Personalisation for Long Term Conditions in Cornwall

www.england.nhs.uk
Personalisation
for
Long Term
Conditions
Bev Matthews
Programme Delivery Lead
&
Julie Renfrew
Delivery Support Manager
LTC Improvement Programme
NHS England
25th November 2015

www.england.nhs.uk
Agenda
10.00 Registration and coffee
10.30 Welcome and introductions
The local context and priorities
National Overview: Personalisation for LTCs
Interactive session 1: LTC (STAR)
Simulation Modelling 1: Testing your integrated care service models
for patients with complex care needs
12.45 Lunch and networking
Simulation Modelling 2: Ensuring effective and efficient discharge
planning for people with LTCs
Feedback on STAR
Interactive Session 2: Navigating Health and Care ideation
Our Declaration: making your own declaration
Summary of day and feedback loop Bev & Kate
15.30 Close

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Key Definitions
• Person not patient
• Long Term Conditions not chronic disease
• Whole person not separation of physical, mental,
emotional and social needs
• Co-ordinated care not integrated care

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LTC Strategy for Person Centred Care:
4
Care & Support
Planning
Embedding personalised
care and support planning
as the core component
Evidence
Improving evidence and
implementation of it to
commission better care
Engagement
Raising professional and
public awareness of and
engagement with PCC
Models of Care
Increasing co-ordination and
continuity of care though
development and testing of
new models
Enablers
Strengthening the enablers
that drive change including
data and incentives
Inequalities
Focussing on areas of
inequality – care homes,
Neuro, MSK, palliative care
for non-cancer conditions

www.england.nhs.uk
LTC Framework
Commitment
to Carers
Frailty
Health Ageing
Guide
Fire Service as
an asset
Care Homes
Quick Guides
Care & Support
Planning
Navigating Health
& Social Care
Self Care
Ambitions for
End of Life Care
Our Declaration
Delivery Models
Planning for Change:
• Capitated Budget
• Contracting
• Simulation Modelling
Patient and
Service Selection
Planning for Change
Workforce
Whole Population Analysis;
Understanding your
population
LTC Dashboard LTC Toolkit

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Increasing demand
• Rise of chronic conditions and multi-morbidity: physical and
mental
• Ageing population
• Increasing system wide expectations: access, treatment, cure
not care
Supply pressures
• Dependence on system
• Hospital and medic-centric care models
• Workforce – recruitment & retention, diversity and culture
• Fragmentation of care in health and to social care
• Crisis curve
Solution – Transforming what we buy and how we buy it:
• Person centred co-ordinated care – whole person approach to
improve outcomes and value
Global challenges

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Prevalence:
• There are 1 million people in England with frailty, 7 million with one LTC, 3 million with
two LTCs, 3 million with three or more, and 0.35 million approaching end of life
Quality of life:
• The larger the number of co-morbidities a patient has the lower their quality of life
• Increasing evidence of over-treatment and harm
• Social isolation/loneliness a risk factor for mortality in over 75s
Impact on the health system:
• The average person with a LTC in the UK spends less than 4 hours a year with a health
professional
• Research has shown that 33% of all GP consultations are now with people with multi-
morbidity
• The number of days in a hospital bed increases strongly with age: those under 40
account for 1 million emergency bed days and those over 85 account for over 7 million
emergency bed days
• Three-fold increase in health costs across all care sectors due to frailty
• 1300 people die each day and 25% of all hospital beds are occupied by somebody who
is dying
National Population Analysis

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• Empowering patients and informal carers to be full
partners in care
• Whole person focus
• Life course approach to care needs
• Strengthening Primary and Community Care
• Older people with increasingly complex needs including
frailty
• New care models moving away from purely medical,
hospital-centric focus
• Strengthen key enablers – IT, Workforce, Technology
• Need for a new purchaser/provider/funding model
Similarities of local and regional
priorities and the NHS

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Outcomes and benefits
• More activated patients have 8% lower costs in the base year
and 21% lower costs in the following year than less activated
patients
• Health coaching can yield a 63% cost saving from reduced
clinical time, giving a potential annual saving of £12,438 per FTE
from a training cost of £400
• Coaching and care co-ordination has shown to reduce
emergency admissions by 24%
• Improved medication adherence improves outcomes and yields
efficiencies, for instance in 6000 adults in the UK with Cystic
Fibrosis, could save more than £100 million over 5-years
• Between 20% and 30% of hospital admissions in over 85’s
could be prevented by proactive case finding, frailty assessment,
care planning and use of services outside of hospital (Mytton et
al, 2012)

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Commissioning: LTC Year of Care
• Launched in 2010 by Department of Health (Sir John Oldham)
commissioned and delivered by NHS England
• Patients receive care that is better managed, delivered seamlessly across
different care settings and focused on patient needs using different
commissioning and funding approaches
• In the final year of a four year programme
• Currently five early implementer health and social economy teams with 22
fast follower teams
Rationale:
 Multi morbidity is common
 Patients with multi morbidity have complex care needs and would
benefit from personalised integrated care
 An integrated payment would encourage integration of services and
cost efficiency

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Multi Morbidity is Common:

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People with complex health and care
needs appear to demonstrate a ‘crisis curve’:

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Trend in total health & social care
costs for a patient cohort
– the crisis curve results mostly from an increase then a
decrease in use of non-elective services

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Pattern of services received by patients
with increasing multimorbidity

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Comparison of the pattern of services (by cost)
delivered to selected patients with ‘very
complex’ health and social care needs

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The total health and social care cost is
strongly related to multi morbidity:

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There are many techniques that can be used to segment a population.
Different segmentation methods select different individuals:
• Only 35% of individuals selected using risk score were also selected by the
multimorbidity method
• Risk score tends to select individuals who have historically used more A&E and
non-elective care
The method used should match the outcomes required for the cohort to ensure
applicability of any planned delivery model.
IT-based segmentation should only be part of the selection: The Commonwealth
fund paper “Segmenting populations to Tailor services, Improve Care, 2015”
sets out the need to go beyond basic risk prediction to target care in most
effectively and efficiently.
Selected patients still need to be assessed for their care needs before a care plan
is developed and services delivered.
Risk Profiling and population
segmentation

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Select
patients for
referral
Assessment
of patient
need
MDT –
develop and
share care
plan
Deliver
services to
patients
Assign to
patient
cohort
Patient
dies or
leaves area
Change to
patient
cohort
Review
contract
and
budget
Set
contract
and
budget
Perform
and
quality
Payment
Patient pathway
Payment
cycle
Generalised patient pathway and the
payment cycle for complex care patients

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Long Term Conditions Year of Care
Currency:

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Delivery Models
The service models being developed by our sites are essentially similar but differ
to match local conditions.
Similarities include:
• Single point of access,
• Care planning and shared care record
• Supported self management
• Care co-ordination
• Community multi-disciplinary team based around primary care,
• Wider neighbourhood support including specialist practitioners, therapists
• Recovery, Rehabilitation and Reablement “services”
• Care navigators and voluntary sector as a key enabler.
Differences include:
• Whole population or selected cohorts
• Formation of new organisations
• New delivery models within and across existing organisations

www.england.nhs.uk
Supporting self-care
25
No LTCs (yet)
Single/dominant
condition
Multiple
conditions
End of life
25m 15 - 20m 5m 330k
'Brief
interventions'
Self - management
training and apps
PAM 1
Care and
support
planning
Advanced care
plans / advanced
directions
Access to
EHR
Digital care
plan
Year of care
funding
PHB 2
IPC 3
1. Patient Activation Measurement
2. Personalised Health Budgets
3. Integrated Personalised Commissioning
Wearables /
apps
Enablers:
Interventions:

www.england.nhs.uk Simulation model
Unbundling recovery simulation model
LTC Resources and Tools:

www.england.nhs.uk
System Transformation Analysis and
Redesign (STAR):
• The LTC HoC framework is both a metaphor and
checklist reflecting a whole system approach, the inter-
dependency of each component and assumes an active
and central role for patients
• This tool allows organisations to gain an understanding
of where they are compared to leading edge practice,
across a range of elements within the LTC framework
approach
• The analysis shows how organisations are performing in
relation to specific elements of person centred
coordinated care (PCCC)
#LTCImp

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System Transformation Analysis and
Redesign (STAR)
• What can we do - together?
• What will we do – to contribute?
• How will we do it – to provide optimal client care outcomes?
• Locate themes in the sections and select topics for further inquiry
• Create shared ideas of a preferred future
• Find Innovative ways to create the future.
#LTCImp

www.england.nhs.uk
Testing your integrated care
service models for patients with
complex care needs
25th November 2015
LTC Year of Care
Commissioning Programme
Simulation modelling tool

www.england.nhs.uk
How might the
tool help you?

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 Theoretical test before implementation
 Test 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 service
change:
 Will it save money?
 Will more GPs be needed?
 Will emergency admissions be reduced?

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• Understand the service model for patients with complex care needs
developed by the LTC Year of Care Commissioning Early
Implementer Sites.
• Adjust the tool to test the impact of implementing a similar service
model for patients with complex care needs in your area.
• Adjust the tool to test the impact of another service model for
patients with complex care needs in terms of changes in cost,
volume and capacity.
• The simulation can be run immediately with pre-populated data and
pre-populated “what if?” scenarios.
• However, populating the model with local data will enable your local
healthcare system to test out impact of change in your own system,
making the simulation more locally meaningful and providing
evidence for local decision making
The LTC YoC Commissioning simulation
tool enables users to:

www.england.nhs.uk
• The simulation models how people with multiple long term
conditions use health and social care services over a typical
year. Services are associated with costs and with resource
use (staff time or bed days), thus the tool outputs results in
terms of activity, costs and resources.
• The patient cohort selected for testing using the tool can be
segmented in up to four groups, with each group having a
different likelihood of accessing services over a year.
• The simulation runs for three years. Patients may move
between groups as the years pass. New patients will join the
patient cohort, and patients will leave the cohort if they die or
leave the local area.
• The simulation aims to represent the way in which these
groups of patients typically use services in all their complexity
and variability. Users can test the impact of changes in service
models prior to implementation, to understand the likely
impact on cost, volume and resource use.
What does the simulation do?

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Who should be interested in simulation?
Service managers, commissioners, finance managers from
both commissioning and provider organisations:
 Those making decisions
 Those planning change (service, workforce, budget)
Simulation can help them with problems on previous page
Informatics and IT professionals:
 Baseline information
 Manipulation of the model
 Interpretation of scenario parameters
 Sense checking results

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A bit about the
underlying data

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Data within the model
 BHR whole population data – 10% with highest risk score
(assumption is that this cohort would be suitable for capitated budget)
 Four resource-usage categories (states) – very high (0%-0.5%); high
(0.05%-2.0%); medium (2.0%-5.0%); and low (5.0%-10.0%).
 Acute, community, mental health and GP practice primary care (no
social care)
Distributions of data:
 Likelihood of a patient accessing a service (i.e. 15% require a MH
contact)
 Number of times a patient attends or admitted
 Costs for each attend/admission type
 Resource use for each attend/admission type

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Baseline data within the model
Changes over time:
 Likelihood of death (or leave local area)
 New patients entering capitated budget cohort
 Transition between resource-usage categories (states)
BHR data. Need to understand where differences might affect
results:
 Activity types
 10% of population
 Distributions and changes over time
But most of these are likely to have a small impact. Your planned
service change is still likely to have the largest impact.

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How the tool
works

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How the tool works – high level overview

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A Year of Care
39%
9%
40%
22%

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A Year of Care – next level
56
%
13
%
62
% 40
%

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• Group
patients by
level of
acuity
• Increasing
numbers of
long term
conditions
What drives the model

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• Patients in each group
access services
• Often more than once
• Each service is
associated with a range
of costs
• Each service has an
associated capacity
How it works
Patient
Services
Costs
Capacity

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Baseline and
scenarios

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Running the model
Baseline versus scenario
 Differences in activity, cost and staff
 Differences in the change in activity, cost
and staff over time

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Scenario 1 (built into model)
Based on Scottish study:
Evidence – There are differences in the % of emergency admissions that
are avoidable depending on the number of long-term conditions (LTCs)
(Payne et al (2013) CMAJ 185(5):E221-E228)

www.england.nhs.uk
Assumption:
 By changing service, emergency admissions could be avoided
 Resources could be shifted to community, mental health & GP
primary care
Activity type Very high High Medium Low
Emergency admission -26.5% -25.5% -24.3% -22.2%
A&E attendance -26.5% -25.5% -24.3% -22.2%
Outpatient attendance -13.25% -12.75% -12.15% -11.1%
Community (contacts & tele) +39.5% +38.25% +36.45% +33.3%
Mental Health (contacts & tele) +6.63% +6.38% +6.08% +5.55%
GP primary care (contacts) +39.5% +38.25% +36.45% +33.3%
What Qs might the tool help give you some direction on...
 Would the new service be cheaper?
 How many new community, MH and GP practice staff would be needed?

www.england.nhs.uk
Based on Health 1000 care navigation focussed service delivery model:
•Move people away from unscheduled care.
•Targets current and future high consumers of health and social care.
The fundamental elements of the care navigation approach are:
 Proactive case finding
 Resources could be shifted to community, mental health & GP primary care
 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 voluntary sector
 Volunteer support on a 1:1 and group basis to encourage physical and social
activity
 Mapping to link patients with local assets and key ‘community makers’

www.england.nhs.uk
Scenario 2 (built into
model)Parameters:
 2% of the population
 No split of resource-use categories
Activity type Living well
Emergency admission -36%
A&E attendance -34%
Outpatient attendance 0%
Community (contacts & tele) +25%
Mental Health (contacts & tele) 0%
GP primary care (contacts) +33%

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Results and
output

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Tariff results

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Example Results:
ED activity

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1. Download simulation model and tool
2. Check the patient number for your chosen population and overwrite if
required. Set proportion of patients in the original patient cohort
3. Decide patient groups and set proportions. Set their likely transition
between groups or leaving the original cohort each year.
4. Enter service access probabilities for each patient group
5. Enter frequency of access distributions for each patient group
6. Enter costs distribution or fixed cost for service. Check reference costs
and change if required. Set a Year of Care tariff if required.
7. Enter resources required for each service
8. Run Simulation and validate results
9. Save local simulation on line and run Scenarios and compare results
10. Export results to inform decision-making
Using the tool – summary of steps

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Over To You….
Using the tool:
1. Running your baseline: what do you need to
think about
2. Creating your scenario: A local LTC service
change
3. Estimated % impact on key service areas

www.england.nhs.uk
Ensuring effective and efficient
discharge planning
25th November 2015
RRR audit and
simulation tool

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Acute to Rehabilitation
Acute Phase
Higher cost
Medical
care
“R” point:
Decision to
discharge to
recovery bed
Transitioning
“L” point
Point of
discharge
“liberation”
RRR facility
DischargeBed in
recovery
-hospital
-community
- Home with
support

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Hip fracture:
• Best practice tariff
• Audit for unbundling the RRR phase
LTC Year of Care:
• Chronic conditions
Why do an audit?:
• Unbundling
• Discharge planning
RRR audits
Process
1. Identify patients
2. Daily audits to assess:
• End of Acute and beginning of RRR phase
• Level of RRR need
• Reason for RRR phase

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RRR audits identify the point in the acute patient
pathway that patients are medically fit for
discharge
Pre
admission
community
phase
“change the tariff at the point when the patients’
needs change and not when they change institution”
---------- Hospital -------------
A CB D
Needforclinicalinput/support
RRR HRG group . . . . . . . . . . . . .
Assessment – prescription for recovery
Acute
phase
1 crosses secondary – community, 2. unlocks rehab resource for different models
3. Puts primary care and social care at earliest point in rehab, 4. sustainable discharge
primary care, community social care and
patient – the “R” point
Recovery, rehabilitation and re-ablement

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• Diverse ‘length of stay’ and ‘days beyond R-point’ values
• Both between conditions but within sites, and between sites
0
2
4
6
8
10
12
14
16
18
20
BHR Kent Stoke & North
Staffs
Leeds
Averagenumberofdays
Average length of stay COPD
Diabetes
Heart Failure
Stroke
0
1
2
3
4
5
6
7
8
BHR Kent Stoke & North
Staffs
Leeds
Averagenumberofdays
Average days beyond R-point COPD
Diabetes
Heart Failure
Stroke
RRR audit - results

www.england.nhs.uk
• R-point – can be a medical,
community/social or patient
reason for delay
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
Awaiting
CommunityBed
Notmedicallyfitfor
dischagre
AwaitingOT/PT
Assessment
BLANK
Forfurther
diagnostics
AwaitingPT/Mental
Health/Social…
Awaitingsocial
careassessment
Unknown
AwaitingOT/PT
AwaitingOT/PT/
SocialCare…
AwaitngMental
HealthAssessment
Nursinghome
assessment
Awaitingsocial
carepackage
Awaitingcare
hometoaccept…
AwaitingDoctor
Discharge
AwaitingCare
HomeAssessment
Awaitingsocial
careassessment…
Awaiting
equipment
AwaitingOxygen
Assessment
Patientrefused
discharge
AwaitingTransport
AwaitingSALT
RRR audit -
results

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Original purposes for RRR audit:
• Proof of concept – could methods be applied to other conditions?
– could methods be applied consistently by various
hospitals?
• Could the PbR tariff for particular HRGs be unbundled?
Conclusions:
• Methods can be applied to other conditions
• Needs to be more specificity in methods description and more consistency
in application of methods to ensure consistency
• Hospital treatment for chronic conditions is extremely variable (unlike hip
fracture), thus unbundling of RRR tariff unlikely.
• Audit methodology useful for discharge planning
0
2
4
6
8
10
12
14
COPD Diabetes Heart Failure Stroke
Averagenumberofdays
Average days to R-pointBHR
Kent
Stoke & North
Staffs

www.england.nhs.uk
http://www.nhsiq.nhs.uk/improvement-
programmes/long-term-conditions-and-
integrated-care/ltc-year-of-care-
commissioning-model/long-term-conditions-
year-of-care-commissioning-unbundling-
recovery-simulation-model.aspx
• Audit report
• Step-by-step guide
• Simulation model
RRR audit – Resources

Simulation modelling tool - Developed as part of the LTC Year of Care Commissioning Programme
SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com
The Simulation

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A look at the
tool

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Over To You….

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Feedback on STAR – 25th Nov 2015

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NAVIGATING
Living independently
with long term conditions
An ethnographic investigation
HEALTH AND CARE
Putting the research into practice
Leeds LTC Workshop - 16th October 2015

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WORKSHOP AGENDA
Introduction
Living with long term conditions
Managing my long term conditions
Personalise my care
The double care-burden
We need to talk about care
1 Key Findings
2 Putting the
research into
practice
3
1
2
3
4
5
Small group discussions
Idea generation
Idea stretch task
1
2
3
Close
4

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INTRODUCTION

www.england.nhs.uk
AIM
To help national, regional and local health and care economies design their future services
effectively, in order to meet the identified needs of people living with multiple long term
conditions, as well as the needs of their carers.
Support
networks
Everyday
context
Relationships
and
interactions
Planning and
coordination
of care
OBJECTIVES
to understand and explore:

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METHODOLOGY
FILMED
ETHNOGRAPHIC
APPROACH WEEK CARE
DIARY AND
REFLECTIVE
INTERVIEW
4
C.9
HOURS
FACE-TO-FACE
PER FAMILY
DIVERSE
SAMPLE OF PARTICIPANTS
15 PATIENTS + FAMILY
FRIENDS + CARERS
36
65+
PATIENTS AGE

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KEY FINDINGS

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Insert films

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PUTTING THE
RESEARCH INTO
PRACTICE

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TASK 1
READ SUMMARY
CARD
1
RE-WATCH
FILM
2
DISCUSS
IN GROUPS
3
WRITE DOWN
LOTS OF IDEAS
415 MINS!

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432TASK 2 1
20 MINS!

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TASK 3
READ THEME
INTRO CARD
1
READ YOUR
TOP IDEA
2
3 MINS PER GROUP!

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Our Declaration 5
o Launched at Expo 2015
o The importance of person-centred care for
people with long-term conditions, 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 We need to motivate health and care
professionals to help us make it a reality
#A4PCC – Action for Person-Centre
Care

www.england.nhs.uk
6 My Declaration
o We want health and care professionals
to declare their commitment to
embedding patient-centred care in their
work
o On a postcard or online at
www.engage.england.nhs.uk/survey/ltc-
declaration
o Ideas that can be shared and developed
o “We want to do this – but we need
support to make it happen”
o Our offer: expertise in engagement,
problem-solving and partnership working#A4PCC – Action for Person-Centred
Care

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7
Using behavioural
change to open
minds
o Make a declaration at
www.engage.england.nhs.uk/survey/ltc-declaration
o Tell your teams about our work
o Encourage them to make a declaration
o Ask them to feed back thoughts and ideas
o Use our 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
Person
with long
term
condition

www.england.nhs.uk
Long Term Conditions Sustainable Improvement Team #LTCImp

www.england.nhs.uk 93
Bev Matthews
@bev_j_matthews
@NHSIQ
#LTCyearofcare #a4pcc
Beverley.matthews@nhsiq.nhs.uk
www.nhsiq.nhs.uk

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