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Using models-of-care-to-understand-the-impact-of-networks-of-care-for-lt cs
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.
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Using models-of-care-to-understand-the-impact-of-networks-of-care-for-lt cs
- 1. Using models ofcare to understand the impact of networks of care for Long Term Conditions Improving health outcomes across England by providing improvement and change expertise
- 2. Welcome A patient’sstory Fiona McLoughlin Setting the context Dr Martin McShane, Director, NHS England Domain 2 Introduction to Long Term Conditions Improvement Programmes Bev Matthews, NHS Improving Quality, Long Term Conditions Programme Delivery Lead The Long Term Conditions House of Care Toolkit Lesley Callow, NHS Improving Quality, Long Term Conditions Delivery Support Manager Developing new models Rob Meaker, Director of Innovation, Barking, Havering and Redbridge CCGs
- 3. Meet the Speakers Fiona McLoughlin, Patient speaker. Fiona has been living with M.E. for eight years. She experiences fatigue and pain, but the most annoying symptom is the brain fog. Her interest in healthcare provision developed after her late mother was diagnosed with the rare neurological condition Progressive Supranuclear Palsy. Dr Martin McShane, Director, NHS England Domain 2 Leading authority on improving the quality of life for people with long term conditions. Appointed NHS England Director in 2012 following illustrious career as a GP and Chief Executive. Bev Matthews, NHS Improving Quality, Long Term Conditions, Programme Delivery Lead Passionate about service transformation through developing networks and leading complex programmes. Providing strategic leadership to partners within health communities, managing stakeholders and working across agencies. Lesley Callow, NHS Improving Quality, Long Term Conditions, Delivery Support Manager Extensive experience leading large scale change programmes for public services nationally and internationally. Registered clinician for adult nursing and public health practitioners. Practice educator on the Nursing and Midwifery Council register, and advisory panel member for Self-Management UK. Rob Meaker, Director of Innovation, Barking, Havering and Redbridge CCGs Leads innovation work across three CCGs, where testing new ideas is critical in developing them so they can be replicated on an economical basis, while ensuring better outcomes for patients. In 2013 the team won the NHS Challenge Prize, for the innovative work undertaken for the “A Year in The Life Project”.
- 4. Fiona McLoughlin and Carol McCullough
- 5. Dr Martin McShane Medical Director (Domain 2) Long Term Conditions NHS England
- 6. Modelling Models ofCare Bev Matthews Programme Lead for Long Term Conditions Improving health outcomes across England by providing improvement and change expertise
- 7. Population profiling 20% 75% 40% 15% Multiple complex conditions Single LTC/ at risk Healthy / minor risk Population segments Cost
- 8. 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
- 9. 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
- 10. Long Term ConditionsYear of Care Commissioning Model Implementation Guide
- 11. Population Level Commissioningfor the Future: Over 30% of people over 75 years have multimorbidity
- 12. Population Level Commissioningfor the Future: Multimorbidity is more common than single morbidity
- 13. Population Level Commissioningfor the Future: The total health and social care cost is strongly related to multimorbidity
- 14. Population Level Commissioningfor the Future: The main contributors to total health and social care cost are acute non-elective admissions
- 15. Population Level Commissioningfor the Future: People with complex health and social care needs appear to demonstrate a ‘crisis curve’
- 16. Population Level Commissioningfor the Future: More community, mental health and social care services are delivered to people following a ‘crisis’ than before the ‘crisis’
- 17. Some indications thatan integrated care plan changes the pattern of services delivered to people Source NHS Barking & Dagenham, Havering and Redbridge CCG
- 18. Long Term ConditionsYear of Care Commissioning Model Implementation Guide
- 20. LTC Year ofCare Simulation Model • A service and system redesign • Understanding the impact of changing service SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com utilisation on: - Flow - Cost - Capacity/Resource • No historic data • Different impacts on organisations, costs and patients • Use local data to test assumptions • Ability to update and review • 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
- 21. SIMUL8 Corporation |SIMUL8.com | info@SIMUL8.com Results: • Cost by each area of service/organisation
- 22. • Costs bystate per year • Average cost per patient • Comparison with tariff SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com Results:
- 23. Future chapters: •Recovery, rehabilitation and reablement clinical audit • Minimum dataset • Getting started Long Term Conditions Year of Care Commissioning Model Implementation Guide
- 26. Join our lunchand learn webinars Population level commissioning for the future Wednesday 3 December 2014 - 13:00 to 13:45 Hosted by Beverley Matthews, NHS Improving Quality Long Term Conditions Programme Lead and Dr Abraham George, Assistant Director & Consultant in Public Health, Kent County Council 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 For more information contact LTC@nhsiq.nhs.uk
- 27. Long Term ConditionsHouse of Care Toolkit Lesley Callow Delivery Support Manager Improving health outcomes across England by providing improvement and change expertise
- 28. Long Term ConditionsHouse 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 a framework for this to be delivered
- 29. The House ofCare in value to people/patients: The House supports National Voices ‘I’ statements My goals/outcomes All my needs as a person were assessed and taken into account. Communication I always knew who was the main person in charge of my care. Information I could see my health and care records at any time to check what was going on. Decision-making I was as involved in discussions and decisions about my care and treatment as I wanted to be. Care planning I had regular reviews of my care and treatment, and of my care plan. Emergencies I had systems in place so that I could get help at an early stage to avoid a crisis. Transitions When I went to a new service, they knew who I was, and about my own views, preferences and circumstances.
- 30. The House ofCare 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)
- 31. The House ofCare - Person centred, coordinated care at three levels National What can national organisations and policy makers can do to enable construction of the House of Care at the next two levels. Local How local health economies ensure that the House of Care involves a whole system approach, including ‘more than medicine’ offers Personal How the House of Care gives professionals on the front line a framework for what they need to do for patients and ask local commissioners to secure for them
- 32. The House ofCare - Person centred, coordinated care at three levels The national level is built and is available at: http://www.nhsiq.nhs.uk/improvem ent-programmes/long-term-conditions- and-integrated-care/ long-term-conditions-improvement- programme/house-of- care-toolkit/national.aspx National What can national organisations and policy makers can do to enable construction of the House of Care at the next two levels.
- 33. The House ofCare - Person centred, coordinated care at three levels Local How local health economies ensure that the House of Care involves a whole system approach, including ‘more than medicine’ offers. The local level is built with case studies continuously being uploaded at: http://www.nhsiq.nhs.uk/improvem ent-programmes/long-term-conditions- and-integrated-care/ long-term-conditions-improvement- programme/house-of- care-toolkit/local.aspx
- 34. The House ofCare - Person centred, coordinated care at three levels Personal How the House of Care gives professionals on the front line a framework for what they need to do for patients and ask local commissioners to secure for them The personal level is built and is constantly being updated at: http://www.nhsiq.nhs.uk/improvem ent-programmes/long-term-conditions- and-integrated-care/ long-term-conditions-improvement- programme/house-of- care-toolkit/personal.aspx
- 35. Rob Meaker Directorof Innovation, Barking, Havering and Redbridge CCGs
- 36. Complex Primary CarePractice in East London
- 37. Overview of BHRCCGs’ Health Economy East Of England Cluster 1 Cluster 3 Cluster 1 Hospital LAS Station Central London Cluster 2 Cluster 4 Cluster5 Cluster4 Cluster 1 Cluster2 Cluster6 Cluster 2 Cluster 3 Cluster 4 Cluster 5 Cluster 6 Walk In Centre Total Population 759,285 BHR Dashboard £55m Havering Non elective admissions £8.8m A&E attendances Barking £36.5m Non elective admissions £7.6m A&E attendances Redbridge £50m non elective admissions £7.6m A&E attendances
- 38. BHR CCGs’ Development Timeline 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 Health 1000 Ltd, the Complex Primary Care Practice, is a Primary Social and Acute Care System located in King George Hospital, Ilford
- 39. How BHR CCGsare Implementing a Primary, Social and Acute Care System Health1000 is a new primary care evolved provider organisation operating a new model of care being developed as part of the Prime Minister’s Challenge fund and aligned to the PACS (Primary and Acute Care Systems) models set out in the 5 Year Forward Plan. The Year of care work provided the foundation for the service design and the supporting capitated budget. The model has been designed in collaboration with the users it intends to serve and will be guided by what people with complex needs want to achieve from their health and social care
- 40. Aligning the PSACSmodel with existing services. EoL / CHC > 5 LTCs Frail/1-3%/2LTCs 3-6%/1LTC Comm Pharmacy GP BHRUT NE London FT Cont. Heath Care Integrated Urgent & Emergency Care Service 111 Urgent Care Centres Voluntary Sector Meds Man Non Year of Care Year of Care Social Care Federated Urgent and Planned Primary Care Services Out of Hospital London Ambulance Complex Care model In the future, a unified urgent primary care service joins patients and clinicians Complex Care Service Individual Care Multidisciplinary Teams Patients Children Elderly or Retired Unemployed Full time mothers or carers Working Adults Complex Patients Planned GP Appointment Online Call2 Practice Non-Direct Emergency Triage Primary Care Prof Support Online Existing urgent care services Unified point of access Urgent Primary Care Appointments Walk-in Centres GP Core Plus Weekend 6-10 pm opening GP core across BHR primary care New or significantly enhanced services Patients flow through primary care Key Existing services Implementing a new model of care, it is essential to align the model with other Key services.
- 41. Complex Care PracticePatient Selection Complex Care cohort Row Labels Cohort Hypertension CHD Diabetes Stroke Depression COPD Heart Failure Dementia LTC 5+ 100 99 96 80 70 80 69 75 36 Scottish modified LTC 4+ 1924 1816 1559 1421 863 793 783 679 303 Grand Total 2024 1915 1655 1501 933 873 852 754 339 211 of the cohort currently receive Integrated case Management Services The Complex Primary Care Practice intends to register 1000, of the 2024 eligible patients Eligible cohort, must have 4 diagnosed long term conditions from Hypertension, CHD, Diabetes, Stroke, Depression, Heart Failure and Dementia.
- 42. The trend inadjusted cost for all patient in the complex care cohort by service type The costs have increased for these patients over the 7 years, presumably as more of the patients in the cohorts need services and/or patients in the cohorts need greater volumes of services The greatest cost increases over the period for patients in the cohorts were primary care and community care. In percentage terms, the cost of acute care has decreased over the period.
- 43. Cost and Activityfor the selected cohort Activity Cost (£) 2012/13 2013/14 2014/15 2012/13 2013/14 2014/15 Primary Care Contact 42.1 45.2 45.1 1,897 2,032 2,030 Pharmacy 134.8 134.1 135.5 2,373 2,362 2,387 Acute care A&E 1.2 1.2 1.0 137 144 120 Outpatient 5.7 5.5 5.6 602 742 764 Daycase 0.6 0.5 0.3 424 366 217 Elective 0.1 0.1 0.1 286 194 174 NEL short-stay 0.2 0.2 0.2 246 228 166 NEL long-stay 0.5 0.5 0.4 1,568 1,570 1,254 Community care Face-to-Face 6.0 10.2 12.3 1,092 1,884 2,172 Telephone 0.5 0.9 1.1 27 47 54 Combined average cost per patient (£) 8,652 9,569 9,337 Total annual cost of patient cohort (£million) 17.51 19.37 18.90 Average annual number of events and average annual cost per patient in the cohort - all CCGs The averages hide a great deal of variation. If we take one example, patient's in the cohorts on average visit A&E once a year but over 50% of patients did not visit A&E at all during 2013/14, and one patient visited 41 times . Perhaps the most striking feature of the data is that large percentages of patient in the complex care cohorts didn't require acute inpatient care at all in 2013/14.
- 44. Commissioning the Service, Who, Where, When Acute Trust Community Trust Health1000 Private Provider Voluntary Sector GP Federation
- 45. PSCAS Staffing Model • Document patient conditions, consider evidence for diagnoses and confirm or challenge these • Record patient preferences e.g. settings of care, treatment approaches • Optimise management against NICE guidance • Initiate patient and carer self management programme where appropriate • Clarify the new system to patient and carer(s) • Clarify emergency procedure • Document and agree care plan with patients /carers • Agree EoL wishes • Agree emergency escalation plan eg to A&E or not • Allocate case manager and team • Educate patient / carer on service and provide details of key contacts (patient-specific) Patient enrolled in programme Data is transferred Initial Visit Care delivery (Preventative) Team Escalation Rapid Response Team • Transfer data from the primary care record and import from any other source e.g. community or social care record and incorporate into a new single electronic care record Programme GP/Nurse Case Manager GP Multi-disciplinary Team (icons are illustrative only, the composition of the team will be tailored to individual patient needs) • Review patient record and need for specialty input • Care is proactive in nature, with regular touch points between the patient and care staff • Care is front-loaded during crises/ exacerbations to prevent escalation • Patient receives face to face visits and or telephone calls on a regular basis depending on personal need • 24/7 option for patient to call for advice • Telehealth monitoring where appropriate • Regular clinical review of needs and adherence to plan tailored to patient need • E patient care plan is accessible to the patient and their family by both electronic and paper means • Patients with more complex management under care of multi-disciplinary team including specialist input • Every admission reviewed as a critical incident for team and patient learning Multi-disciplinary team case conference (includes specialist input as required) • Urgent care team working across the LTC chronic care team responsive to patient emergency with a 1 hour maximum call out • Patients managed via phone until team arrives • Teleheath interaction for care homes and some individual patients where appropriate Social Care Pharmacist Worker Nurse Other professional(s) (as required) Telehealth (where appropriate) UC Team 5 6 7 9a 10a 10b • Obtain patient consent to enter programme • Obtain patient consent for research • Remove patient from current primary care list a re-registered with the new practice Patient consent 4 Patient engagement 3 Patient / Carer • Provide details of the pilot and service to the patient and carer(s)and help them understand ‘what it would mean to them’ • Register patient willingness to participate • GP refers patient to the service if patient response is positive GP engagement 2 • Meet with GPs to provide background to programme • Discuss potential patient(s) for pilot and obtain buy-in from GP • Agree engagement plan for patient(s) GP Programme Rep Patient / Carer Patient / Carer Case Manager Specialty Team Assessment 8 GP Hospital Physician / Geriatrician Self Management and education 9c Patient / Carer Nurse Additional Expertise External expertise accessed as needed (Cardiologist, Dietician, gastroenterologist, Domiciliary Dental Service etc) 9b • Nurse educates patient/ carer on how to use services and manage LTCs • Additional expertise is available quickly via phone or face-to- face as needed Integrated care record GP sends letter to patients 1 GP Patient / Carer • The current GP sends a letter to patient(s) to introduce the service • The letter will also outline next steps to the patient i.e. a face-to-face meeting or phone call with the GP to discuss service in more detail • Interviews with patients to understand the following: What are the gaps in the current service? What would their ideal service look like? What would persuade them to join the new service and leave their GP? Who else would need to be involved in the decision e.g. carer? What do they think of the proposed service model, i.e. care closer to home? • Patients interviewed for co-design are unlikely to be the patients involved in the pilot • Interviews with charities to understand how would they input into the design of a new service and what would be their role in the new service if given opportunity Co-Design of Model with Patients & Charities
- 46. PSCAS Staffing Model ROLE WTE at start up Start up Cover provided WTE by month 3 MD and Geriatrician (50:50 role) 1.0 20 hours direct patient care plus 17.5 hours management plus on call support as required 1.0 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 6.0 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 3.0 Practice Manager 1.0 37.5 hours per week as required to cover 7 days per week on rota 0.5 Nurse 1.0 37.5 hours per week during 8am to 6.30pm 0 OT 0.5 18.5 hours per week during 8am to 6.30pm 3.0 Physiotherapist 0.5 18.5 hours per week during 8am to 6.30pm 2.0 Pharmacist 0.5 18 hours per week Monday to Friday as required 1 Community Nurse 0.0 Not applicable 4.0 Mental health Nurse 0 Not applicable 0.5 Social Worker 1.0 Seconded from Local Authority
- 47. People interviewed aboutthe new Health1000 service told us: “We feel helpless trying to get the best care for our mum.” “The professionals don’t understand all of my needs.” “I just want to be able to go fishing. I don’t want any more operations or medication, I just want to be able to o Fly Fishing again. Why wont anyone help me achieve this ? Complex Care Service Individual Care Multidisciplinary Teams 4+ LTCs Mental Health Social Isolation End of Life Needs Complex Patients Care plan developed Care Navigator Navigation package New and existing services Care (Sectors including Voluntary, Charities, Private Sector, Social models, Communities, user developed services etc) Health 1000 Directory of Services Scope of existing services Scope of IPC development Focus of the IPC application Updated Service updated to meet the registered patient needs Patient Feedback resulting in design changes
- 49. Connect with us Visit the Long Term Conditions web pages at www.nhsiq.nhs.uk The House of Care www.england.nhs.uk/house-of-care Get in touch on twitter: #ltcimprovement #LTCYearofcare