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Messages - Harald Braun

Pages: [1]
1
There were marked differences in the rates at which emergency ACS admissions occurred, both between the broad categories and between individual conditions. These differences are demonstrated in Figure 3.2 (see page 12), where each condition is represented by a box proportional in width to its admission rate. Boxes are arranged vertically by descending contribution to the total admission rate for each ACS type. For example, COPD has a relatively wide box because it had a high admission rate, and is placed near the top because it contributed 24 per cent of all chronic ACS admissions. Dehydration has a narrow box due to its much lower admission rate, and is placed near the bottom with a cluster of conditions that, when combined, contributed fewer than 10 per cent of all acute ACS admissions. The top row shows the admission rates for each of the three ACS categories.

In 2012/13, the vast majority (86 per cent) of ACS admissions were caused by acute and chronic conditions rather than the third category of ACS: other and vaccine-preventable conditions. Five individual ACS conditions accounted for more than half of all ACS admissions. These were urinary tract infection (UTI) and pyelonephritis (16 per cent of ACS admissions, 229 admissions per 100,000), COPD (12 per cent, 163 per 100,000), pneumonia (10 per cent, 141 per 100,000), ear, nose and throat (ENT) infections (9 per cent, 207 per 100,000) and convulsions and epilepsy (7 per cent, 142 per 100,000).

While 27 ACS conditions are specified under the most common definition, it is clear from Figure 3.2 that the majority of these conditions (15) contributed a combined total of fewer than 10 per cent of all ACS admissions. While many of the less common conditions might not seem sufficiently prevalent to be of interest, in some areas they will be of greater concern than others (for example, tuberculosis in London). It is notable that three out of the five most common conditions disproportionately affect older people. In total, 40 per cent of all emergency admissions were for patients aged 65 and over, and this proportion rose to 50 per cent when considering only the ACS admissions. However, COPD, pneumonia and
UTI/pyelonephritis had 75 per cent, 70 per cent and 63 per cent of their admissions for older people, respectively.

The other two of the most common conditions disproportionately affect children and young adults (ENT infections, and epilepsy and convulsions). However, when considering all ACS admissions, half were for patients aged 65 and over, whereas ust 19 per cent were for the under-20s. This confirms that potentially avoidable emergency admission is an issue that predominantly – but not exclusively – affects older people.

For more information visit: http://www.nuffieldtrust.org.uk/sites/files/nuffield/publication/131010_qualitywatch_focus_preventable_admissions_0.pdf

2
The current culture of the delivery of health care remains all too often 'do to' rather than 'work with'. There are challenges around widely shared expectations and behaviours:

The balance of power in encounters; "I don't know, you're the doctor."

That the professionals will 'cure' or at least 'fix' the individual.

That mental health issues are split off- people with mental health issues are less likely to be able to self-manage effectively and people with multiple LTCs are more likely to be overwhelmed by disease burden and become anxious/ depressed.

A problem-saturated view, where an individual's strengths and the assets in their community are not explored or acknowledged.

One of the core aims of encounters between people with LTCs and professionals needs to become the improvement of the knowledge, skills and confidence of the individual to self-care which requires a respectful partnership based approach: "Over 90% of people with LTCs say they are interested in being more active self-managers and over 75% would feel more confident about self-management if they had help from a healthcare professional or peer. Despite this, many people with LTCs have limited knowledge of, or influence over their care. Despite considerable efforts to tackle the most important area, namely the effectiveness, quality and focus of consultations between patients and clinicians, the most significant problem is the reluctance of clinical staff to provide active support for patient engagement. Unfortunately, shared decision making for example, is less common in the UK than in many other countries."

3
Information about services:NHS Choices is the key national portal but it is not well localised. For Tower Hamlets specific information the main portal is through the Idea Store website usually in the form of on line directories. For example, the new mental health service directory, co-designed by users and professionals;'In the Know'-http://www.intheknow.ideastoreonlinedirectory.org/

The Idea Store portal also flags up courses and activities. GP practices have websites of varying quality, some offering signposting to self-care resources. Interlinking of information of improved quality about local resources has been highlighted as an area needing further development. Information about one's own health: By 31 March 2015 GP practices are required to promote and offer the facility for patients to view on-line, export or print any summary information from their records i.e. medications, allergies, adverse reactions and any additional information agreed between the GP and patient. Currently, most practices are only delivering transactions like appointment booking and cancelling or ordering prescriptions.

4
The DEMHOS research looked at the type of ward that people with dementia are admitted to. As expected, with a range of acute physical conditions being the cause of admission, people with dementia are prevalent in a variety of general medical and surgical wards. Indeed, 97% of nursing staff and nurse managers who responded to the DEMHOS research reported that they always or sometimes cared for someone with dementia.

The research also found that the prevalence of people with dementia varies by type of ward, as estimated by nursing staff. For example, 10% of nursing staff respondents said that they currently worked on an elderly care/acute medical ward. Of these respondents, 25% estimated that around one in three people on the ward is a person with dementia at any given time and 50% estimated that at least one in five people on the ward is a person with dementia.

  • Elderly care/acute medical - 10%
  • General medical ward - 9%
  • Surgical - 9%
  • Orthopaedic - 8%
  • Rehabilitation unit - 6%
  • Other ward/no ward mentioned - 58%



5
Engaging with patients will reduce the DNA rate. This can be performed by sending reminders either via txt, email or calling. Ideally an automated referral system should perform this task.

Another way would be to allow patients to re-book their appointment on-line and allow other patients to take your cancellation. This way, patients wanting to see the GP urgently have a chance to pick up a cancelled appointment and not go to A&E, saving £80 in cost to the trust.

6
AI has been implemented in computer games for years to improve the gaming experience and to keep games interesting and fast moving. Basically, it helps the games engine to decide when to change the "script" of the game depending on the players behaviour.
 
In commissioning, Natural Language Processing (NLP) and AI can support users with decisions by providing answers to questions. Such questions can be written in natural language which IBM Watsontm can understand and respond to.

Before IBM Watson can respond, it needs to "learn" by reading many documents and by being asked many relevant questions. The questions that IBM Watson uses for training determine if it is able to understand the context and future questions.

i5 Health is currently training IBM Watson to understand Population Health Management to support commissioners with decision support for service reconfiguration and transformation. During this training period, i5 Health is inviting commissioners to join the training programme and receive a free COP report for their CCG or Trust. Please visit our website to sign up www.i5health.com or email support@i5health.com



7
Avoidable Readmissions – Punishing Patients and Providers



The 30 day readmission rule introduced in 2011/12 is an incentive for hospitals to reduce avoidable unplanned emergency readmissions within 30 days of discharge. Section 6.3.2 in the 2014/15 National Tariff Payment System states that “Providers should not be reimbursed for the proportion of readmissions judged to have been avoidable”. Readmissions relating to maternity and childbirth, cancer, chemotherapy and radiotherapy, renal dialysis, organ transplant, young children, emergency transfers, cross border activity and where patients self-discharged against clinical advice are all payable to the provider.

The scheme was designed to encourage providers and commissioners to manage emergency admissions through planned discharges, preventative initiatives, and greater involvement of experienced clinicians. Commissioners must reinvest money they retain from not paying in post discharge services that support rehabilitation and re-ablement. Commissioners are also required to identify patient groups that would most benefit from those services; they must discuss with providers where this money will be reinvested and must insure coordination with other commissioning decisions.
Commissioners are required to set an agreed readmissions threshold and determine the amount that will not be paid for readmissions above this threshold. Setting a threshold requires measuring how many readmissions could have been avoidable, which is a challenge in itself. Separate thresholds can be set for readmissions following elective admissions and readmissions following non-elective admissions.

To perform this process efficiently, a shortlist of patients that experienced an “avoidable readmission” should be made available to the review team. In this list, each patient should be categorised by the provider where an action could have prevented the readmission. This will inform the commissioner where a service gap exists e.g. hospital, primary care, community, social services etc.

The disadvantage of setting a threshold is that if might put pressure on the provider to reduce readmissions but it does not accurately reflect clinical need of the patient or better outcomes. Instead a more advanced systematic solution should be used utilising algorithms that identify avoidable readmissions consistently, month-by-month, case-by-case that are not payable to providers. Also, it might not have been in the provider’s control where follow-up care failed to deliver or the patient did not adhere to the rehabilitation and an emergency readmission was required.
Setting thresholds are a budgetary solution to a clinical problem where a lot of time and money is spent in discussions about what is over the threshold and not payable. Instead a short-list of patients should be compiled by clinical algorithms that are subsequently reviewed by a clinically led team to decide if the provider gets paid or not.

Readmissions are generally indicative of ineffective patient management and call the quality of care provided across the continuum into question. However, while many readmissions are preventable, some are clinically necessary or unavoidable. Our research at i5 Health shows that over 10% of non-elective readmissions within 30 days are on the same day, over 20% on the next day and over 50% after 7 days of being discharged. Considering the short time-frames after discharge, those readmissions are unlikely to be caused by support services outside the control of the provider and are more likely to be due to low quality care.

Readmissions within 30 days generally account for 12%-16% of all admissions whereby avoidable readmissions account for only 2%-3%. If avoidable readmissions can be reduced, capacity can be released at the provider so that more patients can be treated for, the provider will be paid and the healthcare event will be a much more positive experience for the patient.

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