The Kent LTC Year of Care Programme aims to utilize integrated population datasets to evaluate and improve integrated care initiatives through a capitated funding model and outcomes-based payment methods. The program focuses on identifying and supporting at-risk populations while developing a standard currency for funding and tariff systems. Next steps include enhancing data flow from GP practices, creating commissioning models, and improving data quality to monitor and evaluate integrated care services in Kent.

1. Kent LTC Year of Care Programme:
Using whole population linked
datasets to develop higher value
models of care
Dr Abraham George
Asst Dir / Consultant in Public Health
Kent County Council

2. Aims
• Use whole population integrated data sets to help
commissioners evaluate relative impact of different
integrated care initiatives
• Use routine administration data to develop a different
method of commissioning – capitated funding model –
to intervene earlier, support independent living,
prevent ‘crisis’ and rehospitalisation
• Use the same routine administrative data to develop a
different method of payment for services which is not
cost per activity but is outcomes based
• Design personal health and social care budgets to
support integrated personalisation

3. Setting the scope of our funding model

4. Setting the scope of our funding model

5. Setting the scope of our funding model

6. Developing ‘currencies’ & identify potential “at risk”
cohort
• Whole population approach (SUS & provider data into local data
warehouse)
• Standard currency agreed across Kent
• List segmented by LTC currency (Bands B – E applied - B=2,C=3-
5,D=6-8,E=9+)
• Tariff to be developed for each currency band
• Risk stratification of whole population using hospital and primary
care data
• Risk Score over time mapped (looking for rise in risk score in last
3 to 6 mths)
• Multi-morbidity mapped for ‘at risk’ group across 18 Long Term
Conditions

8. ‘YOC Cohort’

9. YOC vs Non YOC average costs

10. YoC vs non YoC average costs
breakdown

11. Multimorbidity profile (YoC) Cohort
(n=23,600)

12. Multimorbidity profile (Non YoC Cohort)
(n=260,029)

13. Multimorbidity profile (Whole popn)
(n=283,329)

14. Next steps
• Increase the number of GP practices flowing data to
KMHIS
• Increase the number of providers flowing data to KMHIS
• Develop a Data Quality Improvement Plan across the
system
• Work with Commissioners and Providers to develop a
commissioning model in each health system
• Work with commissioners and providers to develop the
contracting model to support the commissioning model
• Develop a standard set of reports and dashboards to
support the monitoring evaluation of Integrated Care
services across Kent
• Use linked datasets for enhanced analytics purposes
(service evaluation, system modelling, economic
evaluation of prevention, etc)