22 oct15 fast followers workshop ltc

LtC Year of Care Commissioning
Fast Follower Community of Practice
workshop
22nd October 2015
#A4PCC #LTCimp #LTCyearofcare

LTC Year of Care Commissioning
Developing a Year of Care Capitated Budget approach for those
with Complex Care Needs
• Programme information
• 5 Early Implementer sites
• Fast Followers Community
• Whole Population Datasets
• Simulation Model

LTC Person Centred Care:
Delivering Person Centred Care for People with LTCs
• Improvement Sites
• LTC Toolkit
• Snapshot Survey
• Simulation Model

LTC Learning Community
Establishing a Virtual Community for All to Share and Learn
• LTC Dashboard
• Case Studies
• Lunch and Learn Series
• The Bulletin
@NHSIQ @bev_j_matthews #LTCImp #LTCyearofcare

Action for Person
Centred Care
o Taking action to make person-centred care for
people with long-term conditions a reality
o Looking at what needs to change and why we
need to change
o Co-produced with NHS England and Coalition
for Collaborative Care and developed with
health and care professionals, policy makers
and people with long-term conditions
o What you can do:
o Make a commitment embedding
patient-centred care in your work at
www.engage.england.nhs.uk/survey/ltc
-declaration
o Tell your teams about our work
o Use the hashtag #A4PCC when you see
work that is relevant to person-centred
care for people with LTCs
o Let us know of any events, activities or
social media opportunities that we can
join forces with you #A4PCC – Action for Person-Centred Care

Date Topic Guest Speaker(s)
4 Nov 2015 Writing letters directly to patients
Tweetchat with @wecommissioners
Bev Matthews
Programme Delivery Lead
NHSIQ
17 Dec 2015 Simulation Model Claire Cordeaux, Executive VP Healthcare
- Simul8
Julie Renfrew, NHS Improving Quality
Coming soon Continuing the discussion about
behavioural change and care
planning
Angela Coulter
Kings Fund
LTC Lunch & Learn E-Seminars
Establishing a Virtual Community for all to share and learn
If you missed previous webinars from our Long Term Conditions Improvement
Programme lunch and learn series you can catch up by downloading the slides and
material:
http://www.nhsiq.nhs.uk/improvement-programmes/long-term-conditions-and-integrated-
care/long-term-conditions-improvement-programme/webinar-series/previous-webinars.aspx

LTC YoC Commissioning
Sharing learning...Dates for diaries...
Date Webinar Led by...
12 November 2015
(note 12pm -1pm)
Creating and Reporting on a
Whole Population Dataset [to
develop a capitated budget]
Peter Gough, Kent & Medway Health
Informatics Service
9 December 2015 Developing robust capitated
budgets
Steve Downing,
Head of Finance, Southend CCG
19 January 2016
(TBC)
Leeds EIS
(Topic TBC)
Tricia Cable, LTC YoC Commissioning
Programme lead, Leeds EIS
11 February 2016 Commissioning Integrated
models of care
Alison Davis, Integration Programme Health
and Social Care, Working on behalf of Kent County
Council and South Kent Coast and Thanet
CCG's
X March 2016
(TBC)
West Hants EIS
(Topic TBC)
Kate Smith, West Hants CCG
All webinars 12.30pm to 1.30pm...
Next fast follower community of practice workshop:
Thursday 4th Feb 2016: Central London (venue TBC)

LTC YoC Commissioning
Fast Follower Community of Practice sites..
Area Lead organisation
Barnsley Barnsley CCG
Bracknell Bracknell & Ascot CCG
Cheshire West Cheshire CCG
East Sussex East Sussex county council
Great Yarmouth Great Yarmouth CCG
Islington & Haringey Whittington Health (Islington & Haringey)
North Hampshire North Hampshire CCG
Northamptonshire Northamptonshire Healthcare NHS FT
Sheffield Sheffield CCG
Slough Slough CCG
South Manchester University Hospital of South Manchester NHS FT
Southwark & Lambeth Southwark & Lambeth Integrated Care
Stockport Stockport CCG
Waltham Forest & East London
Waltham Forest and East London Collaborative (WELC) for Integrated Care,
including Tower Hamlets CCG
Wigan Wigan Borough CCG
Windsor Windsor Ascot & Maidenhead CCG

LTC Year of Care Commissioning
National
Programme
team
FF
FF
FFFF
FF
Early
Implementers
• Conduit
• Access to specific
information / learning
•Virtual facilitation
Networking and learning...
From each other, the early implementer
sites and national experts in various
related fields
Through...
• Email updates
• Our website
• Facilitated Webinars with specialist
input
• National workshops
• Case studies
Support to fast followers...
• Improve confidence and effectiveness of leaders of large
scale change,
• Highlight fresh perspectives on how to plan and lead large
scale change programmes which improve patient
outcomes and public value for the co morbid patient
cohort,
• Present opportunities to tackle local cultural and
organisational barriers to find different ways of working to
improve coordinated care, across the care economy,
• Increase the ability to implement testing of new
processes, tested by others in a safe environment.

Today’s learning outcomes...
• Creating integrated datasets to support
service redesign decision making
• Using behaviour change to support the
delivery of integrated person centred care
• Moving integration to business as usual
• Putting public health and self management at
the front of the new delivery model
• Using the LTC YoC Commissioning simulation
modelling tool

Improving health outcomes across England by providing improvement and change expertise
Simulation for patients
with complex care needs
Jamie Day

 Theoretical test before implementation
 Test service change ideas before you commit resources
 Evidence to support a business case
What is simulation?
Why use it, and for what sort of problems?
To assess variation:
 Set budget – what is the likelihood of under or over-performance?
 Hire new staff – what is the likelihood of too many or too few?
For scenario planning – what is the impact of a proposed change:
 Will is save money?
 Will more GPs be needed?
 Will emergency admissions be reduced?

What drives the model?
Patients with long term conditions by resource use
(risk score or number of long term conditions)

How it works
Distributions in the model for:
• The way that patients in
each group access services
• The number of times
patients access services
• The movement of patients
between groups from year
to year
• The costs of each service
• The resources (staff, bed
days, etc,) required for
each service
Patient
Services
Costs
Capacity

New features
 Pre-populated scenarios
 Scenario wizard
 Ability to compare scenario with baseline in the results
 Improved results
 Upgraded guidance documents
 User testing
 Ability to save runs for comparison later
 Ability to share scenario parameters with other users
On-line testing
Expected release – late November/early December

Scenario 2 (Cornwall)
Age UK Living Well programme
Move people away from unscheduled care.
Targets current and future high consumers of health and social care.
The fundamental elements of the Living Well approach are:
 Proactive case finding
 Resources could be shifted to community, mental health & GP primary
care services
 Guided conversation – a goal-oriented conversation between the
individual and a voluntary sector worker
 Care co-ordination by an integrated care team - based around a GP
practice, facilitated by the voluntary sector
 Volunteer support on a 1:1 and group basis to encourage physical and
social activity
 Mapping to link patients with local services and key ‘community makers’

Scenario 2 (Cornwall)
Evidence:

@NHSIQ
enquiries@nhsiq.nhs.uk
www.nhsiq.nhs.uk
Improving health outcomes across England
by providing improvement and change expertise.

Developing
integrated data to
support service
redesign
decision making
Tricia Cable
Alison Phiri
Mohini Chauhan
NHS Leeds CCG

• The population of Leeds is ~780,000
• The Leeds adult population with at least one long term
condition ~350,000
• 2012/13 one PCT successful in bid to be a YOC EI site
• Moved to three CCG’s in 13/14
• Transformation programme focus on integration
• Integrated Care Pioneer site
Background

Prevalence of CHD,
COPD and Diabetes
is higher than the
rest of the city
Around 40% of the NHS Leeds
South and East CCG population
has one or more LTC
The biggest cause of
years of life lost is due to
cardiovascular disease
cancer and respiratory
disease
More people
have mental
health
problems than
in the rest of
the city, above
the national
average
Health
related
quality of
life for
people with
LTC’s is
significantly
lower than
the national
average
25% of the CCG population have
an existing health problem, which
is above the England average
More people are
living with 2 or 3
LTC’s, compared
to the rest of the
city
By 18/19 PYLL to be
improved by 26.6%
Please note: the data on this slide was taken from a number of sources including; public health profiles, the LSE CCG 2 year plan, NHS England commissioning for value
packs and the NHS England long term condition dashboard.
NHS Leeds South and East CCG

Coronary heart
disease largest
cause of death
in Leeds North
population
Bed days per
emergency hospital
admissions for
people aged 85+
higher than national
average
Around 40% of the
Leeds North population
has at least one long term
condition
Emergency
admissions for all
causes, higher
than rest of the
country
Emergency admissions
for all cancer, higher
than rest of the
country
Please note: the data on this slide was taken from a number of sources including; public health profiles, NHS England commissioning for value packs and the
NHS England long term condition dashboard
NHS Leeds North CCG

Number of emergency readmissions are
significantly higher than the national average,
especially for COPD which is higher than the
rest of the city
Life expectancy
for both males
and females
significantly
lower than rest
of the country
Proportion of older people
living in deprivation is higher
than rest of England
Around 32% of
the NHS Leeds
West CCG
population
has one or
more long
term condition
Number of healthy eating adults
significantly lower than rest of
England
More
binge
drinking
adults
than the
rest of
the city
Hospital
stays for
alcohol
related
harm,
worse
than rest
of UK
Mortality rates from all cancer, all
circulatory disease and CHD is
significantly higher than rest of the
country
Around 50% of the
population are aged
between 25-64
Please note: the data on this slide was taken from a number of sources including; public health profiles, NHS England commissioning for value packs and the NHS
England long term condition dashboard
NHS Leeds West CCG

Overview of the Leeds Year of Care EI Journey
2012/13
• 550 cohort analysis
• Provider cost data
• NT development
2013/14
• Whole population
dataset
• RRR Audit
• NT– phased
implementation
• Case studies
2014/15
dataset
• Leeds Care Record
• NT Development –
all teams
• Primary care
development
• Patient engagement
• Evaluation
2015/16
dataset
• Leeds care Record
• CCG Datapacks
• Shadow capitated
budget
development
• New models of care
development
• NMOC Pilot
development
• Patient engagement
• Evaluation

Self Management –
House of Care
Engagement with
patients
Risk stratification tools
Leeds Care Record
Building
neighbourhood teams
Social Prescribing
Primary Care development
Federation & hub
development
New models of care
Capitated Budget –
financial payment system
Better Care Fund
Structured education
programmes
Pharmacy in primary
care

CASE
MANAGEMENT
DISEASE
MANAGEMENT
SUPPORTED SELF
CARE
POPULATION WIDE
PREVENTION
Which populations do we want to target?
Reducing unplanned
admissions?
Reducing
total costs?
Health outcomes/potential
years of life lost (PYLL)?
Multimorbidity?
Age?
Risk of high
healthcare
utilisation?
Focus on now
or the future?
Frailty?

Developing the data set
What?
• Review of current Information Assets
• Gap analysis
• Developed Leeds Data Model
• Tailored Leeds Data Model for specific purposes.

What?
Leeds Integrated
Health & Social
Care Data Model
Datasets linked on a
common patient identifier
GP Practice
Data Notional costs assigned
Community
Dataset Notional costs assigned
Mental
Health Data Cost per unit assigned
Inpatient
Data
Adult Social
Care Data No costs assigned
Outpatient
Data
A&E Data
Year of Care Combined
Dataset
ACG Grouper
Linked data
processed through
the ACG Grouper to
create risk scores
Input Dataset
Used for
production of
capitated
budgets
Output
Dataset
Used for
cohort
identification
To be defined
Dataset for
shadow
monitoring
Key:

How did we use the dataset
So what?
• Cohort identification – pivot table hell!
• Created a tool that enabled us to make the best use of the data

Introduction to data packs
• Data packs were developed to create an impact and so they
could be easily distributed to stakeholders across the system.
• Inspiration taken from commissioning for value data packs.
• A visual and engaging way of presenting data.
• The data packs do not provide the answers to which cohorts
should be selected. Their purpose is to generate discussion
and to support stakeholders to make a more informed decision
around which cohorts they would like to focus on.
Now What?

Whole population dataset
Analysis of Leeds city wide data involved testing the following
methodologies to understand utilisation of healthcare services, over a
two year period:
a. Patients who had three or more A&E attendances
b. All patients aged 85 and over
c. All patients with a Frailty Index of seven or more
d. All patients with 4 or more long-term conditions
e. All patients in the top 2% by risk of unplanned hospitalisation in the
next 12 months (based on the Kings Fund’s Combined Predictive
Model algorithm).
The analysis demonstrated an increased use of healthcare services
over the subsequent two years when moving from (a) to (e) and points
towards a multimorbidity model.

0
2000
4000
6000
8000
10000
12000
14000
16000
18000
18-34 35-44 45-54 55-64 65-74 75-84 85+
Numberofpatients
Age category
Number of LTC’s, by age, for people with at
least one LTC*
13+
12
11
10
9
8
7
6
5
4
3
2
1
*NHS Leeds South and East CCG

£12,297,218
£11,947,166
£6,591,526
£12,381,539
£2,439,706
£43,220,633
£0 £5,000,000 £10,000,000 £15,000,000 £20,000,000 £25,000,000 £30,000,000 £35,000,000 £40,000,000 £45,000,000 £50,000,000
GP
Community
Mental Health
Outpatients
A&E
Inpatients
Total costs (£)
Servicearea
Total costs of services, for people with at
least one LTC*
14%
13%
7%
14%
3%
49%
% total costs of services
GP
Community
Mental Health
Outpatients
A&E
Inpatients
*NHS Leeds North CCG

-
5,000,000
10,000,000
15,000,000
20,000,000
25,000,000
1 2 3 4 5 6 7 8 9 10 11 12 13+
Totalcosts(£)
Number of LTC/s
Total costs of services, by number of
LTC’s, for people with at least one LTC*
Inpatient
A&E
Outpatient
Mental Health
Community
GP

-
2,000.00
4,000.00
6,000.00
8,000.00
10,000.00
12,000.00
14,000.00
1 2 3 4 5 6 7 8 9 10 11 12 13+
Averagecosts(£)
Number of LTC/s
Average costs of services, by number of
LTC’s, for people with at least one LTC*
Inpatient
A&E
Outpatient
Mental Health
Community
GP

Patterns of multimorbidity*
*NHS Leeds West CCG

Ischemic heart disease
COPD
Depression
(+any other conditions)
1028 people
affected of
which 47%
are male
Average costs
per person,
over a one
year period
£5,399
8.6 average
number of
LTC’s per
person
Total costs,
over a one
year period
£5,550,474
GP costs
£439,814
Inpatient
costs
£3,277,790
A&E costs
£199,067
Outpatient
costs
£438,993
Mental Health
costs
£155,436
Community
costs
£1,039,082

0
10
65
205
153 152
182
150
111
0
50
100
150
200
250
18-34 35-44 45-54 55-64 65-69 70-74 75-79 80-84 85+
Numberofpatients
Age category
Age split of patients who have IHD, COPD
and depression (+any other conditions)*

0 0 1
11
36
119
171
203
153
121
112
51
37
10
3
0
50
100
150
200
250
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Numberofpatients
Number of long term conditions
Numbers of multiple LTC’s for patients
with IHD, COPD and depression (+any other
conditions)*

Heart failure
COPD
Depression
(+any other conditions)
881 people
affected of
which 62%
are female
Average costs
per person,
over a one
year period
£6,299
8.8 average
number of
LTC’s per
person
Total costs,
over a one
year period
£5,549,683
GP costs
£389,000
Inpatient
costs
£3,290,706
A&E costs
£197,096
Outpatient
costs
£406,565
Mental Health
costs
£122,359
Community
costs
£1,143,893

0
10
38
150
139
130
162
152
100
0
20
40
60
80
100
120
140
160
180
18-34 35-44 45-54 55-64 65-69 70-74 75-79 80-84 85+
Numberofpeople
Age category
Age split of patients who have HF, COPD
and depression (+any other conditions)

0 0 0
16
38
81
124
158
136
125
104
49
37
10
3
0
20
40
60
80
100
120
140
160
180
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Numberofpeople
Number of LTC’s
Numbers of multiple LTC’s for patients with HF,
COPD and depression (+any other conditions)

Cohort options
Depression, COPD
and IHD
Depression, COPD
and HF
Number of people affected: 1028 881
Average number of long
term conditions:
8.6 8.8
Total costs: £5,550,183 £5,549,683
Average costs (per patient): £5,399 £6,299
Total GP costs: £439,814 £389,000
Total A&E costs: £199,067 £197,096
Total Inpatient costs: £3,277,790 £3,290,706
Total Outpatient costs: £438,993 £406,565
Total Community costs: £1,039,082 £1,143,893
Total Mental health costs £155,436 £122,359
Comparison table

-
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
COPD
Hypertention
Lipid Metabolism Disorders
Cardiac Arrhythmia
Ischemic Heart Disease
Heart Failure
Peripheral Vascular Disease
Renal Failure
Cerebrovascular Disease
Osteoporosis
Rheumatoid Arthritis
Epilepsy
Parkinsons
Multiple Sclerosis
Hypothroidism
Chronic Pancreatitis
Chronic Liver Disease
Cancer
Depression
Bipolar Disorder
Schizophrenia
Dementia and Delirium
Prevalence of other conditions for patients
who have Diabetes (n=10654)*

£-
£500.00
£1,000.00
£1,500.00
£2,000.00
£2,500.00
£3,000.00
£3,500.00
£4,000.00
-
500
1,000
1,500
2,000
2,500
3,000
18-34 35-44 45-54 55-64 65-74 75-84 85+
Averagecosts(£)
Numberofpeopleaffected
Age category
Number of people with Diabetes (plus any other
condition/s), with average costs associated, by
age*

Data itself can be misleading, therefore triangulation of
data, clinical input and soft intelligence is key
Lessons learnt
Patient engagement

For the purpose of selecting a pilot cohort, the following points have been raised
through clinical input:
Risk factors
• Hypertension and lipid metabolism disorders can be classed as risk for other
conditions, such as IHD, and therefore will not be considered as core conditions
for the purposes of cohort selection. Whilst they are high in number, these
conditions (risk factors) are well managed in primary care and are not associated
with high costs.
COPD
• lower number but high cost
• High unplanned admissions
• High community, primary care and mental health costs
• Life limiting- should end of life patients be included?
• Difficult for primary care to manage
• Benefit from community specialist services (supported by patient feedback).
Clinical input

Depression
• High overall numbers of people affected
• % of patients with 3 or more that include depression
• Could benefit from being better integrated in pathway
Ischemic Heart Disease (IHD)
• Hypertension, lipid metabolism and diabetes are high in number. Each of these are
risk factors for IHD, which is the highest individual long term condition in number.
• A specific cohort based on all patients with IHD:
– Number of people with IHD – 11424. Of these:
– Number of people with hypertension 10472
– Number of people with high cholesterol 9600
– Number of people with diabetes 3378
• IHD could therefore be selected as a comorbidity cohort. This group of patients
are likely to receive care in a reasonably coordinated way within this condition. For
the purposes of improving coordination of care it is more relevant to consider non
associated conditions e.g. IHD and COPD.
Heart Failure
• Progression of IHD
• Life limiting- should end of life patients be included?

I visited my GP 35 times,
in the past year
My name is Bob. I suffer
from COPD, IHD,
rheumatoid arthritis,
high blood pressure,
high cholesterol and
depression
The total cost for my
healthcare, over the year,
was around £9500
I was admitted to
hospital 8 times, which
cost £6000
I was seen by a number of
health professionals and
visited the outpatient clinic
19 times
I am between 45-54 years
old

Having a care plan will
help me feel more
supported to manage
my condition
I want to feel more
empowered to
manage my
condition
Where can I find out about self
help courses for people who
have long-term conditions?
I want to find out more about
my condition. Where are the
best places to do this?
Are there any lifestyle
changes I should make to
help my health?
What do our service users say?
How do I meet other people
who have the same
condition as me? Is there a
local or national support
group?I feel I cannot manage my
condition due to lack of
information and support
How can I make my condition
easier on my family and
friends?

• Data packs have been well received across the three
CCG’s
• Shared widely with different stakeholders
• Improved engagement
• Requests to present at locality meetings
• Requests for more data analysis for specific conditions
Response

• Citywide development of capitated budgets
• The three CCG’s are working closely with primary care to
develop hubs, by using data packs to focus their areas of
collaborative work
• NHS Leeds South and East CCG are developing new
models of care pilots
• Linking in with the Leeds Care Record.
Next steps

12472
22856
14955
21171
14757
0
5000
10000
15000
20000
25000
Beeston Chapeltown Kippax Middleton Seacroft
Numberofpatients
Neighbourhood teams
Neighbourhood team breakdown, for patients with at
least one LTC*

0
1000
2000
3000
4000
5000
6000
7000
LeedsCityMedicalPractice
CityViewMedicalPractice
OakleyMedicalPractice
BeestonVillageSurgery
ShaftonLaneSurgery
CottingleyCommunityCentre
ShaftesburyMedicalCentre
Laybourn&PartnersTheMedicalPractice
BellbrookeSurgery
EastParkMedicalCentre
GardenSurgery
LincolnGreenMedicalPractice
ThePracticeatHarehillsCorner
RoundhayRoadSurgery
TheSurgery
YorkStreet
TheRichmondMedicalCentre
ShakespeareCommunityPractice
AshtonView
ConwayMedicalCentre
GarforthMedicalPractice
GibsonLanePractice
NovaScotia
KippaxHall
MoorfieldHouse
RadshanMedicalCentre
SwillingtonClinic
LingwellCroftSurgery
OultonSurgery
LofthouseSurgery
NewCrossSurgery
TheArthingtonMedicalCentre
WhitfieldPractice
MiddletonParkSurgery
HunsletHealthCentre
ColtonMillMedicalCentre
WindmillHealthCentre
ManstonSurgery
ParkEdgeSurgery
AshfieldMedicalCentre
TheFamilyDoctor
WhinmoorSurgery
Beeston Chapeltown Kippax Middleton Seacroft
Numberofpatients
Neighbourhood team
GP breakdown, by neighbourhood team, for
patients with at least one LTC

The story of what we
are doing in Barnsley to
show how behaviour
change has been used
across Barnsley to
support the workforce
in delivering integrated
person centred care
Hilary Mosley
Lead Nurse,
Commissioning and
Transformation
Barnsley CCG
hilary.mosley@nhs.net

Feeling Powerless Increases the Weight Of The World
People who feel powerless actually see the world differently, and find a
task to be more physically challenging than those with a greater sense of
personal and social power.

Behaviour
Change
Conversations
Year Of Care
Care Co-ordination
I Heart Barnsley
Care Planning
Care Navigation

Care Navigation
TelemonitoringHealth CoachingPost Crisis Support
Elements of Service provided by
the Care Navigation / Telehealth
Service
Interchangeable and mutually supportive
Barnsley Care Navigation / Telehealth
Service

Outcomes Achieved
The outcomes listed below are based on patient service utilisation 6 months prior and post
access to the SWYPFT Care Navigation / Telehealth Service in Bassetlaw for 2013 / 2014.
 Primary Care attendances:
– Reduction 46.5% (Coaching)
– Reduction 14.6% (Telehealth)
 A & E attendances:
– Reduction 31% (Coaching)
– Reduction 35% (Telehealth)
 Emergency admissions:
– Reduction 46% (Coaching)
– Reduction 27% (Telehealth)

http://www.southwestyorkshire.nhs.uk/our-services/care-navigation-and-telehealth/
Link to Lens Story

Chester  Ellesmere Port & Neston  Rural
Making sure you get the healthcare you need
Year of Care for
Patients with Long Term Conditions and
Supported Self Care
West Cheshire Way

Overview
 The West Cheshire Way – what is it
 What’s the story – what is our problem
 What we are doing – why are we doing it
 What is the activity – from Year of Care
to supported Self - Care
West Cheshire Way – Year of Care
and Supported Self Care

West Cheshire CCG
Population – around 260,000
Split into 3 locality areas, City,
Ellesmere Port and rural – broken
down further to 9 cluster areas
37 GP practices

If West Cheshire was a village of 100

m
o
c
v
w
t
se
i
s
The Care Model
Our frail older people will…
l Receive care in the community by their practice supported by
experts when their conditions become more complex to manage
l Have a care plan that they/their carers hold and co-write, use
technology to monitor changes in condition
l Those with several needs will have a single care co-ordinator
l Have frailty identified as a long-term condition
Our babies, children and
young people will...
l Receive care in the
community by their
practice supported by
experts when their
condition becomes more
complex to manage
l Have a care plan that the
family hold and co-write.
l Use technology to monitor
changes in condition.
l Be supported earlier
l Have a single
care co-ordinator
l Not be obese when they
leave primary school
Acute to
community
shift
Supported
self-care
Prevention
and early
detection
Pyramid of need
Our adults with long-term
conditions will…
l Receive care in the
community by their
practice supported by
experts when their Long-
term Conditions become
more complex to manage
l Have a care plan that they
hold and co-write.
l Have technology and
skills to monitor changes
in condition, be cared for
proactively
l Be supported to change
unhealthy lifestyles, be
identified earlier
t

 Current funding models – recurrent and non
recurrent funds i.e. Prime Ministers Challenge
Fund, Innovations Funding, CCG recurrent
budgets
 New models of care – Multi Speciality
Community Provider – new three year funding -
£5 million (Emphasis is very much focused
towards shifting current care model from
hospital based care to new model of
community based, services closer to home and
patient centred care) – ALL PARTNERS ACROSS
THE WEST CHESHIRE WAY FOOTPRINT
West Cheshire Way Funding Model

 Long Term Conditions account for:
 70% of money spent on health and social care
 55% of GP appointments
 68% of hospital outpatients
(Year of Care partnerships, 2015)
 Currently patients are treated by condition rather
than holistically causing care to be inefficient and
unnecessary
The Case for Change

Local Picture
 over 64.9 % of people aged over 65-84 years of age are reported
to have co-morbidities
 Those over the age of 85 + it is reported to be closer to 81.5%
across Cheshire West and Cheshire
 Population forecast will see an increase of over 26% between
2011/2012 and 2021/2022 including by 44% in those aged over 85
 The NHS should be supporting people to be as independent and
healthy as possible if they live with a long-term condition such
as heart disease, asthma or depression, preventing
complications and the need to go into hospital.
(Cheshire West and Cheshire Integrated Joint Strategic Needs Assessment 2014)
What’s the story

 According to Long Term Conditions (LTC) data from
2013/14 within West Cheshire there is a predicted
80,600 (31.6%) individuals living with a Long term
Condition
 Of these, 36,400 live with 2 or more LTC
 Only 4.4% of LTC patients reported in 13/14 having a
Care Plan !!
NHS England Long term conditions Dashboard 2013/14
What's the story

What will the West Cheshire Way
look like
Social
Movement
Year of
Care
Self
management
and prevention
Patients

The Year of Care in West Cheshire is about:
 Redesigning routine health care to be more effective
for both patient and healthcare provider
 Supporting and enabling patients to take control and
gain knowledge and skills to self manage and make
decisions about them with them
 Providing care plans for all LTC patients
 Having prevention and self management pathways for
individuals which are also supportive for their families
and carers
What is Year of Care West Cheshire?

 System mapping
 Created joint working across district and Practice nurses
 Developed robust QIPP programme tracking for each
project – milestones, risks and outcomes
 Identified a prototype cluster to test the model
What have we done to date

To enable us to identify our needs for implementation
we mapped the system of what is currently being
delivered within the CCG demographic relating to year
of Care:
 We currently have 11 out of 36 practices delivering the
Diabetes Year of Care Model
 We have also mapped the training HCA’s have had
across the area to help us identify training needs
moving forward
System mapping

What will Year of Care West
Cheshire Way look like?
Developed by the practice and district
nurses of West Cheshire CCG
Appointment 1
Patient
registers
Results sent to
patients
Appointment 2
Action Plans
Co-created
Menu
Of
Options to
support and
Empower
patients

 Improved experience and engagement for patients
 Reduction in GP, outpatient and inpatient
appointments
 Better clinical outcomes for patients such as hba1c
control /blood pressure management
 Better organisation/consistency of care
What are the proposed outcomes
for this change

 Development of a steering group for the Year of Care
(including acute to community, prevention and self
care)
 Outcomes framework in development
 Infrastructure development i.e. toolkits, action plans
and pathways
 Practices to start to embrace methodologies
What are the next steps to
implementation

West Cheshire Way and New Models of Care (Multi
Speciality Community Provider)
 Improve prevention and self-care
 Work across boundaries
 Support and care for people in their own communities
 Improve the management of long term conditions
Care Models will focus on three key age cohorts:
 Starting Well – Children and Young People
 Adults with Long Term Conditions
 Older people
Prevention and Self Care for Long Term

Conditions
Tools and Resources for Primary Care
Community Models of Care – prevention
•Obesity ‘Daily Mile’ initiative with local primary schools
•Wellbeing coordinators - enablers and facilitators
•Integrated wellness service
•Ivan – community and primary care cluster working
•Pharmacy First
•Brightlife
•Healthy High-street
•Big Community Conversation – social movement
•Community engagement

Cluster Health Fairs
9 Clusters across West Cheshire piloting cluster health days
Ivan will act as the hub of activity, surrounding this will be a
range of other health and care organisations from across acute,
secondary and primary care services offering:
 Health checks – blood pressure testing, spirometry,
blood glucose monitoring
 Promotes Health Screening - cancer
 Integrated wellness service – supporting people to
opt for weight management, stop smoking, exercise
and lifestyle behavioural programmes
 Information, advice and guidance services
 Tele-health and telecare services and information
 Targeted to all age groups

Cluster Health Days
Mr Carrot
engaging with
young people in
Ellesmere Port
I didn’t know I could
have a breast
screening once I was
over the age of 70

Conditions
Community Models of Care – supported self-care
• Diabetes essentials (including pre – diabetes
prevention)
• Self-Management UK – self-care for life
(children, young people and adults)
• Peer led ‘one to one’ coaching – less activated
patients (adults)
• Apps and telehealth/telecare
• iVan – community and primary care cluster
working

Self Management Courses
Self Management UK:
• 2014/15 – delivered eight courses within two geographical areas across West
Cheshire:
• Rural locality (affluent) – social isolation
• Deprived locality (Ellesmere Port) – wider determinants
• More patients engaged from rural localities who were deemed more proactive
towards accessing the courses as opposed to those in deprived localities
• Those in Ellesmere Port required more support from Self Management UK and
GP Practice to support engagement
• Overall 120 patients signed up to the courses and over 70 completed
(completion is determined by those accessing more than four sessions)

Self Care Reunion – follow up
Sharing what has gone well
“I live with this condition daily and sometimes I want to take the focus off my
condition, the course has allowed me to do this”
“I was able to hang my curtains, normally my daughter has to come round and do
this for me”
Other positive outcomes focused on better partnerships with their health
professionals in managing and understanding their conditions. Overall they
reported on starting to have a greater understanding towards how they are able
to manage symptoms/exacerbations differently

Sharing what hasn’t gone well
• People not attending the whole six weeks of the course
• Related to patients reporting illness or other personal factors to non-
attendance
• contents of the letter received which invited them to the course was not always
clear
• More in-depth detail would have been more helpful
• Lack of understanding from their GP Practice; regarding the details and content
of the course.

Self Care Reunion
I have met so many new
friends since attending the
courses and we keep in
touch and support each
other
My husband passed away last
year and I just gave up and
became really ill because of this.
The course helped me get back
on track

Conditions
Social Media Resource
• puffell.com is a unique social media platform that enables
people to self-manage their own health and wellbeing
• It empowers individuals, groups and communities to make
positive changes that impact their overall wellness and
make the most out of their lives
• West Cheshire CCG commissioned a one off co-design and
creation COPD platform to support patients to manage their
condition
• Launched July 2015
• To date 378 people signed up
• 41 tracking their COPD condition

Technologies

Technologies
SpeakSet remote care service
• A video connection from a health professional to a
patient’s TV in their own home.
• Empowers client/local population to live independently
and improves their lives.
• Health professionals can focus on doing what they love,
delivering compassionate care rather than spending
hours a week travelling
• Making it real in West Cheshire as it is targeted towards
homelessness and people living in homeless
accommodation

Technologies
What others say about the devices
On rare occasions you come across new tech
that has the potential to be transformational,
and I feel this can be said about SpeakSet
Ken Clemens CEO, Age UK Cheshire
If these devices can be placed in
Homelessness shelters and support our
more vulnerable patients then this will
target patients that are often unable to
access health care services unless it
becomes an emergency
Homelessness Support
Worker, Richmond Court Chester

Technologies
Case Studies
Homeless residents (36) in accommodation at
Richmond Court. Registered at St Wedburghs
Practice which has a dedicated GP and PN for
homeless people. High rates of DNAs which impacts
on inappropriate attendances and admissions to
Countess of Chester Hospital. Speakset will provide a
remote device between GP practice and Richmond
Court which can offer clinical consultations with both
GP and PN. This can potentially reduce inappropriate
admissions to hospital. It also reduces DNAs within
primary care

Thank You For Listening:
Any Questions?
Further Contact Details:
Patricia Parker – patricia.parker6@nhs.net
James Duckers- james.duckers@nhs.net

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