The document outlines the development of integrated care networks for managing long-term conditions in England, highlighting the importance of person-centered care and risk stratification. It emphasizes the significant healthcare costs associated with multimorbidity and advocates for population-level commissioning to improve service delivery. The 'House of Care' framework is introduced as a model for providing coordinated care, aiming to enhance patient outcomes and reduce overall healthcare expenditures.

1. 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
29th October 2014

2. Drivers for Improvement:
2008 – Polysystems & Person Centred Care
2009 – Risk Stratification
2010 – Integrated data
2011 – LTC management, & The Year of Care
2012 – Integrated Case Management
2013 – Rapid Response & Community Treatment Teams
2014 – Complex Primary Care Practice
2015 – 5 Year Forward View

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

4. Commissioning in silos:
Acute Community Mental Health Social Care Voluntary/
• All PbR
(except YoC or
package
currencies)
Independent
Primary care
Primary care
prescribing
NHS England
as commissioner
• Non-PbR block
contract
• PbR excl drugs
• Crit. Care
Personal
healthcare
budget
Specialised MH
Services
Means-tested
services (incl.
residential)
Within currency
Rehabilitation
palliative &
end of life
Maternity pathway
• Reablement
• Adult Services
PbR MH
clusters
Children’s
services
GP services
Include if possible
Residential
continuing
care (Include if
possible)
Include if
possible

5. Identifying patients:
• Risk stratification tool applied
• LTC codes applied (18 in total - QoF)
• List segmented by LTC currency (Bands B – E applied - B=2,C=3-5,D=6-
8,E=9),
• Risk Score over time mapped (looking for rise in risk score in
last 6 mths – 4 of 6 show an increase) or
• Rapid Riser in last 3 mths (mthly increase in risk score over
past 3 mths and overall increase of >15pts).
• Kent – 80 GP practices, Band B = 2197, Band C= 3506, Band D
=261, Band E= 5 Total 6369 of 729, 275
• Now driving increased engagement in risk stratification

6. LTC Year of Care Commissioning
Implementation Guide

7. Population Level Commissioning for the Future:
Over 30% of people over 75 years have multimorbidity

8. Population Level Commissioning for the Future:

9. Population Level Commissioning for the Future:
The total health and social care cost is strongly related
to multimorbidity

10. Population Level Commissioning for the Future:
The main contributors to total health & social care cost
are acute non-elective admissions

11. Population Level Commissioning for the Future:
People with complex health & social care needs appear
to demonstrate a ‘crisis curve’

12. Population Level Commissioning for the Future:
More community, mental health and social care services
are delivered to people following a ‘crisis’ than before
the ‘crisis’

13. Some indications that an integrated care plan changes the pattern of services
delivered to people

14. LTC Year of Care Commissioning Model
Implementation Guide

16. Why simulation?
• A service and system redesign
• Understanding the impact of changing service
utilization on:
– Flow
– Cost
– Capacity/Resource
• No historic data
• Different impacts on organizations, costs and
patients
SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com

17. LTC Year of Care Simulation Model
SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com
• Use local
data to test
assumptions
• Ability to
update and
review

18. How it works:
• Patients in each “state” have
– A likelihood of accessing certain types of service, including
accessing services more than once
• Acute,
• Community,
• Mental Health,
• Social Care),
• Costs associated with those services
SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com

19. SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com
Results:
• Cost by each area of service/organisation

20. • Costs by state per year
• Average cost per patient
• Comparison with tariff
SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com
Results:

21. LTC Year of Care Commissioning Model
Implementation Guide
Next Chapter:
RRR Clinical Audit:
• Report
• Simulation Model,
• How to Guide

22. Long Term Conditions House of Care:
• The 15 million people in
England with long term
conditions have the greatest
needs of the population
• People living with long term
conditions report that they
require person centred coordinated
care.
• The House of Care provides
framework for this to be
delivered

23. The House of Care: value to the person
This House supports National Voices ‘I’ statements:
My goals/outcomes e.g.
• All my needs as a person were
assessed and taken into
account.
Communication e.g.
• I always knew who was the
main person in charge of
my care.
Information e.g.
• I could see my health and
care records at any time to
check what was going on
Decision-making e.g.
• I was as involved in
discussions and decisions
about my care and treatment
as I wanted to be. Care planning e.g.
• I had regular reviews of my care
and treatment, and of my care
plan.
Emergencies e.g.
• I had systems in place so that
I could get help at an early
stage to avoid a crisis.
Transitions e.g.
• When I went to a new
service, they knew who I
was, and about my own
views, preferences and
circumstances.

24. The House of Care
in value to NHS: £1.2bn:
Avoid ambulatory care
sensitive admissions
though e.g. following
NICE guidelines (1)
£0.8bn:
Reduction of hospital
admissions for common
LTCs through integrated care
esp frailty, comorbid (2)
£0.8-1.2bn:
Reduce use of low value drugs,
devices and elective procedures
using commissioning analytics
and clinician education (3)
£0.2-0.4bn:
Empower people in
supportive self-management
(4)
£1-1.6bn:
Shift activity to cost
effective settings
e.g. pharmacy minor
ailments (5)
£0.4-0.6bn:
Avoidance of drug errors
e.g. through electronic
records/e-prescribing (7)

27. @NHSIQ
@bev_j_matthews ICASE LTC Community
LTC Year of Care Community