The document discusses the Year of Care (YOC) program in Kent, aimed at improving integrated care by sharing data and information across health services. Key findings and activities highlight the identification and risk stratification of patients with long-term conditions, leading to a shift from service-oriented to patient-focused care planning. It emphasizes the importance of collaboration among various health entities and stakeholders to develop personalized care strategies for individuals with complex health needs.

1. Enhancing care by Sharing Data and
Information
Abraham George, Consultant in Public Health/Assistant
Director of Public Health, Kent County Council
Jochen Worsley, Head of Long Term Conditions, East
Kent Federation of CCGs
Bruce Pollington, Deputy Medical Director, Kent
Community Health Trust/Chief Clinical Information Officer
at Kent Integration Pioneer

2. The scale of the problem and the
20%
75%
cost
40%
15%
Multiple complex
conditions
Single LTC/ at risk
Healthy / minor
risk
Population segments Cost

3. 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

4. How we created our Year of Care
currency

5. Identifying patients suitable for YoC
• 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

7. Issues highlighted
Gap Identified by Date identified Action
No standard definitions for
Integrated Care service
across system
EK PG Jan 2014 Flag to WK and link to
Integrated Care plan
work
No method to share care
plans once MDT completed.
(Not even seen by GPs)
EK Project Group Feb 2014 Flag to SRO
Not all practices submitting
data to HISBi
EK PG
WK PG
April 2014
May 2014
Flag to SRO
Ongoing
PLICS and RiO system in
KMPT not flowing data
correctly
KMPT when requested to
submit first data
submission
June 2014 Resolved by KMPT
No standard definition for
integrated care within KCHT
Impact identified by
Programme on YoC ability
to assess impact of ITC
services V’s WP
July 2014 PM worked with KCHT
to standardise
definition. Recording
process agreed Sept
2014
Variable in recording
practice of GP codes in Non
–NHS data
Programme when we
introduced “black box”
solution
Sept 2014 Highlighted to
organisations. With 3rd
sector provided list to
facilitate update.

9. The Year of Care dashboard has so far presented 4 months of activity
and costs worth £57 million from 7 different provider organisations. Of
this £4 million (7% of total spend) represents the proportionate costs
for the YOC cohort (0.3% of total population).

10. YoC & the wider context
• Shift from service orientated Integrated Care as
the definition to Patient focused Integrated Care
Plan (ICP).
• The YoC Cohort identified in primary care for ICP
• Changing behaviour to meeting patients needs
and wishes and not the services ability to deliver.
• Plans shared system wide using the developing
Care Plan Management system
• Developed with and visible to the patients.
• Their wishes, their plan.

11. “Year of Care is a vital component of
Kent’s Integration Pioneer Programme –
with findings being used to underpin Kent’s
Better Care Fund” Jo Frazer – Kent
Pioneer Programme Manager
- “If this works that’s my job done”
- -CCG Head of Finance
“Kent have been successful in linking their transformation of services
with commissioning through the LTC Year of Care programme which
will make that step towards individualised care for people with
complex needs.” Beverley Matthews, LTC Programme Lead,
NHSIQ
“The intelligence from YOC is both informing our thinking on a more
progressive contracting approach incentivising real service
integration”- Hazel Carpenter, Accountable Officer CCG
“This is the first group I have been part of that has moved so far so fast”-
AD Finance Provider
“The year of care programme has been a great enabler in helping us focus
upon and design a holistic ‘health and social care’ model around individual
clients rather than individual disease pathways in a value added, integrated
manner.”- Sanjay Singh Chief GP Commissioner West Kent CCG