This document discusses predictive risk modeling and its applications in integrated care. It provides examples of how predictive risk modeling works, including:
- Developing predictive risk models using pseudonymized patient data to identify individuals at high risk of future health events.
- Evaluating model performance by measuring how well it predicts actual outcomes, with trade-offs between correctly identifying more actual cases versus incorrectly predicting cases.
- Examples of UK projects that use predictive risk modeling to stratify patient populations and target case management or other interventions to high-risk groups, with the aim of improving outcomes and reducing health care costs.
Judith Smith and Chris Ham: Commissioning integrated care - what role for cli...The King's Fund
Dr Judith Smith, Head of Policy at the Nuffield Trust, and Professor Chris Ham, Chief Executive of The King’s Fund, share the findings of their recent research into how NHS commissioners have been commissioning better integrated services and care for people in local areas.
Slides from the workshop 'A modern vision of integrated care and support' led by Dr Martin McShane, Dr Damian Riley (NHS England) and David Pearson (ADASS) - NHS Medical Leaders Conference 2014. - See more at: http://www.icase.org.uk/pg/cv_content/content/view/98680#sthash.45Xs2o9r.dpuf
Chris Ham on making integrated care happen at scale and paceThe King's Fund
Chris Ham, Chief Executive at The King’s Fund, highlights the 16 lessons needed to make a reality of integrated care, drawing on work by the Fund and others to provide examples of good practice.
Steve Laitner on integrated care - innovations in the UKThe King's Fund
Dr Steve Laitner, GP and Associate Medical Director of NHS East of England, discusses integrated care innovations in the UK with a focus on pathway hubs.
Judith Smith and Chris Ham: Commissioning integrated care - what role for cli...The King's Fund
Dr Judith Smith, Head of Policy at the Nuffield Trust, and Professor Chris Ham, Chief Executive of The King’s Fund, share the findings of their recent research into how NHS commissioners have been commissioning better integrated services and care for people in local areas.
Slides from the workshop 'A modern vision of integrated care and support' led by Dr Martin McShane, Dr Damian Riley (NHS England) and David Pearson (ADASS) - NHS Medical Leaders Conference 2014. - See more at: http://www.icase.org.uk/pg/cv_content/content/view/98680#sthash.45Xs2o9r.dpuf
Chris Ham on making integrated care happen at scale and paceThe King's Fund
Chris Ham, Chief Executive at The King’s Fund, highlights the 16 lessons needed to make a reality of integrated care, drawing on work by the Fund and others to provide examples of good practice.
Steve Laitner on integrated care - innovations in the UKThe King's Fund
Dr Steve Laitner, GP and Associate Medical Director of NHS East of England, discusses integrated care innovations in the UK with a focus on pathway hubs.
NICE have now published three guidelines which are relevant to the care and support of older people:
Home care: delivering personal care and practical support to older people living in their own homes
Transition between inpatient hospital settings and community or care home settings for adults with social care needs
Older people with social care needs and multiple long-term conditions
Alongside hosting three workshops, the NICE Collaborating Centre for Social Care is hosting a FREE webinar to introduce these guidelines together and enable frontline practitioners and managers to consider how they can support practice improvement.
Presentación de Nick Goodwin y Judith Smith en el proyecto de The King’s Fund y the Nuffield Trust: "Developing a National Strategy for the Promotion of Integrated Care"
Joint Strategic Commissioning is at the heart of the Public Bodies (Joint Working) Bill. JIT has recently issued guidance on what Partnerships need to do in order to develop Strategic Plans that incorporate a Financial Plan, relating to all integrated resources, by April 2015. This session provides an opportunity to further explore the scale and scope of what partnerships are required to do to deliver on the opportunities and ambitions of integrated health and social care. Contributed by: Joint Improvement Team
Allied health professions as agents of change in reshaping care E33 (1#2)Sophie40
AHPs are uniquely placed in delivering outcomes for integration as they already work across health, social care and the third sector. This workshop will highlight some innovative examples of partnership working, pose questions and initiate debate. Key themes explored will include how putting the person at the centre can improve the individuals care and experience and how self-management and enablement can empower individuals, families and carers. Contributed by: Scottish Government - Allied Health Professionals team
Allied health professions as agents of change and reshaping care E33 (2#2)Sophie40
AHPs are uniquely placed in delivering outcomes for integration as they already work across health, social care and the third sector. This workshop will highlight some innovative examples of partnership working, pose questions and initiate debate. Key themes explored will include how putting the person at the centre can improve the individuals care and experience and how self-management and enablement can empower individuals, families and carers.
Contributed by: Scottish Government - Allied Health Professionals team
Nick Goodwin - Bringing integrated care to lifeAge UK
Dr Nick Goodwin, Senior Fellow, The King's Fund - presentation from Age UK's For Later Life conference, 25th April.
For more information: www.ageuk.org.uk/forlaterlife
Slides - 'Devolution of Health and Social Care to UK Cities' event at Leeds B...HWBPolicy Leeds
The slides from Dr Judith Smith (University of Birmingham) and Warren Heppolette (Greater Manchester) which were shown as part of the public lecture and panel discussion at Leeds Beckett University on 'Devolution of Health and Social Care to UK Cities'. Slides with thanks to Judith and Warren.
Primary care in Europe: can we make it fit for the future?Nuffield Trust
In this slideshow, we explore how and why primary care organisation and delivery needs to change and the factors driving this.
We draw on case studies from various European primary care experts who presented at the European Health Summit 2013, an event supported by KPMG, to review the extent to which different models of primary care are already achieving the characteristics of successful primary care, and how they are doing this.
NICE have now published three guidelines which are relevant to the care and support of older people:
Home care: delivering personal care and practical support to older people living in their own homes
Transition between inpatient hospital settings and community or care home settings for adults with social care needs
Older people with social care needs and multiple long-term conditions
Alongside hosting three workshops, the NICE Collaborating Centre for Social Care is hosting a FREE webinar to introduce these guidelines together and enable frontline practitioners and managers to consider how they can support practice improvement.
Presentación de Nick Goodwin y Judith Smith en el proyecto de The King’s Fund y the Nuffield Trust: "Developing a National Strategy for the Promotion of Integrated Care"
Joint Strategic Commissioning is at the heart of the Public Bodies (Joint Working) Bill. JIT has recently issued guidance on what Partnerships need to do in order to develop Strategic Plans that incorporate a Financial Plan, relating to all integrated resources, by April 2015. This session provides an opportunity to further explore the scale and scope of what partnerships are required to do to deliver on the opportunities and ambitions of integrated health and social care. Contributed by: Joint Improvement Team
Allied health professions as agents of change in reshaping care E33 (1#2)Sophie40
AHPs are uniquely placed in delivering outcomes for integration as they already work across health, social care and the third sector. This workshop will highlight some innovative examples of partnership working, pose questions and initiate debate. Key themes explored will include how putting the person at the centre can improve the individuals care and experience and how self-management and enablement can empower individuals, families and carers. Contributed by: Scottish Government - Allied Health Professionals team
Allied health professions as agents of change and reshaping care E33 (2#2)Sophie40
AHPs are uniquely placed in delivering outcomes for integration as they already work across health, social care and the third sector. This workshop will highlight some innovative examples of partnership working, pose questions and initiate debate. Key themes explored will include how putting the person at the centre can improve the individuals care and experience and how self-management and enablement can empower individuals, families and carers.
Contributed by: Scottish Government - Allied Health Professionals team
Nick Goodwin - Bringing integrated care to lifeAge UK
Dr Nick Goodwin, Senior Fellow, The King's Fund - presentation from Age UK's For Later Life conference, 25th April.
For more information: www.ageuk.org.uk/forlaterlife
Slides - 'Devolution of Health and Social Care to UK Cities' event at Leeds B...HWBPolicy Leeds
The slides from Dr Judith Smith (University of Birmingham) and Warren Heppolette (Greater Manchester) which were shown as part of the public lecture and panel discussion at Leeds Beckett University on 'Devolution of Health and Social Care to UK Cities'. Slides with thanks to Judith and Warren.
Primary care in Europe: can we make it fit for the future?Nuffield Trust
In this slideshow, we explore how and why primary care organisation and delivery needs to change and the factors driving this.
We draw on case studies from various European primary care experts who presented at the European Health Summit 2013, an event supported by KPMG, to review the extent to which different models of primary care are already achieving the characteristics of successful primary care, and how they are doing this.
Nick Goodwin: making a success of care co-ordinationThe King's Fund
Nick Goodwin, Chief Executive at the International Foundation for Integrated Care, looks at how care could be better co-ordinated around people with complex needs, and the challenges around delivering joined-up care.
Integrando los servicios sociales y sanitarios. Una vision desde la internati...Societat Gestió Sanitària
Ponencia a cargo del médico geriatra Marco Inzitari, director de Atención Intermedia, Investigación y Docencia del Parc Sanitari Pere Virgili, en el marco de la VI Jornada Right Care sobre Modelos avanzados en integración de servicios sociales y sanitarios, organizada por la Societat Catalana de Gestió Sanitària el 24 de mayo de 2019.
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
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
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.