Improving health outcomes across England by providing improvement and change expertise
LTC Year of Care
Commissioning Mode...
 Launched in W/C 19th April 2012 with EOI under Dept of Health LTC QIPP
workstream
 Transferred to NHS England in Decemb...
LTC Year of Care: Early Implementer Sites
Health Economy Early
Implementer
Key Partners Regions
Leeds Leeds South and East...
The House of Care
Engaged,
informed
individuals &
carers
Commissioning
Organisational
& clinical processes
Person-
centred...
The House of Care
LTC Year of Care Benefits:
Improved outcomes and wellbeing:
• Patients receive care that is better managed, more seamless ...
LTC Year of Care Currency:
• All PbR
(except YoC or
package
currencies)
Acute Community Mental Health Social Care Voluntar...
RRR audit:
 To support local thinking about RRR and early discharge, particularly in
relation to potential for pathway ch...
• Stakeholder engagement and senior team ‘buy-in’
• Assessment of services to maximise the benefit of integrated care
• Le...
• Senior team ‘buy-in’, eg NCDs
• Stakeholder Engagement, eg Monitor and PbR Team
• Framework for the Model and vision for...
GPs
Community &
Social Care
Assessment
Integrated
Care Team
GP datasets
Acute datasets
Mental
Health
datasets
KMHIS2
GPs
C...
EARLY FINDINGS
Starting with the models for the most complex
individuals with multi morbidity
5%
20%
75%
45%
40%
15%
Multiple complex
con...
Relationship between number of long-
term conditions and cost
Distribution of cost between
Providers
Provider type £ %
Acute £7,827 67.3%
Community £1,083 9.3%
Mental Health £1,028 8.8...
Risk stratification versus no. of LTCs –
do they select the same patients?
Do Integrated Care teams change
service delivery?
RRR audit – are some patients in
hospital when they need not be?
What happens to patients assessed
as having an RRR need?
Percentage of admission length
for RRR phase
Implementing Year of Care
programme in Kent
Dr Abraham P George
Consultant in Public Health
Lead for Kent YOC programme
The journey so far
• Profile of Kent
• Background and work before YOC
• Governance of programme
• RRR audit
• Data sharing...
Profile of Kent
• 1.5 million popn
• 1 County Council, 7
CCGs, 12 districts, 4
acute trusts, 1
community health trust,
men...
Background to YOC
• Whole population
profiling using risk
stratification
• Impact of multiple
morbidities on service
utili...
Governance of programme
• All providers and commissioners involved
• 2/7 CCGs are the sponsor orgns
• KCC Public Health ma...
RRR audit – key results
• > 80 EK patients followed up over 3 months in
• Short stay admissions excluded
• >80% had morbid...
Data sharing arrangements
• Strong historical relationship between KMPHO and
intelligence teams
• Local data warehouse con...
• Whole population person level linked datasets
containing 4 years of activity sent to national team
• Cohort of 1650 (of ...
East Kent – total cost (reference or unit) for patient cohort (552 patients)
Patient selection date = (May 2012)
Crude tar...
East Kent – total cost for patient cohort (552 patients)
2012_13 Trend
cost % cost %
Acute £6,595 56.2% £4,671 43.7%
Commu...
Selecting shadow currencies
Currency No LTCs New Counts
B 2 1042
C 3 822
C 4 449
C 5 197
D 6 80
D 7 31
D 8 5
E 9 1
E 10 1
Selecting YOC cohort
(using ...
• Agree a tariff for each of the currency categories-
finance subgroup to agree costing data.
• Track the activity and cos...
To deliver the evidence for Integrated Commissioning
Building on the Kent approach to Integrated Intelligence
Primary
Care...
@NHSIQ
iCASE - http://www.icase.org.uk/pg/groups/88229/
lesley.callow@NHSIQ.nhs.uk
Abraham.george@kent.gov.uk
Fionuala.Bon...
LTC year of care commissioning model
LTC year of care commissioning model
LTC year of care commissioning model
LTC year of care commissioning model
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LTC year of care commissioning model

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LTC Year of Care Commissioning Model


Lesley A Callow, Delivery Support Manager - Long Term Conditions Year of Care Commissioning Model
NHSIQ

Fionuala Bonnar, Year of Care Programme Manager

LTC Year of Care benefits:
Improved outcomes and wellbeing:
Patients receive care that is better managed, more seamless across different care services and more needs focused.
Reduction in acute admissions to hospital; and shorter lengths of stay when these are required.
Clinical professionals contribute to a more holistic service for patients by working within an integrated patient-centred care plan
 
Local health and Social Care economies:
Provide care that delivers value for money and is better managed by integrated teams.
Incentive to improve services for patients
Improved joint working and shared responsibility for outcomes

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LTC year of care commissioning model

  1. 1. Improving health outcomes across England by providing improvement and change expertise LTC Year of Care Commissioning Model Lesley A Callow Delivery Support Manager LTC Year of Care Commissioning Model NHSIQ Fionuala Bonnar Year of Care Programme Manager
  2. 2.  Launched in W/C 19th April 2012 with EOI under Dept of Health LTC QIPP workstream  Transferred to NHS England in December 2012 to Martin Mc Shane and he is SRO as Director Domain 2  Integration with the ICSP Pioneers  22 Fast Followers  6 Early Implementer Sites LTC Year of Care: Background
  3. 3. LTC Year of Care: Early Implementer Sites Health Economy Early Implementer Key Partners Regions Leeds Leeds South and East CCG, Leeds West CCG, Leeds North CCG, North Southend Southend CCG; Southend Council Midlands and East Kent Kent County County (Social Services Dept), Kent Community Health Trust, East Kent University Hospital FT, Maidstone Foundation Trust, Darent Valley Hospitals FT, Canterbury CCG, Thanet CCG, Swale CCG, Ashford CCG, South Kent Coast CCG, West Kent CCG, Dartford and Gravesham and Swanley CCG. South North Staffordshire and Stoke on Trent Stoke on Trent CCG, North Staffordshire CCG; Stoke on Trent Council; Staffordshire Joint Commissioning Unit; University Hospital of North Staffordshire; Staffordshire and Stoke on Trent Partnership Trust, North Staffordshire Combined Healthcare Trust; West Midlands Ambulance Trust Midlands and East West Hampshire West Hampshire CCG; Hampshire County Council; Hampshire Hospitals NHS FT; Southern Health NHS FT. South Barking, Havering and Redbridge Barking and Dagenham CCG; Havering Emerging CCG; Redbridge Emerging CCG; Barking & Dagenham Council; Redbridge Council; Havering Council; NHS Outer North East London; Barking, Dagenham and Redbridge University Hospitals Trust; North East London NHS FT. London
  4. 4. The House of Care Engaged, informed individuals & carers Commissioning Organisational & clinical processes Person- centred, coordinated care Health & care professionals committed to partnership working Plan Study Do Act
  5. 5. The House of Care
  6. 6. LTC Year of Care Benefits: Improved outcomes and wellbeing: • Patients receive care that is better managed, more seamless across different care services and more needs focused. • Reduction in acute admissions to hospital; and shorter lengths of stay when these are required. • Clinical professionals contribute to a more holistic service for patients by working within an integrated patient-centred care plan Local health & Social Care economies: • Provide care that delivers value for money and is better managed by integrated teams. • Incentive to improve services for patients • Improved joint working and shared responsibility for outcomes
  7. 7. LTC Year of Care Currency: • All PbR (except YoC or package currencies) Acute Community Mental Health Social Care Voluntary/ Independent Primary care Primary care prescribing NHS England as commissioner • Non-PbR block contract • PbR excl drugs • Crit. Care Personal healthcare budget Specialised MH Services Means- tested services (incl. residential) Within currency Rehabilitation palliative & end of life Maternity pathway • Reablement • Adult Services PbR MH clusters Children’s services GP services Include if possible Residential continuing care (Include if possible) Include if possible
  8. 8. RRR audit:  To support local thinking about RRR and early discharge, particularly in relation to potential for pathway changes.  To assess the appropriateness of methodology for long-term conditions (COPD, diabetes, stroke and heart failure), particularly whether there is scope to unbundle the RRR service from the Acute Provider PbR tariff. Health and social care resource utilisation dataset  Support the development of local tariffs for LTC YoC currency  Looking at longitudinal data to support the discussions/understand the impact in changing pathways Whole Population  Gives the evidence to support the currency framework  Validates the framework LTC Year of Care: Data Collections
  9. 9. • Stakeholder engagement and senior team ‘buy-in’ • Assessment of services to maximise the benefit of integrated care • Learn from research, eg models of care, contracting models, weighting LTCs for local tariff • Planning for improvement in data quality and implementation of shadow testing • Assessment of systems and processes to support LTC YoC currency • RRR clinical audit • Local analysis and collection of data to support national analysis • Local tariff development • Share learning with other health economies and national stakeholders LTC Year of Care: Early Implementer Sites Deliverables
  10. 10. • Senior team ‘buy-in’, eg NCDs • Stakeholder Engagement, eg Monitor and PbR Team • Framework for the Model and vision for future years • Simul8 Model for redesigning services • Data analysis and comparison • Programme Management and EI site support • Resolution of barriers, eg Information Governance LTC Year of Care: National Support Team Deliverables
  11. 11. GPs Community & Social Care Assessment Integrated Care Team GP datasets Acute datasets Mental Health datasets KMHIS2 GPs Community Trust1 Acute Trust1 Mental Health Trust1 Social Care Independent sector & voluntary PHE3 NHSIQ A) Referral B) Selecting patient cohort & risk stratification C) Sharing patient cohort (patient register) D) Collecting data/financial monitoring E) National reporting Person ID Referral reason Person ID Client, Clinical & QOF Demographic Pseudo. Person ID only (i.e. single data item shared) Pseudo. Person ID Client, Clinical & QOF Demographic Costs Pseudonymised Person ID Client, Clinical & QOF Demographic Costs Early Implementer team – LTC Year of Care programme Information Governance May include national datasets (CMDS, MHMDS, CIDS, QOF) May include national datasets (CMDS, MHMDS, CIDS, QOF) Processstep description ProcessdataflowsMajordata items Non-NHS organisations 1 Includes both Foundation and non-Foundation Trusts 2 Kent and Medway Health Informatics Service (Interim Safe Haven) 3 PHE – Public Health England safe haven Population List KMHIS2P P P P P P P P P P P P Costing dataset – A, B, C, D & E Shadow testing – A, B, C & D Whole population dataset – D & E
  12. 12. EARLY FINDINGS
  13. 13. Starting with the models for the most complex individuals with multi morbidity 5% 20% 75% 45% 40% 15% Multiple complex conditions Single LTC/ at risk Healthy / minor risk Population segments Cost
  14. 14. Relationship between number of long- term conditions and cost
  15. 15. Distribution of cost between Providers Provider type £ % Acute £7,827 67.3% Community £1,083 9.3% Mental Health £1,028 8.8% Social Care £1,690 14.5% Total £11,628
  16. 16. Risk stratification versus no. of LTCs – do they select the same patients?
  17. 17. Do Integrated Care teams change service delivery?
  18. 18. RRR audit – are some patients in hospital when they need not be?
  19. 19. What happens to patients assessed as having an RRR need?
  20. 20. Percentage of admission length for RRR phase
  21. 21. Implementing Year of Care programme in Kent Dr Abraham P George Consultant in Public Health Lead for Kent YOC programme
  22. 22. The journey so far • Profile of Kent • Background and work before YOC • Governance of programme • RRR audit • Data sharing arrangements • Costing analysis • Plan for shadow testing • Our vision for integrated intelligence
  23. 23. Profile of Kent • 1.5 million popn • 1 County Council, 7 CCGs, 12 districts, 4 acute trusts, 1 community health trust, mental health trust, >200 practices • Governance of commissioning at multiple levels • Different integrated models of care
  24. 24. Background to YOC • Whole population profiling using risk stratification • Impact of multiple morbidities on service utilisation - ‘Crisis curve’ • Modelling how benefits of integrated care could be realised • www.kmpho.nhs.uk/jsna
  25. 25. Governance of programme • All providers and commissioners involved • 2/7 CCGs are the sponsor orgns • KCC Public Health manages programme on behalf of whole county • Implementation at sub Kent level – NK EK & WK • East Kent Federation group of CCGs first to take part and now finalising shadow testing arrangements • Ensure all stakeholders are involved – commissioner, finance, informatics, etc. • Use of risk stratification for costing analysis and shadow testing
  26. 26. RRR audit – key results • > 80 EK patients followed up over 3 months in • Short stay admissions excluded • >80% had morbidity • Average LOS and average length of RRR phase were much higher than the other audit sites • Stroke patients contributed much of the bed days – if excluded LOS would have been reduced by half Kent BHR Leeds Stoke All conditions Excluding stroke Average length of stay (days) 19.72 13.93 5.62 6.71 4.46 Average length RRR phase (days) 6.28 3.29 0.19 3.23 0.69
  27. 27. Data sharing arrangements • Strong historical relationship between KMPHO and intelligence teams • Local data warehouse containing hospital, community health data • Social care data obtained directly from provider • Whole Kent population risk stratified using local tool • Datasets were de-identified at source & and pseudonymised using same encryption method and key • Public Health linked data sets - ‘hub and spoke’ before sending to national team for analysis ‘Whole population person level linked datasets’ • Cannot be re-identified
  28. 28. • Whole population person level linked datasets containing 4 years of activity sent to national team • Cohort of 1650 (of high intensive users) selected for detailed analysis in 13-14 • Report produced which provided us with evidence for indicative tariff • Data used to develop currency and selection criteria Costing analysis
  29. 29. East Kent – total cost (reference or unit) for patient cohort (552 patients) Patient selection date = (May 2012) Crude tariffs and trends
  30. 30. East Kent – total cost for patient cohort (552 patients) 2012_13 Trend cost % cost % Acute £6,595 56.2% £4,671 43.7% Community £1,361 11.6% £1,323 12.4% Mental Health £1,535 13.1% £1,791 16.8% Social Care £2,170 18.5% £2,891 27.1% Total £11,743 £10,676 Crude tariffs and trends
  31. 31. Selecting shadow currencies
  32. 32. Currency No LTCs New Counts B 2 1042 C 3 822 C 4 449 C 5 197 D 6 80 D 7 31 D 8 5 E 9 1 E 10 1 Selecting YOC cohort (using current whole popn dashboard) • Risk stratification tool applied • GP practice and CCG identified • Checked to ensure GP data is active (ie. each practice has submitted data within the last 3 months) • Risk stratification popn profile selected • YoC currency (using QOF LTC codes) is then applied which outlines the following: – Under 18s excluded & Patients with 1 LTC notionally excluded, – List segmented by LTC currency • Risk Score over time mapped (looking for rise in risk score in last 6 mths or rapid riser in last 3 mths (mthly increase in risk score over past 3 mths and overall increase of >15pts)
  33. 33. • Agree a tariff for each of the currency categories- finance subgroup to agree costing data. • Track the activity and cost over the next 12mths – informatics group. • Identify data issues- definitions and gaps • Increase engagement of system and link to existing initiatives • Evaluate information – dashboard. • Communication Next steps
  34. 34. To deliver the evidence for Integrated Commissioning Building on the Kent approach to Integrated Intelligence Primary Care Urgent Care OOH Care Secondary Care Adult Social Care 3rd Sector Mental Health Community Health Kent are collecting activity and actual cost data from all of the above using a cross system pseudonymisation tool. Data pseudonymised/anonymised at source and linked and analysed by Public Health. MONITOR are currently developing guidance on how to develop a person level linked data sets, using Kent’s approach as a case example of best practice. • • We have developed a systematized method for selecting multi – morbidity people at risk and suitable to be included in the Year of Care approach • The selection includes a subjective consent/opt in to facilitate patient choice and clinician intelligence at point of service delivery. • It builds on the whole population data set analysis due to be published by the Year of Care team and distributed nationally at the end of April. • This focus on the integrated intelligence by commissioners enables best practice to flourish and identifies areas for improvement within different provider models of integrated care. • Implementing in Kent across the 3 systems at pace and scale. East Kent leading the way and building consensus across the other systems. • Next steps include agreeing an indicative tariff for year of Care to shadow test in 14/15 – we have sign off in principle to the approach. • We have agreed the metrics to develop a dashboard which systematically reports the results/outcomes at both system and patient level, using existing metrics and data collection. This will be used to jointly measure the impact of YoC on both the individual and the system. Identify cross- system opportunities and barriers to change Collect the data with the support of the system to challenge status quo. Identify opportunity for integrated incentives/penalties across provider organisations. Commission across the system to incentivise the outcomes desired. Commissioners and providers jointly measure impact on individuals and cost of system
  35. 35. @NHSIQ iCASE - http://www.icase.org.uk/pg/groups/88229/ lesley.callow@NHSIQ.nhs.uk Abraham.george@kent.gov.uk Fionuala.Bonnar@kent.gov.uk Improving health outcomes across England by providing improvement and change expertise.

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