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
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.
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
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
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.
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
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
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
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.
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
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
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
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.
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
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.
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.
Using simulation to drive changes in health and care - long term conditions Year of Care model
Bev Matthews and Claire Cordeaux
Presentation from Day 1 of the Health and Care Innovation Expo 2014, Manchester Central
Jacquie White, Deputy Director of NHS England Long Term Conditions, Older People & End of Life Care and Dr Eileen Pepler, Academic, Researcher and Consultant in the Canadian Healthcare will discuss how NHS England work in chronic disease is being translated into a Canadian context.
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
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.
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
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
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
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.
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
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.
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.
Using simulation to drive changes in health and care - long term conditions Year of Care model
Bev Matthews and Claire Cordeaux
Presentation from Day 1 of the Health and Care Innovation Expo 2014, Manchester Central
Jacquie White, Deputy Director of NHS England Long Term Conditions, Older People & End of Life Care and Dr Eileen Pepler, Academic, Researcher and Consultant in the Canadian Healthcare will discuss how NHS England work in chronic disease is being translated into a Canadian context.
Jacquie White, Deputy Director of NHS England Long Term Conditions, Older People & End of Life Care and Claire Cordeaux SIMUL8 Executive Director for Health & Social Care were invited by Centers for Medicare & Medicaid Services to discuss how NHS England work in chronic disease.
Integrated health & social care: service transformation supported by technolo...flanderscare
Wat is de toekomst van zorg op afstand in Vlaanderen? Dat was de centrale vraag van het event van 17 juni. 100 deelnemers dachten hier samen over na. Studiebezoeken aan andere Europese regio's toonden dat daar reeds op grote schaal met telecare en telehealth gewerkt en geëxperimenteerd wordt.
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
Developing Networks of Care through Long Term Conditions Year of Care Commissioning & Long Term Conditions Improvement Programmes
Bev Matthews
Programme Lead for Long Term Conditions @Bev_J_Matthews
Presentation from the Tackling Long Term Conditions conference on 29 October 2014
The path to integration: health and social care – Elaine BaylissNHS Improving Quality
Quality of Life and Death Electronic Palliative Care Co-ordination Systems (EPaCCS)
Improving End of Life Care – Elaine Bayliss
The Path to Integration Health and Social Care
The Wirral Way
Elaine Bayliss is an Improvement Manager and Domain Lead for End of Life Care and EPaCCS, NHS IQ
Presented at NHS Confed 2013
A detailed approach to an integrated health care system in Scotland presented by Dr. Anne Hendry from National Clinical Lead for Integrated Care.
Source Page:
http://www-01.ibm.com/software/city-operations/curam-research-institute/curam-roundtable/index.html
Elizabeth Orton: Leicestershire’s Better Care Fund Nuffield Trust
Elizabeth Orton, Consultant in Public Health and Janine Dellar, Head of Public Health Intelligence at Leicestershire County Council present on evaluating Leicestershire's Better Care Fund programme.
Public Health contribution towards LTC Year of Care Commissioning ModelNHS Improving Quality
Public Health contribution towards LTC Year of Care Commissioning Model
Dr Abraham P. George
Consultant / Asst Director in Public Health
Kent County Council
What is the long term conditions commissioning model?
Anne Hendry: reshaping care pathways for older peopleThe King's Fund
Dr Anne Hendry, Consultant Geriatrician and National Clinical Lead for Quality, Scottish Government, talks about the Reshaping Care for Older People programme in Scotland, which is aimed at improving services for older people by shifting care towards anticipatory care and prevention.
The Joint Improvement Team supports the implementation of this 10 year programme, which began in 2011, and involves 32 integrated partnerships between the NHS, local authority, third and independent sectors. A £300 million change fund is available to the partnerships to 2015.
Working together for Better Care in Richmond HW_Richmond
Presentation from Richmond CCG, Healthwatch Richmond, Hounslow and Richmond Community Healthcare, Kingston Hospital, West Middlesex University Hospital and the Richmond GP Alliance on the changes happening to community services in Richmond.
NHSIQ LTC Year of Care Commissioning Programme shortlisted for HSJ Awards 2014:
HSJ Awards Dragon’s Den presentation on enhancing care by sharing data and information
More at: http://www.nhsiq.nhs.uk/improvement-programmes/long-term-conditions-and-integrated-care.aspx
Southwark and Lambeth-based projects Knee High Design Challenge, Diabetes Modernisation Initiative and Pathway explore what it takes to maintain change in the local healthcare system: understanding the issue & adapting to ever-changing context; gathering & maximising evidence; and building & maintaining meaningful relationships.
Find out more at www.gsttcharity.org.uk
Stopping over-medication of People with Learning Disabilities
(STOMPLD) 2016.
Reducing Inappropriate Psychotropic Drugs in People with a Learning Disability in General Practice and Hospitals in 2016.
Self-management in the community and on the Internet - Presentation 22nd Marc...NHS Improving Quality
LTC Lunch & Learn webinar:- 22nd March 2016
Presenter:- Pete Moore, Educator, Author & Pain Toolkit Trainer
As pain is the most daily health problem reported to a GP-
Developing a national pain strategy- reviews from around the world
An overview of the work carried out by NHS England and NHS Improving Quality's Long Term Conditions Sustainable Improvement Team. It puts the case for why person-centred care has to be at the heart of healthcare.
The final poll for the person centred care images captured at the LTC Midlands and East learning event in November 2015. Which captures person centred care the most to you? Access to records or quality for everyone?
Improving the physical health of patients with severe mental health illness ...NHS Improving Quality
Improving the physical health of patients with severe mental health illness in primary care, by Rhiannon England, GP Clinical Lead, City and Hackney CCG
The Importance of Community Nursing Care.pdfAD Healthcare
NDIS and Community 24/7 Nursing Care is a specific type of support that may be provided under the NDIS for individuals with complex medical needs who require ongoing nursing care in a community setting, such as their home or a supported accommodation facility.
How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
ICH Guidelines for Pharmacovigilance.pdfNEHA GUPTA
The "ICH Guidelines for Pharmacovigilance" PDF provides a comprehensive overview of the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) guidelines related to pharmacovigilance. These guidelines aim to ensure that drugs are safe and effective for patients by monitoring and assessing adverse effects, ensuring proper reporting systems, and improving risk management practices. The document is essential for professionals in the pharmaceutical industry, regulatory authorities, and healthcare providers, offering detailed procedures and standards for pharmacovigilance activities to enhance drug safety and protect public health.
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
Leading the Way in Nephrology: Dr. David Greene's Work with Stem Cells for Ki...Dr. David Greene Arizona
As we watch Dr. Greene's continued efforts and research in Arizona, it's clear that stem cell therapy holds a promising key to unlocking new doors in the treatment of kidney disease. With each study and trial, we step closer to a world where kidney disease is no longer a life sentence but a treatable condition, thanks to pioneers like Dr. David Greene.
CRISPR-Cas9, a revolutionary gene-editing tool, holds immense potential to reshape medicine, agriculture, and our understanding of life. But like any powerful tool, it comes with ethical considerations.
Unveiling CRISPR: This naturally occurring bacterial defense system (crRNA & Cas9 protein) fights viruses. Scientists repurposed it for precise gene editing (correction, deletion, insertion) by targeting specific DNA sequences.
The Promise: CRISPR offers exciting possibilities:
Gene Therapy: Correcting genetic diseases like cystic fibrosis.
Agriculture: Engineering crops resistant to pests and harsh environments.
Research: Studying gene function to unlock new knowledge.
The Peril: Ethical concerns demand attention:
Off-target Effects: Unintended DNA edits can have unforeseen consequences.
Eugenics: Misusing CRISPR for designer babies raises social and ethical questions.
Equity: High costs could limit access to this potentially life-saving technology.
The Path Forward: Responsible development is crucial:
International Collaboration: Clear guidelines are needed for research and human trials.
Public Education: Open discussions ensure informed decisions about CRISPR.
Prioritize Safety and Ethics: Safety and ethical principles must be paramount.
CRISPR offers a powerful tool for a better future, but responsible development and addressing ethical concerns are essential. By prioritizing safety, fostering open dialogue, and ensuring equitable access, we can harness CRISPR's power for the benefit of all. (2998 characters)
Health Education on prevention of hypertensionRadhika kulvi
Hypertension is a chronic condition of concern due to its role in the causation of coronary heart diseases. Hypertension is a worldwide epidemic and important risk factor for coronary artery disease, stroke and renal diseases. Blood pressure is the force exerted by the blood against the walls of the blood vessels and is sufficient to maintain tissue perfusion during activity and rest. Hypertension is sustained elevation of BP. In adults, HTN exists when systolic blood pressure is equal to or greater than 140mmHg or diastolic BP is equal to or greater than 90mmHg. The
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
1. Improving health outcomes across England by providing improvement and change expertise
LTC Year of Care
Commissioning Model
Lesley A Callow
Delivery Support Manager
LTC Year of Care Commissioning Model
NHSIQ
Fionuala Bonnar
Year of Care Programme Manager
2. Launched in W/C 19th April 2012 with EOI under Dept of Health LTC QIPP
workstream
Transferred to NHS England in December 2012 to Martin Mc Shane and he
is SRO as Director Domain 2
Integration with the ICSP Pioneers
22 Fast Followers
6 Early Implementer Sites
LTC Year of Care: Background
3. LTC Year of Care: Early Implementer Sites
Health Economy Early
Implementer
Key Partners Regions
Leeds Leeds South and East CCG, Leeds West CCG, Leeds North CCG, North
Southend Southend CCG; Southend Council Midlands and
East
Kent Kent County County (Social Services Dept), Kent Community Health Trust, East Kent University
Hospital FT, Maidstone Foundation Trust, Darent Valley Hospitals FT, Canterbury CCG, Thanet
CCG, Swale CCG, Ashford CCG, South Kent Coast CCG, West Kent CCG, Dartford and
Gravesham and Swanley CCG.
South
North Staffordshire and
Stoke on Trent
Stoke on Trent CCG, North Staffordshire CCG; Stoke on Trent Council; Staffordshire Joint
Commissioning Unit; University Hospital of North Staffordshire; Staffordshire and Stoke on Trent
Partnership Trust, North Staffordshire Combined Healthcare Trust; West Midlands Ambulance
Trust
Midlands and
East
West Hampshire West Hampshire CCG; Hampshire County Council; Hampshire Hospitals NHS FT; Southern Health
NHS FT.
South
Barking, Havering and
Redbridge
Barking and Dagenham CCG; Havering Emerging CCG; Redbridge Emerging CCG; Barking &
Dagenham Council; Redbridge Council; Havering Council; NHS Outer North East London; Barking,
Dagenham and Redbridge University Hospitals Trust; North East London NHS FT.
London
4. The House of Care
Engaged,
informed
individuals &
carers
Commissioning
Organisational
& clinical processes
Person-
centred,
coordinated
care
Health & care
professionals
committed to
partnership
working
Plan
Study
Do
Act
6. 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 & 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
7. LTC Year of Care Currency:
• All PbR
(except YoC or
package
currencies)
Acute Community Mental Health Social Care Voluntary/
Independent
Primary care
Primary care
prescribing
NHS England
as commissioner
• Non-PbR block
contract
• PbR excl drugs
• Crit. Care
Personal
healthcare
budget
Specialised MH
Services
Means-
tested
services (incl.
residential)
Within currency
Rehabilitation
palliative &
end of life
Maternity pathway
• Reablement
• Adult Services
PbR MH
clusters
Children’s
services
GP services
Include if possible
Residential
continuing
care (Include if
possible)
Include if
possible
8. RRR audit:
To support local thinking about RRR and early discharge, particularly in
relation to potential for pathway changes.
To assess the appropriateness of methodology for long-term conditions
(COPD, diabetes, stroke and heart failure), particularly whether there is
scope to unbundle the RRR service from the Acute Provider PbR tariff.
Health and social care resource utilisation dataset
Support the development of local tariffs for LTC YoC currency
Looking at longitudinal data to support the discussions/understand the
impact in changing pathways
Whole Population
Gives the evidence to support the currency framework
Validates the framework
LTC Year of Care: Data Collections
9. • Stakeholder engagement and senior team ‘buy-in’
• Assessment of services to maximise the benefit of integrated care
• Learn from research, eg models of care, contracting models,
weighting LTCs for local tariff
• Planning for improvement in data quality and implementation of
shadow testing
• Assessment of systems and processes to support LTC YoC currency
• RRR clinical audit
• Local analysis and collection of data to support national analysis
• Local tariff development
• Share learning with other health economies and national
stakeholders
LTC Year of Care:
Early Implementer Sites Deliverables
10. • Senior team ‘buy-in’, eg NCDs
• Stakeholder Engagement, eg Monitor and PbR Team
• Framework for the Model and vision for future years
• Simul8 Model for redesigning services
• Data analysis and comparison
• Programme Management and EI site support
• Resolution of barriers, eg Information Governance
LTC Year of Care:
National Support Team Deliverables
11. GPs
Community &
Social Care
Assessment
Integrated
Care Team
GP datasets
Acute datasets
Mental
Health
datasets
KMHIS2
GPs
Community
Trust1
Acute Trust1
Mental Health
Trust1
Social Care
Independent sector
& voluntary
PHE3
NHSIQ
A) Referral B) Selecting
patient cohort &
risk stratification
C) Sharing
patient cohort
(patient register)
D) Collecting
data/financial
monitoring
E) National
reporting
Person ID
Referral reason
Person ID
Client, Clinical & QOF
Demographic
Pseudo. Person ID only
(i.e. single data item shared)
Pseudo. Person ID
Client, Clinical & QOF
Demographic
Costs
Pseudonymised Person ID
Client, Clinical & QOF
Demographic
Costs
Early Implementer team – LTC Year of Care programme
Information Governance
May include national datasets
(CMDS, MHMDS, CIDS, QOF)
May include national datasets
(CMDS, MHMDS, CIDS, QOF)
Processstep
description
ProcessdataflowsMajordata
items
Non-NHS
organisations
1 Includes both Foundation and non-Foundation Trusts
2 Kent and Medway Health Informatics Service (Interim Safe Haven)
3 PHE – Public Health England safe haven
Population List
KMHIS2P
P
P
P
P
P
P
P
P
P
P
P
Costing dataset – A, B, C, D & E
Shadow testing – A, B, C & D
Whole population dataset – D & E
13. Starting with the models for the most complex
individuals with multi morbidity
5%
20%
75%
45%
40%
15%
Multiple complex
conditions
Single LTC/ at risk
Healthy / minor
risk
Population segments Cost
17. Distribution of cost between
Providers
Provider type £ %
Acute £7,827 67.3%
Community £1,083 9.3%
Mental Health £1,028 8.8%
Social Care £1,690 14.5%
Total £11,628
23. Implementing Year of Care
programme in Kent
Dr Abraham P George
Consultant in Public Health
Lead for Kent YOC programme
24. The journey so far
• Profile of Kent
• Background and work before YOC
• Governance of programme
• RRR audit
• Data sharing arrangements
• Costing analysis
• Plan for shadow testing
• Our vision for integrated intelligence
25. Profile of Kent
• 1.5 million popn
• 1 County Council, 7
CCGs, 12 districts, 4
acute trusts, 1
community health trust,
mental health trust, >200
practices
• Governance of
commissioning at
multiple levels
• Different integrated
models of care
26. Background to YOC
• Whole population
profiling using risk
stratification
• Impact of multiple
morbidities on service
utilisation - ‘Crisis curve’
• Modelling how benefits
of integrated care could
be realised
• www.kmpho.nhs.uk/jsna
27. Governance of programme
• All providers and commissioners involved
• 2/7 CCGs are the sponsor orgns
• KCC Public Health manages programme on behalf of
whole county
• Implementation at sub Kent level – NK EK & WK
• East Kent Federation group of CCGs first to take part
and now finalising shadow testing arrangements
• Ensure all stakeholders are involved – commissioner,
finance, informatics, etc.
• Use of risk stratification for costing analysis and
shadow testing
28. RRR audit – key results
• > 80 EK patients followed up over 3 months in
• Short stay admissions excluded
• >80% had morbidity
• Average LOS and average length of RRR phase
were much higher than the other audit sites
• Stroke patients contributed much of the bed days
– if excluded LOS would have been reduced by
half Kent BHR Leeds Stoke
All conditions Excluding
stroke
Average length of stay
(days)
19.72 13.93 5.62 6.71 4.46
Average length RRR
phase (days)
6.28 3.29 0.19 3.23 0.69
29. Data sharing arrangements
• Strong historical relationship between KMPHO and
intelligence teams
• Local data warehouse containing hospital, community
health data
• Social care data obtained directly from provider
• Whole Kent population risk stratified using local tool
• Datasets were de-identified at source & and
pseudonymised using same encryption method and key
• Public Health linked data sets - ‘hub and spoke’ before
sending to national team for analysis
‘Whole population person level linked datasets’
• Cannot be re-identified
30. • Whole population person level linked datasets
containing 4 years of activity sent to national team
• Cohort of 1650 (of high intensive users) selected
for detailed analysis in 13-14
• Report produced which provided us with evidence
for indicative tariff
• Data used to develop currency and selection
criteria
Costing analysis
31. East Kent – total cost (reference or unit) for patient cohort (552 patients)
Patient selection date = (May 2012)
Crude tariffs and trends
32. East Kent – total cost for patient cohort (552 patients)
2012_13 Trend
cost % cost %
Acute £6,595 56.2% £4,671 43.7%
Community £1,361 11.6% £1,323 12.4%
Mental Health £1,535 13.1% £1,791 16.8%
Social Care £2,170 18.5% £2,891 27.1%
Total £11,743 £10,676
Crude tariffs and trends
34. Currency No LTCs New Counts
B 2 1042
C 3 822
C 4 449
C 5 197
D 6 80
D 7 31
D 8 5
E 9 1
E 10 1
Selecting YOC cohort
(using current whole popn dashboard)
• Risk stratification tool applied
• GP practice and CCG identified
• Checked to ensure GP data is active
(ie. each practice has submitted data
within the last 3 months)
• Risk stratification popn profile selected
• YoC currency (using QOF LTC codes)
is then applied which outlines the
following:
– Under 18s excluded & Patients
with 1 LTC notionally excluded,
– List segmented by LTC currency
• Risk Score over time mapped (looking
for rise in risk score in last 6 mths or
rapid riser in last 3 mths (mthly
increase in risk score over past 3 mths
and overall increase of >15pts)
35.
36.
37. • Agree a tariff for each of the currency categories-
finance subgroup to agree costing data.
• Track the activity and cost over the next 12mths –
informatics group.
• Identify data issues- definitions and gaps
• Increase engagement of system and link to
existing initiatives
• Evaluate information – dashboard.
• Communication
Next steps
38. To deliver the evidence for Integrated Commissioning
Building on the Kent approach to Integrated Intelligence
Primary
Care
Urgent
Care
OOH Care
Secondary
Care
Adult
Social
Care
3rd Sector
Mental
Health
Community
Health
Kent are collecting activity and actual cost data from all of the above using a cross system pseudonymisation tool. Data
pseudonymised/anonymised at source and linked and analysed by Public Health. MONITOR are currently developing
guidance on how to develop a person level linked data sets, using Kent’s approach as a case example of best practice.
•
• We have developed a systematized method for selecting multi – morbidity people at risk
and suitable to be included in the Year of Care approach
• The selection includes a subjective consent/opt in to facilitate patient choice and clinician
intelligence at point of service delivery.
• It builds on the whole population data set analysis due to be published by the Year of Care
team and distributed nationally at the end of April.
• This focus on the integrated intelligence by commissioners enables best practice to flourish
and identifies areas for improvement within different provider models of integrated care.
• Implementing in Kent across the 3 systems at pace and scale. East Kent leading the way and
building consensus across the other systems.
• Next steps include agreeing an indicative tariff for year of Care to shadow test in 14/15 – we
have sign off in principle to the approach.
• We have agreed the metrics to develop a dashboard which systematically reports the
results/outcomes at both system and patient level, using existing metrics and data
collection. This will be used to jointly measure the impact of YoC on both the individual and
the system.
Identify cross-
system opportunities
and barriers to
change
Collect the data
with the support of
the system to
challenge status
quo.
Identify opportunity
for integrated
incentives/penalties
across provider
organisations.
Commission across
the system to
incentivise the
outcomes desired.
Commissioners and
providers jointly
measure impact on
individuals and cost
of system