Tackling long term conditions

Developing Networks of Care:

throughLong Term Conditions Year of Care Commissioning

&

Long Term Conditions Improvement Programmes

Bev MatthewsProgramme Lead for Long Term Conditions29th October 2014

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

Drivers for Improvement:

5%

20%

75%

The scale of the problem and the cost:

45%

40%

15%

Multiple complex conditions

Single LTC/ at risk

Healthy / minor risk

Population segments Cost

Commissioning in silos:

• 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

• 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

Identifying patients:

LTC Year of Care CommissioningImplementation Guide

Over 30% of people over 75 years have multimorbidity

Population Level Commissioning for the Future:

Population Level Commissioning for the Future:

The total health and social care cost is strongly related to multimorbidity

Population Level Commissioning for the Future:

The main contributors to total health & social care cost are acute non-elective admissions

Population Level Commissioning for the Future:

People with complex health & social care needs appear to demonstrate a ‘crisis curve’

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’

Population Level Commissioning for the Future:

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

LTC Year of Care Commissioning ModelImplementation Guide

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• 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

Why simulation?

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• Use local data to test assumptions

• Ability to update and review

LTC Year of Care Simulation Model

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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

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Results:

• Cost by each area of service/organisation

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• Costs by state per year• Average cost per patient

• Comparison with tariff

Results:

LTC Year of Care Commissioning ModelImplementation Guide

Next Chapter:RRR Clinical Audit:

• Report• Simulation Model, • How to Guide

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

The House of Care: value to the personThis 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.

Transitions e.g.• When I went to a new

service, they knew who I was, and about my own views, preferences and circumstances.

Emergencies e.g.• I had systems in place so that

I could get help at an early stage to avoid a crisis.

The House of Carein 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)

@NHSIQ@bev_j_matthews ICASE LTC Community

LTC Year of Care Community