1. National and international integrated
care projects
Dr Judith Smith
Head of Policy
Nuffield Trust
East Cheshire Integrated Care Programme
7 November 2012
© Nuffield Trust

2. Agenda
•Why does integrated care matter?
•What exactly is integrated care?
•On what examples can we draw?
• Where does this sit within the current policy context?
•Is integrated care an idea whose time has come?
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3. Why does integrated care matter?
• Rising levels of chronic disease
• Ageing population
• Increasing levels of hospital admissions and
readmissions, especially among the elderly and
vulnerable, and children
• Economic hard times, and unsustainable health and social
care economies
• And too often we still do not get it right in terms of care co-
ordination, care planning, communication with families
• Somehow, care for frail people with complex needs is not
the pressing priority it needs to be within our health
systems
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4. © Nuffield Trust

5. Policy desire for ‘transformation’
• We keep asserting a desire for care that is more
community-based and less hospital-focused
• Expressed in various ways: Primary care-led NHS; Our
Health, Our Care, Our Say; Transforming Community
Services; Nothing about me without me; etc
• Other countries in a similar place: Australia, Canada, New
Zealand, Netherlands, USA...
• But we have largely failed to achieve the policy intent in
England, as the acute sector has grown, and activity there
has risen (Audit Commission and Healthcare Commission, 2008)
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6. What exactly is integrated care?
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7. A definition of integrated care:
„Achieving integrated care requires those involved with
planning and providing services “to impose the patient
perspective as the organising principle of service
delivery” [Lloyd and Wait, 2005, p7]‟
(Shaw et al, 2011, p7)
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8. Mrs Smith, Mrs Jones... it is the individual‟s experience
that matters
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© Age Concern Picture
Library

9. The term ‘integration’ can be a problem
• „The act of combining or adding parts to make a unified
whole‟ (Collins English Dictionary)
• Raises antibodies about consolidation, centralisation,
incorporation, amalgamation, assimilation, merger...
• And this has certainly been the case in a context of reforms
focused on markets and localism
• We need first of all to understand what is fragmented –
what needs to be integrated, from a patient‟s perspective?
• And perhaps we should focus more on „integrative
processes‟ rather than integration per se?
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10. Integrative processes
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Source: Rosen et al (2011)

11. On what examples can we draw?
Torbay Care Trust (Ham and Smith, 2010)
• Care trust established in 2005
• Desire for better co-ordination of health and social care,
and improved health outcomes
• Five integrated health and social care teams with a single
manager and linked to general practices
• Shared records, single assessment process
• Proactive risk profiling of population and care management
• Some evidence of reduction in emergency admissions to
acute care by older people
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12. Community Care North Carolina (Rosen et al, 2011)
• A network of independent practices, working together to
deliver integrated care via Medicaid programme
• Aims are: better access to primary care; chronic disease
management; evidence-based care co-ordination; and
reduced care fragmentation
• Based on the idea of the medical or primary care home
• Run across 14 regional networks
• Disease management programme, care
management, integrated electronic record system
• Local physician and manager lead each multidisciplinary
network team
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13. New Zealand integrated health networks (Thorlby et al, 2012)
• Have grown out of general practice (IPAs – similar to
multifunds) and community networks that have existed
since the early 1990s
• Now represent extensive primary care infrastructure and
management support across the country
• Given new life by a government policy of Better Sooner
More Convenient, and a need for radically new forms of
care
• Moving towards an integrated health/social care approach
• Working in „alliances‟ and experimenting with new forms of
contracting and risk-sharing
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14. Accountable care organisations for the NHS
• Draw on the Fisher et al (2007) concept of the ACO where
a group of health care providers take on financial and
health outcome risk
• A capitated budget for some or all health needs of a
population
• Explored in Nuffield and NHS Alliance work as a „local
clinical partnership‟ (Smith et al, 2009) or an integrated
care organisation (Lewis et al, 2010)
• Examples now of integrated provider organisations forming
in the NHS – Smethwick, Surrey, NW London, Vitality
(Birmingham)
• South Auckland setting up local community partnerships © Nuffield Trust

15. Common themes
• Trying to set an organisational context within which providers
can deliver care that „imposes the patient‟s perspective‟
• Some are about new organisational arrangements, others
about a mix of new integrative processes
• A burning platform is often present, such as health economy
sustainability or workforce shortages
• All are concerned with a new approach to care
management, risk, budget holding and accountability for
outcomes – partnership working with „grunt‟
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16. Where does this sit in the current policy context?
Beyond commissioning?
• Policy for NHS very focused on addressing „weak‟
commissioning
• Belief in clinically-led commissioning – CCGs
• But research evidence points to limits of such
commissioning, especially re „big ticket‟ items & acute care
• Such commissioners nearly always end up focusing on
development of service provision
• Is it time to think more about clinically-led provider
networks that are more like an ACO?
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17. Possible scenarios
• Group of practices take on a capitated budget and
provide what they can, and commission the rest
• Group of practices together with local hospital (and
community services?) take on a budget for a range of local
services, e.g. urgent care, older people‟s care, children‟s
care
• Group of practices, social services, and community
health services form a network or organisation to hold
budget and commission/provide care for specific groups
• Accountable lead provider where contract is held for a
wider service, subcontracted by the lead provider
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18. Policy considerations (Ham, Smith and Eastmure, 2011)
• Likely to need flexibilities re payment regime – capitated
approach, bundled payments for care pathways
• Needs careful crafting of governance of actual or
perceived conflicts of interest
• A range of organisational and legal forms might apply, and
perhaps several for a single area/network
• And a significant degree of skilled and sustained
leadership to enable the trust and maturity entailed
• Needs an outcomes-based approach to performance
assessment
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19. Is integrated care an idea whose time has come?
• Trying to develop better care, with the user perspective as
predominant, is a long-standing and vital priority
• What distinguishes this time period is the economic context
• Not to change is not an option
• The challenge is not so much about what sort of
organisation is used, but what processes need to be
developed to enable more integrated care
• We need to try these ideas out at scale, and carry out
carefully constructed evaluation to build an evidence base
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20. References
Audit Commission and Healthcare Commission (2008) Is the treatment working?
Progress with the NHS system reform programme. London, Audit Commission
Fisher E et al (2007) Creating accountable care organisations: the extended hospital
medical staff. Health Affairs, 26, no.1, 44-57
Ham C and Smith J (2010) Removing the policy barriers to integrated care in England.
London, the Nuffield Trust
Ham C, Smith J and Eastmure E (2011) Commissioning integrated care in a liberated
NHS. London, the Nuffield Trust
Lewis R, Rosen R, Goodwin N and Dixon J (2010) Where next for integrated care
organisations in the NHS in England? London, the Nuffield Trust and the King‟s
Fund
Lloyd J and Wait S (2005) Integrated care: a guide for policymakers. London: Alliance
© Nuffield Trust
for Health and the Future

21. References
Rosen R et al (2011) Integration in action: four international case studies.
London, the Nuffield Trust
Shaw S, Rosen R and Rumbold B (2011) What is integrated care? London, the
Nuffield Trust
Smith J, Wood J and Elias J (2009) Beyond practice-based commissioning: the
local clinical partnership. London, the NHS Alliance and the Nuffield Trust
Thorlby R, Smith J, Barnett P and Mays N (2012) Independent practitioner
associations in New Zealand: surviving to thrive? London, the Nuffield Trust
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22. www.nuffieldtrust.org.uk
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23. Predictive risk modelling
Dr. Martin Bardsley
Head of Research
Nuffield Trust
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24. Uses of predictive risk techniques
Predictive modelling aims to identify people at risk of future event
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25. Introduction of predictive modelling to UK
• Debate following BMJ paper in
2002 that showed Kaiser
Permanente in California seemed
to provide higher quality
healthcare than the NHS at lower
cost.
• Kaiser identify high risk people in
their population and manage
Getting more for their dollar: a comparison of the
them intensively to avoid NHS with California's Kaiser Permanente BMJ
2002;324:135-143
admissions
Can the NHS learn from US managed care
organisations? BMJ 2004;328:223-225
© Nuffield Trust

26. Uneven distribution of health care resources
The proportion of total costs spent
on patients by category of annual
costs (area of shape) with the
proportion of all patients in annual
cost band (dots)
Around 3% of patients are
responsible for nearly half the
total patient costs
© Nuffield Trust

27. To prevent, we need to predict who will high costs in who in the
future
It‟s not the people
emergency bed days
who are current
Average number of
intensive users
Predictive
models try to
identify
people here
© Nuffield Trust

28. Population wide risk modelling
• Patterns in routine data identify
high-risk people next year
• Use pseudonymous, person-level
data
• Relies on exploiting existing
information:
+ve: systematic; not costly data
collections; fit into existing systems;
applied at population level
-ve: information collected may not be
predictive; data lags
© Nuffield Trust
• .

29. Predictive modelling is only as effective as the intervention it
is used to trigger
• Case Management
Top 0.5%
0.5 – 5.0% • Intensive Disease
Management
6 - 20%
• Less Intensive Disease
Management
21 –
100% • Wellness Programmes
Providers need to know potential costs of the outcome to
build business case for intervention
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30. How does predictive risk
modelling work?
07 November 2012 © Nuffield Trust

31. Protecting individuals’ identities
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32. Developing a predictive risk model
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33. Developing a predictive risk model
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34. Describing a model’s performance
Example: Take 100 people over one year…
7 people have an emergency hospital admission
93 do not
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35. Describing a model’s performance
At the start of the year, no
one knows who‟s who
A predictive risk
model tries to
sort it out
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36. Can improve PPV by focusing on highest risk
Positive predictive value –
PPV (number of predictions
that are correct) = 66%
Sensitivity (number of
actual cases predicted) =
29%
Trade offs: PPV up but
sensitivity down
© Nuffield Trust

37. Estimating potential savings from avoided events?
Savings are linked to cost of
intervention and its effectiveness
£1,400
Example:
• Average costs of readmission for high £1,200
Mean cost of readmission
risk patients are ~£1000
£1,000
• Intervention reduces readmission by £800
10%
£600
• Then intervention has to cost less £400
than £100 per person to save money
£200
£0
Risk score
© Nuffield Trust

38. A predictive risk tool has different elements
•The model
•The software
•The data
•The application....
© Nuffield Trust

39. A predictive risk tool: PARR
• In 2006, the Department of
Health (DH) invested in two Hospital provides SUS
predictive models (or „risk
stratification tools‟) for the NHS
in England.
• PARR widely used by PCTs PCT runs PARR++
(because software was free
and SUS data only)
Patients selected for
intervention (via GP)
• Predicts readmission in next
year – PPV 65%
• Designed to be run by PCTs
periodically, requires up-to-
© Nuffield Trust
date diagnostic codes

40. Range of case finding models available
SPARRA PARR (++)
SPARRA MD Combined Predictive Model
PRISM PEONY
AHI Risk adjuster LACE
ACGs (John Hopkins) MARA (Milliman Advanced Risk
Adjuster)
DxCGs (Verisk) Dr Foster Intelligence High Intensity
Users Model
PARR30 QResearch models eg QD score
SCOPE RISC (United Health Group)
Variants on basic admission/readmission predictions:
Short term readmissions Social care costs
© Nuffield Trust
Condition specific tools

41. NE LONDON Risk profiling for integrated
care: Selecting the cohort
Identify top 1%
risk segment – Modelling
4239 in Redbridge indicates that
90% of these will
have one or
more LTC
Reviewed by
Integrated Care
team – accepted
if suitable
These people accepted into Integrated Care will then be discussed
by the team and a care plan will be developed across both health
and social care

42. SOUTH CENTRAL: Case Management (2) South Central
Primary Care Trust Alliance
________________________________________________________________________________________________
Risk Stratification Disease
Profiling
Resource
ACGs
Case
Case Finding for Patient Education Activities
Management Management
 The Isle of Wight is piloting an innovative project that is directed at people with certain LTCs
who are at an earlier stage of their disease and sit lower down in the risk pyramid
 Their „Café Clinic‟ project is targeting patients in the moderate to high (rather than the very
high) risk categories who have two or more long term conditions
 The objective of the project is to introduce these people to members of the multi-disciplinary
team and members of the voluntary sector who can support them in the management of their
disease
 It is hoped that earlier intervention in the management of these patients and education of
them and their carers will help maintain health status and reduce unnecessary emergency
admissions
 The ACG system has been used to identify cohorts of people to attend these clinics.
Feedback after the first clinics was that all of the patients the tool had identified were suitable
for this new type of service
42

43. Virtual Wards
Virtual Ward = Predictive Modelling + Multi-disciplinary Case-Management
(Hospital at Home)
Virtual Wards and the NHS Devon Experience
Paul Lovell and Todd Chenore

44. Monthly Devon Very High and High-Risk
Predictive Model Patients Identified
Virtual Ward Primary Care and
Complex Care Team Monthly DPM report and VW
Joint Meetings Bed-state reviews
Admit to
Virtual Ward
PATIENT
Charities
Housing
(3rd sector)
ACS Voluntary
Social Case Services
Worker Rep
Manager Virtual Ward Staff
Daily interactions within Mental
team, Regular VW Ward Rounds ACS OT Health CCT and
and Reviews ( Weekly Core Group CRT OT
Primary Care
ACS
Meetings) CCW CRT
Communi Physio
ty Matron CRT
District Nurse
Nurses Practice
CCT Nurses
Co-ordinator GP
(VW Ward Clerk)
COPD
Exacerbation
Community
Specialist Pathways
Nurse Service
Consultant
Outreach
Out-patient
Review
Ward
Assessment
Acute
Admission

45. Devon-Wide Roll-out
Stage 2 - Exert Control on high-risk Group (2011/12)
Year 2 CQUIN LES Funded
Payment to practices by % Bed-state (of bed number limit)
Sign up to Combined Predictive Model
Identify target patients and assign a case-manager (Read Code)
Produce Out of Hours Special Message- active on DDOC Adastra
Full payment- 85% High /Very High Risk and 80% Occupancy over the
year
Devon (Combined) 3-4 Months Input LTC Self-
Predictive Model 85% Management, Education, Social etc (75-80%)
Virtual Ward
Direct Referral Prolonged Admission
15% 12-18 months (20-25%)

46. Risk Stratification (2) South Central
Primary Care Trust Alliance
________________________________________________________________________________________________
• There is often significant variation in case mix between practices across a CCG
• This is either confirming or challenging views about variation in case mix or dependency
between practices
Very High High Moderate Low Healthy Non Users
• This analysis replicates a piece of work
undertaken by the Scottish School of
Public Heath that demonstrated that
multi-morbidity is common in Scotland
• The patterns in this population in South
Central are very similar
Risk Disease
Stratification Profiling
ACGs
Resource Case
Management Managemen
t 46

47. Using the data available
© Nuffield Trust

48. Testing for gaps in care
© Nuffield Trust

49. Disease specific studies
COPD in NE London
• Defining quality “Risk factors” – NICE Quality Standards
for COPD
• Measuring Quality= Health Analytics data extraction
system installed in each surgery
• Education programme at multiple levels – offering
support where needed and wanted
• Empowering patients

50. Identification of Interventions
Establish and monitor a set of 7 core
areas for patient care, within primary care.
1) Post bronchodilator spirometry
2) Severity Measurement
3) Annual review
4) Smoking cessation
5) Pulmonary rehabilitation
6) Self management plan
7) Palliative care
The Health Analytics tool, identified a 10 fold baseline
variation between practices on many quality measures

51. Impact on COPD Admissions
1200
Number of
patients not
diagnosed with
COPD by
GP, having a
COPD related IP
admission (any
type) in the last
681 690 684 12 months
658 656 657 647
641 651 646
610 Number of
599
600 584 patients not
561
540 545 diagnosed with
519 COPD by
499
479 479 GP, having a
461 470 COPD related IP
admission (any
type) in the last
12 months
Total number of
COPD related IP
479 453 632 608 562 534 483 464 664 623 618 617 604 583 562 543 528 514 503 412 398 393 admissions (any
300 type) in the last
12 months
1/1/2010
1/3/2010
1/4/2010
1/6/2010
1/9/2010
1/11/2010
31/1/2011
1/3/2011
1/4/2011
16/6/2011
2/7/2011
4/8/2011
1/9/2011
8/10/2011
21/1/2012
1/2/2012
3/3/2012
8/4/2012
19/5/2012
9/6/2012
19/11/2011
11/12/2011
COPD admissions showing sub analysis by patients
known and not known to GP with a diagnosis of COPD
within : Barking and Dagenham

52. Summary
• Predictive modelling is a practical case finding tool for identifying
high risk patients
• Growing market for predictive models – extending beyond simple
annual predictions of readmissions
• Technical details of model performance is important – but so how is
the way the model is implemented
• Range of ways these models can be put into practice
http://www.nuffieldtrust.org.uk/our-work/predictive-risk
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• Insert presenter‟s email address here
07 November 2012 © Nuffield Trust