Care Coordiation and service change evaluation were key themes at the LtC year of care Commissioning Early Implementer site workshop earlier this week – view the full slide set from the day.

1. West Hampshire Clinical
Commissioning Group
Kate Smith – Senior Commissioning Manager
West Hampshire CCG

2. WHCCG Out of Hospital Strategy;
• Overview
• Where are we now
• Next steps
• Challenges

3. Overview

4. West Hampshire Out of Hospital Model
Proactive Intervention
 Care navigation via 111 or Care Co-
ordinator; care in line with agreed plan
 Primary care urgent care centres
 Rapid access to consultant advice
 Rapid assessment clinics (including
diagnostics); Integrated Rapid response
& crisis intervention services via SPA
Access to community beds (step-up),
home treatment and care support
including night sitting. Rapid, flexible
provision of care packages to meet need
 End of Life – patients supported to die
in place of choice
 Proactive management by SCAS –
enhanced paramedic role
Keeping Well: Early Intervention and Effective Care Co-ordination
 Pro-active risk profiling to identify high risk patients using predictive tools and the combined local
intelligence of health and social care professionals
 Early diagnosis and intervention
 Person Centred Care Planning with patients and carers as active participants defining priorities, goals,
programme implementation, coping strategies, contingency plans for crisis and outcome measures. The
use of Personal Health Budgets and direct payments to enable patients greater choice, flexibility and
control over their own care and treatment
 Care planning to include self-care and supported self-management programmes to put the patient and
their carers in control of their condition. This can include the use of assisted living technology and virtual
intervention tools such as telehealthcare. Utilisation of community support and third sector services,
particularly where patients are isolated and have no viable carer
 Care Co-ordination by named Case Manager; Telephone access to support as needed
Care co-ordination
is a holistic model,
delivered by skilled
health and social
care practitioners
in partnership with
patients, carers
and their GP
Admitting patients
to hospital should
be a last resort;
with the majority
of care provided in
the community.
Community
services need to
be responsive to
proactively meet
changing need
If admission to an
acute hospital is
required, patients
should only remain
in hospital for the
acute phase of
their illness, with
timely transfer or
discharge. Patients
should be
supported to
return home
Supporting Recovery
 Strengthened Community Pull;
hospital in-reach supported by
‘Daily Alert’ information
 Community beds (step-down)
with early supported discharge
either within or as close to a
patients home as possible; ICTs
able to direct use of community
beds & out of hospital services
 Care packages to be quickly
reinstated, adapted to meet
changing need or set up via
pooled budget
 Personal care and
Welcome Home services

5. Eastleigh & Test Valley
Parkside
Boyatt Wd
St Andrews
Pineview
Leighside
Eastleigh
Chandlers
Ford
Park &
St Francis
Fryern
Brownhill
IICTsGPPractices
Eastleigh
Southern
Parishes
Romsey
Blackthorn
Burseldon
Hedge End
West End
St Lukes
Alma Rd
Abbey Md
Night-
ingale
North-
Baddesley
Andover 1 Andover 2
Avon
Valley
Totton &
Lyndhurst
Friarsgate
St Pauls
St Clements
Gratton
Stockbridge
Whitchurch
Lymington
Shepherd’s-
Spring
Derrydown
Adelaide
St Mary’s
Charlton-
Hill
Andover
Totton
Testvale
Forest Gate
Lyndhurst
Fording-
bridge
Ringwood
Corner-
ways
New
Milton
Winchester Andover Totton/Waterside
Sway/Brock
enhurst
Chawton
Wistaria &
Milford
Barton
N.Milton
Arne-
wood
Twin-
Oaks
Winchester
City
Winchester
Rural North
Winchester
Rural South
B. Waltham
Twyford
Wickham
Stokewood
Old Anchor
Winchester
Rural East
Alresford
Mansfield
West Meon
Waterside
Waterside
Forestside
Water-
front &
Solent
West New ForestEastleigh
A Community Based Approach to Integrated Care
Community
Support
Integrated Care Team
GP Practice
Network
Community based, primary
care co-located model
Our approach:
 15 Integrated Care Teams (ICTs) covering 6 Localities
 Teams are co-located and work with a network of practices to
foster meaningful partnerships
 Each Team covers a population of around 30,000 – 50,000
 The core team consists of health and social care professionals
including primary care, community nurses, therapists, social
workers, and Older Persons Mental Health liaison workers.
Each team has a named link Consultant Geriatrician
 The wider team consists of specialist services
 Integrated Care Teams are rooted in communities – they know
and understand their community and actively engage local
voluntary organisations and support networks. ICTs provide a
continuum of care based on individual need
West Hampshire Localities
Specialist
Services

7. National Voices definition
of integrated care as
meaning person centred,
coordinated care:
“I can plan my care with
people who work
together to understand
me and my carer (s),
allow me control, and
bring together services
to achieve the outcomes
important to me”

8. Supporting Recovery and Maximising Independence
Integrated
Care Team
Community Beds
– Core Offer
“ ERS@H is not
appropriate
clinically / safe”
Enhanced Recovery
and Support @
Home
“Time limited support
designed around an
individual to support
recovery and
maximise
independence”
At home or
Recovery Clinics
Acute Trust
“Patients
ONLY in Acute
Trust for
minimal time
required for
acute phase”
Complex Needs
Assessment
“Rapid assessment
and diagnosis –
signposting”
Clinical Triage / SPA
Health and Wellbeing – links with 3rd Sector
Principles of Core Delivery Model:
 The right care will be provided at the right time and in the
right place
 Care will be personalised and tailored to meet individual
health and social need
 A recovery culture, with people supported to maximise their
independence
 Care will be delivered locally either at home or as close to
home as possible
 No patient will be admitted to a bed who could safely be
supported at home. Care at home will always be the default
for care delivery
 Patients will only remain in an acute hospital for the acute
phase of their illness
 Decisions about long term care needs will not be made in an
acute setting
 Care will be delivered by integrated health and social care
teams that are co-located and work with a network of
Practices, with access to specialist support
‘Community Pull’

9. I am
supported to
look after
myself
My carers are
supported
My
environment
is suitable for
my needs
I am able to
live the full
life I want
My mental
health, physical
health and
social care
needs are
addressed
I know what
to do and
expect when
I'm unwell
The Patient Offer
6 pillars of community support
 I understand my condition
 I know how to manage it
and have the appropriate
equipment and
medication
 I am confident and in
control
 I have set my own goals
 I know who to contact
when I need support
 My carer understands my
condition and knows who
to contact when I need
help
 My carers needs are
identified and they are
supported
 My carer feels confident
and in control
 The place I live is suitable
for my needs
 I have the appropriate
equipment to support me
in my home
 I have had the
appropriate adaptations
made to my home to
allow me to stay in it
 My community supports
me
 I know who and where
my self-help groups are
 I know which groups can
help me achieve my
goals
 My life feels enriched by
my social networks
 I have an agreed plan of
care that addresses my
physical, mental health
and social care needs
 My care feels
coordinated
 I know who my care
coordinator is, what they
can do to help support
me and how to contact
them
 I know I will receive rapid
help when I need it
 I know I will be helped
and supported to get
home as soon as I am
well
 Everyone involved in my
care knows about my
goals and care plan
For Patients and Carers: Our Patient Offer

10. For GPs and Community Services
 Becoming more proactive in identifying people that are becoming frail and
vulnerable, rather than waiting for crisis
 A single point of access through which to make referrals
 A standard approach to care planning, including the sharing of plans, of
agreeing the content of plans and lead worker through structured
whiteboard meetings
 Access to a range of services to maintain people in their own homes
 Improved communication and joint working with a greater understanding
of each others roles
 Less duplication

11. Where are we now

12. Programme 1: Early Intervention and Effective Care Co-ordination
Key Work Streams Description Timescales
Integrated Care Team
Development
Programme
Develop the core Integrated Care Team and understanding of each others
roles and responsibilities; ensure shared understanding of integrated care
and embed key components of integrated working in line with the ‘What
Does Good Look Like Framework’
Delivery facilitated through bi-monthly ICT meetings & ICT workshops;
All people 75 years and over to have a named accountable GP
Bypass numbers established for Ambulance, A&E and care home staff
Risk Stratification: Case management register established of patients
identified at high risk of admission (minimum 2% registered adults);
Same day telephone consultations established;
Patients notified of accountable GP and care coordinator
Personalised care plans developed and in place
Jun 2014
Sep 2014
Transformation Fund Established to support Practices in transforming the care of older people
aged 75 and over and those with complex needs. Four Transformation Fund
proposals to be implemented over 12 months. Enables innovative models to
be tested and if successful, embedded in integrated care delivery models
Apr-15
Building Blocks to
Integration (CQUINs)
Care management & care co-ordination: Develop, agree, implement model
Personalised Care Planning: Agree a single process, documentation and
way of sharing plans (including urgent and end of life care plans) via HHR
Scope implementation costs and timescales for delivery
Self-management and shared decision making: Development of self-
management models and processes and roll-out to ICTs
Mar-15
Dec-14
Jan-15
Mar-15
Care Homes Strategy Development of Care Home Strategy (with Quality Team) Sep-15
Care Pathways Review and redesign of wound care, falls and continence pathways Sep-15

13. Programme 2: Proactive Intervention
Key Work Streams Description Timescales
Integrated Rapid
Response Service
There are currently two rapid response services provided by health (via
CCTs) and social care (CRT), with different referral routes. Development of
Integrated Rapid Response model accessed via a single point of access Sep-15
Community
Geriatrician
To ensure greater access to consultant geriatrician advice and assessment
for complex patients; recruitment to additional posts in line with agreed
service specification
Agree alternative models with localities where recruitment unsuccessful
and timescales for delivery
Nov-14
Mar-15
Rapid Assessment
Units
Review of current provision to ensure improved access to consultant advice
and rapid assessment
Mar-15
End of Life Care Development of the End of Life Care Strategy and implementation plan
Implementation of End of Life Incentive Scheme – to include Clinical
Leadership, patient identification and after death analysis
Roll-out Marie Curie project and undertake full evaluation to inform future
commissioning strategy
Ensure sustained provision of Andover Hospice at Home Service and full
evaluation of model to inform future commissioning strategy
Jun-15
Mar-15
Mar-15
Nov-14 –
Mar-15

14. Programme 3: Supporting Recovery
Key Work Streams Description Timescales
Intermediate Care and
Reablement Services
Redesign of intermediate care and reablement services – enhanced support
and recovery at home and universal admission criteria to community beds
Consultation and phased implementation
Oct-14 –
Mar-15
Mar-16
Care at Home (HCC) To procure a new Care at Home Model and contractual framework.
Providers to work as an integral part of ICTs who will direct resource:
Develop new service specification
Complete procurement framework process and award contracts
New service mobilisation
Dec-13
Nov-14
Apr-15
Day Care To procure a new Day Care Service model
To map current provision of Day Care Centres, wound café’s, health and
well-being centres and explore opportunity for co-locating services into
community well-being hubs
Mar-15
Mar-15
Discharge and
Community Pull
Move to a strengthened community pull model to facilitate timely
discharge:
Development of Trusted Assessment – development and roll out of
implementation plan
Sustained delivery of In-reach Co-ordinators and roll-out to MAU and T&O
wards via winter resilience bids
Review of social care discharge team and integration within ICTs; agree
model and implementation plan with agreed timescales for delivery
Sep-14 –
Mar-15
Oct-14 –
Mar-15
Jun-15

15. Next steps

16. • Outcomes dashboard
• Evaluating impact - discovery interviews
• ICT Peer review
• Workforce development – Every Community Contact
Counts
• Proactive care models – Transformation fund
• Federation focus
• New models of care – Vanguard – Primary Care
Access Centre
• MCP provider development

17. Monitoring Effectiveness; Demonstrating Success
Strategic Aims Objectives Key performance indicators OUTCOME
People receive the right care
in the right place and the
right time
Maintain constant focus on
long term quality of care and
the achievement of outcomes
for users
 Reductions in permanent admissions to residential
and nursing care, per 100,000 population
 Reduction in non-elective emergency admissions
(targeted HRGs); reduction in average LoS
 Reduction in the number of excess bed days
 Reduction in delayed transfers of care
 Increased numbers of discharges across 7 days
Achieve
long term
quality
outcomes
Ensure fairness and equality in
broader context underpins
every decision we make
Give service users and their
families choice and control
over their own outcomes
Promoting greater care co-
ordination
Increase self sufficiency and
independence, avoiding
reliance on services wherever
possible and improving overall
experience
 Increased numbers of people having health and
care needs met closer to or within their own home
 Increased use of self-directed support and use of
personal health budgets
 Increased numbers of people dying in their
preferred place of care
 Evidence of development of personalised care plans
and that people are supported to determine
options and are involved in setting and achieving
their own goals
 Increased patient satisfaction
 Increased GP and staff satisfaction
Ensure our
services
meet
demand
Work collaboratively to
deliver integrated care
services that promote
independence and recovery
Protect the sustainability of
services to meet current and
future demographic, financial
and statutory requirements
 Minimum of 65% of service users return home after
a period of rehabilitation/reablement
Ensure our
system is
financially
sustainable

18. Challenges

19. • Evaluation, measuring impact
• Engagement and relationships
• System focus
• Capacity and capability
• New models of care……..

20. LtC Year of Care Commissioning
EIS Project Leads Workshop
5th October 2015
Central London

21. o Taking action to make person-centred
care for people with long-term conditions
a reality
o Looking at what needs to change and why
we need to change
o Co-produced with NHS England and
Coalition for Collaborative Care and
developed with health and care
professionals, policy makers and people
with long-term conditions
o What you can do:
o Make a commitment embedding
patient-centred care in your work at
www.engage.england.nhs.uk/survey
/ltc-declaration
o Tell your teams about our work
o Use the hashtag #A4PCC when you
see work that is relevant to person-
centred care for people with LTCs
o Let us know of any events, activities
or social media opportunities that
we can join forces with you
Our Declaration,
My Declaration
#A4PCC – Action for Person-Centre
Care

22. LTC Year of care commissioning
West Hampshire EIS

23. Care Coordination
Local approaches

24. Operational January 2015, Core Staff Recruited,
Patients No increasing

25. Health 1000
• Health 1000 is a new primary care provider organisation operating a new
model of care as part of the Prime Minister’s Challenge Fund supporting
people with 5 or more LTCs from BHR practices.
• It has a clinical model which includes input from BHRUT, North East
London NHS Foundation Trust, Barts NHS Trust, and the social care
services of the co terminus London Boroughs.
• The service exists in primary care but incorporates specialists “tailored”
to individual needs.
• People consenting to take part are being de registered from their GP and
registered with the Practice and receive a refreshed care plan and a
tailored team (including GP, nurse, social care and consultant specialists)
• Age UK RBH is working as part of the Multidisciplinary team supporting a
cohort of 500 people with multiple LTCs using the Age UK Integrated Care
Model.

26. Project Background
In developing Health 1000, the work with potential
service users and their families revealed that people
have difficulties in accessing services to manage
their own conditions and meet their needs due to:
• Lack of information
• Fragmented options
“We feel helpless trying to get the best for our
mum”
“I just want to be able to go fishing”
“The professionals don’t understand all my needs”

27. Age UK Integrated Care Programme
• It operates across England and brings together
voluntary organisations and health and care services in
local areas to provide an innovative combination of
medical and non-medical support for older people with
long term conditions at risk of recurring hospital
admissions.
• Through the programme Age UK staff and volunteers
become members of primary care led multi-disciplinary
teams providing care in the local community.
• The pathfinder for the programme has been underway
in Cornwall since 2012 and early results have been
highly promising.

28. Aims of the Age UK Integrated Care
Programme
• Improve the health and wellbeing outcomes for older
people with long-term conditions who experience high
numbers of avoidable hospital admissions.
• Deliver cost savings and help alleviate financial
pressures in the local health and social care economy.
• Support and deliver transformational whole system
change by demonstrating how GPs, community care,
hospitals, social care and the voluntary sector can work
together with the older person at the centre.

29. Slide:29

30. BHR Care Navigator Pilot
• The pilot is funded for 2 years by Redbridge, Barking
and Havering CCGs and Age UK.
• The team delivering the pilot includes one Team Leader
and 3 Care Navigators. In addition, we aim to recruit 10
volunteers in the first year to support patients.
• The Care Navigators are fully integrated with the
Health 1000 team and take part in weekly MDT
meetings.
• The pilot has started at the end of August 2015 and so
far 39 Clients have had guided conversations and have
started receiving support from the project.

31. How Does it Work?
• Care Navigators carry out a person centred guided
conversation with patients which covers aspects such as
personal history, living arrangements, financial situation,
support received, likes and dislikes, personal interests, etc.
• Client goals are identified through the guided conversation
which are then translated into a support plan.
• The emphasis of the project is to shift the clients’ focus
from their health condition to pursuing their interests,
becoming more engaged with their community and
developing a good network of support.
• Type of support for client may include referrals to other
services such as befriending, arranging outings, developing
new activities, peer networks, etc.

32. Early Outcomes
• Improving client’s wellbeing by supporting him to achieve his goal
to go fly fishing.
• Supporting client to regain confidence in going out and increase
independence by assisting them to go out shopping and attend a
social club at the Punjabi Centre.
• Coordinating and organising day centre attendance and carer
respite.
• Supporting clients and carers to access services such as Advice and
Information, Befriending Services, Re-ablement, Community
Treatment Team, Care Line, Dementia Services, disabled swimming
facilities, etc.
• Liaising with Health 1000 Practitioners to enable referrals for OT
assessments, Podiatry Services, Counselling, Dietician support,
memory assessments, hearing tests, social care assessments, etc.

33. Case study continued
• The first patient for Health 1000 he is an amazing
character and likes to support the practice as much as
he can. He lost his wife 3 years ago which sent him into
a depression and felt he was losing control. His
illnesses made things worst in turn having to rely on his
family to support him. His son moved in to live with
him.
• He has lived in his community for 20+ years and felt he
was losing touch of what was around him. He was
feeling isolated. He used to be head Forman on
building sites and was the man to know who helped
everyone in the neighbourhood. His passion was
fishing but as he didn’t like eating it!

34. Case study
• When Age UK RBH met him he was very positive about his
experience with Health 1000 and wanted to do anything he could to
be more involved. This is where Fly fishing came up and the
possibility of make a group led by him. We had to find out and
source this which took a number of weeks but we finally contacted
an organisation who could help and we arranged for to do what he
loved most.
• He didn’t stop smiling the whole day he pushed himself and caught
4 trout. He was tried but happy and after a pub lunch he said this
was the best day he had had since before his wife died. He is now
getting ready to be the lead fisherman for Health 1000 fly fishing
group.
• Patients’ son provided feedback to the patient’s GP that since
using Health 1000 his father was feeling better, his medical
condition had improved and he was happier and felt supported.

36. Developing Stakeholder
Outcomes
Martin Ware
martin.ware@nhs.net

37. Based on Work in Staffordshire
2011 - 2014We wanted to answer the question:
If we are commissioning for outcomes, what
outcomes do we want to achieve?

38. Process – Different Perspectives
• Does everyone have the same view?
• We sought to test this through a series of 9 workshops

39. Process – Four Key Groups
Patient / Public Primary Care
Commissioners Providers
1
Work
shop
1
Work
shop
1
Work
shop
6
Work
shop

40. Process – Four Key Groups
Patient / Public Primary Care
Commissioners Providers
Patient / Public Primary Care
Commissioners Providers
Surprisingly
similar
outcomes
Mostly
quantitative
Very similar
themes
between the
six workshops
and mostly
qualitative in
nature

41. Outcomes – Patients / Public 1 of 2
• Avoid Crisis
• Focus on all of the ‘individuals’ needs
• Value and support Carers
• Continuity of Care
• Single coordinator of care (case mgt)
• Proactive/Preventive planning
• Improved Hospital Discharge process
• Equality of Access for all (e.g. dDeaflinks)
• Improve Community Services and links with third sector
• Improvements in the short term/Pace of change
• Improved working between all agencies

42. Outcomes – Patients / Public 2 of 2
• Improved Timeliness of and access to services
• Improved Access to GPs (Appointments, times and services offered)
• Improved quality of Dom Care provision (Care, Timing and reliability)
• Improved access to information (method/location and type)
• Improved Communication around pathways
• Address the confidence in health and Social Care provision (media
bombardment)
• Improve all urgent care services across the board
• Remove confusion over WIC/MIU service provision
• Improve the sharing of patient data to support the patients/Carers
• Contracting Innovation (e.g. providers becomes longer term)
• More support for those who can and want to self-manage

43. Outcomes – Health Professionals
• Avoid Crisis (Reduced Acute and ambulance activity)
• Improve Customer Experience
• Clear/Protocols and Experience (Ease of Referral for GPs)
• Improved Strategic Reporting/System Assurance
• Improved Performance Management (Individual providers and whole
pathways)
• Improve timeliness of and access to services (Right First Time)
• Move to 24/7 service
• Improved flow to reablement and Social Care Early Intervention
• Quality Dom Care / Quality of Residential Care
• Better Information Sharing of patient data across providers
• LHE System efficiencies (E.g. Reduction in beds utilised etc..)
• More Care at Home
• Improved Community Diagnostics
• Improved LHE Overall financial position

44. Next Steps
Outcomes
Design of
Service
How to
measure
success
What Metrics?
What targets?
Don’t forget the qualitative aspects!
Outcome based commissioning
Or
Commissioning for Outcomes?

45. Scott Bennett
Scott.bennett@brookward.co.uk
07769697413
Jo-anna.holmes@ageuk.org.uk

47. Coordinated community care models
Shaping care around communities
in line with needs and assets

48. Video

50. A Matched Control –
Our approach
• Match using
– 6 x living well key LTCs
– gender
– age
– use of services in 6months pre-guided conversation
• Match group specific to each Living Well cohort member
• Match from Penwith GP registered population only
• Matched GP practice activity to retain a single match group for each
member of the Living Well cohort
• Vary age until 10 matches found max +- 5 years
• Compared 6 months pre intervention to up to 6 months post intervention
• Filtered out
– those without matches in the background population, and
– those without 3 months post-intervention represented in the dataset

51. Emergency Admissions
• Living Well Group • Control Group
20.8%
3.8%
• Financial Impact
£1,577
per
patient
p.a.
24.6%
£35 Million

52. Elective Admissions
• Living Well Group • Control Group
21.1%
26.8%
• Financial Impact
£460 per
patient
p.a.
5.7% £11 Million

53. ED Attendances
• Living Well Group • Control Group
20.8%
5.9%
• Financial Impact
£21 per
patient
p.a.
26.7%
£0.5 Million

54. All Admissions
• Living Well Group • Control Group
10.7%
31.8%
• Financial Impact
£670
per
patient
p.a.
21.1% £15 Million

55. Primary Care Usage
• Living Well Group • Control Group
36.6%
49.3%
• Financial Impact
1.7 more
practice
contacts
per
patient
p.a.
12.7%

56. Conclusions
• Five Year Forward View
• Closing the Care and Quality
Gap
• Closing the Health Gap
• Closing the funding and
efficiency Gap
• Triple Aim (IHI)
• Improved Health and
Wellbeing
• Improved Experience of
Care and Support
• Reduced cost of Care and
Support

57. Conclusions
• Five Year Forward View
• Closing the Care and Quality
Gap ✓
• Closing the Health Gap
• Closing the funding and
efficiency Gap
• Triple Aim (IHI)
• Improved Health and
Wellbeing ✓
• Improved Experience of
Care and Support
• Reduced cost of Care and
Support

58. Conclusions
• Five Year Forward View
• Closing the Care and Quality
Gap ✓
• Closing the Health Gap ✓
• Closing the funding and
efficiency Gap
• Triple Aim (IHI)
• Improved Health and
Wellbeing ✓
• Improved Experience of
Care and Support ✓
• Reduced cost of Care and
Support

59. Conclusions
• Five Year Forward View
• Closing the Care and Quality
Gap ✓
• Closing the Health Gap ✓
• Closing the funding and
efficiency Gap ✓
• Triple Aim (IHI)
• Improved Health and
Wellbeing ✓
• Improved Experience of
Care and Support ✓
• Reduced cost of Care and
Support ✓