The document discusses the testing of integrated care service models for patients with complex care needs, aiming to improve their quality of life and experiences through person-centred, coordinated care. It highlights the importance of simulation modelling in advising and influencing care delivery, emphasizing the challenges of managing multi-morbidity and the need for personalized integrated care. The document outlines strategies for enhancing care coordination, addressing inequalities, and implementing effective commissioning and funding approaches within the NHS.

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Testing integrated
care service models
for patients with
complex care needs
using simulation
modelling
Jacquie White,
Deputy Director for LTC
&
Bev Matthews
Programme Delivery Lead
NHS England
20th November 2015

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Person centred co-ordinated
care
“My care is planned with people who work
together to understand me and my carer(s),
put me in control, co-ordinate and deliver
services to achieve my best outcomes.”
Goal:
Improve quality of life and experience of end
of life care for people with long term
conditions and their carers through:

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LTC Strategy for Person Centred Care:
3
Care & Support
Planning
Embedding personalised
care and support planning
as the core component
Evidence
Improving evidence and
implementation of it to
commission better care
Engagement
Raising professional and
public awareness of and
engagement with PCC
Models of Care
Increasing co-ordination and
continuity of care though
development and testing of
new models
Enablers
Strengthening the enablers
that drive change including
data and incentives
Inequalities
Focussing on areas of
inequality – care homes,
Neuro, MSK, palliative care
for non-cancer conditions

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Long Term Conditions Year of Care
Commissioning Programme
• Launched by Department of Health (Sir John Oldham),
commissioned and delivered by NHS England
• In the final year of a four year programme
• Patients receive care that is better managed, delivered
seamlessly across different care settings focused on patient needs using different
commissioning and funding approaches
• Currently five early implementer health and social economy teams with 22 fast
follower teams
Rationale:
 Multi morbidity is common
 Patients with multi morbidity have complex care needs and would
benefit from personalised integrated care
 An integrated payment would encourage integration of services and
cost efficiency

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Multi Morbidity is Common:

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The total health and social care cost is strongly
related to multi morbidity:

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People with complex health and care needs
appear to demonstrate a ‘complex curve’:

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Mental
health care
Acute
care
Voluntary
care
Primary
care
Social Care
What the future looks like
Community
care
Self
care
Change is difficult. It requires time and effort. Simulation modelling
can help to advise, influence and maximise efforts and resources
to achieving integrated care that works around the patient.

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Early Implementer Sites:

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Long Term Conditions Year of Care
Currency:

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Tested Benefits of multi morbidity
• Decision support tool
for NHS continuing
care
• Risk stratification
• Multi morbidity
• Simple method
• Identifies patients with long term conditions
• Can identify patients with acute and mental
health morbidities
• Multi morbidity is common
• Potential for early identification of patient
with complex care needs
• Cost is related to complexity
Selecting Patient for Inclusion:

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Common to all teams Differs between teams
• Multi morbidity for selecting patients
for referral
• Single point of access/assessment
• Shared care record
• Need to change funding flows
• Outcome-based measurement
• Services (providers)
included
• Contracting model and
financial governance
• Palliative / end of life
• Service specific (e.g. cancer or musculoskeletal)
• Integrated care for older persons / frail elderly /
complex care
Experience from Early Implementer Sites:

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 A service and system redesign
 Understanding the impact of changing service utilisation on:
 Flow
 Cost
 Capacity/Resource
 No historic data
 Different impacts on organisations, costs and patients
 Identify patients in each “state”
 A likelihood of accessing certain types of service (Acute, Community, Mental
Health, Social Care), including accessing services more than once
 Demonstrate costs associated with those services.
Why Use Simulation Modelling?

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Dataset Requirements:
 Whole population activity and cost dataset, including acute,
community, mental health and GP practice activity data
 Risk population segmentation (Commonwealth Fund Segmenting
Populations to tailor services, Improve Care, 2015)
SIMUL8 simulation model parameters:
 Distributions for activity and costs, for each cohort and activity type
 Set access rate and staff FTE resource, for each cohort and activity
type
 Rate of movement of patients into cohorts, between cohorts and
death
 Compare current service model with new service model
Preparing for Simulation:

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Select
patients for
referral
Assessment
of patient
need
MDT –
develop and
share care
plan
Deliver
services to
patients
Assign to
patient
cohort
Patient
dies or
leaves area
Change to
patient
cohort
Review
contract
and
budget
Set
contract
and
budget
Perform
and
quality
Payment
Patient pathway
Payment
cycle
Generalised patient pathway and the
payment cycle for complex care patients

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The Simulation Model
Simulation model

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Simulation Model Results

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Simulation Model Results:
Estimated staff shift (FTE)
Acute Community
Mental
Health
Primary
Care
Total -83.5 53.8 3.1 68.4
Patients Mean annual cost per
patient (£)
Potential capitated
budget (£ mill.)
Current New Current New
31,987 £5,881 £5,830 £188.1 £186.5

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• 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 (and offer
support)
• 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”
20
Summary – creating the conditions for
change:

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Unbundling recovery simulation model
LTC Resources and Tools:

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Jacquie White Bev Matthews
@jaqwhite1
#A4PCC
@bev_j_matthews
#LTCyearofcare #a4pcc
jacquie.white@nhs.net Beverley.matthews@nhsiq.nhs.uk
www.england.nhs.uk/resources/reso
urces-for-ccgs/out-frwrk/dom-2/
www.nhsiq.nhs.uk
Please do contact us:
Thank you