National and international integratedcare projectsDr Judith SmithHead of PolicyNuffield TrustEast Cheshire Integrated Care...
Agenda•Why does integrated care matter?•What exactly is integrated care?•On what examples can we draw?• Where does this si...
Why does integrated care matter? • Rising levels of chronic disease • Ageing population • Increasing levels of hospital ad...
© Nuffield Trust
Policy desire for ‘transformation’• We keep asserting a desire for care that is more  community-based and less hospital-fo...
What exactly is integrated care?                                   © Nuffield Trust
A definition of integrated care:„Achieving integrated care requires those involved with  planning and providing services “...
Mrs Smith, Mrs Jones... it is the individual‟s experiencethat matters                                                     ...
The term ‘integration’ can be a problem• „The act of combining or adding parts to make a unified  whole‟ (Collins English ...
Integrative processes                                © Nuffield Trust   Source: Rosen et al (2011)
On what examples can we draw?Torbay Care Trust (Ham and Smith, 2010)• Care trust established in 2005• Desire for better co...
Community Care North Carolina (Rosen et al, 2011)• A network of independent practices, working together to  deliver integr...
New Zealand integrated health networks (Thorlby et al, 2012)• Have grown out of general practice (IPAs – similar to  multi...
Accountable care organisations for the NHS• Draw on the Fisher et al (2007) concept of the ACO where  a group of health ca...
Common themes•   Trying to set an organisational context within which providers    can deliver care that „imposes the pati...
Where does this sit in the current policy context? Beyond commissioning? • Policy for NHS very focused on addressing „weak...
Possible scenarios• Group of practices take on a capitated budget and  provide what they can, and commission the rest• Gro...
Policy considerations (Ham, Smith and Eastmure, 2011)• Likely to need flexibilities re payment regime – capitated  approac...
Is integrated care an idea whose time has come?• Trying to develop better care, with the user perspective as  predominant,...
ReferencesAudit Commission and Healthcare Commission (2008) Is the treatment working?   Progress with the NHS system refor...
References Rosen R et al (2011) Integration in action: four international case studies.   London, the Nuffield Trust Shaw ...
www.nuffieldtrust.org.uk        Sign-up for our newsletter        www.nuffieldtrust.org.uk/newsletter        Follow us on ...
Predictive risk modellingDr. Martin BardsleyHead of ResearchNuffield Trust                            © Nuffield Trust
Uses of predictive risk techniquesPredictive modelling aims to identify people at risk of future event                    ...
Introduction of predictive modelling to UK• Debate following BMJ paper in  2002 that showed Kaiser  Permanente in Californ...
Uneven distribution of health care resources                            The proportion of total costs spent               ...
To prevent, we need to predict who will high costs in who in the   future                                                 ...
Population wide risk modelling•   Patterns in routine data identify    high-risk people next year•   Use pseudonymous, per...
Predictive modelling is only as effective as the intervention it is used to trigger                                       ...
How does predictive riskmodelling work?07 November 2012           © Nuffield Trust
Protecting individuals’ identities                                     © Nuffield Trust
Developing a predictive risk model                                     © Nuffield Trust
Developing a predictive risk model                                     © Nuffield Trust
Describing a model’s performanceExample: Take 100 people over one year…7 people have an emergency hospital admission93 do ...
Describing a model’s performance                             At the start of the year, no                             one ...
Can improve PPV by focusing on highest riskPositive predictive value –PPV (number of predictionsthat are correct) = 66%Sen...
Estimating potential savings from avoided events?Savings are linked to cost ofintervention and its effectiveness          ...
A predictive risk tool has different elements•The model •The software •The data  •The application....                     ...
A predictive risk tool: PARR• In 2006, the Department of  Health (DH) invested in two                            Hospital ...
Range of case finding models available     SPARRA                       PARR (++)     SPARRA MD                    Combine...
NE LONDON Risk profiling for integratedcare: Selecting the cohort                        Identify top 1%                  ...
SOUTH CENTRAL: Case Management (2)                                                            South Central               ...
Virtual Wards Virtual Ward = Predictive Modelling + Multi-disciplinary Case-Management                                    ...
Monthly Devon                               Very High and High-Risk                                                      P...
Devon-Wide Roll-out        Stage 2 - Exert Control on high-risk Group (2011/12)           Year 2 CQUIN LES Funded         ...
Risk Stratification (2)                                                                                    South Central  ...
Using the data available                           © Nuffield Trust
Testing for gaps in care                           © Nuffield Trust
Disease specific studiesCOPD in NE London • Defining quality “Risk factors” – NICE Quality Standards   for COPD • Measurin...
Identification of Interventions Establish and monitor a set of 7 core areas for patient care, within primary care. 1) Post...
Impact on COPD Admissions1200                                                                                             ...
Summary• Predictive modelling is a practical case finding tool for identifying  high risk patients• Growing market for pre...
www.nuffieldtrust.org.uk        Sign-up for our newsletter        www.nuffieldtrust.org.uk/newsletter        Follow us on ...
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  • People are well aware of the need to make large scale savings – much discussed in general termsBut missing from much of hte the discussion about service developmentsIs this just becasue we haven’t been in the right meetingsQIPP – tool for bringing discussions of money to the fore – but can be a the expense of discussions of quality (see example of Calderdale diabetes services – need to prove changes are ‘Qippable’)
  • Overview of the collaboration of project partners, financing and aim of the project. How the position of the HIEC helped to deliver partnership solutions for ARTP spirometry course, Health Foundation Shine award.
  • Judith martin east cheshireic 7nov2012 v2

    1. 1. National and international integratedcare projectsDr Judith SmithHead of PolicyNuffield TrustEast Cheshire Integrated Care Programme7 November 2012 © Nuffield Trust
    2. 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? © Nuffield Trust
    3. 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 © Nuffield Trust
    4. 4. © Nuffield Trust
    5. 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) © Nuffield Trust
    6. 6. What exactly is integrated care? © Nuffield Trust
    7. 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) © Nuffield Trust
    8. 8. Mrs Smith, Mrs Jones... it is the individual‟s experiencethat matters © Nuffield Trust © Age Concern Picture Library
    9. 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? © Nuffield Trust
    10. 10. Integrative processes © Nuffield Trust Source: Rosen et al (2011)
    11. 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 © Nuffield Trust
    12. 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 © Nuffield Trust
    13. 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 © Nuffield Trust
    14. 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. 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‟ © Nuffield Trust
    16. 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? © Nuffield Trust
    17. 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 © Nuffield Trust
    18. 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 © Nuffield Trust
    19. 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 © Nuffield Trust
    20. 20. ReferencesAudit Commission and Healthcare Commission (2008) Is the treatment working? Progress with the NHS system reform programme. London, Audit CommissionFisher E et al (2007) Creating accountable care organisations: the extended hospital medical staff. Health Affairs, 26, no.1, 44-57Ham C and Smith J (2010) Removing the policy barriers to integrated care in England. London, the Nuffield TrustHam C, Smith J and Eastmure E (2011) Commissioning integrated care in a liberated NHS. London, the Nuffield TrustLewis 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 FundLloyd J and Wait S (2005) Integrated care: a guide for policymakers. London: Alliance © Nuffield Trust for Health and the Future
    21. 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 © Nuffield Trust
    22. 22. www.nuffieldtrust.org.uk Sign-up for our newsletter www.nuffieldtrust.org.uk/newsletter Follow us on Twitter (http://twitter.com/NuffieldTrust)June 2011 © Nuffield Trust
    23. 23. Predictive risk modellingDr. Martin BardsleyHead of ResearchNuffield Trust © Nuffield Trust
    24. 24. Uses of predictive risk techniquesPredictive modelling aims to identify people at risk of future event © Nuffield Trust
    25. 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 Californias 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. 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. 27. To prevent, we need to predict who will high costs in who in the future It‟s not the peopleemergency bed days who are currentAverage number of intensive users Predictive models try to identify people here © Nuffield Trust
    28. 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 datacollections; fit into existing systems;applied at population level-ve: information collected may not bepredictive; data lags © Nuffield Trust• .
    29. 29. Predictive modelling is only as effective as the intervention it is used to trigger • Case ManagementTop 0.5%0.5 – 5.0% • Intensive Disease Management6 - 20% • Less Intensive Disease Management21 –100% • Wellness ProgrammesProviders need to know potential costs of the outcome tobuild business case for intervention © Nuffield Trust
    30. 30. How does predictive riskmodelling work?07 November 2012 © Nuffield Trust
    31. 31. Protecting individuals’ identities © Nuffield Trust
    32. 32. Developing a predictive risk model © Nuffield Trust
    33. 33. Developing a predictive risk model © Nuffield Trust
    34. 34. Describing a model’s performanceExample: Take 100 people over one year…7 people have an emergency hospital admission93 do not © Nuffield Trust
    35. 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 © Nuffield Trust
    36. 36. Can improve PPV by focusing on highest riskPositive predictive value –PPV (number of predictionsthat are correct) = 66%Sensitivity (number ofactual cases predicted) =29%Trade offs: PPV up butsensitivity down © Nuffield Trust
    37. 37. Estimating potential savings from avoided events?Savings are linked to cost ofintervention and its effectiveness £1,400Example:• Average costs of readmission for high £1,200 Mean cost of readmissionrisk patients are ~£1000 £1,000• Intervention reduces readmission by £80010% £600• Then intervention has to cost less £400than £100 per person to save money £200 £0 Risk score © Nuffield Trust
    38. 38. A predictive risk tool has different elements•The model •The software •The data •The application.... © Nuffield Trust
    39. 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. 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. 41. NE LONDON Risk profiling for integratedcare: 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. 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. 43. Virtual Wards Virtual Ward = Predictive Modelling + Multi-disciplinary Case-Management (Hospital at Home)Virtual Wards and the NHS Devon ExperiencePaul Lovell and Todd Chenore
    44. 44. Monthly Devon Very High and High-Risk Predictive Model Patients IdentifiedVirtual 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 andand 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. 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. 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. 47. Using the data available © Nuffield Trust
    48. 48. Testing for gaps in care © Nuffield Trust
    49. 49. Disease specific studiesCOPD 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. 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. 51. Impact on COPD Admissions1200 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. 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 practicehttp://www.nuffieldtrust.org.uk/our-work/predictive-risk © Nuffield Trust
    53. 53. www.nuffieldtrust.org.uk Sign-up for our newsletter www.nuffieldtrust.org.uk/newsletter Follow us on Twitter: Twitter.com/NuffieldTrust • Insert presenter‟s email address here07 November 2012 © Nuffield Trust

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