,056 0.8 £35,245 1 £44,056 1.5 £66,084 2.0 £88,112
Helpline and clinical traige and admin £30,270 3 £90,810 3 £90,810 4.0 £121,080 4.0 £121,080
Clinical development and triage, screening training
supervision and new group instructors £44,056 0.8 £35,245 £0 £0 £0
Project clinical leadership -( incorporate clinical
tasks above from 16-17) £51,818 0.8 £41,454 1 £51,818 0.5 £25,909 0.5 £25,909
Slic project support 0.2 0 0 0.0
service management/business support £44,056 0 £0 1 £44,056 1 £44,056 1.0 £44,056
£329,490 £532,413 £621,394 £706,014
Marketing costs £2,000 £2,000 £2,000
Staff travel and mobile devices 10 £10,000 10 £10,000 10 £10,000
Vol sector market stimulation and support £20,000 £10,000 £5,000
Clinical equipment 3,500 3,500 3,500
Non Pay Total £35,500 £25,500 £20,500
Total £567,913 £646,894 £726,514
Overheads at 10%- excl groups £44,273 £45,912 £47,615
Final Total £612,186 £692,806 £774,129
Non Pay
Groups Running Costs
Capacity Gap 121 physio
Core team
Pay Total
15-16 16-17 17-18 18-19
assume productivity with mobile working will
increase capacity from 108 NPts/ yr per wte to 144
Fig 15: option 1 service costs
Current SLIC project units funded Cost to run 1 group
for full year / staff
wte substantive
Groups per
year /wte
per year
Cost
substantive
Groups
/wte
Cost
substantive
Groups per
year /wte
Cost
substantive
Groups per
year /wte
Cost
substantive
Year Cost Per Unit
Community exercise group £5,313 12 £63,756 15 £79,695 22 £116,886 30.0 £159,390
High risk Strength and balance £18,924 1 £18,924 1 £18,924 1.5 £28,386 2.0 £37,848
121 Otago - (Meet through productivity gains) £30,270 0 £0 £0 £0 £0
Eliminate waits from 18-26 weeks to max 12 weeks £51,818 0.0 £0 0 £0 0.0 £0
£44,056 1 £44,056 2.0 £88,112 2 £88,112 2.0 £88,112
£36,559 0.0 £0 1 £18,280 0.5 £18,280
121 physio meet new referral flow (project) demand £44,056 0.8 £35,245 0.5 £22,028 1.0 £44,056 1.5 £66,084
Helpline and clinical traige and admin £30,270 3 £90,810 3.0 £90,810 3.5 £105,945 3.5 £105,945
Clinical development and triage, screening training
supervision and new group instructors £44,056 0.8 £35,245 £0 £0 £0
Project clinical leadership -( incorporate clinical
tasks above from 16-17) £51,818 0.8 £41,454 1 £51,818 1.0 £51,818 1.0 £51,818
Slic project support 0.2 0 0 0.0
service management/business support £44,056 0 £0 1 £44,056 1 £44,056 1.0 £44,056
£329,490 £395,443 £497,539 £571,533
Marketing costs £2,000 £2,000 £2,000
Staff travel and mobile devices 7 £6,500 8 £8,000 8.5 £8,500
Vol sector market stimulation and support £10,000 £10,000 £5,000
Clinical equipment 2,000 2,000 2,000
Non Pay Total £20,500 £22,000 £17,500
Total £415,943 £519,539 £589,033
Overheads at 10%- excl groups £31,732 £37,427 £39,179
Final Total £447,676 £556,965 £628,212
assume productivity with mobile working will
increase capacity from 108 NPts/ yr per wte to 144
Core team
Pay Total
Non Pay
15-16 16-17 Option 2 17-18 option 2 18-19 option 2
Groups Running Costs
Capacity Gap 121 physio
Fig 16: Option 2 service costs
38
5.7 Interdependencies to delivery
The service interfaces with the following organisations;
General Practice
Urgent care services
General rehabilitation services
Voluntary sector services
Care homes - residential and nursing
Acute Trusts.
Because of the specialist nature of this service, overlaps and duplications are not a risk. Opportunities for improved
access exist with these parties, and for relationships to develop with a view to supporting shared goals eg reducing
falls in hospital.
5.8 Potential risks and Mitigation – all options
Option 1 Risks and mitigation
Risk Mitigation
Lack of access by majority of people who need the service
Work with GP Practices and LCNs to support access
Inability to recruit trainers Service manager to monitor and encourage community resource by advertising training courses and seeking a sponsor
Inability to find appropriate venues Team develops a roll out plan based on areas of highest need , and working with community groups to discover appropriate venues.
Potential savings not delivered Regular commissioner / provider review
Lack of referrals Development of local marketing strategies
Number of people who fall increase Raise awareness of falls and service to the public
Staff recruitment problematic Flexible skill mix in team to be shaped around elements of team easiest to recruit
Losing skilled trained staff Commissioners to expedite their decision making to reduce risk of losing staff, and will affect roll out timescales and capacity.
Funding gap for the 30 week courses which have already started.
Commissioners to expedite their decision to prevent effect on existing courses. If full mainstream funding not supported – a wind down fund will be required.
Table 13: Option 1 risks
39
Option 2 Risks and mitigation
Risk Mitigation
Lack of access by majority of people who need the service
Work with commissioners to monitor outcomes and develop case for expansion when agreed
Inequity of access Agree target area priorities with GP Federations
Inability to find appropriate venues Team develops a roll out plan based on areas of highest need, and working with community groups to discover appropriate venues.
Potential savings not delivered Regular commissioner / provider review
Lack of referrals Development of local marketing strategies
Number of people who fall increase Raise awareness of falls and service to the public
Staff recruitment problematic Flexible skill mix in team to be shaped around elements of team easiest to recruit
Losing skilled trained staff Commissioners to expedite their decision making to reduce risk of losing staff, and will affect roll out timescales and capacity.
Funding gap for the 30 week courses which have already started.
Table 14 : Option 2 risks
Option 3 risks and mitigation
Risk Mitigation
Lack of access by majority of people who need the service
Work with commissioners to monitor outcomes and develop case for expansion when agreed
Inequity of access Agree target area priorities with GP Federations
Waiting times remain at 20 weeks for high risk referrals patients are a high risk of falling and emergency admission
Advise commissioners and agree action plan.
Potential savings not delivered Regular commissioner / provider review
Number of people who fall increase Raise awareness of falls and service to the public
Losing skilled trained staff Commissioners to expedite their decision making to reduce risk of losing staff, and will affect roll out timescales and capacity.
40
Funding gap for the 30 week courses which have already started.
Commissioners to expedite their decision to prevent effect on existing courses. If full mainstream funding not supported – a wind down fund will be required.
Table 15: Option 3 risks
Option 4 risks and mitigation
Risk Mitigation
Lack of primary prevention service for people at risk of falling
Whole system risk on activity and resources , raise as a risk on JSNA
Whole system cost continues at £8.25 million meeting emergency needs of people who fall. Organisational impact to LAS and acute Trusts bed capacity
Raise awareness of risk to Health and Social care partners
Potential savings not delivered Whole system risk on activity and resources , raise as a risk on JSNA
Incidence of falls continues unabated Agree action plan with commissioners.
Commissioners unable to meet statutory
obligations to Outcome Frameworks and
CQUINS
Commissioners to raise risk with Performance managers
Losing skilled trained staff Nil
Funding gap for the 30 week courses which have already started.
Commissioners to expedite their decision to prevent effect on existing courses. If full mainstream funding not supported – a wind down fund will be required.
Table 16: Option 4 risk
41
6 Appendix 1 – modelling assumptions
6.1 Falls business case modelling assumptions Metrics used to evaluate interventions impact:
The intervention: An improved Falls prevention pathway, to ensure effective proactive interventions for citizens at
risk of falls, utilising a refined referral and triage process, a range of adherence strategies, and engagement with
voluntary and community sector, councils and other leisure providers
To evaluate the intervention impact, we have analysed the following metrics:
A. Falls related A&E attendances (people aged >=65) B. Falls related ELIP (after trauma) and NELIP with hip procedure (aged >=65) C. Falls related ELIP (after trauma) and NELIP with no hip procedure (aged >=65) D. Falls related care home admissions (people aged >=65) E. Falls related ambulance conveyances (people aged >=65) F. Falls related ambulance call outs without conveyance (people aged >=65) G. Community spend specifically attributable to fall related ELIP / NELIP
Metrics
Data Source Data
Definitions /
Assumptions
Impact Assumptions Initiative Scale-Up
A - Falls
related A&E
attendances
(people
aged >=65)
Extrapolated using the
source data for metrics B
and C (see below)
See
nex
t sl
ide
40 % reduction in
activity and spend –
based on evidence
sources cited in the
business case
% of target population
(people aged over 65
susceptible to a fall) to
which the initiative is
rolled out.
This is dependent on
how long the
preventative benefits
last for an individual
once seen under the
programme (the
different scenarios are
modelled) Assuming
the preventative
benefits last on
average 4 years then:
FY2015 = 14%
FY2016 = 30%
FY 2017 = 48%
B - Falls
related ELIP
(trauma) /
NELIP with
hip
procedure
(people
aged >=65)
GSTT 12/13 episode level
dataset extrapolated for
all Southwark and
Lambeth activity
40 % reduction in
activity and spend –
based on evidence
sources cited in the
business case
C - Falls
related ELIP
(trauma) /
NELIP with
no hip
procedure
(people
GSTT 12/13 episode level
dataset extrapolated for
all Southwark and
Lambeth activity
40 % reduction in
activity and spend –
based on evidence
sources cited in the
business case
42
aged >=65) FY 2018 = 67%
FY 2019 = 71%
FY 2020 = 74%
With benefits lasting
up to FY2023 for
patients seen in FY2020
D - Falls
related care
home
admissions
- GSTT 12/13 episode level
dataset extrapolated for
all Southwark and
Lambeth activity
- Spend data: Health &
Social Care Information
Centre (avg cost per
resident per week = £525
in 2014/15)
40 % reduction in
activity and spend –
based on evidence
sources cited in the
business case
E - Falls
related
ambulance
conveyances
(people
aged >=65)
Estimated using results
from a report focussing on
falls in older people in
Greater Manchester (TIIG
Greater Manchester.
Themed Report June
2014) and applying this to
the number of A&E
attendances (metric A)
See
nex
t sl
ide
40 % reduction in
activity and spend –
based on evidence
sources cited in the
business case
% of target population
(people aged over 65
susceptible to a fall) to
which the initiative is
rolled out:
This is dependent on
how long the
preventative benefits
last for an individual
once seen in the
programme (different
scenarios are
modelled) Assuming
the preventative
benefits last on
average 4 years then:
FY2015 = 14%
FY2016 = 30%
FY 2017 = 48%
FY 2018 = 67%
FY 2019 = 71%
FY 2020 = 74%
With benefits lasting
up to FY2023 for
patients seen in FY2020
F - Falls
related
ambulance
call outs
without
conveyances
(people
aged >=65)
Estimated using results
from a report focussing on
falls in older people in
Greater Manchester (TIIG
Greater Manchester
Themed Report June
2014) and applying this to
the number of A&E
attendances (metric A)
40 % reduction in
activity and spend –
based on evidence
sources cited in the
business case
G -
Community
spend
specifically
attributable
to fall
related ELIP
/ NELIP
SLIC person level Year-Of-
Care database for 2012/13
40 % reduction in
activity and spend –
based on evidence
sources cited in the
business case
43
Further detailed assumptions
Metrics Data definitions / assumptions
A - Falls related A&E
attends (people aged
>=65)
• No falls diagnosis present in the GSTT A&E dataset. However, an audit at
KCH indicates the ratio between admissions and discharges for falls related
A&E attendances is 1:5. We have applied this reasoning to approximate the
number of A&E attends based on admissions from metrics B and C below
B - Falls related ELIP
(trauma) / NELIP with
hip procedure
(people aged >=65)
• Admissions (NELIP or ELIP) with an HRG relating to a hip procedure
(excluding hip procedures for non-trauma) :
- HA11A - Major Hip Procedures category 2 for Trauma with Major CC
- HA11B - Major Hip Procedures category 2 for Trauma with
Intermediate CC
- HA11C - Major Hip Procedures category 2 for Trauma without CC
- HA12B - Major Hip Procedures category 1 for Trauma with CC
- HA12C - Major Hip Procedures category 1 for Trauma without CC
- HA13A - Intermediate Hip Procedures for Trauma with Major CC
- HA13B - Intermediate Hip Procedures for Trauma with Intermediate
CC
- HA13C - Intermediate Hip Procedures for Trauma without CC
- HA14A - Minor Hip Procedures for Trauma with Major CC
- HA14B - Minor Hip Procedures for Trauma with Intermediate CC
- HA14C - Minor Hip Procedures for Trauma without CC
C - Falls related ELIP
(trauma) / NELIP with
no hip procedure
(people aged >=65)
• Admissions (NELIP or ELIP) with a diagnosis code relating to a fall:
- ICD-10 Chapters: W00 – W19
• Admissions (NELIP or ELIP) with a HRG :
- HA91Z - Hip Trauma Diagnosis without Procedure
D - Falls related care
home admissions
• Admissions which satisfy definitions for metrics B and C above, AND also with
a discharge destination code specifying ‘care home’
E - Falls related
ambulance
conveyances (people
• Estimated using results from a report on falls in older people in Greater
Manchester (TIIG Greater Manchester Themed Report June 2014) - 71% of
falls related A&E attendances arrive by ambulance, and ratio between
44
aged >=65) ambulance call outs with and without conveyance is 1:1
• The cost of an ambulance conveyance is assumed to be £195 in FY2015
F - Falls related
ambulance call outs
without conveyances
(people aged >=65)
• Estimated using results from a report on falls in older people in Greater
Manchester (TIIG Greater Manchester Themed Report June 2014) - 71% of
falls related A&E attendances arrive by ambulance, and ratio between
ambulance call outs with and without conveyance is 1:1
G - Community spend
specifically
attributable to fall
related ELIP / NELIP
• Community contacts spend (not including community inpatient) compared
individual patients for 3 months after a fall with the 3 months before a fall
Other assumptions used
Metric type Assumption
Activity baseline • Activity growth assumed to move in line with ONS trend based population projections – based on projections segmented by 5 year age bands for people aged 65 and above in Southwark and Lambeth
• Activity grows annually between 1.5% and 2.7% between FY2015 and FY2024
Spend baseline • The growth in the activity baseline compounded with spend factors such as NHS cost inflation, provider efficiency (negative inflation), and other case mix and volume growth - based on NHSE planning guidance
• Net annual spend inflation of 1.6% assumed between FY2015 and FY2024
Initiative Costs (Set-up costs / recurrent costs)
• Initiative costings supplied by the SLIC project team. We have modelled the case where the programme is only offered up till FY2020. Therefore there are no initiative costs beyond this year, though some levels of savings will still be seen till FY2024 as the preventative benefits of the intervention typically last more than a year (different scenarios modelled in the model)
6.2 Financial analysis
Business Case Model Falls Option 1 Business Case Model Falls Option 2 Business Case Model Falls
Option 3
SLIC_Business Case_Model_Falls_Option 1_20151209.xlsm
SLIC_Business Case_Model_Falls_Option 2_20151209.xlsm
SLIC_Business Case_Model_Falls_Option 3_20151209.xlsm
45
Business Case Model Falls Summary
SLIC_Business Case_Model_Falls_Option 3_20151209.xlsm
7 Appendix 2 - Demand, capacity and productivity existing community rehab
and falls service
The CRAFS service provides a wide range of interventions for clients with complex non neurological rehabilitation
needs including delivery of the falls service. Detailed Analysis of caseloads during 2014-15 showed 88% of all
referrals are related to falls risk, even if this is not identified on the referral. The remainder are a range of issues such
as backpain, post op elective surgery, some respiratory, cancer and end of life.
The service accepts referrals from all sources hospitals and community and consists of 3.8 wte physiotherapists in
Southwark and 4.6 wte in Lambeth. There is no other community physiotherapy service provided other than the
specialist neuro-rehab teams and MSK out patients. This service picks up all other needs.
Whilst a number of people referred to the service are able to attend Falls classes run by assistants, a significant
number of complex patients require 1-1 individual therapy intervention to meet their needs.
Whilst the number of referrals to the service and the complexity of the patients has been increasing the staffing
levels of therapists have not. Therefore the service is constantly operating with a significant waiting list or backlog of
clients ranging up to 20 weeks.
Figure 1. monthly referrals for 1-1 therapeutic intervention packages
46
Negative Impact of waiting lists on patient outcomes
Patients waiting in the back log for individual 1-1 therapy input have a greater risk of deteriorating and being
admitted to hospital, or requiring rapid response/ @home interventions due to lack of an earlier therapeutic
intervention.
Despite prioritising referrals for urgency, and seeing patients with an identified urgent need within 1-3 weeks , some
patients do deteriorate whilst on a waiting lists and end up in crisis and require acute intervention. This is
demonstrated by the number of patients referred to ERR and @home whilst on a waiting list. This was a total of 271
patients over an 18 month period. This not only requires a more costly intervention, it also has an adverse impact on
the well-being and confidence of the individual.
Number of individuals REFERRED TO ERR OR @HOME whilst on waiting lists for physio or other falls interventions April 14- Oct 15
121 PHYSIO OTHER TOTAL
LAMBETH 55 35 90
SOUTHWARK 127 54 181
TOTAL 182 89 271
Productivity gains
The service have implemented strategies to increase flow of patients through skillmix, rigorous use of diary/
timetabling of clients and setting targets for staff of new patient and follow up contacts. The data shows that
numbers of contacts have increased since these targets were set in April/ May and this has led to an increase in the
number of new patients being seen per month.
Figure 2. total contacts per month
Demand
The Southwark service receives and average of 60 referrals per month, whilst Lambeth team receive an average of
66 new referrals per month.
Capacity
Currently staff are delivering initial assessments to an average of 9 new patients per month per 1.0 wte, alongside
delivering 1-1 therapeutic intervention packages for existing patients and newly assessed patients.
47
Southwark Capacity
3.8 wte staff deliver 9 new patients per month ( this takes into account actual clinical capacity after annual leave/
training etc.) 9 x 3.8 wte = 34 new patients per month. This leaves a deficit of 26 new patients per month.
Lambeth Capacity
4.6 wte staff deliver 9 new patients per month 9 x 4.6 wte = 41 new patients per month. This leaves a deficit of 25
patients per month.
Demand /Capacity Mismatch
There is a significant demand / capacity mismatch and patients are breeching 18 week referral times and 3 week falls
standards. Approximately 1500 referrals a year with a capacity to see about 800.
In Southwark only 57 % of new referrals can be seen creating a constant queue for the service of the remaining 43%
of accepted new patient referrals per month. In Lambeth 60% of New patient referrals are seen with existing
capacity with 40% in the queue.
Figure 3: graph to show demand capacity mismatch and area under graph of unmet need.
Proposal to improve patient flow and resolve demand /capacity mismatch
It is proposed that the service continues the lean transformation work to realise efficiency to release more clinical
capacity and increase the number of new patients seen per month to a minimum of 10 per 1.0 wte.
This would mean that the service would require an additional 4.7 wte staff across the two teams to reduce the
waiting times and have more of an admission avoidance /preventative impact and to deliver health promotion
outcomes for clients referred.
In addition, mobile working is being rolled out and it is hoped this would enable each wte to stretch their targets to
see 12 new patients per month, limiting the additional requirement to approximately 4.0 wte , which is
incorporated into the business case.
This would reduce maximum waiting times to 3 weeks and achieve accepted standards preventing deterioration,
referrals to @home/ERR and avoidable admissions to hospital.
48
8 Appendix 3 – Health questionnaire used with clients
EuroQol Group EQ-5D
Under each heading, please tick the ONE box that best describes your health TODAY.
MOBILITY
I have no problems in walking about
I have slight problems in walking about
I have moderate problems in walking about
I have severe problems in walking about
I am unable to walk about
SELF-CARE
I have no problems washing or dressing myself
I have slight problems washing or dressing myself
I have moderate problems washing or dressing myself
I have severe problems washing or dressing myself
I am unable to wash or dress myself
USUAL ACTIVITIES (e.g. work, study, housework, family or leisure
activities)
I have no problems doing my usual activities
I have slight problems doing my usual activities
I have moderate problems doing my usual activities
I have severe problems doing my usual activities
I am unable to do my usual activities
PAIN / DISCOMFORT
I have no pain or discomfort
I have slight pain or discomfort
I have moderate pain or discomfort
I have severe pain or discomfort
I have extreme pain or discomfort
ANXIETY / DEPRESSION
The best health you can imagine
10
20
30
40
50
60
80
70
90
100
5
15
25
35
45
55
75
65
85
95
49
I am not anxious or depressed
I am slightly anxious or depressed
I am moderately anxious or depressed
I am severely anxious or depressed
I am extremely anxious or depressed
50
9 Appendix 4 – FES-I