Stockport Health and Care Outcomes

Transcription

1 1 Stockport Health and Care Outcomes Clinical and Social Outcomes shortlist and October Expert Reference Groups Nov/Dec 2016

2 2 Contents Section Page Overview 3 Draft shortlist of Clinical and Social Outcomes 6 Appendix 1: Expert Reference Groups 9 ERG 1 Healthy and Acutely Ill 10 ERG 2 Long-term Conditions 16 ERG 3 End of Life 22 ERG 4 Frailty and/or Dementia 26 Appendix 2: Further Information 32

3 3 Outcomes Framework - High Level Plan June November 2016 Dec 2016 Feb 2017 Mar 2017 Mar 2018 Population Segmentation evidence review Clinical and Social Outcomes selection and sign-off Person- Centred Outcomes selection and sign-off Draft Outcomes Framework ready for negotiation with MCP Outcomes Framework version 1 part of shadow MCP contract October Expert Reference Groups January Expert Reference Groups

4 4 Overview Clinical and Social Outcomes A draft shortlist of Clinical and Social Outcomes (CSOMs) has been developed following the 4 Expert Reference Groups (ERGs) in October. The following slides describe the steps taken to develop the draft short-list of Clinical and Social outcomes. The detailed results and comments from each of the ERGs are also included in Appendix 1. N.B. These outcomes are only part of the whole Outcomes Framework Personal Outcomes will also be developed with the Expert Reference Groups in January, with a full set of outcomes ready by March 2017.

5 Stages to develop the Clinical and Social Outcomes (CSOMs) 5 Expert Reference Groups Check and Challenge Next steps Long-lists of >100 CSOMs collated by Outcomes-Based Healthcare. ERGs discussed and voted on their priority outcomes (see Appendix 1). The top scoring outcomes recommended by each ERG were then collated and assessed together as a whole shortlist. A core group of ERG Clinical Leads, Commissioner and BI Leads, and Healthwatch representative reviewed the shortlisted outcomes, considering: Spread of outcomes / duplication; Initial MCP focus on the over-65 population; Review of Stockport s JSNA and RightCare priorities to identify any gaps (see Appendix 2); Strategic considerations, including health inequalities and populationwide mortality measures. A revised shortlist was created, with explanation of adjustments provided below. The shortlist of 25 Clinical and Social Outcomes will be reviewed and endorsed by: Outcomes Steering Group 22/11 Joint Commissioning Board 7/12 Stockport Together Executive Board 12/12 Health and Care Integrated Commissioning Board (2017) The 25 will be taken forwards for data analysis to produce a baseline position for each outcome. N.B. The final Outcomes Framework will be subject to contractual negotiation with the MCP.

6 25 Clinical and Social Outcome Measures (draft shortlist as at 30/11/16) 6 Strategic indicators to be monitored Age standardised mortality: decrease the overall number of people dying Mortality measures in relation to inequality Reduce Potential Years of Life Lost (PYLL) from causes amenable to healthcare Reduce prevalence gap of long-term conditions: Hypertension, Diabetes, AF, COPD and CKD Increase Healthy Life Expectancy H6 H9 H11 H12 H13 Healthy (5) (whole population) Reduce total no. of episodes of ill health that require emergency hospital admission for acute conditions that should not usually require admission Increase people's physical activity Reduce obesity in the population Reduce smoking in the population Reduce alcohol consumption in the population LTC 5 LTC 14 LTC 15 LTC 16 LTC 17 LTC 25 LTC 27 LTC 30 LTC 42 Long-Term Conditions (9) Premature Mortality: Decrease deaths in people with Serious Mental Illness Reduce smoking in people with LTC and/or disability Reduce obesity in people with LTCs and/or disability Reduce the total number of episodes of ill health that require emergency hospital admission in people with LTCs, organ failure, and/or disability Reduce the number of days disrupted by care for people with LTCs, organ failure, and/or disability Reduce strokes in people with diabetes and/or circulatory conditions Reduce the complications of diabetes (such as stroke, MI, lower limb amputations, end-stage renal failure (ESRF), and blindness) Reduce the number of exacerbations, per person with organ failure, that require emergency hospital admission Increase proportion of cancers diagnosed at an early stage F8 Frailty and/or Dementia (8) Increase the amount of time OPwF/D spend at their place of residence F10 Reduce new pressure ulcers in OPwF/D at place of residence or hospital F11 Reduce serious falls in OPwF/D F13 Reduce the incidence of delirium in OPwF/D F14 Reduce the incidence of incontinence, urinary tract infections (UTIs) and severe constipation in OPwF/D F15 Reduce the prevalence gap of dementia F17 Appropriate discharge: Reduce the number of OPwF/D being re-admitted to hospital as an emergency within 30 days of discharge F22 Improve recovery following fragility fractures back to baseline 30 and 120 days after fragility fracture EOL1 EOL4 EOL7 Person-Centred Outcome Measures to be developed in Jan/Feb 2017 End of Life (3) Increase in people dying in their preferred place of death Increase the proportion of people on the Palliative Care Register for those who are expected to die within the next [12 months] Reduce the need for emergency hospital care for people in their last [4 weeks] of life The full framework will be made up of both Clinical/Social and Personal Outcomes.

7 7 Key messages Health inequalities Outcomes concentrated in the most deprived areas will incentivise targeted support to reduce health inequalities (e.g. smoking and alcohol consumption). Prevalence gap of key long-term conditions Increased early identification (i.e. finding those who have not yet been diagnosed) will support improvement of outcomes for long-term conditions. Mental health Dementia, serious mental illness and depression in the over 65s are included in the selected Clinical/Social Outcomes. Wellbeing, anxiety etc will be prioritised in the Personal Outcomes. All ERGs and Steering Group have emphasised the importance of mental health alongside physical health. Whole population outcomes: Healthy segment preventative outcomes will apply to the whole population (i.e. all ages). Outcomes predominantly for the under 65s will be the focus of phase 2 (SMI, employment etc).

8 Detail of adjustments 8 Outcomes removed (duplication): LTC 18 - Reduce unplanned hospitalisation for chronic ambulatory care sensitive conditions Similar to LTC 16 as a measure of emergency admissions for similar cohorts of people full details in Appendix 2. Outcomes added to ERG priorities during check and challenge stages: LTC 17 Reduce the number of days disrupted by care for people with LTCs, organ failure, and/or disability LTC 25 Reduce strokes in people with diabetes and/or circulatory conditions F10 Reduce new pressure ulcers in OPwF/D at place of residence or hospital F22 Improve recovery following fragility fractures back to baseline 30 and 120 days after fragility fracture Outcomes postponed to Personal Outcomes section: H15 Improve self-reported well-being (satisfaction, happiness, anxiety, life feeling worthwhile) F18 Improve the % of adult social care users who have as much social contact as they would like F19 Improve health-related quality of life for older people Outcomes held until Phase 2 (extending outcomes framework to under 65 population): LTC 24 Reduce incidence of self harm/injury in people with depression and/or serious mental illness LTC 46 Employment for those in contact with secondary mental health services Mortality measures: Mortality included as balancing measures to avoid perverse incentives. These will be monitored across the whole population but will not have payment attached to them.

9 Appendix 1 Expert Reference Groups: votes and comments 9

10 10 ERG 1 Healthy and Acutely Ill

11 ERG 1 Healthy and Acutely Ill Overview ERG1 had a clear preference for 7 of their 22 outcomes, with an emphasis on local health inequalities. 11 Preferred outcome groupings: Public Health Outcome Measures (#9-14) were popular, particularly physical activity, smoking, alcohol consumption and obesity. The group highlighted the relationship between mental health and smoking, and suggested that people with mental illnesses should be included as a component of this outcome. Alcohol-related liver disease (#14) was recognised as an outlier in Stockport, although it received fewer votes than consumption. Healthy Life Expectancy was the preferred Mortality Measure (#1-4). Although recognised as problematic to measure, the group liked its correlation to other outcomes, quality of life and health inequalities. Self-reported well-being was the preferred social outcome (#15-17), over employment or sickness absence rates. The latter were recognised as key influencers of physical and mental health, but could potentially be less relevant for the over 65 population. Appropriate, safe and warm housing was also suggested as a key component of this outcome. Least preferred outcome groupings: There were reservations about the three outcomes relating to need for emergency care (#5-7), but #6 was preferred, and recognised as a measure of an integrated system focused on prevention. This focused on reducing emergency admissions for potentially avoidable acute conditions, including infections (ear, nose, throat, kidney and urinary tract) and heart failure. One discussion group suggested removing the discharge from hospital measure (#8), as too broad and only giving a snap-shot in time. None of the acutely ill segment outcomes were preferred (#18-22). These were seen as too process focused, with participants expressing a preference of focusing on other acute conditions or vaccination rates instead. To note: Many ERG1 outcomes are likely to be whole population measures (rather than just healthy 11 segment). Obesity, smoking and employment outcomes were also discussed in ERG 2 to focus on people with LTC.

12 ERG 1 voting 12 Votes ERG 1 - Top 10 Outcomes Top votes Regular votes H9 H2 H12 H13 H11 H6 H15 H10 H5 H8 No. of long-list outcomes 22 Total number of people voting 22 Total votes per person 7 No. of top votes per person 3 Ref Top 10 Outcomes Top votes Regular votes 12 Total votes % of 'top 3' votes in ERG H9 Increase people's physical activity % H2 Increase healthy life expectancy % H12 Reduce smoking in the population % H13 Reduce alcohol consumption in the population % H11 Reduce obesity in the population % H6 H15 Reduce the total no. of episodes of ill health that require emergency hospital admission for acute conditions that should not usually require hospital admission Improve self-reported well-being (satisfaction, happiness, anxiety, life feeling worthwhile) % % H10 Improve people's diet and nutrition % H5 H8 Reduce the total no. of episodes of ill health that require... emergency hospital admission and/or A&E attendance Reduce the number of discharges of people, who are back in hospital on day 30 after discharge % %

13 ERG 1 voting continued 13 Ref Remaining Outcomes Top votes Regular votes Total votes % of 'top 3' votes in ERG H14 Reduce serious illness requiring emergency hospital admissions in people with alcohol-related liver disease % H17 Reduce sickness absence rates % H22 * Improve outcomes from planned treatments (hip replacement, knee replacement, groin hernia, varicose veins) % H16 Increase employment rates % H18 * Reduce deaths within 30 days following a hospital admission for pneumonia and/or influenza % H3 Increase life expectancy % H19 * Reduce length of hospital admissions for pneumonia and/or influenza % H20 H4 H7 * Reduce readmissions in people who have needed hospital admissions for pneumonia and/or influenza Reduce Potential Years of Life Lost (PYLL) from causes amenable to health care Reduce the total no. of episodes of ill health that require... readmission to hospital as an emergency within 30 days of discharge % % % H1 Overall (crude) mortality: decrease the overall number of people dying % H21 * Reduce deaths within 30 days following emergency hospital admission for trauma and/or injury % TOTAL *Outcomes related to Acutely Ill Segment

14 ERG 1 detailed comments 14 Top Outcomes ERG Comments General comments: Health inequalities must be considered mentioned frequently in relation to top outcomes - 9, 2, 12, 11. H9 Increase people's physical activity H2 Increase healthy life expectancy H12 Reduce smoking in the population H13 Reduce alcohol consumption in the population Highest voted outcome supports mental health and wellbeing, as well as all aspects of people s lives. Also impacts on life expectancy of older people. The group liked the emphasis on 'healthy', not just 'life expectancy. Recognised that this is problematic to measure but highly correlated with other measures. Group emphasised the relationship between mental health and smoking, and that people with mental illnesses should be included as a component of this outcome. Discussion is the better measure alcohol use or liver disease? This received more votes than #14 (emergency admissions for alcohol-related liver disease) which was described as a lag indicator and H13 being more preventative and broader. Comment to include drug consumption. Should be applied across the whole population, although issue of data availability to be explored. H11 Reduce obesity in the population Useful measure, and must consider health inequalities. Preferred to #10 (diet and nutrition). H6 Reduce the total no. of episodes of ill health that require emergency hospital admission for acute conditions that should not usually require hospital admission One table described this as the best of a bad bunch for outcomes relating to need for Emergency Care (#5, 6, 7), which were seen by some as processes not outcomes. Others recognised this as a good measure of an integrated system i.e. the whole system working well, including strong prevention to avoid emergency admissions. Should consider physical and mental wellbeing. Comments on other acute conditions and services e.g. speed of testing, increasing GP accessibility, reducing urgent care demand in primary care etc. H15 Improve self-reported well-being (satisfaction, happiness, anxiety, life feeling worthwhile) Group highlighted importance of community wellbeing / combatting isolation e.g. people living on their own. Links with personal outcomes mental wellbeing, feelings of being in control, and number of social contacts. Mental wellbeing is crucial; Stockport has a comparatively high level of prescribing medication for people with mental health problems - need to incentivise more talking therapies. Comment to include 'appropriate, safe, warm housing as an outcome. WEMWEBs as a measure Recognition that this is self-reported via surveys so difficult to measure accurately.

15 ERG 1 detailed comments continued Ref Remaining Outcomes ERG Comments H10 H5 Improve people's diet and nutrition Reduce total no. of episodes of ill health that require... emergency hospital admission and/or A&E attendance Obesity (#11) preferred. Difficult to measure - BMI and smoking are measurable. Influenced by access to affordable food and social networks. Would measure admissions for all people, including those with LTC focus on LTC in ERG2 outcomes. 15 H8 H14 Reduce the number of discharges of people, who are back in hospital on day 30 after discharge Reduce serious illness requiring emergency hospital admissions in people with alcohol-related liver disease Only gives a snapshot difficult to relate to a specific group e.g. frequent fliers/ frail. One table recommended to remove this outcome. Recognised as an outlier in Stockport. H17 Reduce sickness absence rates Includes acute episodes of mental-health related issues. Is this less relevant for >65s? H22 Improve outcomes from planned treatments (hip /knee replacement, groin hernia, varicose veins) People often complain about the quality of the joint replacement. H16 Increase employment rates Strong link to health outcomes, but is volunteering more relevant for >65s? H18 Reduce deaths within 30 days following a hospital admission for pneumonia and/or influenza Some disliked this measure preferred to focus on identification. However, some saw it as helpful - deaths are often because adults with pneumonia are not being seen quickly enough, so earlier diagnosis and treatment would be needed to achieve this outcome. H3 Increase life expectancy Problematic to measure H19 H20 H4 H7 H1 H21 Reduce length of hospital admissions for pneumonia and/or influenza Reduce readmissions in people who have needed hospital admissions for pneumonia and/or influenza Reduce Potential Years of Life Lost (PYLL) from causes amenable to health care Reduce the total no. of episodes of ill health that require... readmission to hospital as an emergency within 30 days of discharge Overall (crude) mortality: decrease the overall number of people dying Reduce deaths within 30 days following emergency hospital admission for trauma and/or injury Agree generally, but not in its current form - would prefer outcome on vaccination rates. Adults with pneumonia are not seen quickly enough. Disliked this measure Disliked this measure - admission rates to be reviewed. Problematic, but useful measure. Disliked this measure - not just within 30 days, some are beyond. Too process focused. Problematic to measure. 15 Possible to reduce trauma but difficult to prevent death within 30 days. Neck of femur patients - Allstrick assessment

16 16 ERG 2 Long-Term Conditions

17 ERG 2 LTC overview 17 Overview of Outcome groupings: Over 80% of the ERG voted to address premature mortality in people with serious mental illness (even though this outcome applies predominantly to those aged under 65). A concern was flagged that this outcome could lead to increased use of medication for people with SMI. Other Mortality Outcomes (#1-13) were generally unpopular, with only #9 and 10 (reducing under 75 mortality from liver disease and cancer) gaining a couple votes. Risk factor outcomes (#14/15) relating to obesity and smoking in people with LTC were also common votes, with links to mortality / liver disease / cancer mortality noted. A respondent queried the impact on over 65s with LTC. Of the Acute outcomes (#18-24, 49-51), #18 was the favourite: reducing unplanned hospitalisation for chronic ambulatory care sensitive conditions, for which Stockport is in the worst quartile nationally. These conditions include: infections, diabetes, blood diseases, dementia, convulsions and epilepsy, cardiovascular disease and respiratory conditions. The group generally preferred broader outcomes over specific conditions (of the 14 LTC in scope). An exception to this was early diagnosis of cancer (#42), as well as complications relating to diabetes (#27) from #25-29, where comments drew out the need for integrated provision for co-morbidities. Outcomes relating to disruption by care (#16-17) both made the top 10, as patient-centred outcomes. #16 favoured in the votes as a broad measure to reduce emergency admissions across all 3 population segments. The discussion was balanced between avoiding admissions, attendances and repeat attendances, as well as length of stay / disruption by care. For Segment 7 outcomes (#30-33), the broadest outcome #30 was favoured to reduce exacerbations requiring emergency admission for all people with organ failure, with the group keen to promote 17 early management to avoid admission.

18 ERG 2 LTC overview - continued 18 Key themes from the ERG: Discussion about social outcomes relating to employment and housing (even though these may be less relevant to the >65s population), reflected the ERG s focus on the importance of mental health outcomes. Top 15 votes included #24, 46, 48 and 13 in order: reducing self-harm, employment, appropriate accommodation and reducing suicide rate, although many participants said they would prefer to include a more general measure to focus specifically on people with mental illness. Personal outcomes were discussed as a crucial underpinning to many of these clinical and social outcomes. For the over 65 population, the importance a sense of purpose and reducing social isolation was highlighted (whether by employment or other community involvement). Some people found it difficult to make the link between outcome measures that describe acute settings (e.g. emergency admissions) with the need for a system-wide approach to achieve the outcomes (e.g. quality community services). Although areas of high local performance (e.g. stroke) or low prevalence (e.g. learning disabilities in the over 65s) were not prioritised, the ERG still recognised their importance. The voting shows a few clear priorities from the ERG, but the top 8-12 were relatively evenly spread. A view across all the ERGs will help to clarify the number of outcomes from this ERG. 18

19 14 12 Top votes Regular votes ERG 2 LTC voting Votes No. of long-list outcomes 51 2 Total number of people voting 17 0 LTC5 LTC27 LTC18 LTC30 LTC16 LTC15 LTC42 LTC14 LTC24 LTC17 Total votes per person 8 No. of top votes per person 4 Ref Top 10 Outcomes Top votes Regular votes Total votes % of 'top 3' votes in ERG LTC5 Premature mortality: decrease deaths in people with Serious Mental Illness (SMI) % LTC27 Reduce the complications of diabetes (such as stroke, MI, lower limb amputations, endstage renal failure (ESRF), and blindness) % LTC18 Reduce unplanned hospitalisation for chronic ambulatory care sensitive conditions % LTC30 LTC16 Reduce the number of exacerbations, per person with organ failure, that require emergency hospital admission Reduce the total number of episodes of ill health that require emergency hospital admission in people with LTCs, organ failure, and/or disability % % LTC15 Reduce obesity in people with LTCs and/or disability % LTC42 Increase proportion of cancers diagnosed at an early stage % LTC14 Reduce smoking in people with LTCs and/or disability % LTC24 LTC17 Reduce incidence of self harm/injury in people with depression and/or serious mental illness Reduce the number of days disrupted by care for people with LTCs, organ failure, and/or disability % %

20 ERG 2 LTC voting continued Arthritis Asthma Atrial Fibrillation Cancer Cardiovascular Disease (stroke) Reminder of 14 priority LTC in scope: Chronic Kidney Disease COPD Coronary Heart Disease (MI) Depression Diabetes Epilepsy Heart Failure Hypertension Serious Mental Illness 20 Ref Remaining Outcomes Top votes Regular votes Total votes % of 'top 3' votes in ERG LTC46 Employment for those in contact with secondary mental health services % LTC48 Adults in contact with secondary mental health services who live in stable and appropriate accommodation % LTC34 Reduce emergency admissions for people with learning disability % LTC49 Reduce deaths within 30 days following a hospital admission for stroke % LTC19 Reduce acute symptoms related to diabetes control % LTC13 Reduce suicide rate % LTC45 Employment for those with learning disabilities % LTC44 Employment for those with LTCs % LTC9 Reduce under 75 mortality from liver disease % LTC10 Reduce under 75 mortality from cancer % LTC47 Adults with a learning disability who live in stable and appropriate accommodation Outcomes with one regular vote: 2, 3, 6, 21, 23, 25, 26, 28, 29, 31, 39, 40, 51 Outcomes with zero votes: 1, 4, 7, 8, 11, 12, 20, 22, 32, 33, 35, 36, 37, 38, 41, 43, % TOTAL

21 ERG 2 detailed comments 21 Ref Outcomes ERG Comments LTC5 LTC27 LTC18 LTC30 LTC16 LTC15 LTC42 LTC14 LTC24 Premature mortality: decrease deaths in people with Serious Mental Illness (SMI) Reduce the complications of diabetes (such as stroke, MI, lower limb amputations, end-stage renal failure (ESRF), and blindness) Reduce unplanned hospitalisation for chronic ambulatory care sensitive conditions Reduce the number of exacerbations, per person with organ failure, that require emergency hospital admission Reduce the total number of episodes of ill health that require emergency hospital admission in people with LTCs, organ failure, and/or disability Reduce obesity in people with LTCs and/or disability Increase proportion of cancers diagnosed at an early stage Reduce smoking in people with LTCs and/or disability Reduce incidence of self harm/injury in people with depression and/or serious mental illness The only mortality outcome that was chosen (LTC1-13). Mental health measures need to consider education, information & life circumstances. Need to think about communication, prevention and language. Concern this outcome could lead to increased use of medication for people with SMI. Co-morbidities should be provided for in a 'one-stop' fashion. Sharing information is essential - need the system to talk to each other. Concern that some of these will take a long time to come through e.g. amputations, hence difficult to change in a reasonable timeframe. Good outcome because having diabetes often leads to many other health problems. Feels more like a process? Only outcome chosen relating to Segment 7 (serious organ failure) from LTC Can only achieve these outcomes by managing it early, in the community without the need for admission. Acute exacerbations for any LTC Admissions are preventable and avoidable What is the impact on service users who worry about 'wasting services time? Difference between admissions, attendances and chronic attendances. Balance between acute and LoS (LTC 17 days disrupted by care). Lifestyle risk factors both obesity and smoking voted for (#14 and 15). Links also with # 1 (crude mortality), #9 (<75 mortality from liver disease), and #10 (<75 mortality from cancer) How much difference will this outcome make to >65s with a LTC? See LTC 15. Prefer personal reported outcomes as needs are different. Life expectancy for this group is improving What about carers, health checks and Learning Disabilities? Often related to recession i.e. employment, and usually in younger people. LTC17 Reduce the number of days disrupted by care for people with LTCs, organ failure, disability Patient-centred. Very important outcome from a patient perspective currently poor communication between primary and secondary care.

22 22 ERG 3 End of Life

23 ERG 3 EOL - overview 23 The ERG had a clear preference for three outcomes: #1, 4 and 7: #1 was the top voted outcome due to its emphasis on empowerment, choice and control. However, the ERG recognised the challenge to accurately capture a person s preferred place of death, particularly as this can change over time and be influenced by disease/frailty. Until preferred place of death is routinely recorded and linked with actual death, a proxy measure must be used. Based on evidence that the majority of people do not wish to die in hospital, a pragmatic measure in the first instance is the total number of deaths in hospital compared to total number of deaths overall. #4 to increase people on the Palliative Care Register was recognised as a helpful measure to support the achievement of better outcomes by identifying the population cohort early enough to put in place appropriate planning and support. The ERG expressed a strong desire for the PCR to be more effective, built into contracts and centred on MDTs. There was recognition that the PCR can have a variable impact in practice, but that identifying the people in need of palliative care and support was an important first step. #7 was preferred as a broad outcome, rather than a specific focus on pain control or respiratory infections (#8/9). This outcome measures total number of emergency admissions in the last weeks of life, when emergency care requiring hospital admission should ideally be kept to the minimum possible. The group recognised some emergency care is genuinely required and unavoidable, but felt reducing inappropriate access could be achieved by increasing proactive support in the community. The ERG recorded a particular dislike for #2. Although a nationally recorded measure, a third of respondents had concern that this data would capture sudden death and misrepresent discharge to care homes. The ERG also felt that Patient Reported Outcome Measures may be more relevant for this population group. 23

24 Votes ERG 3 End of Life voting Top votes Regular votes EOL1 EOL4 EOL7 EOL5 EOL6 Ref Outcome Top votes No. of long-list outcomes 9 Total number of people voting 19 Total votes per person 3 No. of top votes or stars per person 1 Regular votes Total votes % of 'top votes in ERG 3 EOL1 Increase in people dying in their preferred place of death % 24 EOL4 EOL7 EOL5 EOL6 Increase the proportion of people on the Palliative Care Register for those who are expected to die within the next [12 months] Reduce the need for emergency hospital care for people in their last [4 weeks] of life Increase the time spent at home/place of residence in people in their last [4 weeks] of life Reduce the need for emergency hospital care for people on the Palliative Care Register % % % % EOL2 Increase in people dying in their usual place of residence % EOL3 EOL8 EOL9 Reduce the number of deaths in hospital from residents of care homes Reduce emergency hospital admissions for respiratory infections in people in their last [4 weeks] of life Reduce emergency hospital admissions for pain control in people in the last [4 weeks] of life % % % TOTAL

25 ERG 3 End of Life comments 25 Ref ERG Comments General comments want to understand what the building blocks to achieving the outcomes are. EOL1 Increase in people dying in their preferred place of death Top voted outcome due to emphasis on empowerment, choice and control. Challenge to capture/ accurately measure personal preference - CSF register needs to be recorded and regularly updated. Personal preference can change how to manage this in practice? Place of death is influenced by disease/frailty. Also good symptom control e.g. if family are struggling then preferred place may change. Need resources to enable this can be limited by social care / lack of carers. EOL4 EOL7 Increase the proportion of people on the Palliative Care Register for those who are expected to die within the next [12 months] Popular vote ERG emphasised need for an effective palliative care register centred on MDTs. Important that the PCR is useful as it defines the cohort want it to be incorporated into contracts. Increasing registered people is not technically an outcome, but helpful proxy that supports the achievement of other outcomes. Debate in the ERG about how effective the register is: Variable impact on care in practice can be just a tick-box Used effectively it helps to identify deteriorating course and brings people together to discuss support and plan appropriate care. Need useful definitions of care and support for the register. Wording: suggestion to focus on effective Gold Standard Framework, rather than proportion. Reduce the need for emergency hospital care for people in their last [4 weeks] of life Preferred over EOL8 & EOL9 which are closely related. Wording: instead of 'reduce need', suggestion to have 'reduce inappropriate access'' need to differentiate between appropriate access. How will this be measured? Achievable by increasing support, e.g. out of hospital palliative care 24/7. EOL5 Time spent at home - benefit of increasing patient control, but this received few votes. EOL6 Responses suggested this outcome could be fairly subjective, and were unclear how to measure need. EOL2 EOL3 EOL8 EOL9 Dying in usual place of residence is a nationally recorded measure. However, a third of respondents highlighted that they would definitely not want this outcome included. Concern that the data captures sudden death, and misrepresents discharge to care home. Potential overlap with ERG4 - this outcome is generally worse if the person is frail. No votes specific to care homes preferred increase time spent at home/residence than number of deaths in hospital. Potential benefit of more control for the person. No votes some concern that these could become a perverse measure. EOL 7 was preferred to a specific focus on pain control or respiratory infections. 25

26 26 ERG 4 Frailty and Dementia

27 ERG 4 Frailty and Dementia overview 27 None of the mortality outcomes (#1-4) were a key priority, as the ERG preferred to focus on quality of life over mortality. Of these, #3 (reduce excess winter deaths) was of most interest. Improved out of hospital support for people with dementia and/or frailty was a key theme of discussion, reflected in votes for outcomes seen as indicators of joined up care and preventative support across the system: #8 was the highest voted outcome of the ERG, emphasising time spent at home (#5-8). As well as being patient-centred, it was seen as a measure for appropriate integrated care and improved communication, but needs to be balanced with necessary admissions during the initial window of opportunity where appropriate. #6 and 7 were variants of a measure to reduce emergency admissions (#6/7). Taken together, these would move into contention for 8 th place on the shortlist. Similarly, appropriate and sustainable discharge (#16/17) to reduce hospital readmissions were both highlighted, with a slight preference for readmissions within 30 days of discharge over 91 days of discharge. However, some expressed concern that addressing admissions would not necessarily lead to better care for people at home. Complications of frailty (#9-14) were of high priority for the ERG. The reduction of serious falls, delirium and incontinence/utis/severe constipation all gained high votes. They were recognised as being closely related to each other, with significant impact on quality of life and needing increased preventative education. Delirium during treatment for hip fracture (#21) was also the most popular of the acute outcomes. Almost half of the ERG chose reducing the prevalence gap of dementia as a regular vote but not top 3 priority. Comments also asked how to address the time between diagnosis and follow-up. Outcomes related to well-being and quality of life (#18/19) were also popular, with ERG emphasis on social isolation, awareness of care needs and prevention of deterioration, despite limitations of the NASCS survey. The voting revealed some higher priorities, but the top 8-12 outcomes were relatively evenly spread. 27

28 Votes ERG 4 Frailty/Dementia voting Top votes Regular votes 28 No. of long-list outcomes 22 Total number of people voting 22 Maximum votes per person 7 No. of top votes per person 3 Ref OPwF8 Top 10 Outcomes (ordered by total votes) Increase the amount of time older people with frailty and/or dementia spend at their place of residence Top votes Regular votes Total votes % of 'top 3' votes in ERG % OPwF11 Reduce serious falls in older people with frailty and/or dementia % OPwF13 Reduce the incidence of delirium in older people with frailty and/or dementia % OPwF19 Improve health-related quality of life for older people % OPwF14 Reduce the incidence of incontinence, urinary tract infections (UTIs) and severe constipation in older people with frailty and/or dementia OPwF17 Appropriate discharge: Reduce the number of older people with frailty and/or dementia being re-admitted to hospital as an emergency within 30 days of discharge OPwF15 Reduce the prevalence gap of dementia (reducing the gap between people diagnosed with dementia, and the estimated number of people with dementia) % % % OPwF16 Sustainability of discharge: Reduce the number of older people with frailty and/or dementia who are back in hospital on day 91 after discharge % OPwF3 Reduce excess winter death rates % OPwF21 Reduce the incidence of delirium who are undergoing treatment for hip fracture %

29 ERG4 Frailty/Dementia voting continued Ref Remaining Outcomes OPwF18 Improve the percentage of adult social care users who have as much social contact as they would like OPwF10 Reduce new pressure ulcers in older people with frailty and/or dementia at place of residence or in hospital Top votes Regular votes Total votes 29 % of 'top 3' votes in ERG % % OPwF6 Reduce the emergency hospital admissions rate per older person with frailty "emergency admission- overall rate measure" % OPwF7 OPwF9 Reduce the rate of emergency hospital admissions per admitted older person with frailty - "emergency admission- readmission measure" Reduce potentially avoidable infections (C Difficule, MSSA, MRSA, E Coli) in older people with frailty and/or dementia % % OPwF4 Increase life expectancy at age % OPwF5 Reduce the proportion of older people with frailty requiring at least one emergency hospital admission - "emergency admission- population proportion measure" OPwF22 Improve recovery following fragility fractures back to baseline 30 and 120 days after fragility fracture OPwF1 Overall crude mortality - decrease the number of people dying in older people with frailty and/or dementia % % % OPwF12 Reduce fragility fractures in older people with frailty and/or dementia % OPwF2 Age of death - increase the average age of death in older people with frailty and/or dementia % OPwF20 Reduce deaths within 30 days after hip fracture % TOTAL

30 ERG 4 Frailty / Dementia detailed comments 30 Top Outcomes 8 Increase the amount of time OPwFD spend at their place of residence ERG Comments Top-voted outcome for this group - seen as a measure for appropriate care. A few commented that care at home should include regular GP reviews. Improving communication between disciplines will ease worry about treating people out of hospital. Linked to #17 (reduce emergency readmissions within 30 days of discharge). Some admissions are necessary in people with frailty or dementia first 4 days as the window of opportunity. 11 Reduce serious falls in OPwFD Loss of confidence after a fall linked to an increase demand on services (rehab, primary & community care). Keen to incentivise preventative agendas (including nutrition and exercise). 13 Reduce the incidence of delirium in OPwFD Delirium was highlighted as having a significant impact on quality of life. Close links between #13 and #14 i.e. delirium and incontinence/utis/severe constipation (hydration). Delirium is observed by families and often not picked up by clinicians. Education for prevention of delirium is needed. 14 Reduce incidence of incontinence, UTIs and severe constipation in OPwFD 19 Improve health-related quality of life for older people From a patient perspective, these issues have a huge impact on people s quality of life very important outcome Close links with #13 above. If managed well, would impact on #16 (sustainable discharge). Emphasised social isolation and prevention of future deterioration, which needs increased awareness of care needs, expectations etc. Several comments on limitations of the annual NASCS (survey) - currently only sent to individuals who have care packages, and needs to be expanded and more frequent. Links with #18 (social contact in adult social care users), and #4 (increase life expectancy at age 75). 17 Appropriate discharge: Reduce no. of OPwFD being re-admitted to hospital as an emergency within 30 days of discharge 15 Reduce the prevalence gap of dementia Indicator of joined up care - need to support preventative action. Linked to #8 (time spent at residence) and #16 (sustainable discharge). Danger that sorting out hospital admissions won t necessarily lead to better care how can we improve people s care at home? Already a national focus Need to address the time between diagnosis and follow-up. How quickly can dementia be picked up when a patient presents to A&E without a carer?

31 ERG 4 Frailty / Dementia detailed comments continued 31 Outcomes 16 Sustainability of discharge: Reduce the number of OPwFD who are back in hospital on day 91 after discharge ERG Comments Indicator of joined up care and requires system-wide partnership working to achieve. Suggestion to combine #16 and #17. Closely related to management of continence and hydration (links with #14). 3 Reduce excess winter death rates Preferred mortality outcome (out of 4) if pushed to choose. Moderately frail people can be extremely affected by winter and need practical support. Other mortality outcomes (#1-4): why increase life expectancy should be about quality > quantity. 21 Reduce the incidence of delirium who are undergoing treatment for hip fracture Concern about the increasing frequency of incidence. Suggestion to combine #20 and #21 (reduce deaths within 30 days after hip fracture). Other Outcomes 9 Reduce potentially avoidable infections (C Difficule, MSSA, MRSA, E Coli) in OPwFD 10 Reduce new pressure ulcers in older people with frailty and/or dementia at place of residence or in hospital Already measured nationally. Some cynics hospital contact increases risk but antibiotic resistance is a quick fix. Long recovery time-frame. Need to educate carers to prevent incidence.

32 Appendix 2 Further Information 32

33 Indicative segment information 33 Segment Criteria Estimated number of people over 65 yrs % Total 1 Healthy No diagnosis 14, % 3 Acutely Ill Not available 4 Long-Term conditions 5 Serious Disability Arthritis, Hypertension, CHD, Stroke /TIA, Depression, HF, AF, COPD, Asthma, CKD, Diabetes, Epilepsy, Cancer, SMI LD, Downs Syndrome, Sensory disability, Mobility Impairment 6 End of Life Not available 7 8 Limited Reserve and Exacerbations Frailty and/or Dementia 42,366 73% 2,300 4% Not available Dementia, HisFall 7, % Total >65 population in Stockport = 57,966 Estimates taken from JSNA GP data analysis

34 LTC for over 65s 34 Condition No. of >65s % of people with condition who are >65 Chronic Kidney Disease (CKD) 6, % Atrial Fibrillation (AF) 4, % Heart Failure (HF) 2, % Stroke or Transient Ischaemic Attack (TIA) 4, % Coronary Heart Disease (CHD) 9, % Chronic Obstructive Pulmonary Disease (COPD) 4, % Cancer 5, % Hypertension 27, % Rheumatoid Arthritis (16+) % Diabetes 8, % Epilepsy % Severe mental health % Asthma 4, % Depression (18+) 4, % Learning disability % Cerebral palsy % Downs syndrome 4 1.7% Autism % Total >65 population 55,600

35 Priorities indicated in RightCare (all ages) Text highlighted in green indicates where outcomes are linked to these priorities 35 Trauma and Injuries This outcome priority includes the following quality measures: Mortality from accidents all ages; Injuries due to falls in people aged 65+; Unintentional and deliberate injury admissions, 0-24 years; All fracture admissions in people aged 65+. Gastro-intestinal This outcome priority includes the following quality measures: Mortality for liver diseases under 75 years; Alcohol specific hospital admissions; Emergency admissions for alcoholic liver disease condition (19+) Admissions for C related end-stage liver disease/hcc; Reported C-Diff cases. Mental Health Musculoskeletal This outcome priority includes the following quality measures: Physical health checks for patients with SMI; Mental health hospital admissions (quarterly opportunity); This outcome priority includes the following quality measures: % patients 75+ years with fragility fracture treated with BSA; Hip replacement emergency readmissions 28 Emergency hospital admissions for selfharm; Mortality with dementia 65+; Rate of emergency admissions aged 65+ with dementia. days; % fractured femur patients returning home within 28 days; Hip fracture emergency readmissions 28 days. Maternity Not relevant as only analysing over-65 population for ST in phase 1 of outcomes. As taken from the RightCare Where to Look pack for October 2016, under the Outcomes heading on page 13.

36 Priorities indicated in Joint Health and Wellbeing Strategy/JSNA Stockport Health Needs Overview: Stockport has oldest age profile in Greater Manchester currently 19.4% people are aged 65+, likely to rise to 21.8% by 2024, an additional 9,681 people. Cancer most common cause of death (causing 29% of all deaths and 42% of early deaths; 40% of cancer is preventable). Key facts health determinants: 18% smoke (41% in Brinnington). 26% drink unhealthily (7,000 alcohol related admissions per year). 25% are obese (62% are overweight or obese). Text highlighted in green indicates where outcomes are linked to these priorities Key facts mortality causes: 2,700 deaths a year. 29% of cancer; 28% of heart disease; 14% of lung disease. Key facts LTCs: 43,000 with hypertension. 19,600 with asthma. 14,200 with diabetes (17+). Key facts mental wellbeing: 16,400 with depression (18+). 2,400 with dementia. 2,400 with psychosis. 36 Stockport Health Priorities The overall objectives for health and wellbeing in Stockport are to improve life expectancy and reduce health inequalities. For all ages: Increasing levels of physical activity as an effective preventative action at any age. Focus on improving healthy life expectancy for all as the priority, focusing especially in the most deprived areas. Continue work to integrate and improve care systems, especially minimising the use of unplanned hospital care. For Ageing Well: Supporting healthy ageing across Stockport, recognising that preventative approaches that promote self care and independence are essential at every life stage. Aim to prevent and delay the need for care whilst responding to the complexity of needs that older people with multiple long term conditions may have. Continuing to improve the identification of and support available to those with dementia and their carers. As taken from the Stockport Joint Health and Wellbeing Strategy , pages 6-8 the Stockport Health Needs and Priorities are taken from the Stockport JSNA

37 37 Removal of LTC 18 (duplicate) Assessment of LTC 18, 30 and 16 LTC18 Unplanned hospitalisation (emergency admissions) for chronic ACS conditions LTC 16 Emergency admissions for people with LTCs, disability and/or organ failure LTC16 and LTC18 are similar in that they measure total number of emergency admissions (admissions rate) for similar cohorts of people. Both LTC16 and LTC18 include: Asthma, Heart Failure, Diabetes, COPD, Angina/Chronic IHD, HTN, Epilepsy Conditions exclusive to LTC16: Arthritis, AF, Cardiovascular Disease, Learning and Physical Disabilities, Neurological end stage disease (MND, Parkinson s, MS), CMD, CKD Conditions exclusive to LTC18: Chronic viral hep B, anaemia, and dementia Due to the overlap, we would recommend selecting one of these and not both. LTC18 is defined by the NHS as including those conditions that are more amenable to proactive management. Since it s a national measure, there will also be benchmark data available. However, it is possible to look at this outcome for people aged 65 and over (in which case, benchmark data is unavailable as the NHS measure looks at all people including children). LTC16 will give greater coverage and includes all conditions defined by Stockport s segmentation work. LTC30 Average number of exacerbations per person with organ failure, that require emergency hospital admission This is different from LTC16 and LTC18 primarily because it s a frequency of admissions measure (rather than a pure admissions rate measure). i.e. it will be an average number of emergency admissions per year, for people in segment 7 only. Important to note, that information used to define segment 7 (e.g. to exclude mild forms of COPD, heart failure and so on) is principally held in primary care, so although a value can be obtained from SUS data alone, a more accurate value can be obtained with primary care data access.