HOLISTIC HOSPITAL CARE AT HOME - RHETORIC TO REALITY Professor Bim Bhowmick OBE DL MD FRCP

HOLISTIC HOSPITAL CARE AT HOME -RHETORIC TO REALITY

Professor Bim Bhowmick OBE DL MD FRCP

NHS : Do we need change? YES & WE MUST

WHY? (67 years old & chronically disabled & rattling)

The NHS must CHANGE or Die

Hospitals on the Edge? Time for Action


Royal college of Physicians October 2012

BMJ July 2012

So how do we do it?“The gap between hospital & home is unsustainable and, for the sake of our frailest and most vulnerable patients it

must be closed”BMJ 24 November 2012


A novel & radical approach:

specialist in out-of-hospital settingsKings fund October 2014

Bhowmick Innovative Model(BIM)

Academy of rhetorics

• Privacy and dignity, compassion and respect must be maintained

• Care must be patient centred • Primary care, secondary care and

Community Care-joined up• Resources must be transferred from acute

services to the community sector.


Bhowmick Innovative Model(BIM)Academy of rhetorics

• Care to be provided at home• Care to be provided near home• Early intervention• Prevent Hospital admission• Integrated service• Whole system delivery


BIM

Some facts:• Wales has the highest elderly population

compared to other countries in the U.K• Over 75s will increase by 75% in two decades• Hospitals are full to bursting• 70% of beds are occupied by patients with

chronic diseases especially Elderly• 70 pence of an NHS pound is spent for the

elderly.


NHS SYSTEM IN CRISIS

• 4-hour WAITS in A&E ↑ 50% in 2014-2015 compared with 2013-2014

• Delays in getting patients into A&E ↑ 63%

• 12-hour trolley wait ↑ 700% in a year

• Delays in discharge ↑ 29% than 1 year ago.


(BMJ 2015)

Bed Crisis

• “Emergency patients occupy elective beds.• Patients requiring social care occupy emergency

beds.• Ordinary patients occupy Intensive care beds.• Intensive care patients occupy Theatre

Recovery .• Gridlock occurs when there is NOWHERE LEFT

TO DISPLACE.”


Unscheduled Emergency Care:The Way Forward

BHOWMICK INNOVATIVE MODEL (BIM)

Torfaen

Ynys Mon/ Anglesey

PROFESSOR BIM BHOWMICK OBE DL MD FRCP

CONSULTANT COMMUNITY PHYSICIAN

Unscheduled Emergency Admissions‘Minus Ten Bed Syndrome’


2000 beds(2006-2012)

Creation of virtual beds and ward in the Community

Increasing

emergency

admission

Elderly

DTOC

Delayed

discharge

(old and very old)

“Blocked Beds”

PRESSURES ON NHSPRESSURES ON NHS

Delivery of Clinical Futures

(Reduction of acute beds)


Silver tsunami

Primary Care Secondary Care

Voluntary


Social Care

TRIBALISMTRIBALISM

Patient and Carer

WHOLE SYSTEM APPROACHLOCAL INTEGRATED PLANNING/COMMISSIONING/EVALUATION

Patient and Carer

Primary Care Secondary Care

Voluntary


Social Care

BIMINTEGRATED CARE

BIMINTEGRATED CARE

SECONDARY CARE

Physicians

A&E

MAU

SERVICE DEPARTMENTS

Biochemistry, Haematology, Radiology.LEADER

Forming the teamVOLUNTARY

ALLIANCE

CARERS GROUP

CARE HOMES -Proprietors

SOCIAL SERVICES

Chief Exec. Officer, Director, Head of Adult Services, Councilors,

CHC

AMBULANCE SERVICE FALLS TRANSPORT

COMMUNITY PHARMACIST

GENERAL PRACTITIONERS

Mon Enhanced Care (MEC) / TORFAEN

GROUNDWORK TO LINK UP SERVICES

Patch MDT

Old Age Psychiatry

Palliative Care


District Nursing

CARE & REPAIR

GOING

GOING

GONE

Normally just able Off to HOSPITAL

Time away from carers and social network

Care package interrupted or withdrawn

Ward admission

Reduced confidence

Disorientation, loss of routine

Reduced mobility

Increased confusion

MDT review

‘Unsafe for discharge’

DTOC

Bed blocking

Earliest InterventionThe ‘3G’ Syndrome


Prevent admission

Reduce DTOC

Prevent premature admission to care homes

VIRTUAL WARD

Resident at own home, care homes or sheltered housing

Diagnostics

SINGLE POINT OF ACCESS

Health Care Assistants,

Nurse Assessors, Consultant.

REFERRING BODIESHealth practitioners,

Step up to Admit Community Hospital

EMI

Specialist Nurses

COPD Stroke

Heart Failure

General Practitioner

Patch Reablement

Team Emergency

Social CareVoluntary

ServicesAmbulance


Out of hours service

Palliative Care

Minor Injury Unit

Hospital at Home (MEC/TORFAEN)

Integrated Care

General Practitioner

• Time response – 2 hours

• Community Equipment

Types of Emergency Admissions in the Elderly

ITU Critically Ill

UTI Urinary Tract Infection

TUI Totally unnecessary inpatient

TIU To inform the undertaker


Types of Emergency Admissions in the Elderly

ITU Critically Ill

UTI Urinary Tract Infection

TUI Totally unnecessary inpatient

TIU To inform the undertaker


Integrated Management Team

Hospital Admission Avoidance Scheme

MINDING THE GAP/ WORKING TOGETHER (BIM)MINDING THE GAP/ WORKING TOGETHER (BIM)

GP, Social Services, Matron, Consultant.

JOINT CO-ORDINATOR

• Large Multi-Disciplinary Group

Steering Board

MEC

Steering Board

Torfaen

Intermediate Care Directorate

(Clinical Director, Business Manager, Locality Manager).

LHB’s, Trust, Social Services, GP’s, Consultants & Voluntary Bodies


MEC CASE STUDY 1

• 86 year old retired Anaesthetist.• PMH: AF, PPM, CKD Stage II, hypertension, progressively

slowed down, recurrent chest infections• Fell in bathroom at night• Partner noticed noisy chest and commenced abx as per

previous advice from GP.• GP visited next morning, sleepy ++. Diagnosed chest

infection. Referred to MEC.• Lab results satisfactory. Undiagnosed PD. Aspiration

pnuemonia right side.


MEC CASE STUDY 1

• Managed at home with significant improvement. ANP visited daily for 5 days, then once weekly for 3/52.

• Consultant visit x 2• Mobilising easily, discharged from MEC back to

GP.• No further admissions last 7 months


MEC CASE STUDY 2• GW – 84, Female, lives alone, manages with home care.

• Recently Fractured Neck of Femur. Discharged 3 weeks ago.

• PMH: Breast Ca 5 yrs ago with mets to spine. Uterine cancer with daily PV bleeds (on tranexamic acid), CKD stage III, hypertension, chronic anaemia.

• 2nd June 2012 sudden onset of acute pain, left axilliary region and became breathless.

• GP referred to MEC

• Provisional clinical diagnosis – Pulmonary embolism


MEC CASE STUDY 2• Commenced appropriate treatment at home and

arranged CTPA next morning confirming the diagnosis.

• GP & ANP continued to manage her at home with increased support from Social Services and family.


MEC CASE STUDY 3

• Nov 2012 93 year old female in a residential home.

• GP referral to MEC• Fall; Slurred speech; Weak right side; Gone off

legs; Diarrhoea for 2 Days; ? AF.• PMH: CCF; HTN; CKD stage 3; Hypothyroidism;

Diverticular disease.• MEC Diagnoses• Rapid AF (heart rate 124pm); T.I.A. (resolving);• Diarrhoea due to faecal impaction


MEC Case Study 3 cont’d

• Blood Results: Hypokalaemia(2.7mmol);• Osteomalacia (low Ca++: low phosphate:

raised alkaline phos).• Managed at the residential home with

Physiotherapy.• Repeat Bloods/ Repeat visits: All well.• Discharged back to GP in 2 weeks.


MEC RESULTS

Volume of activities Total Referrals Total Visits Admission/Attendance Avoided

July 2012 -December 2012 127 595 121

REFERRALS TOSOCIAL SERVICE

12


Torfaen OutcomesVolume of activities Total Referrals Total Visits Admission/Attendance

Avoided

Jan 2007-Dec 2007 744 1569 578

Jan 2008-Dec 2008 1369 4111 1124

Emergency Admission/attendance

Delayed Transfers of Care

Daytime admissions from care homes

Admission to Care Homes from the Community AND

Social services underspent for first time

Approximately 2million pounds savings (Audit Commission 2009


The Model Delivers the Changes we Need

• Older persons do not want hospital admission. We provided a choice.

• We changed the culture of patients and carers automatically wanting hospital admission.

• We changed the culture of GPs – ‘one size fits all’ by supporting them at the point of need. with urgent diagnostics and secondary care opinion.


The Model Delivers the Changes we Need

• We broke down barriers between the ‘tribes’.

• Professional boundaries - medics, nurses, therapists, social workers - broken down (teams without walls)

• Mental health partnership very important• Voluntary sector and independent sector

must be inclusive


Finally.....To Succeed...

• Strong & Persuasive CLINICAL leadership.

• Focused vision.• Passion, Persistence, Pennies.• Dedicated team.


BIMVIRTUAL WARD IN THE COMMUNITY

Rhetoric to Reality

• Privacy & Dignity YES• Pts choice YES• Alternative to acute admission YES• Continuity of Care YES• No boarding out YES• Pt & Carers Satisfaction YES



Rhetoric to Reality

• Treat & manage at home • Treat & manage in the

Community Hospital• Urgent intervention• Urgent Investigation• Cost Effective• Hard Work• “Thick Skinned”

YES

YES

YES

YES

YES

YES

YES



Rhetoric to Reality

INTEGRATION

Working Together WithG.P.’sSocial ServicesDistrict NursesVoluntary AllianceE.M.I.Palliative CareAmbulanceCare Homes

YES


BIM

• Bevan commission 2013 recommended to the Health Minister that BIM is adapted as the basis for a national standard for NHS Wales.


BIM

VIRTUAL WARD IN THE COMMUNITYRhetoric to Reality

Finally Hospital ceases to be “somewhere” it becomes

everywhere.

YES


BIM

• Further information can be found at the following websites –

www.bimbhowmick.co.uk

www.bevancommission.org


http://www.bimbhowmick.co.uk/

http://www.bevancommission.org/

Grateful thanks to MEC Team

Dr Stephen McVicar – General Practitioner

Mr Stephen Sloss – Interim Director of Social Services.

Mrs Annwen Davies – Head of Adult Social Services.

Mrs Kate Thomas – Locality Matron

Mrs Cheryl Hindle – Joint MEC Co-ordinator

Advanced Nurse Practitioners – Ann, Karen, Bryona,

Health Care Workers

• “I can honestly say that the way this initiative is working under the inspirational leadership of Prof. Bhowmick is the most innovative and best of any model of care that I have ever seen.” - Chair of the Voluntary Alliance

• “I write on behalf of the Elected Members, Senior Officers and all staff in Adult Services at the Isle of Anglesey County Council to thank you most sincerely for your efforts, drive and immense success on the Island over the past year…” Head of Adult Social Services

• “You have built up a team from nothing and have engendered in the nurses a definite ‘spirit de corps’. You have managed to obtain services from the secondary sector through your negotiating skills.” – GP

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HOLISTIC HOSPITAL CARE AT HOME - RHETORIC TO REALITY Professor Bim Bhowmick OBE DL MD FRCP