Developing Risk Prediction to Support Preventative and Anticipatory Care in Scotland – Enhancing SPARRA (Version 3)

Examples of Practice

Information Services Division (ISD) was keen to further develop the Scottish Patients at Risk of Readmission and Admission (SPARRA) tool to identify patients who may benefit from a more anticipatory approach to their care; planning for events or exacerbations to reduce the risk of emergency hospital admission.

SPARRA is a tool which predicts a patient’s risk of emergency admission; a patient with a SPARRA score of 50% has a one in two chance of being admitted to hospital in the following year.

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Scottish Partnership for Palliative Care (SPPC)

Examples of Practice

Palliative care is not just “terminal care” over a few weeks or days.   Palliative care approaches are relevant to people living with advance disease, regardless of length or clarity of prognosis.

Around 38 000 people with palliative care needs die in Scotland each year and a much larger number are living with advanced progressive disease.  Most are older people.  Around 30% of acute bed days are used by people in their last year of life, and over 50% of people will die in hospital, although most people express a preference to die at home.  How Scotland cares for those approaching the end of life is therefore an issue of major and universal significance for the Scottish population and has a major impact on how Scotland uses scarce healthcare resources.

Palliative care is an integral part of achieving the transformational change (and shift of resources) envisioned in Reshaping Care for Older People.  Regardless of the success of preventative strategies death and dying is inevitable.  And unless we get this part of the trajectory right we are likely to continue to commit huge health care resources to providing care in the acute sector for people whose preference would be for care elsewhere.

Good quality palliative and end of life care is fundamental to delivering the safe, effective and person-centred care described in the Dementia Strategy and the Healthcare Quality Strategy.

Research indicates that patients who have been identified and placed  on a palliative care register are more likely to have their needs/wishes met, for example they are more likely to die at home (75%) as opposed to those who are not on the register (22% die at home). Currently, most people on a register have a cancer diagnosis but palliative care is relevant to people with any advanced life threatening disease.  References: Murray S.A, Boyd K, Sheikh A, Thomas K, Higginson, IJ. Developing primary palliative care. BMJ. 2004; 329:1056.

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Older People’s Advice Service (OPAS), operated by Link Housing Association

Examples of Practice

To combat poverty and financial exclusion by improving take-up of older people’s benefits with particular emphasis on clients who have health problems, are housebound, or who live in remote areas.

The service aims to ensure that hard to reach older people are given an opportunity to claim the benefits and access the support that they require.  Typically older people do not access benefits and support due to multiple barriers.  The OPAS delivery model aims to overcome these barriers.

The project focused on Falkirk, Clackmannanshire, West Lothian, North Lanarkshire and Glasgow.

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Nairn Anticipatory Care Planning (ACP) and Integration: A Primary Care Pilot Study Aimed At Reducing Unplanned Hospitalisation

Examples of Practice

The number of people in the UK aged over 65 is growing and is forecast to reach 16.1 million by 2035.  The burden of disease associated with aging will increase as will the demands on health services including end-of-life and palliative care.  The National Confidential Enquiry into Patient Outcome and Death in 2008 found that rather than advanced care planning and palliation taking place, some patients were subjected to excessively active interventions in their last months of life.

The pilot study aimed to ascertain whether using primary and secondary care data to identify patients at risk of hospital admission and agreeing and implementing an Anticipatory Care Plan in this population could help to reduce hospital admission rates.   Anticipatory care planning allows patients to express their wishes for care prior to a sudden deterioration in their health.

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Family (& Carers) Group Conferencing

Examples of Practice

One example was a lady with Dementia who was referred in order to consolidate support available and identify any areas that might require assistance. However, during preparation it transpired that this elderly lady was also a victim of financial abuse. The family knew this was going on and wanted it stopped but did not know what to do about it.  The Family Group Meeting brought these concerns into the open. Social work was informed of these allegations but they agreed to wait for the outcome of the Family Group Meeting before pursuing their own enquiries.

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