Marina Lupari: An overview of PARR in practice in Northern Ireland

An overview of Parr in practice in Northern

Ireland.

Marina LupariHead of nursing- research &

development, NHSCT/PhD student, UU

Key Statistics for Northern Ireland

1.8 people living in N. Ireland 160k emergency admissions to hospital each

year. Over 700k attendances at A&E Depts. Our Ambulance service provides over 350k

journeys, of which 88k are emergencies. 5 integrated Health & Social Care Trusts.

About the NHSCT The Northern Health and Social Care Trust provides

a broad range of health and social care services. The Northern Health and Social Care Trust became

operational on 1 April 2007, combing 3 legacy trusts. It is geographically the largest trust in Northern

Ireland and operates from approximately 150 locations, serving a population of 443k people.

The Trust employs approximately 14,000 staff. We have an annual budget of £550 million.

We provide a range of services from nine hospitals and a large number of community based settings including people's own homes.

Drivers for Change - 2004 The Health Economy had recognized a need for

tighter financial efficiency and cost effectiveness in service delivery.

better approaches to the management of chronic disease. These multiple challenges included:

the under-coordination of health services, limited incentives and training for health care professionals.

poor diagnostic methods, limited disease management protocols, lack of patient involvement in managing disease.

stove-piped funding mechanisms. These realities underpinned:

recent efforts to change existing structures and practices in order to increase service efficiency in chronic disease management

and improve health outcomes for people living with chronic illness.

Care pathways links between primary, secondary and community care services in chronic disease management

Primary Care

Patients with known Chronic condition –exacerbation of condition

Appropriate investigations to confirm diagnosis

Secondary Care

Patient with suspected Chronic disease

GP referral onwards for support

Community Based Specialist Nurse

Continuing Care Nurse (CCN) visits pt at home

Patient assessment, review, treatment, education, referral to other professionals services & support programmes including domiciliary services

Primary Care

Nursing Team

Community rehab inc cardiac/ pulmonary rehab

Chronic Conditions Management programme

ACAHT-acute needs

Patient support Group

Hospitalisation

Multi skills

network

Case Finder

Case Management Co-ordinator

PARR Assessment

Asst. Technology

Care pathways links between primary, secondary and community care services in chronic disease management

Primary Care

Patients with known Chronic condition –exacerbation of condition

Appropriate investigations to confirm diagnosis

Secondary Care

Patient with suspected Chronic disease

GP referral onwards for support

Community Based Specialist Nurse

Continuing Care Nurse (CCN) visits pt at home

Patient assessment, review, treatment, education, referral to other professionals services & support programmes including domiciliary services

Primary Care

Nursing Team

Community rehab inc cardiac/ pulmonary rehab

Chronic Conditions Management programme

ACAHT-acute needs

Patient support Group

Hospitalisation

Multi skills

network

Case Finder

Case Management Co-ordinator

PARR Assessment

Asst. Technology

Overview of the PARR Tool and Data Preparation Process

THE ‘CASELOAD MANAGEMENT’ PROCESS

Patient admitted/discharged

Activity recorded on Trust PAS

Activity downloaded into PARR Via Business Objects, Trust Designed MS Access Database

Risk Level IdentifiedSifting & criteria applied

CCN Nurse assesses, acceptsCASE FINDING DATABASE

PARR DATABASE

OTHER PATIENT

DATA APPLIED

Activity Type

1-2 years PRIOR to Referral to CCN service

Within 1 year

PRIORto

Referral to

CCN service

Within 1 year AFTERReferral to CCN service

Admissions 110 215 143

Spell Beddays 1466 2307 1903

Avg LoSpell 13.3 10.7 13.3

% of Individuals who had Adms in year (%/167) 35.3% 68.9% 38.3%

Avg No. of Relevant Adms per individual (n=167) 0.7 1.3 0.9

Actual No. of Individuals who had relevant Adms in the year 59 115 64

Initial review of CICM service

Admissions to UHT by Diagnostic Group - for those Admissions in both Year BEFORE & AFTER Referral to CCN

05

101520253035

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

Jul

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

2005 2006 2006 2007

2. within 1 year PRIOR to Referral to CCN service 3. within 1 year AFTER Referral to CCN service

Diabetes Heart Other Resp

Count of Date of Admission Only

Time Banding Years Date of Admission Only

Condition

Post CCN Service

Drivers for Change - 2007 Proposal to Centralise the PARR Analysis to allow for the

identification of admissions/activity across different providers to be integrated.

Trusts moving to “Real Time” recording of Clinical Diagnoses and thereby aiding the identification of prospective “Caseload Management” patients in real time.

Regional Unique Identifier now available i.e. HCN to track individuals across services.

Need to tie in other data sources, i.e. Primary Care activity such as Attendances at surgery, Out of Hours service usage, Medications etc. to improve complexity of PARR Tool (subject to evidence/research).

Organise for N.I. Deprivation Measures to be added to PARR Tool.

Need to understand full capability of PARR and it’s application to service provision.

Summarisation of key components of study design & methodology

Case ManagementIntroduced

Locality A

Intervention GroupLocality A (n=295)

CM Care

Data GatheringPatient specificFIMHR-QOLEconomic ProformaCarers Strain Index- Carers Focus group

April 06… June 2008- November 2009 approx

Comparison Group Locality B (n=295)

Usual Care

Data GatheringPatient specific FIMHR-QOLEconomic Proforma Carers Strain Index- Carers Focus group

Research Objectives and link to PARR Aim- to establish if the introduction of a case management

approach for chronic conditions is effective and/ or cost effective

Does PARR predict patients accurately at risk of rehospitalisation and how can we move towards prediction of avoidable rehospitalisations?

What is the relationship between PARR, reduction in rehospitalisations and the intervention?

Is there any relationship between PARR and the specific chronic condition, and/or presence of co-morbidities ?

“PARR” identified referrals to CICM

Result of Assessment No. %CCN caseload 1122 33.5%

CCN Discharge 319 9.5%

Mortality 670 20.0%

Renal Failure 27 0.8%

Inappropriate referral CCN 826 24.7%

Other handover 103 3.1%

Palliative care 82 2.4%

PCNT handover 46 1.4%

Service declined 154 4.6%

3349Position @ Jun09

Distribution Chart showing PARR Scores across Research Groups

199

56

2310 5 1 1

216

44

14 9 4 4 2 20

50

100

150

200

250

20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-99

Control Group Intervention Group

Count of ID

PARR

Research Group

Distribution Chart of Major Chronic Conditions by Research Group

295

46

145

113

186

295

61

193

113

158

0

50

100

150

200

250

300

350

No. in Research Group Asthma COPD Diabetes Heart Failure


Distribution Chart showing the Multiple Co-Morbidities for Research Groups

01020304050607080

Asth

ma

Asth

ma / D

iabete

s

Asth

ma / D

iabete

s /H

eart

Failu

re

Asth

ma/ C

OP

D

Asth

ma/ C

OP

D/ D

iabete

s

Asth

ma/ C

OP

D/ D

iabete

s/

Heart

Failu

re

Asth

ma/ C

OP

D/ H

eart

Failu

re

Asth

ma/ H

eart

Failu

re

CO

PD

CO

PD

/ D

iabete

s

CO

PD

/ D

iabete

s/ H

eart

Failu

re

CO

PD

/ H

eart

Failu

re

Dia

bete

s

Dia

bete

s/ H

eart

Failu

re

Heart

Failu

re


Drop Page Fields Here

Count of ID

Chronic Conditions

Research Group

PARR

Chronic Conditions Research Group 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-99 Total

Asthma Control Group 4 2 2 1 9

Intervention Group 7 2 9

Asthma / Diabetes Control Group 6 1 1 8


Asthma / Diabetes /Heart Failure Control Group 3 1 4


Asthma/ COPD Control Group 1 1 1 3

Intervention Group 2 1 1 4

Asthma/ COPD/ Diabetes Control Group 2 1 1 4


Asthma/ COPD/ Diabetes/ Heart Failure Intervention Group 2 2

Asthma/ COPD/ Heart Failure Control Group 2 2


Asthma/ Heart Failure Control Group 10 4 2 16


COPD Control Group 29 14 3 4 1 51

Intervention Group 47 3 1 2 2 1 1 57

COPD/ Diabetes Control Group 14 4 1 19

Intervention Group 21 4 1 2 28

COPD/ Diabetes/ Heart Failure Control Group 12 5 3 1 1 22


COPD/ Heart Failure Control Group 34 6 3 1 44

Intervention Group 50 10 6 2 1 1 1 71

Diabetes Control Group 9 1 3 1 1 15


Diabetes/ Heart Failure Control Group 34 5 1 1 41


Heart Failure Control Group 39 13 2 2 1 57


Grand Total 415 100 37 19 9 5 3 2 590

Distribution Chart : Showing "relevant" rehospitalisations

63 63

4752

89

76

5142

0

10

20

30

40

50

60

70

80

90

100

T0 T3 T6 T9

Yes


Sum of SumOfAdmissions

Included in Study T Band

Research Group

Distribution chart: Beddays by Relevant Conditions across Research Groups

678632 649

560

699 673

384 367

0

100

200

300

400

500

600

700

800

T0 T3 T6 T9

Yes


Sum of SumOfLength of Spell1

Included in Study T Band

Research Group

Distribution Chart: Relevant Adms by PARR Score

132

48

168

20

1

150

37

18 2015

7 11

0

20

40

60

80

100

120

140

160

20-29 30-39 40-49 50-59 60-69 70-79 80-89

Yes


What have we learnt so far ?

We know PARR can predict people at risk of all rehospitalisations for about 75 % of people

We know PARR and our intervention can save rehospitalisations / beddays

We know we need to look at how better to predict those people at risk of avoidable rehospitalisations

We need to look at the impact of social deprivation for NI

So where to now?

Continue with data analysis Investigate the relationship of PARR and

avoidable re hospitalisations more fully DHSSPS have agreed to run PARR across NI Look at what everyone else is doing and see

how we can improve

Health & Medicine

Marina Lupari: An overview of PARR in practice in Northern Ireland