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Holly Holder & Ian Blunt: Integrated care pilot evaluation
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Holly Holder & Ian Blunt: Integrated care pilot evaluation


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  • by project funding of £10m - £10m made available release of emergency admissions tariff Under changes to the emergency admissions tariff introduced in 2010, local commissioners pay 100% of the tariff for an emergency admission but the trust retains only 30% for emergency admissions above 2008/9 levels; the remaining 70% goes to NHS London. NHS London, following negotiations with NWL PCTs, agreed to release this money back into the sector to fund the pilot.
  • 1 – each MDG holds a register of all patients over 75 and/or with diabetes 2. MDG uses ICP information tool to stratify patients by risk of emergency admission 3. Providers agree to provide the care as recommendment in the ICP parthways and protocols 4. Each patient given an individual IC plan 5. Patients receive care from range of providers – all sharing information on the joint IT tool 6. Small number of most complex cases are discussed at the MDT conference – aim to plan and coordinate care 7. MDG meets regularly to review its performance.
  • Information from patients based on relatively small numbers – so should be treated with some caution. : duplication of data entry, problems with interoperability and functionality
  • Nuffield First, we monitored the service use of the general population of inner North West London and the pilot's target population by observing patterns of activity in administrative data sets. Eligibility was determined by age and diagnoses on admission to hospital, and represented a rolling cohort of patients. These were contrasted with other areas of London and national data sets. The second part of the analysis examined a fixed cohort of patients who had received a care plan compared to matched individuals taken from other areas with similar population characteristics– this represented changes associated with ‘usual care’. Patterns of hospital use for both groups were compared using a generalized difference-in-differences regression approach at the person level. This approach has been used in a number of earlier studies [19-20]. A wide range of variables were used for matching participants to controls. These were a predictive risk score for emergency hospital admission in the next 12 months, age, sex, prior hospital utilisation, total number of chronic health conditions, area-level deprivation score and history of 15 specific health needs. We assessed the similarity of the matched control group to the group of the pilot’s patients by using the standardised difference, where a value greater than 10 per cent is indicative of a meaningful difference between the groups [21].In both approaches we tested the level of service utilisation before and after the start point of the pilot or the care plan.
  • Transcript

    • 1. © Nuffield Trust Inner North West London Integrated Care Pilot – year one evaluation 8 July 2013 Holly Holder Fellow in health policy Ian Blunt Senior Research Analyst
    • 2. © Nuffield Trust© Nuffield Trust What is the inner North West London Integrated Care Pilot?
    • 3. © Nuffield Trust Aims of the pilot Large-scale programme to improve the coordination of care for people over 75 years of age and/or adults living with diabetes. Aims: •Improve outcomes for patients •Create access to better, more integrated care outside hospital •Reduce unnecessary hospital admissions •Enable effective working of professionals across provider boundaries
    • 4. © Nuffield Trust Setting up the pilot Started in July 2011 Initial £10m investment from NHS London Involved organisations: • Five local authorities • Three acute hospitals • Two community hospitals • 104 general practices • Representatives from Age UK and Diabetes UK Area covers 550k patients
    • 5. © Nuffield Trust At the local level – multi-disciplinary groups
    • 6. © Nuffield Trust Our evaluation Evaluation of the first year active Sept 2011 – July 2012 Four strands of research, in partnership with Imperial College Department of Primary Care and Public Health
    • 7. © Nuffield Trust© Nuffield Trust Key findings on Strategic implementation & context and Patient & professional experience
    • 8. © Nuffield Trust Qualitative data collection Data collection methods Number completed Semi-structured interviews with senior leaders of the pilot & participating organisations and other health policy experts 37 Focus groups with healthcare professionals and managers 4 Survey of healthcare professionals 51 completed in full (25.5% response rate) Survey of service users enrolled in the pilot 405 completed in full (20.25% response rate) Observation of IMB meetings and meetings of its committees 30 hours Observation of MDG meetings (of which ten hours were transcribed, coded and analysed in detail) 20 hours Semi-structured interviews with GPs about the influence of the ICP on diagnosis rates Seven general practices
    • 9. © Nuffield Trust Strategic implementation What worked well? •Successful engagement of organisations from across health and social care, assisted by a clear vision of aims •Sophisticated governance structures critical for engagement of organisations •Financial incentives important for bringing people on board Challenges •Balancing local autonomy with overall accountability •Symbolic financial incentives •Achieving more direct engagement of service users
    • 10. © Nuffield Trust Patient and professional experience What worked well? •Health professionals had a high level of commitment to the pilot, in particular the care planning process •Care planning and Multi Disciplinary Groups improved collaboration and levels of professional knowledge Challenges •Majority of patients had not experienced any changes •Care planning IT tool led to dissatisfaction amongst many practitioners. Over half of professionals felt workloads had increased
    • 11. © Nuffield Trust© Nuffield Trust Impacts on service use and cost - evaluation using predictive risk techniques
    • 12. © Nuffield Trust Quantitative data collection and three-armed approach The general population of inner North West London and the pilot’s target population: •Observed activity using administrative data sets •Contrasted to other areas of London and nationally A fixed cohort of patients who had received a care plan compared to individuals with similar population characteristics: •Observed changes associated with ‘usual care’ •Matched control group identified by: predictive risk score for emergency hospital admission, age, sex, prior hospital utilisation, health conditions etc Patients with care plan by end 2011 (1,494) Patients eligible for ICP (35,607) All patients in ICP practices (502,920)
    • 13. © Nuffield Trust Emergency admissions for ‘ICP eligible’ patients
    • 14. © Nuffield Trust Distinct emergency admission patterns by financial year in the main provider FY 2009/10 FY 2010/11 FY 2011/12
    • 15. © Nuffield Trust Analysis at person level Months >>> Analysis at practice level gives insight into overall patterns of service use… … but much more powerful to take patients known to have received a specific intervention and generate person level controls
    • 16. © Nuffield Trust Recruitment and statistical power Problem of early evaluation Recruitment starts only after ICP has established itself Patients need some follow-up time We have 3 month data lag Performing analysis after end of first year – only 1495 eligible patients
    • 17. © Nuffield Trust Summary measures on matching Matches drawn from population of similar PCTs Controls well matched in all categories
    • 18. © Nuffield Trust Output indicators for cases and controls +0.09 (p=0.519) -18 (p=0.758)
    • 19. © Nuffield Trust© Nuffield Trust Final thoughts
    • 20. © Nuffield Trust Understanding year one of the iNWL ICP • ICP is an ambitious programme of transformational change, being implemented at a time of major reform in the NHS • Substantial progress was made in designing and implementing a highly complex intervention, and had brought together diverse health and social care providers • However, it was in the early stages of change and it was too early to demonstrate benefits in terms of service use and patient outcomes • After year one a second pilot in outer North West London has been established. Move towards a more ambitious ‘whole systems’ approach based on risk stratification rather than disease pathways, in both pilots
    • 21. © Nuffield Trust Lessons for evaluation • International evidence suggests a minimum of three to five years before there is an impact on activity, patient experience and outcomes • Important to time evaluation accordingly and manage expectations on when changes might become apparent (and detectable) • However there is value in continuous monitoring of outcomes, particularly when contrasting change within the local context with what is happening elsewhere
    • 22. © Nuffield Trust Further information first-year-inner-north-west-london-integrated-care-pilot
    • 23. © Nuffield Trust26 July 2013 Sign-up for our newsletter Follow us on Twitter: © Nuffield Trust Insert presenter’s email address here