Role of Risk Prediction in achieving our 2020 Vision
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Role of Risk Prediction in achieving our 2020 Vision
Dr Anne Hendry
National Clinical Lead for Quality
JIT Associate
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• 21% rise in 65+ from 2006 – 2016
62% rise by 2031
• 38% rise in 85+ by 2016• 144% rise by 2031
• 1 in 3 aged 75+ have two or more
Long Term Conditions
Headline Projections
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LTC Prevalence by Age People reporting a chronic condition (by age)
0
10
20
30
40
50
60
70
80
1972 1975 1981 1985 1991 1995 1996 1998 1998 2000 2001 2002
Year (note: data from1998 is w eighted)
% o
f s
am
ple
0-4y
5-15y
16-44y
45-64y
65-74y
75+
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Most people with any long term condition have multiple conditions in Scotland – Scottish School of Primary Care
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Projected Demand for Health and Social Care, All Ages, 2008/09 prices.
Health and Social Care Demand Projections, £ mn, 2008/09 prices
5,000
6,000
7,000
8,000
9,000
10,000
11,000
12,000
13,000
14,000
15,000
2010 2015 2020 2025 2030
Year
Co
st £
mn
HLE constant
Change HLE = 0.5 change LE
Change HLE = Change LE
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Projected Scottish Government spending
20,000
22,000
24,000
26,000
28,000
30,000
32,000
£ M
illio
ns (
2010
-11
Pric
es)
2009-10 2025-2616 years
£42 billion
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Sustainable Quality
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A 2020 Vision
• Integrated primary and social care, and more effective working with the Voluntary sector
• A focus on prevention, anticipation and supported self management in order that everyone can live longer healthier lives at home, or in the community as long as possible.
• When hospital treatment is required, and cannot be provided in a community setting, day case treatment should be the norm and it should be provided in the place which can guarantee highest quality, safety and a good experience.
• A focus on ensuring that people get back into their home or community environment as soon as appropriate, with minimal risk of re-admission.
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Reshaping Care Pathway
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Population model
Professional Care
Self Managem
ent
Care Care ManagementManagement
DiseaseDiseaseManagementManagement
Supported Supported Self CareSelf Care
Level 3Level 3Complex coComplex co--morbidity morbidity 3 3 –– 5%5%
Level 2Level 2Poorly controlled single Poorly controlled single disease 15 disease 15 –– 20%20%
Level 1Level 1Well controlled Well controlled (70(70--80% of LTC 80% of LTC population)population)
Population Wide Prevention, Health Improvement & Health Promotion
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Anticipatory Care and Self Management
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Day Care and Respite
Residential Care
Care and support at
Home
Rehabilitation / reablement
Extra Care Housing support
Meals
Laundry
Third Sector capacity
Primary Care Team & Care
Managers
Tele Health
Tele Care
Integrated Locality Team
Hub
Integrated Locality Team
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Telehealthcare
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Anticipatory Care Planning
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Anticipatory Care Plans Highland
• Cohort with ACP in place
34% reduction in emergency new admissions and a 57% reduction in emergency OBDs compared to previous year
• No ACP but SPARRA risk > 50% (control)
56% increase in emergency new admissions and an 83% increase in emergency OBDs compared to previous year
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Complex Polypharmacy
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Chronic Medication Service
1. Registration of Patients
81,100 by 1224 community pharmacists
2. Pharmaceutical care Planning
3. Therapeutic Partnership to generate serial prescription 24-48 weeks
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Serial Dispensing Early Adopters
• 42 GP practices and 84 Community Pharmacists across 12 NHS boards
• 3000 serial prescriptions for 5500 medicines for approx. 1000 patients
• SG working with Health Boards to extend this to all by April 2013
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NHS Scotland Rate per 1,000 Attendance at Emergency Departments and Admissions for Females by Age Group from
0ct 2010 to Sep 2011
-
50
100
150
200
250
300
350
400
450
0-4
5-9
10-1
4
15-1
9
20-2
4
25-2
9
30-3
4
35-3
9
40-4
4
45-4
9
50-5
4
55-5
9
60-6
4
65-6
9
70-7
4
75-7
9
80-8
4
85+
age
rate
Attendance Rate
Admission Rate
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