LTC Year of Care Commissioning Model
Lesley A Callow, Delivery Support Manager - Long Term Conditions Year of Care Commissioning Model
NHSIQ
Fionuala Bonnar, Year of Care Programme Manager
LTC Year of Care benefits:
Improved outcomes and wellbeing:
Patients receive care that is better managed, more seamless across different care services and more needs focused.
Reduction in acute admissions to hospital; and shorter lengths of stay when these are required.
Clinical professionals contribute to a more holistic service for patients by working within an integrated patient-centred care plan
Local health and Social Care economies:
Provide care that delivers value for money and is better managed by integrated teams.
Incentive to improve services for patients
Improved joint working and shared responsibility for outcomes
This document provides an agenda and information for a workshop on proactive health coaching for the Long Term Conditions Year of Care Commissioning Early Implementer Sites. The workshop will include presentations on proactive health coaching from Health Navigator Ltd and case studies of patients who received proactive health coaching. One case study describes a female patient in her mid-60s with a history of syncope, anxiety, social isolation, and past sexual abuse who had 15 emergency department attendances and 10 hospital admissions in the past year. After 133 days in a proactive health coaching program, she has had only 2 emergency department attendances and no admissions. The coaching helped her recognize triggers for her syncope episodes and develop strategies to avoid stressful situations. A second
Fire service as an asset: providing telecare support in the community Webinar...NHS Improving Quality
Guest speaker: Steve Vincent - West Midlands Fire Service & Simon Brake from Coventry Council
Hosted by: Bev Matthews, Long Term Conditions Programme Lead, NHS England
Learning Outcomes:-
To better understand the role that the Fire and Rescue service can provide as a community asset to support health needs Enhancing the quality of life for people by supporting them to stay in their own home, even in a crisis
LTC year of care commissioning early implementer sites workshop held on 1 December 2014. Featuring Dr Martin McShane, Rob Meaker and Renata Drinkwater.
Using models-of-care-to-understand-the-impact-of-networks-of-care-for-lt csNHS Improving Quality
The document discusses using models of care to understand the impact of networks of care for long term conditions. It describes a patient-centered "House of Care" framework for delivering coordinated care to people with long term conditions. The House of Care aims to provide person-centered care that addresses all of a patient's needs at both the local level, through integrated systems involving health, social care and other services, and at the personal level through care planning and self-management support. Implementing the House of Care framework could save the NHS money by reducing unplanned hospital admissions and empowering patients.
Presentation slides Frailty: building understanding, empathy and the skills t...NHS Improving Quality
Frailty: building understanding, empathy and the skills to support self-care
Guest speaker:Dr Dawn Moody, Director - Fusion48
An opportunity to learn about some innovative approaches to making the health and care workforce 'Fit for Frailty'* (*British Geriatrics Society 2015).
Learning outcomes:
To explore the Frailty Fulcrum as a tool for holistic assessment and management of frailty
To hear how Virtual Reality is being used to build empathy for older people living with frailty
To learn about the impact of a county-wide, multi-agency, multi-professional training an toolkit for care professionals working with older people
Resources:www.fusion48.net
Electronic Palliative Care Coordination Systems (EPaCCS): Improving Patient C...NHS Improving Quality
Speaker slides from the national conference, 'Electronic Palliative Care Coordination Systems (EPaCCS): Improving Patient Care at End of Life', 17 March 2016
NHS England and partners have published six Quick Guides to bring clarity on how best to work with the care sector. They can be accessed at www.nhs.uk/quickguides
Want to find out how the care sector can support local systems in the run up to winter? Want to break down barriers between health and care organisations? Want to find out how Leicester has achieved a 60% reduction in care home admission costs? Want to finally break down the myths around sharing patient information and assessments? Want to use other people's ideas and resources?
Webinar outcomes:
Introduction to the care homes quick guides
Two examples of models referenced in the guides:
- Angela Dempsey, Baker Tilly on the Quest4care tool
- Dawn Moody on MDT working and a model implemented in a CCG
Guest Speakers: Nicola Spencer and Emily Carter - NHS England
LTC Year of Care Commissioning Model
Lesley A Callow, Delivery Support Manager - Long Term Conditions Year of Care Commissioning Model
NHSIQ
Fionuala Bonnar, Year of Care Programme Manager
LTC Year of Care benefits:
Improved outcomes and wellbeing:
Patients receive care that is better managed, more seamless across different care services and more needs focused.
Reduction in acute admissions to hospital; and shorter lengths of stay when these are required.
Clinical professionals contribute to a more holistic service for patients by working within an integrated patient-centred care plan
Local health and Social Care economies:
Provide care that delivers value for money and is better managed by integrated teams.
Incentive to improve services for patients
Improved joint working and shared responsibility for outcomes
This document provides an agenda and information for a workshop on proactive health coaching for the Long Term Conditions Year of Care Commissioning Early Implementer Sites. The workshop will include presentations on proactive health coaching from Health Navigator Ltd and case studies of patients who received proactive health coaching. One case study describes a female patient in her mid-60s with a history of syncope, anxiety, social isolation, and past sexual abuse who had 15 emergency department attendances and 10 hospital admissions in the past year. After 133 days in a proactive health coaching program, she has had only 2 emergency department attendances and no admissions. The coaching helped her recognize triggers for her syncope episodes and develop strategies to avoid stressful situations. A second
Fire service as an asset: providing telecare support in the community Webinar...NHS Improving Quality
Guest speaker: Steve Vincent - West Midlands Fire Service & Simon Brake from Coventry Council
Hosted by: Bev Matthews, Long Term Conditions Programme Lead, NHS England
Learning Outcomes:-
To better understand the role that the Fire and Rescue service can provide as a community asset to support health needs Enhancing the quality of life for people by supporting them to stay in their own home, even in a crisis
LTC year of care commissioning early implementer sites workshop held on 1 December 2014. Featuring Dr Martin McShane, Rob Meaker and Renata Drinkwater.
Using models-of-care-to-understand-the-impact-of-networks-of-care-for-lt csNHS Improving Quality
The document discusses using models of care to understand the impact of networks of care for long term conditions. It describes a patient-centered "House of Care" framework for delivering coordinated care to people with long term conditions. The House of Care aims to provide person-centered care that addresses all of a patient's needs at both the local level, through integrated systems involving health, social care and other services, and at the personal level through care planning and self-management support. Implementing the House of Care framework could save the NHS money by reducing unplanned hospital admissions and empowering patients.
Presentation slides Frailty: building understanding, empathy and the skills t...NHS Improving Quality
Frailty: building understanding, empathy and the skills to support self-care
Guest speaker:Dr Dawn Moody, Director - Fusion48
An opportunity to learn about some innovative approaches to making the health and care workforce 'Fit for Frailty'* (*British Geriatrics Society 2015).
Learning outcomes:
To explore the Frailty Fulcrum as a tool for holistic assessment and management of frailty
To hear how Virtual Reality is being used to build empathy for older people living with frailty
To learn about the impact of a county-wide, multi-agency, multi-professional training an toolkit for care professionals working with older people
Resources:www.fusion48.net
Electronic Palliative Care Coordination Systems (EPaCCS): Improving Patient C...NHS Improving Quality
Speaker slides from the national conference, 'Electronic Palliative Care Coordination Systems (EPaCCS): Improving Patient Care at End of Life', 17 March 2016
NHS England and partners have published six Quick Guides to bring clarity on how best to work with the care sector. They can be accessed at www.nhs.uk/quickguides
Want to find out how the care sector can support local systems in the run up to winter? Want to break down barriers between health and care organisations? Want to find out how Leicester has achieved a 60% reduction in care home admission costs? Want to finally break down the myths around sharing patient information and assessments? Want to use other people's ideas and resources?
Webinar outcomes:
Introduction to the care homes quick guides
Two examples of models referenced in the guides:
- Angela Dempsey, Baker Tilly on the Quest4care tool
- Dawn Moody on MDT working and a model implemented in a CCG
Guest Speakers: Nicola Spencer and Emily Carter - NHS England
Transforming care for learning disabilitiesNHS England
The document summarizes key findings from the Health and Social Care Information Centre's 2013 Learning Disabilities Census report for England. It finds that over two-thirds (68.3%) of the 3,250 service users surveyed across 104 provider organizations had been prescribed antipsychotic medication. Additionally, nearly half (47.4%) of service users had been prescribed antidepressant medication. The document suggests these findings indicate high rates of psychotropic medication prescription among people with learning disabilities in England.
The document discusses using simulation modeling to assess the impact of proposed changes to healthcare services for patients with long-term conditions and complex care needs. It provides examples of scenarios that were modeled, including transferring some resources from unscheduled to community care. The online simulation tool allows users to input different scenarios, compare results to baseline data, and share scenarios with other users. The tool aims to help healthcare organizations test potential service changes before implementing them.
Midlands and East GP Forward View access update event July 2017NHS England
A presentation from the GP Forward View update event in July 2017 for Midlands and East, giving the latest information on improved access to primary care.
Commissioning Integrated models of care
Kent LTC Year of Care Commissioning Early Implementer Site
Alison Davis, Integration Programme Health and Social Care, Working on behalf of Kent County Council and South Kent Coast and Thanet CCG's
Integrated data to support service redesign decision making 19 01 2016 finalNHS Improving Quality
Integrated data to support service redesign decision making
Leeds LTC Year of Care Commissioning Early Implementer Site
Tricia Cable, Year of Care Lead
Alison Phiri, Business Intelligence Manager
Mohini Chauhan, Year of Care Commissioning Manager
Learning Disabilities: Share and Learn Webinar – 27 July 2017NHS England
Topic One: Transforming care for children and young people with autism
Guest speakers: Sarah Jackson and David Gill, NHS England and Pat Smith, Autism East Midlands
This webinar looks at some of the challenges seen, such as gaps in provision for children and young people with autism, and will discuss some of the work that is taking place to address these issues.
Topic Two: “The assuring transformation data system” - how to upload data and run reports
Guest speakers: Andy Tookey, NHS England and Judith Ellison and Sarah Freeman, NHS Digital
This webinar is aimed at people who are new to reporting assuring transformation (AT) data or who are unsure how to run reports.
Slides from a lunch and learn webinar hosted by NHS England's Long Term Conditions Team, on the topic of health coaching by lay professionals.
The speakers and Anya de Longh and Jim Phillips.
The document summarizes the key themes of the NHS 5 Year Forward View plan. It outlines the plan's vision for new models of integrated care focused on populations of 50,000 people. The plan acknowledges an estimated annual funding gap of £30 billion by 2020/21 for the NHS and the need for efficiency savings and increased funding. It also emphasizes the importance of prevention, personalization, technology, and social determinants of health for a sustainable healthcare system.
New Care Models - the story so far, pop up uni, 2pm, 3 september 2015NHS England
Expo is the most significant annual health and social care event in the calendar, uniting more NHS and care leaders, commissioners, clinicians, voluntary sector partners, innovators and media than any other health and care event.
Expo 15 returned to Manchester and was hosted once again by NHS England. Around 5000 people a day from health and care, the voluntary sector, local government, and industry joined together at Manchester Central Convention Centre for two packed days of speakers, workshops, exhibitions and professional development.
This year, Expo was more relevant and engaging than ever before, happening within the first 100 days of the new Government, and almost 12 months after the publication of the NHS Five Year Forward View. It was also a great opportunity to check on and learn from the progress of Greater Manchester as the area prepares to take over a £6 billion devolved health and social care budget, pledging to integrate hospital, community, primary and social care and vastly improve health and well-being.
More information is available online: www.expo.nhs.uk
This document provides an overview and summary of the planning guidance for the NHS in England for 2015/16. It outlines the key priorities and requirements for the coming year which include maintaining performance standards, implementing new models of care, improving prevention, workforce development, digital transformation, and driving efficiency. Local areas are encouraged to develop plans that align commissioner and provider budgets and activity in line with the priorities of the Five Year Forward View.
Transforming Care: Share and Learn Webinar – 31 August 2017NHS England
Helping people with a learning disability to give feedback
Guest Speakers: Ruth Hudson - Insight Specialist, Joe Penrose - Insight and Feedback Officer, Katie Matthews, Aaron Oxford and Thomas Chalk - Learning Disability Network Managers
NHS England’s Insight and Learning Disability Engagement teams recently published their bite-size guide to helping people with a learning disability to give feedback.
The webinar is aimed at staff who do not have much experience of involving people with a learning disability in giving feedback. It is of particular interest to staff working in Patient Experience and Communication and Engagement roles. Most of the services people with a learning disability use are the same services as everyone else, and so it is important they are included in feedback and engagement work. Join the teams on the webinar to find out more about increasing the representation of one of the most seldom heard groups of people.
Midlands and East GP Forward View update event May 2017NHS England
A presentation from the GP Forward View update event in May 2017 for Midlands and East, giving the latest information on what the Forward View is delivering.
Keynote - Future of primary care networksNHS England
The document summarizes the key themes and learnings from the National ICS Primary Care Development Programme in the UK. The three main points are:
1) Primary care networks are being established to improve coordination of care across practices and community services for populations of 30,000-50,000 people. This allows for integrated working at the right scale.
2) Five themes are emerging around empowering primary care through equal partnerships, understanding population needs to target care, managing resources and reducing variation, integrated working across services, and networks working at the right scale.
3) Early results show the new models are starting to have an impact, with a 15% reduction in referrals and emergency admissions in one integrated care
CNO Summit 2015 - New Care Models, Sam jonesNHS England
The document summarizes the NHS Five Year Forward View and the new care models program, which aims to address challenges facing the NHS through five new care models: multispecialty community providers, integrated primary and acute care systems, acute care collaboration, enhanced health in care homes, and urgent and emergency care. It outlines the 50 vanguards selected to pioneer these new care models and the support provided to help them implement changes.
The document discusses the NHS Digital Academy, which will be responsible for ensuring international excellence in training and education for clinical information officers and other digital health leaders. The Academy will support leaders from exemplar NHS trusts and complement existing workforce development programs. It will include distance learning, partnerships with international organizations, and experiential learning through digital health projects at exemplar sites. The document also briefly mentions the MyNHS data visualization and customization tool, as well as new domains for conditions like dementia and diabetes. Finally, it outlines plans to launch an online triage service for NHS 111.
This document discusses how the Healthcare Quality Improvement Partnership (HQIP) supports quality improvement through various programs and tools. HQIP manages the National Clinical Audit Programme which includes 34 national audits across different clinical areas. It also oversees other national programmes focused on specific topics like learning disabilities. HQIP helps align quality improvement programs with NICE guidance and standards. Tools like clinical audits and the Quality Standard Service Improvement Template help providers assess current practice against standards and plan improvements. NICE guidance and quality standards can support quality improvement when implemented using these resources.
How will Sustainability and Transformation Plans (STPs) help deliver the Five Year Forward View?
Matthew Swindells and Simon Enright, NHS England, and Julia Ross, North West Surrey CCG
Day One, Pop-up University 7, 10.00
Shubham Goel (Contact Center Manager) - ResumeShubham Goel
Shubham Goel is seeking a challenging position that allows him to enhance his skills and contribute to organizational goals. He has over 9 years of experience in the service industry, including roles as a Contact Center Manager and Assistant Manager of Operations. He is skilled in team management, customer relationships, and driving process excellence. Currently, he is pursuing an MBA in International Business and Marketing from IMT Ghaziabad.
The document introduces Magnet Code 3.0, a smartphone controller platform that allows existing microcontroller and laptop projects to be enhanced by integrating smartphone features. It allows microcontroller projects to be controlled and monitored remotely from a smartphone. Some key benefits outlined include adding features like cameras, sensors, GPS and more. The document provides an overview of Magnet Code's features and toolbox modules, instructions for setup, and examples of how it can transform old projects into more advanced solutions.
Transforming care for learning disabilitiesNHS England
The document summarizes key findings from the Health and Social Care Information Centre's 2013 Learning Disabilities Census report for England. It finds that over two-thirds (68.3%) of the 3,250 service users surveyed across 104 provider organizations had been prescribed antipsychotic medication. Additionally, nearly half (47.4%) of service users had been prescribed antidepressant medication. The document suggests these findings indicate high rates of psychotropic medication prescription among people with learning disabilities in England.
The document discusses using simulation modeling to assess the impact of proposed changes to healthcare services for patients with long-term conditions and complex care needs. It provides examples of scenarios that were modeled, including transferring some resources from unscheduled to community care. The online simulation tool allows users to input different scenarios, compare results to baseline data, and share scenarios with other users. The tool aims to help healthcare organizations test potential service changes before implementing them.
Midlands and East GP Forward View access update event July 2017NHS England
A presentation from the GP Forward View update event in July 2017 for Midlands and East, giving the latest information on improved access to primary care.
Commissioning Integrated models of care
Kent LTC Year of Care Commissioning Early Implementer Site
Alison Davis, Integration Programme Health and Social Care, Working on behalf of Kent County Council and South Kent Coast and Thanet CCG's
Integrated data to support service redesign decision making 19 01 2016 finalNHS Improving Quality
Integrated data to support service redesign decision making
Leeds LTC Year of Care Commissioning Early Implementer Site
Tricia Cable, Year of Care Lead
Alison Phiri, Business Intelligence Manager
Mohini Chauhan, Year of Care Commissioning Manager
Learning Disabilities: Share and Learn Webinar – 27 July 2017NHS England
Topic One: Transforming care for children and young people with autism
Guest speakers: Sarah Jackson and David Gill, NHS England and Pat Smith, Autism East Midlands
This webinar looks at some of the challenges seen, such as gaps in provision for children and young people with autism, and will discuss some of the work that is taking place to address these issues.
Topic Two: “The assuring transformation data system” - how to upload data and run reports
Guest speakers: Andy Tookey, NHS England and Judith Ellison and Sarah Freeman, NHS Digital
This webinar is aimed at people who are new to reporting assuring transformation (AT) data or who are unsure how to run reports.
Slides from a lunch and learn webinar hosted by NHS England's Long Term Conditions Team, on the topic of health coaching by lay professionals.
The speakers and Anya de Longh and Jim Phillips.
The document summarizes the key themes of the NHS 5 Year Forward View plan. It outlines the plan's vision for new models of integrated care focused on populations of 50,000 people. The plan acknowledges an estimated annual funding gap of £30 billion by 2020/21 for the NHS and the need for efficiency savings and increased funding. It also emphasizes the importance of prevention, personalization, technology, and social determinants of health for a sustainable healthcare system.
New Care Models - the story so far, pop up uni, 2pm, 3 september 2015NHS England
Expo is the most significant annual health and social care event in the calendar, uniting more NHS and care leaders, commissioners, clinicians, voluntary sector partners, innovators and media than any other health and care event.
Expo 15 returned to Manchester and was hosted once again by NHS England. Around 5000 people a day from health and care, the voluntary sector, local government, and industry joined together at Manchester Central Convention Centre for two packed days of speakers, workshops, exhibitions and professional development.
This year, Expo was more relevant and engaging than ever before, happening within the first 100 days of the new Government, and almost 12 months after the publication of the NHS Five Year Forward View. It was also a great opportunity to check on and learn from the progress of Greater Manchester as the area prepares to take over a £6 billion devolved health and social care budget, pledging to integrate hospital, community, primary and social care and vastly improve health and well-being.
More information is available online: www.expo.nhs.uk
This document provides an overview and summary of the planning guidance for the NHS in England for 2015/16. It outlines the key priorities and requirements for the coming year which include maintaining performance standards, implementing new models of care, improving prevention, workforce development, digital transformation, and driving efficiency. Local areas are encouraged to develop plans that align commissioner and provider budgets and activity in line with the priorities of the Five Year Forward View.
Transforming Care: Share and Learn Webinar – 31 August 2017NHS England
Helping people with a learning disability to give feedback
Guest Speakers: Ruth Hudson - Insight Specialist, Joe Penrose - Insight and Feedback Officer, Katie Matthews, Aaron Oxford and Thomas Chalk - Learning Disability Network Managers
NHS England’s Insight and Learning Disability Engagement teams recently published their bite-size guide to helping people with a learning disability to give feedback.
The webinar is aimed at staff who do not have much experience of involving people with a learning disability in giving feedback. It is of particular interest to staff working in Patient Experience and Communication and Engagement roles. Most of the services people with a learning disability use are the same services as everyone else, and so it is important they are included in feedback and engagement work. Join the teams on the webinar to find out more about increasing the representation of one of the most seldom heard groups of people.
Midlands and East GP Forward View update event May 2017NHS England
A presentation from the GP Forward View update event in May 2017 for Midlands and East, giving the latest information on what the Forward View is delivering.
Keynote - Future of primary care networksNHS England
The document summarizes the key themes and learnings from the National ICS Primary Care Development Programme in the UK. The three main points are:
1) Primary care networks are being established to improve coordination of care across practices and community services for populations of 30,000-50,000 people. This allows for integrated working at the right scale.
2) Five themes are emerging around empowering primary care through equal partnerships, understanding population needs to target care, managing resources and reducing variation, integrated working across services, and networks working at the right scale.
3) Early results show the new models are starting to have an impact, with a 15% reduction in referrals and emergency admissions in one integrated care
CNO Summit 2015 - New Care Models, Sam jonesNHS England
The document summarizes the NHS Five Year Forward View and the new care models program, which aims to address challenges facing the NHS through five new care models: multispecialty community providers, integrated primary and acute care systems, acute care collaboration, enhanced health in care homes, and urgent and emergency care. It outlines the 50 vanguards selected to pioneer these new care models and the support provided to help them implement changes.
The document discusses the NHS Digital Academy, which will be responsible for ensuring international excellence in training and education for clinical information officers and other digital health leaders. The Academy will support leaders from exemplar NHS trusts and complement existing workforce development programs. It will include distance learning, partnerships with international organizations, and experiential learning through digital health projects at exemplar sites. The document also briefly mentions the MyNHS data visualization and customization tool, as well as new domains for conditions like dementia and diabetes. Finally, it outlines plans to launch an online triage service for NHS 111.
This document discusses how the Healthcare Quality Improvement Partnership (HQIP) supports quality improvement through various programs and tools. HQIP manages the National Clinical Audit Programme which includes 34 national audits across different clinical areas. It also oversees other national programmes focused on specific topics like learning disabilities. HQIP helps align quality improvement programs with NICE guidance and standards. Tools like clinical audits and the Quality Standard Service Improvement Template help providers assess current practice against standards and plan improvements. NICE guidance and quality standards can support quality improvement when implemented using these resources.
How will Sustainability and Transformation Plans (STPs) help deliver the Five Year Forward View?
Matthew Swindells and Simon Enright, NHS England, and Julia Ross, North West Surrey CCG
Day One, Pop-up University 7, 10.00
Shubham Goel (Contact Center Manager) - ResumeShubham Goel
Shubham Goel is seeking a challenging position that allows him to enhance his skills and contribute to organizational goals. He has over 9 years of experience in the service industry, including roles as a Contact Center Manager and Assistant Manager of Operations. He is skilled in team management, customer relationships, and driving process excellence. Currently, he is pursuing an MBA in International Business and Marketing from IMT Ghaziabad.
The document introduces Magnet Code 3.0, a smartphone controller platform that allows existing microcontroller and laptop projects to be enhanced by integrating smartphone features. It allows microcontroller projects to be controlled and monitored remotely from a smartphone. Some key benefits outlined include adding features like cameras, sensors, GPS and more. The document provides an overview of Magnet Code's features and toolbox modules, instructions for setup, and examples of how it can transform old projects into more advanced solutions.
The Zika virus has spread to more than 50 countries, including the United States. In fact, Texas recorded its first case of locally-acquired Zika in November 2016. Here is some basic information to help you protect yourself and your family.
The document discusses the benefits of meditation for reducing stress and anxiety. It states that meditation can calm the mind and body by lowering heart rate and easing muscle tension. Regular meditation of 10-20 minutes per day is recommended to experience positive effects on both mental and physical health.
This document provides a summary of Muhammad Aamir's qualifications and work experience. It includes his contact information, objective of seeking a suitable position, competencies including sales and customer service skills, and work history in sales and marketing roles at Mideast Metals FZCO and Belhasa Driving Center Dubai where he gained experience in areas like sales, procurement, and fleet coordination. It also lists his educational qualifications and computer skills.
adaQuest is a company that helps clients build strategies and capabilities to meet new challenges through a variety of consulting, project management, and software development services. It allows clients to choose the right combination of services needed and provides experts to help accomplish goals with precise cost control. Clients can control their strategy and operations through a flexible outsourcing model where they only pay for work produced.
The document outlines the roles and responsibilities of a Manager - Managed Services Assurance - Service Management position over 3 pages. The roles include: 1) managing customer service portfolios and network diagrams; 2) overseeing incident, service level, and change management; 3) maintaining business relationships and providing performance reports; 4) handling financial management, capacity management, and partner management; 5) fulfilling orders and ensuring service availability; 6) developing processes, service improvement plans, and leading a team of service managers; and 7) interacting with other functions to promote customer satisfaction and knowledge sharing.
Devolved powers 'the Manchester story' - Elderly care conference 2015, Jessic...Browne Jacobson LLP
The document outlines several workstreams and initiatives to transform primary care in Greater Manchester. It discusses establishing leadership and governance structures, devolving responsibilities and resources, and enabling strategies around areas like workforce, communications, and digital integration. Key priorities for primary care include developing multidisciplinary care teams, improving access through digital technology and increased services, and a focus on quality and joining up care between primary, community, and secondary services. Standards are being developed and implemented to provide same-day access to primary care seven days a week by the end of 2015.
Commissioning for outcomes,
Wednesday 21 January 2015 - 13.00 to 13.45
Hosted by Bob Ricketts CBE, Director of Commissioning Support Services and Market Development for NHS England.
Sharing and Learning Together to Deliver High Quality End of Life Care for AllNHS Improving Quality
Sharing and Learning Together to Deliver High Quality End of Life Care for All
Presentations from the Sharing and Learning Together to Deliver High Quality End of Life Care for All event held on
Tuesday 24 June 2014, Congress Centre, London, WC1B 3LS
#nhsiqeolcare
Population Level Commissioning for the Future
Wednesday 3 December 2014, 1pm – 1.45pm
Dr Abraham George
Assistant Director/Consultant in Public Health
Kent County Council
&
Beverley Matthews
LTC Programme Lead, NHS Improving Quality
NIHR CLAHRC East Midlands Annual Meeting 2015 presentations - Day 2CLAHRC-NDL
This document summarizes the proceedings of the NIHR CLAHRC East Midlands annual meeting on March 25, 2015. The meeting brought together partners from Nottinghamshire Healthcare NHS Foundation Trust and the Universities of Nottingham and Leicester to share progress and learning over the past year. Key highlights included 18 research projects making progress, over £500,000 in matched funding received, and the establishment of a 90-member faculty. The East Midlands AHSN discussed supporting implementation of CLAHRC projects through knowledge brokers and £525,000 in funding. Presentations also covered priority areas like individual placement and support for employment, bipolar disorder research, and building effective partnerships across the region.
Making Seven Day Services a reality, pop up uni, 2 pm, 3 september 2015NHS England
Following discussions on reducing weekend mortality rates, four clinical standards were identified as having the most impact: timely consultant review, access to diagnostics, access to interventions, and ongoing review. Each NHS trust was asked to complete a self-assessment tool to establish a baseline for meeting these standards by September 2015. The results will be used to track national progress in implementing seven-day services. Key lessons from early adopter sites included the importance of workforce, shared vision, increased partnerships, measurement, leadership, and patient experience.
Human: Thank you for the summary. Summarize the following section of the document:
Step Up Step Down - Key Outcomes
- Monthly report and dashboard to measure:
- Number
The document provides an overview of the National End of Life Care Update in the UK by Prof Bee Wee. It discusses the NHS Long Term Plan's focus on personalizing end of life care and introducing proactive care planning for those in their last year of life. It also outlines new service models for older people, children, and young people. The document summarizes reforms to the GP Quality and Outcomes Framework to improve early identification of those nearing end of life. Priorities and approaches for 2019/20 are presented, including responding to challenges in end of life care.
Professor Kamlesh Khunti - Introduction to CLAHRC East MidlandsCLAHRC-NDL
Professor Kamlesh Khunti, Director of NIHR CLAHRC East Midlands - Introductory presentation given at CLAHRC East Midlands launch event, 14 February 2014, Loughborough.
Greater Manchester's visionary approach to integrated care
Delivered by the Greater Manchester Health and Social Care Partnership
Day Two, Pop-up University 8, 16.00
This document discusses personal health budgets in the UK NHS. It provides background on personal health budgets, which allow patients more choice and control over how their health needs are met. The document outlines several pilots of personal health budgets, including one focused on delivering them in end-of-life care. It shares early experiences from different pilot sites, finding that personal health budgets improved outcomes and choices for patients while often costing less than traditional care packages. The document provides resources for learning more about personal health budgets and their implementation in the NHS.
CNO Summit 2015 - Commissioning Nurse Leaders, Jane CummingsNHS England
The document discusses the Commissioning Nurse Leaders Network established in 2013 by NHS England to support senior nurse leaders in clinical commissioning groups. It provides information on membership, which includes over 350 chief nurses and their deputies. The network hosts events and webinars on topics like the 5 Year Forward View and quality improvement. Examples are given of how commissioning nurses are leading change by transforming services, sharing child health information, safeguarding vulnerable children and groups, and developing system leaders.
UCLP is considering its role and focus as Academic Health Science Networks (AHSNs) are launched across England. It has made progress in recent projects but seeks members' views on its future direction. Options discussed include:
1) Maintaining its current geography and partners or expanding further north to include Anglia Ruskin Health Partnership and Hertfordshire
2) Balancing the benefits of increased scale with additional logistical challenges of more partners
3) Continuing to focus on research, education, project delivery, and improving healthcare across both AHSC and AHSN functions
Members' input will help shape UCLP's evolving role in an "AHSN world".
The document discusses challenges facing the NHS in England and reforms proposed to address them. It outlines population aging and rising chronic disease prevalence as challenges. The Five Year Forward View proposes integrated primary and community care networks and greater emphasis on prevention. However, public health budgets are being cut even as needs rise. The success of reforms will depend on evaluation of outcomes, efficiency, experiences and the impact of funding changes.
The NHS 5 Year Plan -Neil Goulbourne presentationmckenln
The document discusses the implementation of the NHS Five Year Forward View. It outlines three key gaps - in prevention, care models, and funding - that must be addressed. It then describes five new care models being tested, including integrated primary/acute care systems and multispecialty community providers. Local health systems are invited to develop new models that can be replicated nationally to transform care delivery and close the gaps.
The document summarizes the progress of integrated health and social care in the UK. It discusses initiatives in Northern Ireland, Scotland, and Wales to integrate services through organizational structures and partnerships. In England, integrated care efforts have focused on developing new payment models, leadership programs, and evaluating 14 pioneer sites demonstrating innovative integrated models of care. While challenges remain, the government is committed to supporting integration through aligned policies, incentives, and a long-term strategy focused on improving outcomes for individuals.
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Long Term Conditions Year of Care Commissioning Programme - Early Implementer Site workshop - 14 May 2015
1. WELCOME
LTC Year of Care Commissioning
Early Implementer Sites Workshop
14th May 2015
2. Plan for the day
NHSE visits - Early Implementer Sites Feedback and Discussion
NHS England Update – LTC YoC Commissioning and 5 year forward view
Jacquie White, NHS England
Whole population dataset analysis
Jamie Day, NHS Improving Quality
Improving data quality
Bruce Pollington, Kent EIS
Health 1000 – service model and staff profile
Colleen Atkinson, BHR EIS
15/16 LTC YoC Commissioning programme plans
Update from EIS
Discussion and group work
3. To Do list
Questions at the ready
5 year forward view and LTC YoC commissioning @ 11.00
Data Quality @ 12.25
15/16 LTC YoC Commissioning plans - EIS
Summary updates on EIS plans
Completion of template during group working session
Thinking during the day
What can your site contribute to the LTC YoC Commissioning fast follower
community of practice
4. To register email LTC@nhsiq.nhs.uk
LTC Lunch & Learn Series ….coming soon…
Date Webinar Hosted by Bev Matthews &
27 May 2015
12.30 – 1.30pm
Primary Care Workforce for
the 21st Century
Sharon Lee
Primary Care workforce facilitator
South Kent Coast CCG
4 June 2015
12.30 – 1.30pm
Fire and rescue service –
prevention through home
health and safety checks
Peter O’Reilly, Chief Fire Officer
Geoff Harris, Asst County Fire Officer
Manchester Fire and Rescue Service
9 June 2015
12.00 – 1.00pm
(at FF workshop)
Health 1000 – A complex Care
Organisation
Rob Meaker
Barking, Havering and Redbridge
6. www.england.nhs.uk
To transform the co-ordination of person centred care and quality of life for people
with Long Term Conditions through implementation of improved commissioning
mechanisms:
• Improved outcomes and wellbeing:
• Patients receive care that is planned with them, more seamless across different care
services and more needs focused.
• Clinical professionals supported to provide a more holistic service
• Reduction in acute admissions to hospital; and shorter lengths of stay when these are
required.
• Local health & Social Care economies:
• Provide care that delivers value for money and is better managed by integrated teams.
• Incentive for providers to work together to improve services for patients
• Improved joint working and shared responsibility for outcomes
6
Purpose of LTC Year of Care
Commissioning Programme – April 2012
7. www.england.nhs.uk
The LTC Year of Care journey
National
initiatives
(pre
2012)
Health &
Social
Care Act
(2012)
National
Collaboration
for integrated
care (2013)
Person
centred
co-
ordinated
care: LTC
framework
(2013)
Five year
forward
view
5YFV
(2014)
Post
election
?
Integration
pilots,
Community
Matrons, Self
management,
Technology,
PHB,
LTC Year of
Care
Commissioning
Programme
“Duty”, New
organisations,
roles and
responsibilities
– Local,
National
National
support –
Narrative,
definition,
Better
care fund,
Integration
pioneers
Permissive
framework for
local
implementation –
House of Care
Clarity of vision,
priorities, new
national
programmes:
“new models of
care”,
“integrated
personal
commissioning”
?
7
LTC Year of
Care:
Development
year and site
selection
LTC Year of Care:
1st year –
experimentation
to define scope
LTC Year of
Care:
2nd year –
technical
phase (data
and
analysis)
LTC Year of
Care:
2nd year –
technical
phase (data
and analysis
LTC Year of
Care:
3rd year –
development
of currencies
and new
delivery
models
LTC Year of
Care:
4th year –
implement
currencies
and local
prices,
testing
delivery
models
8. www.england.nhs.uk
We are facing a rising burden of avoidable illness
across England from unhealthy lifestyles:
•1 in 5 adults still smoke
•1/3 of people drink too much alcohol
•More than 6/10 men and 5/10 women are
overweight or obese
Furthermore:
•70% of the NHS budget is now spent on long term
conditions
•People’s expectations are also changing
4
5YFV:
Demand for care is rapidly growing
9. www.england.nhs.uk
New technologies and treatments
•Improving our ability to predict, diagnose and treat disease
•Keeping people alive longer
•But resulting in more people living with long term
conditions
New ways to deliver care
•Dissolving traditional boundaries in how care is delivered
•Improving the coordination of care around patients
•Improving outcomes and quality
…but the financial challenge remains, with the gap in
2020/21 previously projected at £30bn by NHS England,
Monitor and independent think-tanks
5YFV:
There are new opportunities
10. www.england.nhs.uk
The 3 gaps
• Health and wellbeing
• Care and quality
• Funding
Priorities for action
• Prevention,
• Empowering patients,
• Engaging communities,
• The NHS as a social movement,
• New care models
LTC YoC Commissioning Programme laying the foundations for the
transformational action needed
10
5YFV:
11. www.england.nhs.uk
• Personal Health Budgets
• Pricing strategy
• Integrated personal commissioning programme
• Information Governance
• Improvements in data and information
• Testing new models of care
• Supporting other initiatives to progress
• Continued ministerial interest
• Increasing international interest – WHO, EU
Proving it’s possible
11
LTC YoC - Input, Impact and
Influence
12. www.england.nhs.uk
Framework: The House of Care
People*
Services –
delivery*
Services - care management*
System*
* WHO Framework for action on integrated care
13. www.england.nhs.uk
Framework
13
Organisational &
Clinical Processes
Informed and
engaged patients
and carers
Health & Care
Professionals
committed to
partnership
working
Commissioning
• Information and
technology
• Case finding & risk
stratification
• Care Planning
• Safety and
Experience
• Guidelines,
evidence and
national audits
• Self Management
• Patient activation
• Health literacy
• Information and
Technology
• Group and Peer
Support
• Care Planning
• Carer support
• 3rd sector support
• Community
mobilisation
• HSC Integration
• Multi Disciplinary
Teams
• Health coaching
• Behaviour change
(Clinical activation)
• Workforce
development
• Care Planning
• Care Co-ordination
• Needs Assessment
and Planning
• Joint Commissioning
• Joint funding (BCF,
shared risk and
reward)
• New models of care
• Metrics and
Evaluation
• Service User and
Public Involvement
• Care Planning
Key factors needed to deliver Person Centred Coordinated Care and that are
being supported nationally: Care & support planning as the golden thread
14. www.england.nhs.uk 14
Purpose of LTC Year of Care Commissioning
Programme – April 2012 May 2015
To transform the co-ordination of person centred care and
quality of life for people with Long Term Conditions through
implementation of improved commissioning mechanisms:
Improved outcomes and wellbeing:
• Patients receive care that is planned with them, more seamless across different
care services and more needs focused.
• Clinical professionals supported to provide a more holistic service
• Reduction in acute admissions to hospital; and shorter lengths of stay when
these are required.
Local health & Social Care economies:
• Provide care that delivers value for money and is better managed by integrated
teams.
• Incentive for providers to work together to improve services for patients
• Improved joint working and shared responsibility for outcomes
15. www.england.nhs.uk
• National and local co-production
• Agreed vision, case for change, definition and narrative
• Permissive framework with national guidance, enablers,
resources, case studies: local implementation irrespective
of starting point
• Local partnerships, strategy, action plan, metrics and
milestones: flexible and adaptable
• Build on learning – own and others (translate into local
system)
• Use improvement methodology to manage change
• Culture eats strategy – engagement, engagement,
engagement to gain ownership
• Keep focussed on the aim: person centred co-ordinated
care for all by understanding “what matters most”
15
Summary – creating the conditions
for change
17. www.england.nhs.uk
Health 1000 -The Wellness
Practice
An experiment
Colleen Atkinson Interim Practice Manager
and Programme Manager for Innovation BHRCCGs
18. www.england.nhs.uk
May
2013
• Early Implementer
site for YOC
• Advanced data
sets from primary
care, acute
community and
social care
• PMCF Bid to
include testing of
capitated budget
being developed
to one provider in
early 2014
• PMCF Bid to include
testing of capitated
budget being
developed to one
provider in early
2014
• PMCF bid approved
may 2014
May
2014
• Started work
on project
May
2014
June-September
2014
• academic development of
the service model and
staffing requirements
with UCLP
• Set up of the legal entity
to operate the service
• Source premises
• Source clinical leadership
October 2014-
January 2015
• Commence recruitment of
staff
• Training
• Premises set up
• Legal entity formed
• APMS discussions started
• Engagement with practices
• January 16th APMS contract
signed
• January 19th first patient
registered
19. www.england.nhs.uk
Key features of the proposed model
• GP lead model of chronic disease management with
proactive case management of medical and social care
• Tele-monitoring
• Patient and carer education and enhanced self-
management
• Promotion of independence and personal responsibility
• Shared care record with agreed care plan
• Quality improvement embedded in culture
• Key worker skills and competencies developed
24. www.england.nhs.uk
ROLE WT Cover provided
MD and Geriatrician (50:50
role)
1.0 20 hours direct patient care plus 17.5 hours management
plus on call support as required
HCS Key workers 5.0 73.5 hours per week 8am to 18.30pm Monday to Sunday.
This is a dual function role covering reception and health
care support and requires two members of staff to be on duty
during 08.00 to 18.30pm Monday to Friday
GPs 3.0 52 hours per week 08am to 18.30pm Monday to Friday plus
On call for 5 hours per week Monday to Friday 6.30 to 8pm
and 24 hours on Saturday and Sunday from 8am to 8pm
A total of 81 hours per week
Practice Manager 1.0 37.5 hours per week as required to cover 7 days per week
on rota
Nurse 1.0 37.5 hours per week during 8am to 6.30pm
OT 0.5 18.5 hours per week during 8am to 6.30pm
Physiotherapist 0.5 18.5 hours per week during 8am to 6.30pm
Pharmacist 0.5 18 hours per week Monday to Friday as required
Workforce Plan
25. www.england.nhs.uk
Challenges in setting up the service provision
• Establishing the financial arrangements for the service as set up and
then BAU and capitated budget moving forward
• CQC registration
• Insurances wider provision of services
• Accountancy for new provider and challenge of complicated pass
through costs in addition to the back office function provided by CCG
• GPs and the Provider list and having a non GP as the clinical lead
• CCG membership
• Receiving records from practices- system challenges
• Legal requirements for the Limited Company, APMS contract
26. www.england.nhs.uk
will
• Recruiting clinical teams for a time limited project and people leaving
• GPs and the Provider list and having a non GP as the clinical lead
• Setting up the new practice on Vision, registration links, CQRS,
prescribing, training all staff, setting up templates to ensure
consistencies in data collection
• Remote working on clinical system
• Set up clinical rooms, equipment, IT, estates, cleaning waste,
consumables, telephony, courier drops
• Training new staff from start with no leaders
• Receiving records from practices- system challenges
• Summarising records by GP
27. www.england.nhs.uk
Changes to clinical management
• Visiting patients in hospital to speed discharge
• Visiting consultant appointments with patient
• Rationalising hospital appointments
• Providing responsive social care interventions and
support
• Providing joint assessments with therapists and
managing clinical risk
29. www.england.nhs.uk
Cultivating a team with different dynamics and
culture
Clear shared vision, goals and ethos
Flat structure
Learning and development philosophy
Everyone counts, has a voice and is listened to
Quality improvement methodology
Regular team meetings
Comprehensive induction programme
Time to think and test
Joint assessments and care planning
Shared goal orientated care plans
Holistic patient focus
33. Data Quality
LTC Year of Care Commissioning Programme Early
Implementer Sites Workshop
14th May 2015
Dr Bruce Pollington
34. What is Data Quality?
Data is of high quality if, "they are fit for their
intended uses in operations, decision making,
and planning.” (J.M.Juran)
35. ISO 9000 - Quality Guidelines
•data quality can be defined as the degree to which
a set of characteristics of data fulfils requirement to
describe a situation. Characteristics are,
•completeness,
•validity,
•accuracy, - typos, missing spelling
•consistency, use of standards
•availability and timeliness.
36. Quality data requires planning
•the proliferation of data sources and exponential
growth in data volumes can make it difficult to
maintain high-quality data.
•To fully realize the benefits of big data,
organizations need to lay a strong foundation for
managing data quality.
37. Data Quality tools /processes
• Data profiling – understand the quality issues
• Data standardization – conform to quality rules
• Matching or Linking - use "fuzzy logic" to find duplicates
recognising that 'Bob' and 'Robert' may be the same
individual.
• Monitoring - keeping track of data quality. Software can
also auto-correct the variations based on pre-defined
business rules.
• Batch and Real time - Once the data is initially cleansed
(batch), put in place processes to keep it clean.
38. What is a Quality Management System?
•A quality management system (QMS) is a set of
policies, processes and procedures required for
planning and execution (production/ development/
service) of the core business.
•ISO 9001:2008 is an example of a Quality
Management System.
39. Uk Bodies Responsible for Quality Standards for
NHS and Social Care
• The Information Standards Board for Health and Social
Care (ISB) closed on 31 March 2014.
• Responsibility for information standards has transferred to
the Standardisation Committee for Care Information (SCCI).
• SCCI is responsible to NIB for the identification,
commissioning and successful implementation of
information standards, collections and extractions.
• New standards - Information Quality Assurance Programme
(Data Quality) replaced by Standards Consulting Group
(SCD) - consultancy service within Data Standards and
Products, part of the Technology Office.
40. Some YoC pertinent standards
• IQAP - Merging Trust Master Patient Indexes in Shared Instances - LSP
Requirements - Nov 2005.
• The UK edition of SNOMED CT, ISB 0034,
• READ v2 & v3 withdrawn by April 2020
• ISB 0021 International Classification of Diseases
• ISB 0090 Organisation Data Service
• ISB 0084 OPCS Classification of Interventions and Procedures
• ISB 0149 NHS Number
• ISB 1554 Data Transfer Service - secure application-to-application messaging
• ISB 1523 Anonymisation Standard for Publishing Health and Social Care Data
• ISB 0092 Commissioning Data Sets (CDS)
• ISB 1500-8 Common User Interface - Address Input and Display - Time
Display
• ISB 0070 Healthcare Resource Groups (HRG)
41. Costing Guidance
•HFMA - Acute Health Clinical Costing Standards
2015/16
•HFMA - Materiality and quality score (MAQS) template
- Acute (February 2015)
•Monitor - Approved costing guidance Updated
February 2015
•Currently intra–org focused cover Acutes and Mental
health only, but intention is for linkage across orgs in
future.
42. Personal Social Services Research Unit (PSSRU)
•Unit Costs of Health and Social Care
•Nationally-applicable unit costs for more than 100
health and social care services
•Can be used where other cost information is not
available - is the source of primary care costs
43. Principles of NHS costing Monitor
• Principle 1: Stakeholder engagement
• Effective costing requires input from a wide range of stakeholders, including
frontline clinical staff and departments providing clinical support services
such as pathology
• Principle 2: Consistency
• A consistent approach to costing is required across or within organisations
• Principle 3: Data accuracy
• Accurate costing relies on the quality and coverage of the underlying data
input
• Principle 4: Materiality
• Costing effort should be focused on material costs and activities
• Principle 5: Causality and objectivity
• Costing should be based on how resources are used during the patient
journey, to minimise its subjectivity
44. So what does this all mean for YoC EI
•What are our data quality issues?
•Common themes
•Data completeness
•Variation to interpretation of terminology
•Intra-organisational data consistency
•Inter-organisational data consistency
•Kent for example has 107 orgs data flowing will end up
with over 200
•Variation in costing methodologies
•No standard or guidance fully covers a whole place
capitated funding model
45. What can we achieve during life cycle of YoC EI
•What processes do we already have in place for DQ?
•What can be learn from each other
•Plan Do Study Act cycles
•Data Profiling – target areas for high impact
•Peer review/ critical friend for cross pollination of
good practice
•Is there a need to develop a ‘whole place capitated
funding quality standard & guidance’ informally for
YoC & parallel stream with SCCI / Monitor
46. The Kent Data Quality Programme
The initial work will include the following
• Frequency count and proportion of total records with missing
NHS number
• Bias assessment of to check for systematic/random bias,
Completeness/data stability:
• Frequency and proportion of variables by field including null
values
• Agreed data dictionary for each data set
• Assessment of critical variables TBA defined
• Periodic assessments of variance in frequency (especially for
critical variables) to check for data completeness and stability
over time
• Built in fatal/non-fatal error thresholds - TBA
• Assessment of the scale and scope multiple GP practice
registrations
62. Kent LTC Year of Care Programme:
Using whole population linked
datasets to develop higher value
models of care
Dr Abraham George KCC Public Health
63. EK- 38 GP practices pop – 352307(of 88 practices pop 752374)
Band B = 3549, Band C = 4993 Band D = 562
Band E = 22 – total 9129 (cumulative – 1 double count)
WK – 13 GP practices pop 141,504 (of 64 practices pop 533585)
Band B = 1097, Band C = 1702 Band D = 256
Band E = 10 – total 3065 (2 duplicates)
NK – DGS 33 practices pop 250999 (of 34 practices pop 253646)
Band B = 2304, Band C = 3401 Band D = 425
Band E = 20 – total 6150
Currently Kent totals are 18568 of 744,810
Key achievements
• Currency developed using RS and LTCs
• Linked Data for 18k people
• Linked and costed for 18k people
70. Variation between YoC and Non YoC Anon
April – Dec 2014
YOC Currency Total Cost Total YoC Patients at end Sep
Average Cost per patient
by Band
Average Cost of
Activity
No Activities per
patient
Not YoC £49,792,527.82 114679 £434.19 £178.87 2.43
B £2,035,833.58 1031 £1,974.62 £156.74 12.60
C £4,988,804.06 2193 £2,274.88 £172.66 13.18
D £2,151,609.96 795 £2,706.43 £164.41 16.46
E £399,402.89 112 £3,566.10 £134.07 26.60
Total YoC 9575650.49 4131 £2,318.00 £165.25 14.03
Overall Total 59368178.31 118810 £499.69 £176.53 2.83
Not YoC £89,888,222.62 187197 £480.18 £193.30 2.48
B £5,276,325.30 2291 £2,303.07 £179.57 12.83
C £8,583,289.03 3303 £2,598.63 £188.22 13.81
D £1,747,937.81 522 £3,348.54 £173.13 19.34
E £219,997.45 44 £4,999.94 £228.69 21.86
Total YoC 15827549.59 6160 £2,569.41 £183.95 13.97
Overall Total 105715772.20 193357 £546.74 £191.84 2.85
72. Next steps – EK
• Develop detailed implementation plans in SKC to support ICO
• Develop detailed plan to support dashboard use with
Vanguard site – Estuary View Whitstable.
• Increase the number of GP practices flowing data to KMHIS
– need SKC and Thanet for ICO work
• GPs to give permission for their practice data to be reported –
– the list of consultations. This gives basic details on when the consultation was,
where it took place, who did it and the cost.
• Develop a Data Quality Improvement Plan across the system
starting with EK
• Agree evaluation framework for each initiative and build
dashboard.
73. Next steps WK
• Create letter template for GPs and brief
presentation to go to clinical cabinet.
• Links to CPMS work – Malti and Andrew
• Agree Evaluation and funds to support beyond
2015-16.
74.
75. Year of Care – Southend on Sea
Working together for a healthy Southend
Steve Downing
76. Success so far;• Single Point of Referral (SPOR)
• Integrated Community Teams
• Successful section 251 application
• Shadow tariff developed Provider sign up
• Integrated Commissioning Team – NHS Southend CCG and Southend
Borough Council have formed a new Integrated Care Commissioning
Team, this joint venture sees the commissioning function of both
organisations coming together to be directly responsible for
commissioning across health and social care in Southend, supported by
clinical and social care leads and will be accountable to both the CCG
and Council.
77. Next Steps
• Care co-ordination is a key theme running through future
plans, specifically to improve services and patients experience
for those with LTC’s.
• Work with the providers and data teams to implement
processes to run shadow tariff.
• Task and finish groups established to progress review, redesign
and enable commissioning of truly integrated services
• Develop LTC pathway with emerging personalised health
budget project with care co-ordinators
78. How will we be doing this;
Link to pioneer & Better Care Fund (BCF)work streams;
• Community Recovery & Independence – Merge SPOR and social care
assess team.
• Review community MDTs’ reablement, step up/down beds.
• Facilitate prevention, escalation a& maintenance ( particularly for LTCs)
through care co-ordinators.
• Primary Care Hubs – Co-ordination of care, geographical areas, all ages
with a focus on LTCs.
• End of life – Early identification and increased access to appropriate
support and co-ordination. Enabling people to achieve their preferred
place of death.
• Develop risk sharing arrangements with both providers and social services
80. •Data analysis of ~320,000 people across Leeds
who have one or more LTC
•Business case development for agreed Leeds
West CCG pilot
•National EIS visit from Martin McShane and
Jacquie White
Progress to date
81. YearofCareEIS
projectteam
YearofCare
citywideproject
NHS Leeds North
CCG pilot
NHS Leeds South
and East CCG pilot
NHS Leeds West
CCG pilot
Whole
population
~320,000
patients
Shadow
monitoring
15/16
Identified
patient
cohorts
Leeds CCG
populations
Testing:
• Form of capitated budget
• Provider to provider relationships
• Evaluation of pilots
Track patients over 15/16 to:
• Understand what
happens to patients
• Service utilisation
• How much services cost
• Cross reference the
cohort costs with
contract costs
• Understand variation
from baseline data
• Refine currency
categories
82. Shadow monitoring (from 1April 2015 data):
• Whole population (320,000 patients)
• Each individual CCG
• Specific patient cohorts
Each CCG in Leeds will identify a different cohort and
develop their own pilot model
Shadow monitoring plans 15/16
83. Informatics/analysis
• Investigate links between multimorbidity/comorbidity
with age, frailty and cost
• Analysis by GP practice and Neighbourhood Team (NT)
Finance/capitated budget
• Define basis for calculating budget; whole population,
CCG population and CCG pilot population
• Understand inclusions/exclusions, activity and spend
• Agree estimated currency categories by number of LTC
15/16 headline plan
84. Pilot models
• Engagement with each CCG around their pilot model
• Agreement of each CCG pilot model
• Define and agree service delivery model for each pilot
model
Evaluation
• Social value - University of Leeds
• Economic
• NHS outcomes measures
• Patient agreed outcomes/benefits
15/16 headline plan
86. West Hampshire CCG – 2015/16
Year of Care: A key enabler
In progress;
Governance and leadership
Messages
Refresh data and shadowing
Data Quality Improvement
Supporting Integrated working;
Profiling and modelling – simul8
Cross referencing – ACG and 2%
Integrated care teams, MCPs etc
Outcomes framework and peer review
Proactive modelling – transformation fund
Care homes
Mental Health
Embedding frailty
Improving commissioning;
Commissioning models
Impact, levers and mechanisms for change
Outcomes
Editor's Notes
Jan data only has acute data and a very small proportion of community beds and walk in services data in charts as it comes directly from SuS.