Using models of care to understand the impact of networks of care for Long Term Conditions

1. Using models of care to understand
the impact of networks of care for
Long Term Conditions
Improving health outcomes across England by providing
improvement and change expertise

2. Welcome
A patient’s story
Fiona McLoughlin
Setting the context
Dr Martin McShane, Director, NHS England Domain 2
Introduction to Long Term Conditions Improvement
Programmes
Bev Matthews, NHS Improving Quality,
Long Term Conditions Programme Delivery Lead
The Long Term Conditions House of Care Toolkit
Lesley Callow, NHS Improving Quality,
Long Term Conditions Delivery Support Manager
Developing new models
Rob Meaker, Director of Innovation, Barking, Havering and Redbridge CCGs

3. Meet the Speakers
Fiona McLoughlin, Patient speaker.
Fiona has been living with M.E. for eight years. She experiences fatigue and pain, but the most annoying
symptom is the brain fog. Her interest in healthcare provision developed after her late mother was diagnosed
with the rare neurological condition Progressive Supranuclear Palsy.
Dr Martin McShane, Director, NHS England Domain 2
Leading authority on improving the quality of life for people with long term conditions. Appointed NHS England
Director in 2012 following illustrious career as a GP and Chief Executive.
Bev Matthews, NHS Improving Quality, Long Term Conditions, Programme Delivery Lead
Passionate about service transformation through developing networks and leading complex
programmes. Providing strategic leadership to partners within health communities, managing stakeholders and
working across agencies.
Lesley Callow, NHS Improving Quality, Long Term Conditions, Delivery Support Manager
Extensive experience leading large scale change programmes for public services nationally and internationally.
Registered clinician for adult nursing and public health practitioners. Practice educator on the Nursing and
Midwifery Council register, and advisory panel member for Self-Management UK.
Rob Meaker, Director of Innovation, Barking, Havering and Redbridge CCGs
Leads innovation work across three CCGs, where testing new ideas is critical in developing them so they can
be replicated on an economical basis, while ensuring better outcomes for patients. In 2013 the team won the
NHS Challenge Prize, for the innovative work undertaken for the “A Year in The Life Project”.

4. Fiona McLoughlin and
Carol McCullough

5. Dr Martin McShane
Medical Director (Domain 2)
Long Term Conditions
NHS England

6. Modelling Models of Care
Bev Matthews
Programme Lead for Long Term Conditions
Improving health outcomes across England by providing
improvement and change expertise

7. Population profiling
20%
75%
40%
15%
Multiple
complex
conditions
Single LTC/
at risk
Healthy /
minor
risk
Population segments Cost

8. Commissioning in silos:
Acute Community Mental Health Social Care Voluntary/
• All PbR
(except YoC or
package
currencies)
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

9. Identifying patients:
• Risk stratification tool applied
• LTC codes applied (18 in total - QoF)
• List segmented by LTC currency (Bands B – E applied - B=2,C=3-
5,D=6-8,E=9),
• Risk Score over time mapped (looking for rise in risk score in last
6 mths – 4 of 6 show an increase) or
• Rapid Riser in last 3 mths (mthly increase in risk score over past 3
mths and overall increase of >15pts).
• Kent – 80 GP practices, Band B = 2197, Band C= 3506, Band D
=261, Band E= 5 Total 6369 of 729, 275
• Now driving increased engagement in risk stratification

10. Long Term Conditions Year of
Care Commissioning Model
Implementation Guide

11. Population Level Commissioning for the Future:
Over 30% of people over 75 years have
multimorbidity

12. Population Level Commissioning for the Future:
Multimorbidity is more common than single
morbidity

13. Population Level Commissioning for the Future:
The total health and social care cost is strongly
related to multimorbidity

14. Population Level Commissioning for the Future:
The main contributors to total health and social
care cost are acute non-elective admissions

15. Population Level Commissioning for the Future:
People with complex health and social care needs
appear to demonstrate a ‘crisis curve’

16. Population Level Commissioning for the Future:
More community, mental health and social care
services are delivered to people following a ‘crisis’
than before the ‘crisis’

17. Some indications that an integrated care plan changes
the pattern of services delivered to people
Source NHS Barking & Dagenham, Havering and Redbridge CCG

18. Long Term Conditions Year of
Care Commissioning Model
Implementation Guide

20. LTC Year of Care Simulation Model
• A service and system redesign
• Understanding the impact of changing service
SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com
utilisation on:
- Flow
- Cost
- Capacity/Resource
• No historic data
• Different impacts on organisations, costs and
patients
• Use local data to test assumptions
• Ability to update and review
• Patients in each “state” have A likelihood of
accessing certain types of service, including
accessing services more than once:
- Acute
- Community
- Mental Health
- Social Care
• Costs associated with those services

21. SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com
Results:
• Cost by each area of service/organisation

22. • Costs by state per year
• Average cost per patient
• Comparison with tariff
SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com
Results:

23. Future chapters:
• Recovery,
rehabilitation and
reablement clinical
audit
• Minimum dataset
• Getting started
Long Term Conditions Year of
Care Commissioning Model
Implementation Guide

26. Join our lunch and learn
webinars
Population level commissioning for the future
Wednesday 3 December 2014 - 13:00 to 13:45
Hosted by Beverley Matthews, NHS Improving Quality Long Term Conditions
Programme Lead and Dr Abraham George, Assistant Director & Consultant in
Public Health, Kent County Council
Commissioning for outcomes
Wednesday 21 January 2015 - 13:00 to 13:45
Hosted by Bob Ricketts CBE, Director of Commissioning Support Services and
Market Development for NHS England
For more information contact LTC@nhsiq.nhs.uk

27. Long Term Conditions House of Care Toolkit
Lesley Callow
Delivery Support Manager
Improving health outcomes across England by providing
improvement and change expertise

28. Long Term Conditions House of Care
• The 15 million people in
England with long term
conditions have the greatest
needs of the population
• People living with long term
conditions report that they
require person centred coordinated
care
• The House of Care provides
a framework for this to be
delivered

29. The House of Care in value to
people/patients: The House supports
National Voices ‘I’ statements
My goals/outcomes
All my needs as a person were
assessed and taken into
account.
Communication
I always knew who was the
main person in charge of
my care.
Information
I could see my health and
care records at any time to
check what was going on.
Decision-making
I was as involved in
discussions and decisions
about my care and treatment
as I wanted to be. Care planning
I had regular reviews of my care
and treatment, and of my care
plan.
Emergencies
I had systems in place so that
I could get help at an early
stage to avoid a crisis.
Transitions
When I went to a new
service, they knew who I
was, and about my own
views, preferences and
circumstances.

30. The House of Care in
value to NHS:
£1.2bn:
Avoid ambulatory care
sensitive admissions
though e.g. following
NICE guidelines (1)
£0.8bn:
Reduction of hospital
admissions for common
LTCs through integrated care
esp frailty, comorbid (2)
£0.8-1.2bn:
Reduce use of low value drugs,
devices and elective procedures
using commissioning analytics
and clinician education (3)
£0.2-0.4bn:
Empower people in
supportive self-management
(4)
£1-1.6bn:
Shift activity to cost
effective settings
e.g. pharmacy minor
ailments (5)
£0.4-0.6bn:
Avoidance of drug errors
e.g. through electronic
records/e-prescribing (7)

31. The House of Care - Person
centred, coordinated care at three levels
National
What can national
organisations and policy
makers can do to enable
construction of the House
of Care at the next two
levels.
Local
How local health
economies ensure that the
House of Care involves a
whole system approach,
including ‘more than
medicine’ offers
Personal
How the House of Care
gives professionals on the
front line a framework for
what they need to do for
patients and ask local
commissioners to secure for
them

32. The House of Care - Person centred,
coordinated care at three levels
The national level is built and is
available at:
http://www.nhsiq.nhs.uk/improvem
ent-programmes/long-term-conditions-
and-integrated-care/
long-term-conditions-improvement-
programme/house-of-
care-toolkit/national.aspx
National
What can national organisations and
policy makers can do to enable
construction of the House of Care at the
next two levels.

33. The House of Care - Person centred, coordinated
care at three levels
Local
How local health economies ensure that
the House of Care involves a whole
system approach, including ‘more than
medicine’ offers.
The local level is built with case
studies continuously being
uploaded at:
http://www.nhsiq.nhs.uk/improvem
ent-programmes/long-term-conditions-
and-integrated-care/
long-term-conditions-improvement-
programme/house-of-
care-toolkit/local.aspx

34. The House of Care - Person centred,
coordinated care at three levels
Personal
How the House of Care gives
professionals on the front line a framework
for what they need to do for patients and
ask local commissioners to secure for
them
The personal level is built and is
constantly being updated at:
http://www.nhsiq.nhs.uk/improvem
ent-programmes/long-term-conditions-
and-integrated-care/
long-term-conditions-improvement-
programme/house-of-
care-toolkit/personal.aspx

35. Rob Meaker
Director of Innovation, Barking,
Havering and Redbridge CCGs

36. Complex Primary Care Practice
in East London

37. Overview of BHR CCGs’ Health
Economy
East Of
England
Cluster 1
Cluster 3
Cluster 1
Hospital LAS
Station
Central
London
Cluster 2
Cluster 4
Cluster5
Cluster4
Cluster 1
Cluster2
Cluster6
Cluster 2
Cluster 3
Cluster 4
Cluster 5
Cluster 6
Walk In
Centre
Total Population 759,285
BHR
Dashboard
£55m
Havering
Non elective admissions
£8.8m
A&E attendances
Barking
£36.5m
Non elective admissions
£7.6m
A&E attendances
Redbridge
£50m
non elective admissions
£7.6m
A&E attendances

38. BHR CCGs’ Development
Timeline
2008 – Polysystems & Person Centred Care
2009 – Risk Stratification
2010 – Integrated data
2011 – LTC management, & The Year of Care
2012 – Integrated Case Management
2013 – Rapid Response & Community Treatment Teams
2014– Complex Primary Care Practice
Health 1000 Ltd, the Complex Primary Care Practice, is a Primary Social and Acute Care
System located in King George Hospital, Ilford

39. How BHR CCGs are Implementing a Primary,
Social and Acute Care System
Health1000 is a new primary care
evolved provider organisation
operating a new model of care being
developed as part of the Prime
Minister’s Challenge fund and aligned
to the PACS (Primary and Acute Care
Systems) models set out in the 5 Year
Forward Plan.
The Year of care work provided the
foundation for the service design and
the supporting capitated budget.
The model has been designed in
collaboration with the users it intends
to serve and will be guided by what
people with complex needs want to
achieve from their health and social
care

40. Aligning the PSACS model with
existing services.
EoL / CHC
> 5 LTCs
Frail/1-3%/2LTCs
3-6%/1LTC
Comm
Pharmacy
GP
BHRUT
NE
London
FT
Cont.
Heath
Care
Integrated
Urgent &
Emergency
Care Service
111
Urgent
Care
Centres
Voluntary
Sector
Meds Man
Non
Year of
Care
Year of
Care
Social
Care
Federated
Urgent and
Planned
Primary Care
Services
Out of
Hospital
London
Ambulance
Complex
Care model
In the future, a unified urgent primary care service joins patients and clinicians
Complex Care Service
Individual
Care
Multidisciplinary
Teams
Patients
Children
Elderly or
Retired
Unemployed
Full time
mothers or
carers
Working
Adults
Complex
Patients
Planned GP
Appointment
Online
Call2
Practice
Non-Direct
Emergency Triage
Primary Care Prof
Support
Online
Existing urgent care services
Unified
point of
access
Urgent Primary Care Appointments
Walk-in
Centres
GP Core
Plus
Weekend
6-10 pm
opening
GP core
across BHR primary care
New or significantly enhanced
services
Patients flow through primary
care Key Existing services
Implementing a new model of care, it is essential to align the model with other
Key services.

41. Complex Care Practice Patient
Selection
Complex Care cohort
Row Labels Cohort Hypertension CHD Diabetes Stroke Depression COPD Heart Failure Dementia
LTC 5+ 100 99 96 80 70 80 69 75 36
Scottish modified LTC 4+ 1924 1816 1559 1421 863 793 783 679 303
Grand Total 2024 1915 1655 1501 933 873 852 754 339
211 of the cohort currently receive Integrated case Management Services
The Complex Primary Care Practice intends to register 1000, of the 2024
eligible patients
Eligible cohort, must have 4 diagnosed long term conditions from
Hypertension, CHD, Diabetes, Stroke, Depression, Heart Failure and
Dementia.

42. The trend in adjusted cost for all patient in the
complex care cohort by service type
The costs have increased for these patients over the 7 years, presumably as more of the patients in the
cohorts need services and/or patients in the cohorts need greater volumes of services
The greatest cost increases over the period for patients in the cohorts were primary care and community care.
In percentage terms, the cost of acute care has decreased over the period.

43. Cost and Activity for the
selected cohort
Activity Cost (£)
2012/13 2013/14 2014/15 2012/13 2013/14 2014/15
Primary Care Contact 42.1 45.2 45.1 1,897 2,032 2,030
Pharmacy 134.8 134.1 135.5 2,373 2,362 2,387
Acute care A&E 1.2 1.2 1.0 137 144 120
Outpatient 5.7 5.5 5.6 602 742 764
Daycase 0.6 0.5 0.3 424 366 217
Elective 0.1 0.1 0.1 286 194 174
NEL short-stay 0.2 0.2 0.2 246 228 166
NEL long-stay 0.5 0.5 0.4 1,568 1,570 1,254
Community care Face-to-Face 6.0 10.2 12.3 1,092 1,884 2,172
Telephone 0.5 0.9 1.1 27 47 54
Combined average cost per patient (£) 8,652 9,569 9,337
Total annual cost of patient cohort (£million)
17.51 19.37 18.90
Average annual number of events and average annual cost per patient in the cohort - all CCGs
The averages hide a great deal of variation. If we take one example, patient's in the cohorts on average visit A&E once
a year but over 50% of patients did not visit A&E at all during 2013/14, and one patient visited 41 times .
Perhaps the most striking feature of the data is that large percentages of patient in the complex care cohorts didn't
require acute inpatient care at all in 2013/14.

44. Commissioning the Service,
Who, Where, When
Acute Trust Community
Trust
Health1000
Private
Provider
Voluntary
Sector
GP
Federation

45. PSCAS Staffing Model
• Document patient conditions, consider evidence for diagnoses and confirm or
challenge these
• Record patient preferences e.g. settings of care, treatment approaches
• Optimise management against NICE guidance
• Initiate patient and carer self management programme where appropriate
• Clarify the new system to patient and carer(s)
• Clarify emergency procedure
• Document and agree care plan with patients /carers
• Agree EoL wishes
• Agree emergency escalation plan eg to A&E or not
• Allocate case manager and team
• Educate patient / carer on service and provide details of key contacts (patient-specific)
Patient enrolled
in programme
Data is
transferred
Initial Visit
Care delivery (Preventative) Team Escalation
Rapid Response Team
• Transfer data from the primary
care record and import from any
other source e.g. community or
social care record and
incorporate into a new single
electronic care record
Programme
GP/Nurse
Case Manager
GP
Multi-disciplinary Team
(icons are illustrative only, the composition of the
team will be tailored to individual patient needs)
• Review patient
record and need
for specialty input
• Care is proactive in nature, with regular
touch points between the patient and care
staff
• Care is front-loaded during crises/
exacerbations to prevent escalation
• Patient receives face to face visits and or
telephone calls on a regular basis
depending on personal need
• 24/7 option for patient to call for advice
• Telehealth monitoring where appropriate
• Regular clinical review of needs and
adherence to plan tailored to patient need
• E patient care plan is accessible to the
patient and their family by both electronic
and paper means
• Patients with more complex management under care of
multi-disciplinary team including specialist input
• Every admission reviewed as a critical incident for team
and patient learning
Multi-disciplinary team case
conference (includes specialist
input as required)
• Urgent care team working across the LTC
chronic care team responsive to patient
emergency with a 1 hour maximum call out
• Patients managed via phone until team
arrives
• Teleheath interaction for care homes and
some individual patients where appropriate
Social Care Pharmacist
Worker
Nurse
Other
professional(s)
(as required)
Telehealth
(where appropriate)
UC Team
5 6 7
9a 10a
10b
• Obtain patient consent to
enter programme
• Obtain patient consent for
research
• Remove patient from current
primary care list a re-registered
with the new
practice
Patient consent
4
Patient engagement
3
Patient /
Carer
• Provide details of the pilot and
service to the patient and
carer(s)and help them
understand ‘what it would mean
to them’
• Register patient willingness to
participate
• GP refers patient to the service if
patient response is positive
GP engagement
2
• Meet with GPs to provide
background to programme
• Discuss potential patient(s) for
pilot and obtain buy-in from GP
• Agree engagement plan for
patient(s)
GP Programme
Rep
Patient /
Carer Patient /
Carer
Case
Manager
Specialty Team
Assessment
8
GP
Hospital
Physician /
Geriatrician
Self Management and
education
9c
Patient /
Carer
Nurse
Additional Expertise
External expertise
accessed as needed
(Cardiologist, Dietician,
gastroenterologist,
Domiciliary Dental Service
etc)
9b
• Nurse educates patient/
carer on how to use
services and manage LTCs
• Additional
expertise is
available quickly
via phone or face-to-
face as needed
Integrated
care record
GP sends letter to
patients
1
GP
Patient /
Carer
• The current GP sends a letter to
patient(s) to introduce the
service
• The letter will also outline next
steps to the patient i.e. a face-to-face
meeting or phone call with
the GP to discuss service in
more detail
• Interviews with patients to understand the following: What are the gaps in the current service? What would their ideal service look like? What would persuade them to join the new
service and leave their GP? Who else would need to be involved in the decision e.g. carer? What do they think of the proposed service model, i.e. care closer to home?
• Patients interviewed for co-design are unlikely to be the patients involved in the pilot
• Interviews with charities to understand how would they input into the design of a new service and what would be their role in the new service if given opportunity
Co-Design of Model with Patients & Charities

46. PSCAS Staffing Model
ROLE WTE at
start up
Start up Cover provided WTE by
month 3
MD and Geriatrician (50:50
role)
1.0 20 hours direct patient care plus 17.5 hours management
plus on call support as required
1.0
HCS Key workers 5.0 73.5 hours per week 8am to 18.30pm Monday to Sunday.
This is a dual function role covering reception and health
care support and requires two members of staff to be on
duty during 08.00 to 18.30pm Monday to Friday
6.0
GPs 3.0 52 hours per week 08am to 18.30pm Monday to Friday
plus
On call for 5 hours per week Monday to Friday 6.30 to
8pm and 24 hours on Saturday and Sunday from 8am to
8pm
A total of 81 hours per week
3.0
Practice Manager 1.0 37.5 hours per week as required to cover 7 days per week
on rota
0.5
Nurse 1.0 37.5 hours per week during 8am to 6.30pm 0
OT 0.5 18.5 hours per week during 8am to 6.30pm 3.0
Physiotherapist 0.5 18.5 hours per week during 8am to 6.30pm 2.0
Pharmacist 0.5 18 hours per week Monday to Friday as required 1
Community Nurse 0.0 Not applicable 4.0
Mental health Nurse 0 Not applicable 0.5
Social Worker 1.0 Seconded from Local Authority

47. People interviewed about the new
Health1000 service told us:
“We feel helpless trying to get the
best care for our mum.”
“The professionals don’t understand
all of my needs.”
“I just want to be able to go fishing. I
don’t want any more operations or
medication, I just want to be able to
o Fly Fishing again. Why wont
anyone help me achieve this ?
Complex Care Service
Individual
Care
Multidisciplinary
Teams
4+ LTCs
Mental Health
Social Isolation
End of Life Needs
Complex
Patients
Care plan
developed
Care Navigator
Navigation
package
New and existing services
Care
(Sectors including Voluntary, Charities,
Private Sector, Social models, Communities,
user developed services etc)
Health
1000
Directory of
Services
Scope of existing services Scope of IPC development
Focus of the
IPC
application
Updated Service updated to meet the registered
patient needs
Patient Feedback resulting in
design changes

49. Connect with us
Visit the Long Term Conditions
web pages at www.nhsiq.nhs.uk
The House of Care
www.england.nhs.uk/house-of-care
Get in touch on twitter:
#ltcimprovement
#LTCYearofcare