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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
Improving health outcomes across England by providing improvement and change expertise
LTC Year of Care: Background
Launched in W/C 19 th 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: Early Implementer Sites
Health Economy Early Implementer
Leeds Southend Kent
Key Partners Leeds South and East CCG, Leeds West CCG, Leeds North CCG, Southend CCG; Southend Council 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.
Regions North Midlands and East 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
The House of Care Engaged, informed individuals & carers
Plan
Organisational & clinical processes
Do
Person centred, coordinated care Health & care professionals committed to partnership working
Act Study
Commissioning
The House of Care
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
LTC Year of Care Currency:
Within currency Acute Community Mental Health Social Care Voluntary/ Independent Primary care • All PbR (except YoC or package currencies) Rehabilitation palliative & end of life Personal healthcare budget PbR MH clusters • • Reablement Adult Services • NHS England as commissioner Non-PbR block • contract PbR excl drugs • Crit. Care Residential continuing care (Include if possible) Specialised MH Services Means tested services (incl. residential) Maternity pathway Children’s services Include if possible GP services Include if possible Primary care prescribing
LTC Year of Care: Data Collections 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: Early Implementer Sites Deliverables
• • • • • • • • • 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: National Support Team Deliverables
• • • • • • • 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
Early Implementer team – LTC Year of Care programme Information Governance
A) Referral B) Selecting patient cohort & risk stratification C) Sharing patient cohort (patient register) D) Collecting data/financial monitoring E) National reporting GPs Community & Social Care Assessment Integrated Care Team Population List P KMHIS 2 GP datasets
Costing dataset – A, B, C, D & E Shadow testing – A, B, C & D Whole population dataset – D & E
Acute datasets Mental Health datasets Person ID Referral reason Person ID Client, Clinical & QOF Demographic May include national datasets (CMDS, MHMDS, CIDS, QOF) 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 P P P P P P GPs Acute Trust 1 KMHIS 2 Mental Health Trust 1 Community Trust 1 Social Care Independent sector & voluntary P P PHE 3 P P Non-NHS organisations Pseudo. Person ID only (i.e. single data item shared) Pseudo. Person ID Client, Clinical & QOF Demographic Costs May include national datasets (CMDS, MHMDS, CIDS, QOF) P NHSIQ Pseudonymised Person ID Client, Clinical & QOF Demographic Costs
EARLY FINDINGS
Starting with the models for the most complex individuals with multi morbidity Multiple complex conditions 5% Single LTC/ at risk 20% Healthy / minor risk 75% Population segments 45% 40% 15% Cost
Relationship between number of long term conditions and cost
Distribution of cost between Providers
Provider type
Acute Community Mental Health Social Care
Total
£ % £7,827 67.3% £1,083 £1,028 9.3% 8.8% £1,690 14.5%
£11,628
Risk stratification versus no. of LTCs – do they select the same patients?
Do Integrated Care teams change service delivery?
RRR audit – are some patients in hospital when they need not be?
What happens to patients assessed as having an RRR need?
Percentage of admission length for RRR phase
Implementing Year of Care programme in Kent
Dr Abraham P George Consultant in Public Health Lead for Kent YOC programme
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
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
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
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
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
All conditions 19.72
Excluding stroke 13.93
BHR
5.62
Leeds
6.71
Stoke
4.46
Average length of stay (days) Average length RRR phase (days)
6.28
3.29
0.19
3.23
0.69
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
Costing analysis
• 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
Crude tariffs and trends
East Kent – total cost (reference or unit) for patient cohort (552 patients)
Patient selection date = (May 2012)
Crude tariffs and trends
East Kent – total cost for patient cohort (552 patients) Acute Community Mental Health Social Care
Total 2012_13
cost £6,595 £1,361 £1,535 £2,170
£11,743
% 56.2% 11.6% 13.1% 18.5%
Trend
cost £4,671 £1,323 £1,791 £2,891
£10,676
% 43.7% 12.4% 16.8% 27.1%
Selecting shadow currencies
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)
Currency No LTCs New Counts B
2 1042
C
3 822
C C
4 5 449 197
D D D E
6 7 8 9 80 31 5 1
E
10 1
Next steps
• 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
Building on the Kent approach to Integrated Intelligence Primary Care Urgent Care OOH Care Adult Social Care Secondary Care
3 rd 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. To deliver the evidence for
Integrated Commissioning Collect the data with the support of the system to challenge status quo.
Identify cross system opportunities and barriers to change 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
@NHSIQ iCASE http://www.icase.org.uk/pg/groups/88229/ [email protected]
Improving health outcomes across England by providing improvement and change expertise.