Implementing the LTC Model of Care across Kent & Medway ... · PDF filestratification is independent of diagnosis and so will address the difficulty in identifying non-cancer patients

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Implementing the

LTC Model of Care

across

Kent & Medway

June 2012

“Moving from a ‘See and Treat’ Service

to a Prevention Service”

Version 1.3

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Foreword

This paper seeks to clarify and summarise the work already done as well as future work that

needs doing in order to effectively and efficiently implement the national QIPP LTC Model of

Care approach across Kent and Medway. It is divided into four sections:

1. Introduction – a short explanation and rationale behind the national LTC model of

care approach emphasising the epidemiological shift towards an aging population

associated with multiple morbidities and its impact on health and social care services.

Evidence around the LTC model of care approach has been explained in other

national guidance and so is not repeated here.

2. Where are we now? – Description of the current work across Kent & Medway that has

been carried out or has been planned for implementation. Test run of a locally

available risk stratification tool attempts to estimate the health care spend of the top

8840 high risk patients in 11/12 which may help us understand the future economic

benefits of adopting such an approach.

3. Where do we need to be? – Outline of the 20 key elements and interdependencies for

the successful implementation of the LTC Model of Care work. A simple format has

been used to describe most of the sections:

a. Vision statement

b. How will it be done?

c. What good will look like in 3 to 5 years time?

This information has been compiled from a variety of sources both locally as well as

nationally.

4. How do we get there? – A suggested list of actions, based on the above areas, for

CCGs and provider organisations. If acceptable, this may help inform future CCG

mobilization plans for implementation.

The purpose of this guidance is not to impose a new framework for operationalising

the LTC Model of Care but more around raising awareness on the key factors / criteria

for success as well as showcasing and sharing examples of best practice in Kent &

Medway as a resource for CCGs to build upon should they wish.

The guidance is expected to be regularly updated every few months to determine where

CCGs and provider organisations are in terms of implementation and readiness as well as

acknowledge further new and rapidly emerging innovations. Further analysis using risk

stratification on other areas such as social care and mental health care spend may also be

included as well.

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I would like to convey my thanks and gratitude to the following people who helped me pull this

guidance together in such a short span of time and apologies to whomever I have not

acknowledged yet but contributed to this report as well:

Phillip Round, James Lampert, Janice Grant, Tony Obayori, Mark Gray, Jenny Thomas, Rob

Stewart, Peter Green, Natasha Roberts, Anne Marie Morgan, Paul Bolton and Kent &

Medway HIS, Colin Styles and Sussex HIS, Debbie Smith, Claire Cotter, Eldon Macarthur,

Julia Morant, Justin Chisnall, Ama Rai, Julie Van Ruyckevelt, Amanda Barnard, Hazel Price,

Jamie Sheldrake, Jill Rutland, Bruce Pollington, Claire Martin, Helen Buckingham, Evelyn

White, Mark Lemon, Tuan Nyugen, Jagen John, Jude Mackenzie, Sharon Lee.

Dr Abraham P George

Assistant Director Public Health

June 2012

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CONTENTS

1. Introduction – the national and international context ................ 5

2. WHERE ARE WE NOW? .................................................................................... 8

GOVERNANCE AND MANAGEMENT OF THE LTC PROGRAMME WORK ...................... 9

PATIENT ENGAGEMENT AND CONSULTATION……………………………………………...9 CURRENT FINANCIAL SITUATION ................................................................................... 10

DATA SHARING AND RISK STRATIFICATION……………………………………………….13 CLINICAL DASHBOARDS ................................................................................................... 15

INFORMATION GOVERNANCE AND SHARING OF RECORDS ...................................... 16

INTEGRATED TEAM PILOTS ACROSS KENT & MEDWAY ............................................. 16

TELEHEALTH AND TELECARE ......................................................................................... 17

MOVING TOWARDS A SINGLE ASSESSMENT FRAMEWORK ....................................... 18

THE USE OF AUDIT+ IN MEDWAY CCG ........................................................................... 19

3. Where do we need to be? .............................................................................. 20

1 ENSURING ROBUST CCG GOVERNANCE ARRANGEMENTS .............................. 23

2 IMPROVING UNDERSTANDING OF PUPULATION NEED ...................................... 23

3 THE IMPORTANCE OF A ROBUST MINIMUM DATASET ........................................ 25

4 ACHIEVING FINANCIAL BALANCE .......................................................................... 26

5 SETTING UP ROBUST INFORMATION GOVERNANCE ARRANGEMENTS .......... 31

6 A COMMON DATA REPOSITORY/WAREHOUSE ................................................... 33

7 DECISION MANAGEMENT SYSTEM – DEVLOPING A ROBUST DASHBOARD .... 35

8 MAKING INFORMATION ACCESSIBLE .................................................................... 37

9 THE USE OF TELEMEDICINE AND INTERACTIVE CARE TECHNOLOGY ............ 38

10 THE USE OF TECHNOLOGY BY STAFF .............................................................. 39

11 THE USE OF TECHNOLOGY BY THE PATIENT .................................................. 40

12 CHOOSING THE IDEAL RISK STRATIFICATION/RISK PROFILING TOOL ........ 42

13 INTEGRATED HEALTH AND SOCIAL CARE TEAMS .......................................... 44

14 EMPOWERING PATIENTS TO SELF CARE AND SELF MANAGE ...................... 48

15 A SINGLE ASSESSMENT FRAMEWORK .............................................................. 51

16 END OF LIFE CARE ............................................................................................... 53

17 PREVENTING LONG TERM CONDITIONS ........................................................... 54

18 TRANSFORMING SOCIAL CARE .......................................................................... 55

19 EVALUATION OF WHOLE SYSTEMS CHANGE ................................................... 56

20 COMMUNICATIONS AND ENGAGEMENT ............................................................ 57

4.How do we get there? ........................................................................................ 59

References ...................................................................................................................... 63

Appendix 1 Risk stratification Analysis .................................................................................... 64

Appendix 2 HISBi Dashboards and Reports ........................................................................... 68

Appendix 3 Integrated health and social care teams ............................................................. 73

Appendix 4 Technology to support self management and self care ....................................... 84

Appendix 5 Audit + .................................................................................................................. 87

Appendix 6 Information Sharing AgreementI .......................................................................... 92

Appendix 7List of Urgent Care metrics based on Bolton Urgent Care Dashboard ................. 93

Appendix 8 ............................................................................................................................... 94

Appendix 9 ............................................................................................................................... 96

Appendix 10 EQ5D questionnaire ........................................................................................... 98

Appendix 11 FACE guidance ............................................................................................... 101 Appendix 12 Case conferencing.………………………………………………………………….102

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INTRODUCTION – THE NATIONAL AND INTERNATIONAL

CONTEXT

The emerging importance of multiple morbidities

The OECD report (2011) on multi morbidity states that chronic and degenerative diseases

(particularly dementia) are responsible for over 75% of the burden of disease in industrialised

countries. Over half of the hospital and physician encounters are represented by people with

multiple chronic conditions and this is increasing. This has been caused by a significant

demographic change / epidemiological transition over the last 50 years and is still continuing

across many countries including the UK - increasing life expectancy, falling birth rates,

migration leading to a growing older population. A whole systems change approach is

needed to move from ‘see and treat’ system we have now currently towards a

preventive system.

The health professional workforce policies and professions need to change as they deal with

the increasing prevalence of people with multiple chronic conditions over the next few

decades. Often professionals with specialisms are locked into fragmented, reductionist and

dysfunctional health care provision, divided into numerous single condition professions and

are often reluctant to co-ordinate care outside their areas of technical expertise. The correct

mix of primary care and specialists should be organised around the newly defined categories

of health needs and educational reform to promote new learning skills for integrated and

coordinated care towards understanding the needs of the person rather than the disease.

Effective health care delivery will also demand co-ordinated fiscal systems to generate a

competitive provider market through patient- choice, case-based payments and pay-for-

population health-performance models. In addition, this needs flexibility to integrate other

essential areas such as mobility, housing, nutrition, social relations and income.

Addressing the challenge should result in expanding and redesigning new business but there

may still be strong, conflicting forces and goals between who pays, who delivers and who

judges quality. In long-term care, providers need to discard professional resistance of familiar

role design and control and address funding parameters and the re-distribution of professional

responsibility and authority.

There also needs to be robust change in quality measures. Performance needs two areas of

change. First, existing tools need to be updated and / or newly developed, to support

integrative health professions related to health rather than disease. Secondly performance

must be monitored to indicate how care is affecting quality of life, how well the care co-

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ordination is being performed and physician performance to shape physician and patient

behaviour.

The impact on unscheduled care

The Nuffield Trust (2010) states that the number of emergency admissions in England rose by

12 per cent between 2004 to 2009 – a additional but unsustainable 1.35 million extra

admissions of which 40 per cent of that increase was attributed to the effects of population

aging. It also suggests that advances in medical care and management have reduced the

length of stay that patients have in hospitals, which in turn has freed up more available beds

and allows doctors to admit more patients. The study of hospital bed utilisation in Kent and

Medway in 2011 showed that no active acute care takes place during half of inpatient days,

and that about one in ten (post 48 hour) admissions, ‘theoretically’, did not require acute

hospital admission, had there been alternatives available. Therefore it appears that in our

current system, it is the acute hospital which has its doors open all hours and guarantees to

see all comers within four hours. For years the NHS has provided this ‘default to admission’

when alternatives are not immediately available or not perceived to be appropriate on the

occasion in question. The cycle is reinforced when services across hospital, primary,

community and social care providers are fragmented, which can lead to miscommunication

delays in care and avoidable ill health and costs.

Long term conditions and mental health

The Kings Fund (2012) states that at least a third of people with long-term physical health

conditions also have mental health problems. These can lead to significantly poorer health

outcomes and reduced quality of life. Costs to the health care system are also significant – by

interacting with and exacerbating physical illness, co-morbid mental health problems raise

total health care costs by at least 45 per cent for each person with a long-term condition and

co-morbid mental health problem. Care for large numbers of people with long-term conditions

could be improved by better integrating mental health support with primary care and chronic

disease management programmes, with closer working between mental health specialists

and other professionals.

The impact on health inequalities

The interaction between co-morbidities and deprivation makes a significant contribution to

generating and maintaining inequalities. Studies have shown a clear and consistent inequality

between age and socio-economic groups which becomes exacerbated with co-morbidity.

However, a lack of joined up / integrated care can also lead to inequity of service (caused by

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poor communication leading delays in treatment and referral) resulting in health inequalities.

Patient safety data reveals that nearly 140,000 patient safety incidents were recorded in 2011

/ 2012 with over 5% being classified as Moderate to Severe including fatal. In Kent there were

36,138 incidents with around 6% classified as being moderate to severe. The complexity of

care for people with Long Term Conditions needs to be organized by appropriate integrated

teams and accessible services and advice, across all levels of care, to begin reducing

inequalities for those experiencing chronic conditions.

The impact of disease based clinical guidelines

Research carried out by the University of Dundee (2012), in which the national LTC

programme is largely based upon reaffirms what has been said already but emphasises that

clinical evidence and guidelines are largely created for individual diseases, and most

randomised trials exclude multimorbid and elderly people. They rarely account for

multimorbidity or help clinicians to prioritise recommendations from several guidelines. The

result is that patients with multimorbidities might be prescribed several drugs, each of which is

recommended by a disease-specific guideline, but the overall drug burden is difficult for

patients to manage and potentially harmful.

The impact on end of life care and hospital mortality

It is believed that a significant number of patients at end of life will have a ‘frailty

trajectory’ and may not necessarily be at the highest risk of hospitalisation but are

coming to the end of their life just the same. While end of life care services are well

integrated with cancer services, a high proportion of non-cancer patients miss out on the

opportunities for appropriate end of life care due to late or non- identification. Risk

stratification is independent of diagnosis and so will address the difficulty in identifying non-

cancer patients as they approach end of life. This has significant potential for impact in terms

of appropriateness of care and hence also quality of care.

The impact of dementia

The risk of developing dementia doubles every five years, with a 65 year old having a 1.3 %

chance of having dementia and a 95 year old having 32.5% chance. In Kent the highest levels

of dementia can be seen in the 85 plus age range in addition to 4 or more other LTCs they

maybe having. Traditionally LTCs has not included dementia but due to the growing evidence

of the fact that people with dementia are highly likely to have a more than one physical LTC

then assessment and care management should acknowledge this and be more integrated.

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THE KENT & MEDWAY PICTURE

Where are we now?

There has been considerable interest and enthusiasm generated in Kent and Medway which

foresee major change to the culture and infrastructure of health and social care over the next

3 to 5 years. Much of the interest has been re-energised by the input from QIPP (Quality

Innovation Productivity Prevention) National team for LTCs in collaboration with consortia

leaders in the South East by designing a specific programme of work in this field. Two out of

three workshops have already been conducted by the national team describing and sharing

best practice nationally around risk stratification and integrated health and social care teams.

The third one on self care & self management will be held on the 4th July 2012.

CCGs embrace entirely the effective efficient timely management of LTC’s as a priority for

learning and clinical change for the total population, positively identifying those areas of

inequality that would benefit from additional focus as well as impacting on other key areas

such as unscheduled care, dementia, end of life care and mental health. Widespread interest

in being a fast follower has been secured and so support for this enthusiasm deliver the

challenging LTC agenda in the coming years. The K&M Integrated Plan Board representing

all providers and commissioners is committed to encouraging the systematic adoption of the

three principles of the LTC model of care approach across all CCGs to enable primary care

teams to refocus on patients with the highest risk of crises, by delivering coordinated

interventions and targeted care and empowering them to self care and self manage.

Within Kent, the Families and Social Care Directorate in Kent County Council in partnership

with Kent Community Health Trust have developed a blueprint for whole system

transformational change. This sets out the proposed themes:

o Prevention, independence and wellbeing

o Supporting recovery, maximising independence and assessing at the right time and in the

right place

o Support at home and in the community

o Place to live

o Every penny counts

o Doing the right things well

A six month review (finishing in September 2012) is being carried out to determine what

changes will be required underpinning the six themes that will fulfil vision for adult social care

by 2015, is for it to be based upon adding maximum value by working with NHS and other

statutory partners; with a focus on prevention and targeted intervention; ensuring services

respond rapidly; supporting carers and individuals to do more for themselves. It will be

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coproduced between relevant stakeholders across health and social care as well as patient

and carer representatives, and oversight of all initiatives will increasingly reside, post-

transition in partnership governance arrangements.

CCGs are involved in the LTC QIPP development and making progress towards all three

drivers (risk profiling, integrated health and social care teams, systematised supported self-

care. An attempt has been made to describe the current status of the key areas that indirectly

or directly relate to the 3 drivers:

1. Governance and management of the LTC programme work

2. Patient engagement and consultation

3. Current financial situation in PCT Cluster and local authority

4. Data sharing and risk stratification

5. Clinical Dashboards

6. Information governance

7. Integrated team pilots

8. Telehealth and Telecare

9. Moving towards a single assessment framework

10. Use of Audit + in Medway CCG

1. Governance and management of the LTC programme work

A multi-agency team exists to see through the project locally, at all levels of the organisations

within the local health economy from Chair & CEO level through to practitioners delivering

services within their organisations. In this time of transition, governance arrangements look to

the Health & Wellbeing Board as the future vehicle for oversight and delivery of the

programme, linked to the Integrated Strategic Operating Plan (ISOP). Programme support is

provided on a “matrix delivery” basis, combining business intelligence, technology support. IT

infrastructure support, programme management and so on, which is expected to move to the

local Kent & Medway Commissioning Support service (to be clarified in detail by August 2012

for health and possibly earlier for the social care commissioning and provision split) where the

former can be commissioned by CCGs should they wish such support to continue in this form.

At this stage, this appears to be the model that CCG’s would wish to commission although

SLA agreement is not expected until the autumn, as with the outcome of the commissioning

support service approval deadline.

2. Research on patient (with LTCs) engagement and consultation In 2009 an evaluation of existing services to support self care was conducted in West Kent,

including over 40 face to face discussions with people with long term conditions and carers.

The aim was to:

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• Explore the challenges for people living with LTCs and their carers throughout the

whole experience cycle

• Discover how people used NHS and Social Care Services to assist them in managing

their condition

• Explore what encourages self-managing behaviours

The key areas of importance to the interviewees were:

� Easily accessible information – for both patient and carers

Timely, relevant, accessible information throughout the journey of their condition for

patient and carers, from the point of diagnosis, tailored as needs change and/or

dependency increases, through a range of information media – e.g. booklets, web-based

– and a variety of outlets, e.g. Gateways, GP practices, clinics

� Education and training – for patients and carers, so that they can both manage the

condition and their emotional responses to it more effectively

� Peer support and networks held in high regard, for sharing with others having

similar experiences, to build confidence and motivation (‘not alone in experiencing

this’) and to reduce social isolation that often occurs through their condition(s)

� Increased access to non-medical interventions – alternative

therapies/approaches, peer support groups, stress management/coping techniques

(often provided through voluntary organisations)

� Fast access to specialist teams – knowing they can access these and get feedback

reduces anxiety and potential visits to GP or A&E

� Greater options for promoting exercise and maintaining mobility

� Better knowledge of condition at GP level – so that the GP can give or signpost to

the right information

� Improved confidence/self esteem through own work contribution – paid or voluntary

(examples given of acting as patient mentor to student nurses, helping to run peer

support groups)

Most people who felt they had taken control of their own situation reported an

improved sense of well-being and better health outcomes.

3. Current Financial Situation

Kent and Medway PCT Cluster

Recent assessment of progress, using LTCs as the primary diagnosis, with a straight line

projection to the end of 2012 shows broadly no increase across the cluster as an average,

however by CCG’s in each of West Kent, East Kent & Medway, it is as follows:

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West Kent 3.4% rise (957 spells from target)

East Kent 16.8% rise (1,979 spells from target)

Medway 24.7% rise (623 spells from target)

However, as a proportion of all unscheduled admissions across the cluster, those with an LTC

primary diagnosis is approximately 10% of all unscheduled admissions, with a value of £8m,

which increases to just under 30% of all admissions if LTC secondary diagnosis is included.

Thus we are addressing a minimum lost financial opportunity in the range of £8m to £56m,

which can be considered to still be on the conservative side, given that patients with multiple

co-morbidities may not have an LTC as their primary or secondary diagnosis, on admission.

In 2012/3, our ISOP commits our Local Health Economy to at least £24.6m of that being

delivered in addition to that realised by CCG Commissioning Plans, which implies that at

least this much, must be found in year. To do this, we must progress the LTC programme as

efficiently as possible without delay.

Kent County Council

As mentioned earlier, Kent County Council have released a long term outline plan around

Transforming Social Care to improve the social care outcomes for the people of Kent, but will

operate on a reduced budget. The current budget (£352 million) for adult social care and how

it is distributed between services is shown above and provides the baseline against which

changes through the transformation programme will be measured.

(Information on Medway social services is expected to be included in a future refresh of this

guidance).

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A brief analysis of the economic opportunity identified using a risk profiling approach

A preliminary analysis was undertaken to ‘test run’ a risk profiling tool developed by the

Sussex HIS which is explained more in detail in the next section. This tool uses the Combined

Predictive Model approach developed by the King’s Fund and generates risk score estimating

the likelihood of chronic emergency admission over the next 12 months. Approximately 3

years worth of SUS data up to 10/11 were extracted and sent to the team with an aim to risk

stratify the K&M population in a snapshot in time and estimate the total cost (and activity)

attributed to secondary health care for the top 0.5% of the K&M population (or approximately

8900 patients) who are at the highest risk of rehospitalisation during 11/12. The data is based

outpatient, inpatient and A&E attendance figures. The top 0.5% (Band 1 out of 4) is an

artificial trim point based on the Kaiser Permanente model pyramid of care where the

population is divided according 4 strata in terms of the complexity of their illness and level of

care. Initial results (details shown in Appendix 1) have shown:

o The total secondary health care spend in K&M for 11/12 was £577 million (of which

non elective care was £235 million or 41% of total spend)

o The total cost of secondary health care spend for Band 1 patients was £34 million.

o More than 85% of Band 1 patients were over the age of 50.

o Band 1 patients represented a proportion of up to 8.5% (8.0%) in terms of total

admission costs (activity).

o The total cost of unscheduled care spend for the top 0.5% population was £22 million

which was 11% of unscheduled care spend for the whole K&M population.

o The proportion of non-elective admission costs (activity) out of total admission

activity for the top 0.5% was 71% (36%)

o The average hospital costs per Band 1 patient was £3,927 (of which £2540 was for

non elective care)

o The average number (per patient) of outpatient attendances, admissions and A&E

attendances in Band 1 was 6, 3 and 2 respectively (rounded off to the nearest whole

number)

o In terms of admissions, patients in Band 1 also represented 12% of total number of

bed days in the K&M population.

o Approximately 1441 (16.3%) patients in Band 1 have died since April 2011 (this may

be an underestimate due to challenges in the historical reconciliation of patient

master index and the SUS dataset). 43% of these patients died in hospital.

o Analysis of health care for Band 1 patients in 09/10 and 10/11 revealed a total spend

of £31 million and £65 million respectively. This implies the ‘crisis’ year for these

patients was actually in 10/11 following which hospital activity came down in 11/12.

o A crude analysis of annual bed utilization for band 1 patients indicates that

approximately 210 beds were used in 09/10 and 11/12 compared to 475 beds in

10/11, implying a difference of 265 beds. This could be used as a benchmark to

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determine future contract renegotiations (bed closures) for acute trusts ensuring the

sustainability of LTC Programme while transition into a different payment mechanism

going forward (see section 4 on ‘Achieving Financial Balance’).

o A limited analysis of GP activity in the DGS CCG patch (the only CCG which

currently shares primary care data with K&M HIS as explained in the next section)

showed approximately 858 patients (currently on the GP register and excluding

deceased patients) in Band 1 generated approximately 67000 consultations

(appointment, phone contacts, home visits) or approximately 78 consultations per

patient in 10/11 or almost 2% of total GP consultation activity.

4. Data sharing and risk stratification The K&M Health Informatics Service (HIS) currently synthesises SUS data and Kent

Community Health Data. However DGS CCG is the only organisation streaming primary care

data for the purpose of their Clinical Dashboard known as the GPMIS (explained in detail in

the next section).

Only two organisations have been historically using a risk stratification approach

(developed by the Sussex HIS) to identify high risk / impact users for proactive case

management approach. They are Medway CCG (but on a limited basis) and Kent Community

Health Trust (shown in the diagram below).

The Sussex Combined Predictive Model is based on the King’s Fund / Health Dialog

algorithm, which draws on up to 1000 variables using acute provider data and community

service data predominantly from secondary care inpatient, outpatient, A&E records and data

from primary care, to provide patient profiling information for clinical staff. The output

provided is a risk score per patient from 0-100 which denotes the likelihood of a patient being

admitted to hospital as an emergency case in the forthcoming year. The model stratifies entire

populations (practices, PBC groups, PCTs etc) according to risk bandings. These bandings

are calibrated around utilisation of hospital services. The diagram above shows the current

position of how data flows between different organisations and the different dashboard

reporting systems – Sussex CPM, GPMIS, Medeanalytics and Audit + - link with their

respective CCGs.

An outline business case has just been agreed recommending the spread of three

enabling facilities to all CCGs in Kent and Medway:

1 Combined Predictive Model risk stratification system

2 Management Information System

3 Health Surveillance and Management System such as Audit+

It also recommends the expansion of the Kent and Medway data warehouse in order

to support the spread of the tools using an incremental approach for implementation. Each

CCG or CCG federation expected to appoint a project manager, who will together constitute a

steering group.

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5. Clinical Dashboards Urgent care intelligence is now being made available via a range of clinical dashboards for

CCGs. Three of them have been described below. Further details including screenshots of

live reports are available in Appendix 2.

K&M HISBi for DGS CCG

The KMHIS business intelligence system, HISbi, uses data that is stored on the KMHIS Kent

and Medway Data Warehouse. This is a local store of NHS data from a range of sources

particularly primary care, secondary care, national Secondary Uses Services (SUS) and

community health. HISbi is based on IBM Cognos, acknowledged by Gartner to be one of the

market leaders in business intelligence software. IBM Cognos is a flexible and powerful

application that can be used to display and analyse data in different ways. It aims to deliver a

reporting system that is automated and dynamic. Coupled with the data extracted and

processed automatically though the Kent and Medway Data Warehouse, it is possible to

produce regular reporting and intelligence that requires little or no human intervention

between someone entering details on a system and it appearing as intelligence on a report.

Medeanalytics

In South West Kent, GPs are now using Medeanalytics software to bring together information

from a variety of sources, including the HISbi warehouse and GP practice information

systems. Medeanalytics aims to provide 360 degree performance radar to improve financial,

operational and clinical outcomes, through:

• Underlying key theme dashboards providing insight into the influencing factors driving

the current position of any scorecard

• Alerts to signal target breaches sent by e-mail to relevant nominated key managers

and clinicians

• Predictive analytics tools with forward forecasting to assess the future impact of

current performance

• Drill-down to individual patient records to assist further investigation or audit

SHREWD

Another example of local use of dashboards is the Single Health Resilience Early Warning

Database, or SHREWD. This is a highly operational system showing at a glance the current

pressures within the urgent care system. Relevant agencies from both health and social care

update the tool on a regular basis, with the status of key indicators of pressure displayed as

red, amber or green. The tool is accessed by participants in the daily urgent care

teleconferences to highlight risk areas and inform operational decision-making.

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6. Information governance and sharing of records Till date there has not been a consistent or effective framework for sharing of personal and

sensitive patient data between data silos. In this context data silos sit at various points within

the local health economy, on GP PAS systems, on mental health provider systems, acute

systems and Social Services records etc. Interoperability between electronic systems and

inconsistency of record keeping (e.g. consistent and effective utilisation of READ codes

versus free text and manual / paper records) has proved problematic to resolve. This has

been further compounded by a lack of a clear and understandable patient data sharing

consent model that has the capacity to establish patient trust that records will be shared

appropriately and shared and stored securely. Nationally the NHS has a poor record for data

breaches and inappropriately shared or lost records form regular news stories which

undermine patient trust. In addition to this, the Information Commissioner’s Office (ICO) has

recently begun to exercise their powers to fine organisations for data breaches and recent

months have seen the first fines levied against NHS bodies.

Historically, there has been an implied consent model for the use of personal data by the

NHS. This was refined by the Summary Care Record project which established informed

consent but only against a basic dataset. Recent developments in clinical provision, including

more proactive approaches such as LTC, envisage scenarios for cross service working to

provide improved care. However, the patient consent model for sharing information in this

way has not been present or at least has not been explicitly communicated to patients.

7. Integrated team pilots across Kent & Medway Past discussions between KCC and Kent Community Health NHS Trust have resulted in a

shared desire to integrate community health and social care to deliver better outcomes to

people and deliver more efficient and cost-effective delivery models. The principle to explore

how integration could work in Kent was approved by the East Kent and West Kent

Commissioning Committees in 2011. This included the decision to develop 3 pilot sites

starting with Swale, Dover and Maidstone & Malling. This process is being overseen by the

Health and Social Care Integration Programme (HASCIP) which is led by KCC and KCHT. It

has initially identified three strategic models as a framework to support the development of

locality based integrated community health and social care:

Model A:

- Includes Single Point of Access

- Integrated short term team (current intermediate care and social care Assessment

and Enablement Teams)

- Primary Care multidisciplinary team (community matrons, primary care nursing, social

care case management) – based around clusters of GP Practices, with a focus on

people with LTC.

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Model B:


- Primary Care Multidisciplinary teams (community matrons, primary care nursing,

social care case management)– based around clusters of GP Practices

- Note that there is no distinction between short term and long term management of

cases.

Model C:


- Rapid Response Team (nursing)

- Community Assessment and Rehabilitation Team (incorporating intermediate care,

social care Assessment and Enablement)

- Primary Care Multidisciplinary Teams (Primary care nursing, community matrons and

social care case management).

The pilots are still work in progress. The number and locations of the Single Points of

Access needs to be determined and is being led by KCC in partnership with KCHT and

CCGs. Appendix 3 describes the set up, location and the current status of integrated pilots

across Kent & Medway. Evaluation of the pilots and evidence of best practice elsewhere will

shape future commissioning intentions. The approach being taken in Medway is to undertake

a feasibility study to transfer staff into one organisation. Following the outcome of this study a

recommendation will be made to commissioners so that they can ensure they are maximising

system benefits.

There is a considerable amount of work being undertaken nationally to develop a

range of integrated care models. There will then need to be a commissioning led process to

identify the best models for each of the K&M health and social care economies.

8. Telehealth and Telecare Following the success of the Whole System Demonstrator pilot, telecare and

telehealth has been mainstreamed into everyday business / service delivery. In telecare,

assessments are undertaken by frontline social care teams in KCC and is used as one of the

tools in meeting the assessed needs. For example, people who are risk assessed and

identified by social services for falls related injuries are provided with a falls monitor as part of

a telecare package. In telehealth, evidence from Kent telehealth and WSD pilots recommends

the best service delivery model for roll out of telehealth is to patients on the case load of

community matrons and specialist nurses who are currently using the SPOKE risk

stratification tool to identify high risk patients.

The Kent and Medway Technology Programme, built on the success of the pilots, has

initiated the following workstreams:

18

1 Innovation – to explore how new and existing technologies can be deployed in new

pathways through horizon scanning, testing and identifying which are appropriate and if

they can be utilised locally.

2 Implementation – As mentioned earlier, telehealth and telecare has been mainstreamed

in to service delivery using current eligibility / referral criteria

3 Benefits Realisation – academic support is being explored to evaluate the benefits of

technology programme as part of a whole systems transformation change

4 Partnership Working in Europe - Kent County Council is working collaboratively with

partners to share knowledge and skills for purpose of securing European funding.

Appendix 4 describes the general principles of telehealth and telecare and lists many

of the systems that are currently available.

9. Moving towards a single assessment framework Kent County Council implemented the DH accredited FACE (Functional Assessment in

Community Environments) assessment tool in September 2009 with agreement from Eastern

and Coastal Kent PCT and West Kent PCT. Changes within the NHS led to delays in the work

required to implement a common toolset, KCHT will role out the FACE toolset on 25th June

2012.

Further work is now being undertaken with the Acute Trusts and pilots will be run in QEQM,

WHH and in MTW during the next few months. A pilot using Digipens to complete FACE

assessments is being undertaken with DGS CCG, KCHT and FSC staff. Phase one will

create pdf documents saved on a supplier provided server, Phase two will populate the GP

Vision System, Community Information Systems and also aims to populate the social care

client system.

Work is also being undertaken within KCC to implement a Resource Allocation System

(RAS). The FACE web based system provides an estimated Personal (Social Care) Budget

based on the needs identified in the assessment. The FACE form to collect the data, analysis

of the scores generated using the FACE form determines the weightings to be assigned to

each item that most accurately predict resource requirements. This statistical model or

formula can then be used to generate an indicative budget for new clients i.e. for RAS

purposes. This provides the benefit of having a constant model for allocating resources and

will also be used in the future to support commissioning.

Work is still to be done to further the CAF agenda as the IT infrastructure will need to support

the business to make the sharing of real time assessment information happen, the

specification for CIS and for the Digital pen project included the need to interface with other

systems and this will also need to be reflected with systems within KCC.

19

10. The use of Audit+ in Medway CCG This is a primary care based risk profiling tool but not directly linked into LTC Model of Care

Approach. Audit+ can act as a complementary approach by identifying people further down

the population pyramid who may be at risk of an LTC. It has benefits around 4 key domains –

Prevention, Early Diagnosis, Better Management and improved benchmarking of Primary

Care Performance, recording of prevalence, prescribing, call recall for health checks and

other alerts.

Through the use of individualised patient prompts (directly into clinical IT systems):

- Clinicians and care workers ‘get it right’ at the time of seeing the patient as opposed

to other systems that show what has / has not been done or ‘what’s gone wrong’.

- Allows lists of patients to be viewed at practice level and practice achievement to be

viewed at CCG level, allowing targeted support.

- Supports the implementation of NICE guidelines in Primary Care

- Systematically embed public health in Primary Care, support the management of

niche conditions, support screening programmes, simplifying administration and

perform risk assessments.

- Analyses the individual patients’ notes and adds ‘QOF style’ prompts to remind

clinicians to consider care options appropriate to that individual.

Appendix 5 lists the scope of areas where prompts can be created plus some useful

screenshots.

20

WHERE DO WE NEED TO BE?

What would our health and social care system look like in 3 to 5 years time?

The NHS and Social Care Long Term Conditions Model (shown below) though developed

some years ago is still valid, broadly outlining the key elements of true health system in 3

main areas, infrastructure, delivery system and better outcomes.

Source: Department of Health (2005)

While the national team have emphasised the 3 key principles for implementation, in Kent &

Medway, a number of other key interdependencies and elements have also been identified as

critical to the success of the LTC Model of Care Approach:

1 Ensuring robust CCG governance arrangements

2 Improved understanding of population need

3 The importance of a robust minimum dataset

4 Achieving financial balance and transforming payment systems by

commissioning based on need / risk profiling

5 Setting up robust information governance arrangements

6 A common data repository / warehouse

7 Decision management system – developing a robust dashboard

8 Making information accessible and sharing it across organisations

21

9 The use of telemedicine and interactive care

10 The use of technology for staff to enable agility mobility connectivity

11 The use of technology for the patient

12 Choosing the ideal risk stratification / risk profiling tool

13 Developing and operating integrated health and social care teams

14 Empowering patients to self care and self manage

15 Moving towards a common assessment framework

16 Applying the LTC model of approach towards the End of Life Care

agenda

17 Preventing Long Term Conditions

18 Transforming Social Care – developing pooled health and social care

budgets to enable the LTC model of care approach

19 Robust evaluation of whole systems change

20 Communications and Engagement

Within health, there is a need to better align the initiatives and services that exist using the

three key drivers as well as in disease specific pathways that touch on elements of these

drivers, as a classification against which we can assess the ISOP and cover gaps in delivery.

The LTC steering group have developed a schematic for classification of this transformational

change and its infrastructure which is shown below:

22

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23

1 ENSURING ROBUST CCG-LED GOVERNANCE ARRANGEMENTS

Vision

CCGs will need to demonstrate probity and good governance commensurate with their

responsibilities for effective implementation, operation and monitoring of the LTC Model of

Care work.

How will it be done?

The necessary arrangements will not be dissimilar as to what they are already obliged to

comply as per existing national guidelines (Towards Authorisation 2011) such as:

• Governance arrangements that show clear and effective bonds across member practices

and demonstrate clear and transparent processes for discharge of functions.

• Robust systems and processes in place for effective decision-making and to manage

conflicts of interest.

• A scheme of delegation with underpinning processes to delegate decision-making to an

appropriate level.

• CCGs need to ensure that their governance arrangements that recognise

collaborative working across (county wide) partner organisations to facilitate

integrated care.

What good will look like in 3 to 5 years time?

o There are clear lines of accountability and decision making between member

practices, CCGs and partner organisations to discharge functions specifically towards

the LTC Model of Care Approach.

o CCGs will have set up regular monitoring arrangements (ideally through systems

within their clinical dashboards as discussed in section 7) of individual (or group of)

practices as to their conduct and uptake of integrated case management. For

example, this could be done determining how often practices (or practice managers)

are logging onto their patient records for case management.

2 IMPROVING UNDERSTANDING OF POPULATION NEED

Vision

Commissioners will need to acknowledge the importance of the rise of multi-morbidity and

how it is closely linked to the ageing of the population. Living better while living longer is not

however automatic and requires appropriately supportive environments and policies. Many of

these lie outside the health area. But better disease prevention and management, reforms to

the financing of health, imaginative use of new technologies and new ways of organising and

24

delivering health care and social care are needed which focus on enabling people to remain

independent and healthy for longer and seek to avoid or delay the need for resource-intensive

institutional care (OECD 2011).

There needs to be a gradual shift in profiling population health needs, from describing

separate disease and programme areas towards one of risk strata and risk cohorts. Improved

linkage and joining data sets from different agencies (social care, mental health,

ambulance) will help give a true holistic picture of population health in terms of patient

cohorts at high risk and more importantly, understand what proportion of health and social

care spend is impacted on these different cohorts along the population pyramid. Public

Health will be at the forefront of this to ensure a gradual transition towards a more

robust and accurate approach to describing assessing and monitoring population

health.


o Critical population epidemiology - the development and regular refresh of products such

as the JSNA and individual CCG Health profiles led by Public Health will help describe,

quantify and explain the risk profile of the population, particularly the top 0.5% to 1%

population as well as estimate economic benefits of an integrated approach to prevention

and optimising quality of care, reducing service inequity (due to lack of joined up care)

and ultimately health inequalities. Commissioning based on need / risk profiling (as

opposed to commissioning based on activity) will eliminate bias due to double

counting when estimating and distinguishing the economic benefits of different

QIPP initiatives.

o Identifying best practice – identifying appropriate non medical / non clinical interventions

to improve health and wellbeing of population using a proportionate targeted approach for

different risk groups (emphasised by the Marmot Review of Health Inequalities 2010). A

good example will be use of Health Trainers working within integrated teams to empower

patients to self care and self manage. This is explained in section 14.

o Monitoring and evaluation – A good risk stratification tool will have a number of other core

functionalities apart from predictive modelling which are explained in section12. For

example, the use of risk scores to track and trace patients’ progress before and after

integrated case management may be a future standard indicator of performance for

CCGs and individual practices are delivering.

o Success of the benchmark Utilization Review across all 4 acute trusts in Kent and

Medway in 2011 implies the future need for it to be repeated at least on an annual

basis to determine the success of the various QIPP initiatives and should involve

Social Care colleagues in the auditing process. It could also provide an evaluation

and audit function supporting the Year of Care funding model (described in detail

25

in Section 4) particularly around the development of the ‘RRR’ tariff which relating

to the non acute phase of a hospital spell.

o Maintaining and improving quality assurance of risk profiling – that there is a regular

iterative process that feeds back to provider organisations with regards to the reliability

and validity of the data sets they share with the data repository / warehouse.

o In 3 to 5 years time, assuming the integrated approach has been successful and that use

of secondary care services has been minimised alongside an increase usage and

optimisation of primary and community care services for chronic disease management,

the risk profiling approach will be more reliant on primary care and community health data

for predictive modelling than hospital data and so further research and development (see

section 19) is required to explore what other potential markers / variables / systems in

primary care can be used (for eg. use of audit + explained in section 17).


o JSNA, JHWS and individual CCG profiles will have transformed their formats of assessing

population health and social care needs using both risk and disease profiling approaches

appropriately across the different population risk strata.

o That risk stratification will help JSNA and JHWS towards effectively developing CCG

commissioning intentions and plans.

o Risk profiling information will inform regular needs assessment for key programme

workstreams such as urgent care, end of life care, dementia and mental health.

o Annual utilization reviews of hospital and community beds will be led by Public Health

with clinical support from CCGs and provider agencies including social care.

3 THE IMPORTANCE OF A ROBUST MINIMUM DATASET

Vision

The quality of the minimum data sets by the respective provider organisations and agencies

should meet the minimum requirements for Completeness, Accuracy, Relevance (or

Representativeness) and Timeliness. That activity data that is recorded will not only inform

financial and payment purposes but also clinical effectiveness and evaluation relevant for the

national QIPP LTC programme.


The National Audit Office (2004) summarised the key factors affecting the quality of data that

provider agencies need to be mindful of:

o absent or inadequate operational controls

o lack of policies and procedures

o inadequate supervision of operational practice

o inadequate IT infrastructure leading to proliferation of off-line parallel systems and

databases

26

o unclear or out-of-date standards and definitions for data

o information systems and resources geared to reporting for accountability purposes

not informing service delivery leading to lack of frontline ownership of data quality

o inadequate status and funding for clinical records and coding

o poor management and leadership resulting in an overall lack of priority given to data

quality

Exploratory / consultation work has already started in some provider agencies to meet the

minimum data requirements for the LTC programme to explore the some of the above issues.

For example, adult social care data in Kent County Council is collected on their SWIFT data

base. NHS numbers are being batch loaded onto it and is expected to be completed in June

2012. However, while activity data is coded and entered, there is also a significant amount of

free text data that is collected but may not suit current purposes.

(SECAMB) ambulance data does not routinely record NHS numbers on their data set

describing call out details and so further exploration is required as to how and where data

could be matched here.

A quality assurance framework is required to ensure that the data sets shared by the

different agencies, meets the requirements for the LTC programme. For example, if some

patients were erroneously identified through risk stratification and not found to be complex or

high risk after examining care records, the integrated teams need to feedback to the provider

agencies particularly acute trusts who collect and code hospital PAS data for SUS purposes.

Another example is that many GP practices still record information as free text and so

hopefully participation in this whole systems changes will encourage them move towards a

more complete and efficient read coding.


A regular feedback reporting mechanism that assures the robust collection of data from all

provider agencies. This will not only improve quality of data but also the predicting power of

the tool seen through an increase in sensitivity and positive predictive value indicators,

explained in section 14.

4 ACHIEVING FINANCIAL BALANCE AND TRANSFORMING PAYMENT SYSTEMS BY COMMISSIONING BASED ON NEED/RISK PROFILING

Vision

In 2010, Kent and Medway set out commissioning intentions for the period to 2015. The

national challenge had been to achieve a 20% reduction in emergency admissions for people

with LTCs, and a 25% reduction in their length of stay from a 2008/9 baseline, by 2014/5.

27

MONITOR says ‘An effective reimbursement system should incentivise improvements in both

the quality of patient care and the efficiency of providers (and therefore the system as a

whole). This requires a rigorous and comprehensive set of information’.

The DH guidance on Year of Care funding model for LTC (2012) states that commissioners

will need to move towards financial model that will be an annual risk adjusted capitation

dedicated budget which is based on individual person’s need which will improve

outcomes and deliver a more effective use of resources by focussing providers on moving

away from episodic, activity driven funding flows towards person centred care irrespective of

organisational boundaries. It is expected that this health (and ‘free social care’) care budget

will be also linked to and build on the personal health budgets from social care services as

well in future.


The following key elements are probably required to move towards an ideal system:

• Two sets of information will be required:

- A calculated risk score derived from the population level risk profiling of the LTC

cohort (this is explained in detail in section 12). At the very least primary, secondary

and community data will need to be used.

- Individual assessment using a DH accredited assessment tool set. Nationally, the

model proposed will utilise the DST (Decision Support Tool) for Continuing Health

Care (CHC) to provide consistent categorising:

o LTC stable / low complexity

o LTC stable / some complexity

o LTC unstable/high complexity

o Palliative Care/End of Life

In Kent, the FACE tool set which is DH accredited (section 15) is possibly expected to

be used in place of the CHC framework.

28

Source: Department of Health (2012) QIPP Long Term Conditions - Supporting the local implementation of

the Year of Care Funding Model for people with long-term conditions

• Developing an initial classification matrix

This will help referencing low to high levels of functional need against low to high levels of

complexity of health need will support understanding and refinement of the classification

system. The matrix allows sub-division of the three main levels of need to provide a more

sensitive assessment and classification process (shown below).

• Pricing the capitation fee for each individual high risk LTC patient

The aim is to develop a year of care capitation fee for each level of need using the costing

work described above. As the level of need is determined by both a calculated risk score and

an individual assessment it is expected that there will be less subjectivity in how people are

classified. The capitation fee for each group will be the average expected level of resource

needed, while some people may need more and some who need less resource it is

anticipated that variance in the cost of delivering care will average out across the LTC

population. Further details are expected once the national pricing work is completed.

• Developing the Recovery, Rehabilitation & Reablement (RRR) tariff model

29

The K&M Utilization Review indicated at least 50% of bed days occupied during (mostly

elderly) patients’ admissions were not a result of their acute care (the diagnostics, therapeutic

interventions or surgery and immediate treatment response) but are for their RRR. This model

aims to change the responsibility for care, and the tariff, at the point when the patients’ needs

change not at the point at which they change institutions.

• Linking personal (social care) budgets and ‘Year of Care’ risk adjusted capitation

health budgets together

Both budgets have a potentially strong complementary relationship to each other, giving to

ability to commission the right mix of services from the right providers at the right time with the

co-ownership between the integrated team and the patient. Discussions are under way as to

how transformation of commissioning and provisioning of Adult Social Care services in Kent

could possible use similar approaches. People who use social care already receive a

Personal Budget, either as a managed service or via a Direct Payment, it is anticipated that

understanding the combined health and social care cash envelope will provide the opportunity

to develop plans across the system to devolve some or most of the integrated commissioning

responsibilities at the integrated team level.

• Developing appropriate risk sharing agreements with providers

Future options for contracting should ideally emphasise on risk sharing arrangements that

reflect a true commitment to focus on patient outcomes to allow for greater individual

choice, while securing the most effective methods of treatments ensuring crisis avoidance

and hospital admission avoidance. This means that the risk may be at the expense of payers,

or [providers] or both - but never at the expense of patients.

• Acknowledgement of links with other national policies. These include:

o Development of tariffs for post discharge care into specified areas such as

(cardiac rehabilitation, pulmonary rehabilitation, hip and knee replacement)

o Three million Lives – this is described in detail under enabling technologies for

the patient

o Mental Health PbR development using appropriate clustering tool based on

patient mental health need / diagnostic group.

o Palliative Care funding model.


- A locally agreed tariff system across K&M based on the Year of Care funding model,

allocating risk adjusted budgets derived both from Health and Social Care

organisations, co-managed and owned by the integrated teams and patients.

- Redesigned contracts between CCGs and provider agencies underscoring the

outcomes based on patient need moving away from activity based commissioning.

30

This will need to be done BEFORE implementing the LTC model of care programme.

Central to the renegotiation is the estimation of hospital bed capacity that will need to

be taken out / transformed to ensure programme sustainability. For example, based

on the risk stratification analysis discussed earlier, an estimated 265 beds in a year

across K&M (for both planned and unplanned admissions) may need to be closed.

- Appropriate risk sharing and accountability arrangements among commissioners and

providers around crisis prevention (particularly at the integrated team level), outlining

contingency plans for risk mitigation.

- A reduction of unscheduled care activity and cost as per the national QIPP LTC

targets.

- The risk stratification analysis done earlier estimates up to 6% of annual total acute

trust activity could be transformed by the LTC programme delivery by way of

integrated team case management.

- Suggested outcome measures mentioned in the DH guidance include:

Outcome Measure

1 Person & carer confidence in services/care

given & own abilities to self care

• Annual survey of people supported by the

integrated care team (from each level of need)

using the QIPP LTC 6 questionnaire, aiming to

achieve 75% at level 3 or higher in each question.

2 Person’s level of need:

Improvement/Maintenance/Reduction of

deterioration

• Annual changes in EQ5D score - total number of

people whose score has reduced, maintained, or

increased

3 Use of resources: shift in spend across

services, reduction in acute admissions and

length of stay, reduction in long term care costs

• Total LTC spend, split per sector (community,

secondary, social, third and independent sector)

and per level of need

• Numbers of people and spend in each of the

three levels of need (per 1000) and spend per

head of population

• Number and spend of acute unplanned

admissions and bed days relating to LTC for each

level of need and the annual % change compared

to the previous 12 months (per 1000) and as a

subset for the HRGs that are separated through

the RRR model (see annex 5)

31

• Total number and cost of bed days in residential

and in nursing home beds in each level of need

(per 1000) and those that are publically funded

• Number of people that were previously living at

home transferred from an NHS facility to a

nursing or residential home

5 SETTING UP ROBUST INFORMATION GOVERNANCE ARRANGEMENTS

Vision

The Department (2012a) sets out the following ambitions for information governance:

o Information used to drive integrated care across the entire health and social care sector,

both within and between organisations

o Information regarded as a health and care service in its own right for us all – with

appropriate support in using information available for those who need it, so that

information benefits everyone and helps reduce inequalities

o A change in culture and mindset, in which our health and care professionals,

organisations and systems recognise that information in our own care records is

fundamentally about us – so that it becomes normal for us to access our own records

easily

o Information recorded once, at our first contact with professional staff, and shared securely

between those providing our care – supported by consistent use of information standards

that enable data to flow (interoperability) between systems whilst keeping our confidential

information safe and secure

o Our electronic care records progressively become the source for core information used to

improve our care, improve services and to inform research, etc. – reducing bureaucratic

data collections and enabling us to measure quality

o A culture of transparency, where access to high-quality, evidence-based information

about services and the quality of care held by Government and health and care services

is openly and easily available to us all

o An information-led culture where all health and care professionals – and local bodies

whose policies influence our health, such as local councils – take responsibility for

recording, sharing and using information to improve our care

Therefore primary care and all other provider agencies have recognised the need for

cross sharing of sensitive patient records to ensure services are effectively delivered. A

framework for embedding best practice with regard to the exchanging of sensitive patient

information between data controllers and data processors to be considered for development

to meet this goal. Key to this is the development of an acceptable patient data sharing

consent model.

32

The current political agenda for management of personal and sensitive data (as defined by

the Data Protection Act) sees two streams coming together. The first is ‘no decision about

me without me’ and the second is an increasingly active ‘ownership’ of clinical datasets by

patients.

If an effective and legally compliant patient data sharing consent model can be achieved,

partner organisations will be able to share information proactively via a secure gateway which

potentially may comply with Data Protection Act and Caldicott Guardian Principles.

How it will be done?

A Privacy Impact Assessment (PIA) is being drafted which addresses patient consent issues

along with other technical issues such as security of data during sharing and storage. The

Data Controller / Data Processor relationships need to be examined in some detail to

establish clearly who is determining the purposes for which data is being shared, who has

legal liability for the data and who needs to provide assurances for the way in which data is

processed. The PIA will identify the stakeholder organisations involved, the possible risks

and the broad recommendations for mitigation, some of which were suggested at the recent

local workshop on Information Governance and use of Medical Interoperability Gateway

(MIG) for sharing of care records.

It should be noted that overcoming patient consent hurdles for the processing of personal

data across multiple services may pose a considerable challenge. Significant consultation

across all stakeholders and patient representative groups along with other organisations such

as the ICO will need to be undertaken to determine when will patients be consulted and by

who and where will consent or dissent to share records across multiple data processors be

recorded.

Following this, the Kent & Medway information sharing agreement will form the basis for any

information sharing with the Standard Operating Procedure (SOP) template (Appendix 6)

used to detail the specific circumstances surrounding the proposed information share:

• Transmission of minimum data sets from all relevant health and social care provider

agencies to the data warehouse i.e. K&M HIS, for the purpose of clinical dashboard

development and risk profiling including critical population epidemiology.

• The sharing of care records across different provider agencies via MIG to enable

information integration between primary and secondary clinical settings. This will be

essential for the operational working of the integrated teams explained more in detail in

section 7.

The current patient consent model will need to be built based on the patient being physically

present when the clinician wishes for other organisations to access his / her care record.

However this will be revisited to consider how patient consent may be obtained when they are

not physically present to allow other organisations to access care records.

33

What good will look like?

Good will resemble a patient consent model that all stakeholders can have confidence in and

take assurance from. Significant discussion between stakeholders is likely needed to achieve

this.

ENABLING TECHNOLOGIES

6 A COMMON DATA REPOSITORY/WAREHOUSE

Vision

Patient level activity real time data from our main health and social care organisations

will need to be pooled and collated in one place, namely the data warehouse run by the Kent

and Medway Health Informatics Service, of which the Business Intelligence wing will have

operational supervision.


Activity data is required from the following organisations as per the diagram above:

- All GP practices across K&M. (Practices in DGS CCG practice are already doing so)

- All 4 acute trusts in Kent and Medway (already available)

- Kent Community Health Trust (already available) and Medway Community Health

34

- Kent County Council

- Medway Unitary Authority

- Kent and Medway Partnership Trust

- South East Coast Ambulance Trust

Note that the key patient identifier number is NHS number. Adult social services in Kent

County Council is one of the non NHS organisation in the above list, and will have completed

batch loading NHS numbers on their SWIFT database by end of June ready for linkage with

other datasets in the ware house.

SECAMB do not collect NHS numbers as part of their data recording and so further

discussion is required to link the SECAMB activity with other data sets (mentioned earlier in

section 3).

The diagram below shows how the data repository / warehouse fits into the logical

architecture of an end to end predictive modelling solution:

o Use of a Data Warehouse platform to store and manage data feeds, predictions and

business application processing of predictions

o Use of Extract Transform Load to get and prepare source data ready for prediction

processing

o A bespoke prediction tool interfacing to the Data Warehouse

o Bespoke business applications interfacing to the Data Warehouse and also using a

Business Intelligence platform to provide any required analytical functionality

o A portal front end to the prediction tool and business applications, which provides

security and access control

Source: QIPP Digital Technology (2012)

35

What good will look like?

A data warehouse / repository of all health and social care activity data to be used for risk

profiling and clinical dashboards, including a K&M wide end to end predictive modelling

solution.

7 DECISION MANAGEMENT SYSTEM – DEVELOPING A ROBUST DASHBOARD

Vision

Business intelligence should provide a single, consolidated review of organisational

performance from a wide range of existing, disparate data sources. It will enable senior

managers to see what is going on in parts of the system they would not normally have sight

of, by enabling disparate information within existing systems to be consolidated and

presented in a single, graphical, easy-to-understand dashboard view. In short, dashboards

can connect silos of information to achieve performance excellence. Examples of how

dashboards may be used include:

• Visual presentation of performance measures

• Ability to identify and correct negative trends

• Measurement of efficiencies/inefficiencies

• Ability to generate detailed reports showing new trends

• Ability to make more informed decisions based on collated business intelligence

• Aligning strategies and organizational goals

• Saving time compared to running multiple reports

• Gaining total visibility of all systems instantly

• Quick identification of data outliers and correlations

Why is this important?

Senior managers need access to relevant, accurate management information in order to take

confident assessments of performance. The ability to gain a fast and accurate snapshot of

performance is too often a time-consuming, inefficient and costly exercise in generating

reports, which may be out of date by the time the report is received and which do not contain

the most critical and relevant data on which to base important decisions.

What are the key principles?

The principles behind any successful business intelligence system are simple, these are:

• The data should be from a single source. This ensures that:

o everyone is using the same data

o the data gradually improves in completeness and accuracy

36

o there can be links made between data from different sources and sectors

o the data is consistent, reliable and trusted.

• As much of the processing is done by the data warehouse to make the data useable

and understandable. Codes should be converted to names and calculations

performed consistently.

• The reporting is clear, understandable, reliable and timely. In particular, dashboards

should contain the key information for the subject and the user should be able to

easily pick up the key issues or areas of interest. From there, a drill down to more

detailed reports should be available to be able to focus onto the areas of interest and

to get a record level list if necessary.

How to do it?

1 Strong Clinical Leadership has been recognised as a critical success factor in the

successful implementation and use of the dashboard. Therefore the workstream should

be led by a senior local clinician, typically a senior GP or another senior clinical member

of the local health economy.

2 Ensuring good clinical engagement through ongoing consultation. Give clinicians an early

view of the dashboard interface to ensure it meets with their requirements and arrange

awareness raising sessions to spread best practice across other practices.

3 Selecting clinical metrics for the dashboard will depend on understanding where

information gaps are, how having access to information will help, and what action clinical

teams will be able to take by having access to the information. A list of possible urgent

care metrics are found in appendix 7.


CCGs will have agreed a front end solution for a clinical dashboard developed by a chosen

provider. The front end solution will be linked to the logical architecture for end to end

predictive model shown in the diagram in section 6.

The dashboard will be made available to practices and can generate reports from patient level

to CCG level and vice versa with the flexibility of multiple cross tab analysis using various

parameters and source of data from different organisations for eg. frequency of non conveyed

callouts for falls by GP Practice / postcode.

This will generate an agreed set of metrics (linking both activity and cost on the same

analysis) that will be updated regularly and in real time. The dashboard will play an integral

part in performance management across all major programme areas including the LTC

programme by way of uptake integrated case management as mentioned in section 1.

37

8 MAKING INFORMATION ACCESSIBLE AND SHARING IT ACROSS ORGANISATIONS

Background

The NHS Connecting for Health (2012) states that a number of groups have tried to address

the problem of system interoperability over the years with varying levels of success. The

Interoperability Toolkit (ITK) is a fresh attempt to try and fill the vacuum by providing a list of

specifications, technologies and implementation guides which are consistent and applicable

across a wide range of domains and localities to support interoperability across local health

and social care organisations. It aims to reduce complexity and therefore expenditure by

publishing a series of common specifications and then by policing the deployment of those

specifications through the ITK accreditation scheme, the ITK will bring a level of

standardisation to the market and act as the 'de-facto' connectivity standard for local

interoperability throughout the NHS.

Vision

The use of an interoperability gateway such as the Medical Interoperability Gateway (MIG) to

share care records between multiple organisations such that it will not alter the way the care

record is managed.

The MIG was developed under a joint venture (Healthcare Gateway Limited - HGL) between

the GP clinical suppliers EMIS and INPS. The MIG meets NHS Connecting For Health’s

Interoperability Toolkit (ITK) and HL7 interoperability standards.

How do we do it?

1 Audit of systems

Well over a hundred systems broadly related to health informatics are currently operating

across K & M ranging from collection and reporting of hard data such as SUS to viewing of

Early Discharge Notifications (eDN) in primary and community care. A comprehensive audit is

underway to catalog and describe these systems. The results of this audit is expected by mid

June is expected to contribute greatly towards the MIG development, exploring the feasibility

of how they could be interconnected.

2 Establishing the MIG along with viewers for care records

The MIG should offer a set of services for exchanging data between third party systems.

Interoperability gateways such as MIG does not hold any clinical or patient records.

Systems of participating organisations will be connected to the interoperability gateway. Care

record viewers that are compatible with the interoperability gateway and comply with technical

specification as well as information governance protocol are used to view care records.

Care records will be viewed when a patient presents his / herself. Clinician has the

opportunity to request from the patient to view the patient GP records, or may view record in

an emergency setting without explicit consent.

38

3 Establish information governance protocol along with patient consent

Information sharing protocol will be established between participating organisations. The

current county wide Information Sharing Agreement is proposed as the basis.

MMH eDN

EKHT eDN

MTW eDN

GP Systems

MIG

Data Stream

MIG Care Record Viewer

EMIS & INPS

EMIS Web & INPS V360

Centrally hosted system

No Practice Data is held

on the MIG


An interoperability gateway that allow viewing of care records and plans, in a secure

controlled and auditable way from clinical systems from the following:

1 Acute Trusts in Kent and Medway

2 Community care providers in Kent and Medway

3 All General Practices in Kent and Medway

4 Out of Hours services in Kent and Medway

5 Hospices

9 THE USE OF TELEMEDICINE AND INTERACTIVE CARE TECHNOLOGY

Vision

The aim is to expand as necessary the use of telemedicine and technology that support

visual clinical collaboration to enable improve collaboration and interactive health delivery and

management.

How do we do it?

Two models have been identified where there appear to be clear benefits:

o The one clinician to many patients – current examples include those within stroke

care and dermatology.

o Many clinicians to one patient – current examples include oncology multi-disciplinary

team meetings.

39

Telemedicine and interactive care technology could be equally applied in other clinical

settings as follows:

1 Outpatient Clinics – such as in Prison Health where each prisoner who needs to attend an

outpatient clinic requires two guards, who are funded by the NHS. Telemedicine

technology can enable live consultation to some of these patients, removing the need to

transport the prisoner to the hospital with consequent savings in time, money and better

security.

2 Inpatient consulting, such as in virtual wards rounds and also where a consultant is

required to see and talk to a patient who is in another location.

3 Consultation with a General Practitioner and creation of mobile or virtual clinical services.

4 Pre-assessment or rapid assessment of patients for treatment or referral. For example, in

or from Elderly Care Homes, Ambulance, Minor Injury Units.

5 Improved triage by involving clinicians who may not normally be included in the triage

process. For example, Minor Injury Units (MIUs) could gain access to specialist clinicians.

6 Liaison with centres of excellence for improved advice and guidance, which currently

happens in dermatology. Currently MIUs are able to receive specialist input in specific

cases to ensure appropriate referrals.


Telemedicine and interactive technology used to enable delivery of care and clinical services

in appropriate clinical settings, especially to support integrated care teams.

Telemedicine and interactive technology used to reduce need for patient to be in same

physical space as carer or clinician before clinical care can take place.

10 THE USE OF TECHNOLOGY BY STAFF – AGILITY MOBILITY CONNECTIVITY PREMISES AND KIT SHARING

Vision

Improvement and availability of technology that enable staff to work anywhere. The aim is to

enable staff with technology that provides access to all applications and information that they

require, from location, through their preferred computing device, which include smart phones

and computing tablets. This includes access to online real time information, ability to capture

information electronically, and provision of secure infrastructure. Benefits include reduced

operating costs such as travel, contact time, office space, document handling, improved

productivity by increasing throughput rate.

How do we do it?

Five key technologies are involved

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1 Secure communication and connectivity. This includes connectivity between all buildings

and organisations, as well as mobile and smart device connectivity.

2 Secure and simple remote access by staff to their home network.

3 Virtualisation of applications to enable access by staff to application using any device,

including personal devices owned by staff.

4 Voice over IP technology that lowers cost of telecommunications, and enable staff to

roam and be reached with the same phone number.

5 Print service virtualisation that enable staff to print in any NHS building in Kent and

Medway.


Staff being able to work anywhere, and access with any device (including smart devices)

applications required, in a secure and safe way.

11 THE USE OF TECHNOLOGY BY THE PATIENT

Vision

There needs to be improved level of awareness among patients, public, carers and health

professional around the use of technology. This will be supported by the delivery of the ‘3

million lives’ campaign that will see people with long term conditions and social care needs

who will benefit from this over the next five years, of which the LTC Model of Care approach

is a key enabler.

How do we do it?

Telehealth and telecare have been rolled out by community matrons and adult social services

respectively. Uptake and quality of referrals is expected to improve with integrated teams

approach toward effective case management solution. Work has already started to extend the

use of technology across the wider population who would benefit from these solutions via the

respective disease management pathways.

The importance of the Kent & Medway Technology Programme

There are a plethora of emerging technologies and they can be adopted into many clinical

situations and key pathways. However, due to the sheer scale of the opportunities available

to clinicians it is essential that the key strands of the technology field are funnelled through a

clear structure that enables evaluation of technology and make it responsive to the needs of

patients and their stakeholders of care. This structure brings together experts from health,

social care, IT, local industry and higher education in a coordinated programme that can

deliver key benefits and manage risks and issues effectively.

Promoting tele-technology to the public

41

A sustained consistent campaign to promote the usefulness of telehealth and telecare by

linking into and working with local peer support groups of for eg. Diabetes UK, British Lung

Foundation and Stroke Association, as well as explain the emerging importance of multiple

morbidities and how telehealth will optimise management of not just one condition but other

underlying co-morbidities.

Promoting tele-technology to service providers

Kent & Medway Technology Programme will support and ensure the recruitment of more

clinical champions from primary care and acute care (possibly at an organisational level) to

spread the positive messages among peers.

Information resource

A dynamic online library that will catalogue and describe the fast emerging and existing

solutions that can be used by integrated teams and other service providers for their patients,

using personal health budgets enabling choice and control. It will expect to link into existing

directory of services (for eg. NHS Direct and Kent Social Care Directory) and peer support

groups like Stoke Association and Diabetes UK.

IT solutions linking data from telehealth and telecare technologies back to integrated teams

and service providers for effective case management

This requires the same solutions as described in the Enabling technologies section


The top 0.5% patients will be supported by technologies purchased using their personal

health and social care budgets as part of their case management by integrated teams

wherever applicable

Patients with LTCs further down the risk pyramid should be aware of self management / self

care principles and may consider purchasing technology solutions for themselves

Access to data generated by the technologies should be made accessible through the IT

infrastructure such as the MIG.

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THE LTC MODEL OF CARE

3 PRINCIPLES

12 CHOOSING THE IDEAL RISK STRATIFICATION/RISK PROFILING TOOL

Vision

A system (based on a common algorithm and specification across Kent & Medway) at

each CCG that will have the following core functionalities:

1 Risk stratification

Profiling of individuals and populations by clinical and resource needs for needs, assessment,

clinical resource planning, and whole system design including demand management (this

links into the chapter on understanding need)

2 Predictive modelling

Identification of multi-morbid, high-patients who could benefit from systematic care and case

management.

3 Disease Profiling

Identifying patients sub groups by individual long-term conditions and relative risk and costs 4

4 Resource Management

Consortia and practice resource management support. Shows use of resources weighted for

case-mix hence more clinically-led comparative performance as well as understanding current

spending, management of financial risk, realistic inter-practice comparisons

5 Budgeting

Allocation and setting of budgets below Consortia level using population case-mix as superior

measure to deprivation. Also supports person-specific budgeting through Year of Care

funding model (see section 4).

The process

An end to end solution for predictive modelling is summarised in the diagram below. A critical

part of the process is the data mining step where the model must be built from a sufficiently

large corpus of data. This consists of an ‘example’ which normally represents an individual.

Associated with an example is a collection of attributes, where an attribute measures a

specific aspect of an example. The age of an individual and their gender are attributes that

are for example commonly used in most models. The collection of examples is normally

called the training dataset which is then used for training the model. Choosing which

attributes to include in an example and which examples to collect into a training dataset will

be constrained by the available data sources.

43

Criteria for success

Effectiveness - There are two measures of the effectiveness of a predictive model sensitivity

and predictive value.

- Sensitivity measures the percentage of patients from the general population who are truly

high risk as identified by the model. This can be as high as 90% for the top 1% of

patients.

- Predictive value measures the percentage of those patients identified by the model who

are confirmed to be high risk following further investigation and assessment.

Predictive power – This is dependent on a combination of data items including service

utilisation and/or cost in both secondary and ambulatory care (including GP services),

demographic (age, sex), diagnostic (particularly co-morbidity), functional deficit (measured or

self-reported) and multiple prescribed medications. NOTE: It is important to acknowledge

the issue around identifying high risk patients BEFORE they reach crisis (as

demonstrated in the results of the test run of the Sussex HIS tool described earlier)

otherwise the full opportunity benefit of hospital admission and attendance avoidance

through crisis prevention is missed because patients are being identified by the risk

stratification process only at the time of crisis. Thus a more intensive use and input of

primary care and other non-hospital data is essential which current tools do not

possess at the moment.

Application to all risk categories - High risk patients are just one end of a spectrum amongst

all those patients with long-term conditions. There is still the need to identify people (further

down the risk pyramid) with a single long-term condition diagnosis who would benefit from

44

care management or those needing a less intense programme such as supported self-

management or health promotion.

Research and development – In this regard, a long term solution is to ensure adequate R&D

support (see section 19) to develop the tool bespoke for use within K & M to ensure not only

consistency across the region that benefit partner organisations (like KCC and KMPT) but

also flexibility among CCGs.

Ability to predict different events – Flexibility of the tool is required to explore the predictive

power of other events such as falls, death (see section 16) etc.

Consistency and flexibility

The Nuffield Trust (2011) states ‘When deciding where to run the model, it is important to

consider the trade-off between flexibility and the costs of implementation and development.

For example, the initial costs of establishing a central or regional tool might be relatively high,

but in the long run this option might be more cost effective than leaving every CCG to

implement its own model. However, implementing a single model across a region or

nationally may mean that there is less local flexibility regarding the choice and design of the

tool’.

13 DEVELOPING AND OPERATING INTEGRATED HEALTH AND SOCIAL CARE TEAMS

Vision

To ensure that patients with complex health and social care needs receive the right care, in

the right place, at the right time, underpinned by a ‘team around the patient approach’,

whereby identified providers across health and social care, collaborate together within a

systematic framework to offer multi disciplinary, co-ordinated and quality care.

How do we do it?

Care Coordination

Care Coordination is key to successful integrated team working. Care coordination can take

different forms ranging from coordination of care by the lead clinician to a more administrative

function to support case conference meetings and undertake administrative tasks to support

the effective interface between, primary, secondary, community, social care, third sector and

out of hours providers. It should act as the pivotal link between the multidisciplinary team,

patients and carers, commissioners and providers.

Referral process

Patients will be identified in one of 2 ways. The first will be the risk stratification list involves

identifying people in the top 1% considered at risk of a hospital admission in the next 12

months through the agreed risk stratification tool.

45

Alternatively, patients may be referred through other means and other stakeholders for

integrated case management and could be triaged in for discussion provided:

- they have been identified in the risk stratification list and have sufficiently high risk

score, or

- if their risk score is found low but there have been exceptional health and social

issues (ie. safeguarding) that warrant an urgent MDT discussion and intervention.

Triage process

This will be led by the care coordinator with or without the help of GP, community matron, etc.

will establish whether these individuals should be considered for an integrated team approach

and assign the appropriate intervention. Review of the list of high risk patients may be based

on following possible criteria:

1 Exclude patients who have already died (most of this exclusion would have already been

done at source but there may have been patients who may have died after the list was

generated)

2 Patients in need for medication review due to polypharmacy, care home resident, mental

health issues, etc.

3 Patients with emerging complex needs requiring straightforward direct intervention from a

community matron

4 Patients with complex needs who have already accessed all relevant services including

community matron but still poses a high risk of rehospitalisation, where an MDT case

conference will be of benefit.

5 Considering majority of the patients identified will be the frail elderly, it is expected one or

all of following 3 important domains will need to assessed which depend on the

configuration and success of the care plan to be developed – falls and fracture

prevention, dementia care and end of life preferences. The core team will need to

liaise with or invite the relevant specialists in order to ensure success.

The final list of patients to be subject for MDT intervention will require multi agency

assessment which involves using the FACE toolset documentation (see section 14). The

assessment information will inform the DST score.

Membership of the core team

The core team should ideally consist of those professionals/disciplines/interventions which

would need to be considered for all patients with long term conditions and complex health

needs:

o GP

o Named district nurse

o Community matron

46

o Social worker (depending on eligibility and assessment)

o Care Coordinator/Care Liaison Officer

o Health Trainer (this is explained in detail under the self care self management)

o Pharmacist

o Other specialists who may be providing significant support to a patient, may be

requested to join the core team for a set period of time. These may be community

based such as COPD, Heart Failure, or hospital based such as cardiology, chest

medicine, palliative care, acute physician, etc.

o Early results from the evaluation of the 16 integrated pilots across England and

Wales (RAND Europe 2012) indicate an increase in emergency admissions in at least

6 of them possibly attributed to a lack of timely acute specialist input into the

integrated case management. Thus it maybe expected that a great majority of

patients would benefit from the input of the Care of the Elderly physicians who

generally look after the medical and rehabilitative needs of these patients. In

light of growing burden of multi-morbidity in elderly patients, it has been suggested

their proactive involvement can help in the escalation plan mentioned below, search

for reversible causes of ill health or loss of function in older people, without delay.

Through the course of the MDT case management discussion and detailed holistic

assessment, it may be found that in up to 16% of patients (based death rates in Band

1 patients), their prognosis is poor and are likely to benefit from advance care

planning, implying the need for palliative care specialists / consultants to be

involved in the discussion at an early stage.

.

Source: NHS ONEL 2011

Assessment process

The Department of Health (2011) suggests that Assessment and care planning are

part of one process. Care planning should result in a care plan being agreed for the individual

who should be supported to participate as much as they can in the process.

Assessment should:

47

• be a joined-up process between health and social care, facilitating joined-up care planning

and delivery of care;

• have a named professional leading the process and coordinating services;

• be person centred;

• be collaborative;

• be holistic and recognise potential conflicts;

• be based on outcomes;

• simplify the processes

The Shepway pilot demonstrates one example of how the assessment process is

delivered. The initial contact with the patient is made by the GP via letter followed by a phone

call from the practice to obtain patient consent to be included on the programme and address

any other concerns. At the MDT meeting, the referral will be discussed with the team and the

matron will be the first one to go to see them to begin the formal assessment (section 15).

They will be seen by the Matron first and then by a Health Trainer and a pharmacist (section

14) at which point they will be discussed at the next MDT when these visits have been made.

The progress will be monitored on a regular basis through the MDT process and a date will be

set to meet with the appropriate members of the team who are involved with the patient

themselves and appropriate support family or carers if required to formulate the plan with the

participants perspective.

Multidisciplinary Case Conferencing The decision to organise one off or regular case conferences (as well as who needs to attend)

for patients depends very much on the discussions by the core team during the triage and

assessment processes. The prognosis and management of patients with extremely complex

needs and worsening crises requires further input from other specialists such as palliative

care, cardiology, chest medicine, acute medicine, etc. in order to develop robust escalation

care plans ensuring effective exacerbation prevention and management. Examples of case

conferencing pilots (for COPD patients) carried out in Stockport in 2010 are outlined in

Appendix 12.

Developing a care plan

Following assessment, all members of the Core team are expected to contribute to the

development of the patients’ care plan and to complete actions as agreed, within timescales

identified in this care and support plan. A standard patient care plan template will be

developed to support consistency in care plan development. The 2012 QIPP Digital

Technology document entitled ‘Technical Approaches to Sharing a Care Plan not only defines

broadly what is and what is not care plan but also attempts to generalise the different types

across continuum of care for LTC (see Appendix 8)


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o The integrated team approach to case management has been rolled out to all top 0.5%

population identified using risk stratification.

o There should ideally be a 100% involvement of specialists and specialist teams in MDT

case conferences, especially from acute and mental health trusts wherever applicable.

o An escalation care plan is developed for case managed patients as and when required,

detailing the appropriate preventative measures and contact details of primary and

community care providers ho would be responsible.

o Up to 11% of unplanned annual hospital activity could be reduced through implementation

of the LTC programme indicating transformational change (reduction) in the workload of

hospital specialists, thus freeing up more of their time to participate.

14 EMPOWERING PATIENTS TO SELF CARE AND SELF MANAGE

Vision

Department of Health (2006) recommends: To create a fully integrated system, with

appropriately trained front-line staff, to enable people with long term conditions to take greater

responsibility for their own care. This will be done through the following:

o Providing understandable and easily accessible information that will enable people to

assess their own condition, know what is ‘normal’ and recognise and monitor their

symptoms.

o Allowing people to undertake strategies to aid their recovery and supporting them to have

the confidence and skills to better deal with their condition.

o Involving people in interpreting results so they understand what action needs to be taken

and why

o Helping people to understand why it’s so important they take their medicines and how to

do so

The evidence and rationale explaining how self care self management contributes towards

improved quality of care and health and wellbeing is shown in Appendix 9.

How do we do it?

Online Personalised Care Planning

A locally delivered online personalised care planning service that will allow patients to be

active partners in their care, working together with their care professionals (health and social

care). Information will flow between the care records and the personalised care plan, which

can be developed by the patient, and enables the digital delivery of targeted information and

learning material based around the plan. Much of this will be realised through the enabling

technologies described earlier.

Engagement with patient reference groups

49

Community and voluntary groups play an important role in boosting people’s confidence and

getting them involved in their community. Many local community groups (some of which are

local branches of national organisations) focus on specialist areas such as diabetes, stroke,

Parkinson’s Disease, falls prevention exercise classes known as postural stability, etc. CCGs

and integrated teams should engage with them as early as possible to improve on existing

referral and communication links that will benefit the LTC programme.

Telehealth and Telecare

This has been explained earlier in detail under ‘Use of technology for the patient’ how

assistive technologies can help towards providing relevant accessible information to help

manage their condition.

Other home adaptations

The main objective is to restore and maintain independence by making day to day living and

getting about in your home, easier and safer. This will often be considered for people who

are coming out of hospital. Examples of home adaptations include grab rails or banisters,

ramps, widened doors, stair lifts etc.

Health Trainers

Who are they?

They are an existing non-clinical, non-medical workforce, trained to support behaviour change

and healthy lifestyle choices, meeting clients on a one-to-one basis over a number of weeks

or sessions (6-8). The service is holistic and client centred. Currently they are deployed in

disadvantaged areas, working with groups and partner agencies to reach people in the

community who might need support to navigate and access public services, and to lead

healthier lives or make healthier choices. The idea is that they reach those people not

effectively engaged in the healthcare system, or whose circumstances impact negatively on

their health and wellbeing.

How do they link with the LTC Model of Care Approach?

The NHS Health Trainer skill set naturally lends itself to supporting individuals in self

management. They frequently work with individuals using motivational interviewing

communication styles, supporting client-led ‘quick-win’ goal setting, advocacy, building self-

efficacy, and signposting clients to support services in their local communities, similar to the

Health Coaching function mentioned in LTC Model of Care members’ guide. Thus their role

strategically links and complements the role of the care coordinator and the community

matron and should be part of the core team.

They are familiar with other services in the public and voluntary sector that can support

individuals with a range of issues including debt, employment, benefits, childcare, and other

50

‘life’ issues such as bereavement, that often form barriers to better health. They can also help

with health literacy which is often a barrier to full patient engagement.

Adapting the Health Trainer role for Integrated Care

Health Trainers tend to work more often with young and working age adults as opposed to the

complex frail elderly who are usually managed by the integrated team. Their background is

neither clinical nor medical, and so while they would not exclude individuals with long term

conditions, the health trainer would provide support within the scope of the patient’s

capabilities, viewing ‘the patient as the expert in their own life’.

Should Health Trainers be engaged in the LTC Model of Care approach, further work is

required to explore:

o They would need additional training to orientate them to the specific needs of older

people, particularly those with complex medical needs, and the support services available

to them (eg: medicines management support through pharmacies)

o They would need to be included in the Integrated Care Team rather than just ‘referred to’

in order to understand the full patient pathway and understand the patient’s perspective.

o Additional investment will need to be allocated for their employment specifically to support

LTC patients.

o The philosophy of the ‘time limited’ intervention should be sustained with the focus on the

empowerment of patients to ‘self manage’

o Clear systems of support would need to be in place should they be expected to visit

patients in their own homes or in care homes, as this would be a diversion from their

current scope of activity.

Community Pharmacists

While not formally part of the integrated core team, referral into the Medicines Use Review

(MUR) service by community pharmacists can help improve patient knowledge, adherence

and use of their medicines by:

o Establishing the patient’s actual use, understanding and experience of taking their

medicines

o Identifying, discussing and resolving poor or ineffective use of their medicines

o Identifying side effects and drug interactions that may affect adherence

o Improving the clinical and cost effectiveness of prescribed medicines and reducing

medicine wastage

The pharmacist will perform an MUR to help assess any problems patients have with their

medicines and to help develop the patient’s knowledge of their medicines. No more than 400

MURs may be provided at each community pharmacy in any year. At least 50% of all MURs

undertaken in a year must be on patients who fall within one of the national target groups.

There are three national target groups which are:

51

o Patients taking high risk medicines (as described by the British National Formulary)

o Patients recently discharged from hospital

o Patients prescribed certain respiratory medicines

All patients receiving the MUR service must sign a consent form which allows the pharmacy

contractor to share information from the MUR with patient’s GP or CCG as part of a clinical

audit. If patients do not consent to share their information then they will not be able to access

the service. MURs are usually conducted with patients on multiple medicines, except where

the patient is taking one of the high risk medicines.


o Patients are active members of his / her care plan development, together the

integrated team

o Health trainers will play a role in case management as part of the team and act as

patient representatives or advocates to improve health wellbeing

o The care plan will detail suitable options for self care and self management which are

ideally non-NHS community based such as postural stability classes for falls

prevention

o As mentioned earlier in section 3, suggested outcome measures could include:

o Annual survey of people supported by the integrated care team (from each level of

need) using the QIPP LTC 6 questionnaire, aiming to achieve 75% at level 3 or

higher in each question.

o Annual changes in EQ5D score - total number of people whose score has reduced,

maintained, or increased. An example of such changes are shown from the Liverpool

Proactive Care pilot in Appendix 10.

15 A SINGLE ASSESSMENT FRAMEWORK

Vision

To develop and implement a Single Assessment Framework using the DH accredited FACE

assessment tool set for more effective information exchange to enable independent living

through the improved integration of community support services, support received in hospitals

and intermediate care and longer term support in the community and in residential care

settings (Appendix 11). Collecting assessment information in a consistent way will reduce

duplication for people who access support from panoply of professionals and organisations. It

enables the process to be streamlined and will provide the foundation for good decision

making in relation to the right care, at the right time and importantly, in the right place.

How do we do it?

Collaborative working and agreement with other provider organisatons

52

As mentioned earlier, KCC has implemented the FACE assessment documents and KCHT

plan to begin their implementation on 25th June. This alone will not reduce the duplication or

provide the intended benefits of shared documentation. It will however begin to provide an

opportunity for a shared record to be used in the community. Nursing staff and other providers

of health and care will have access to the same information regarding a patient/ service user’s

condition/circumstances and provide a tailored package of care based on this ‘whole’ record.

Mapping out where, when and how the assessment should be carried out as part of the

integrated team approach

Work will be required to determine who and how will the assessment be carried out by

integrated teams by initial mapping to identify touch points and ensuring a lean process. The

Shepway Pilot discussed earlier shows one example of how and when it could be delivered.

Equally, the same work will need to be done within the Acute Trusts to develop a process to

maximise the potential efficiencies.

Information governance and the use of the Medical Intraoperability Gateway

Within KCC the client system has been developed with the documentation and therefore

social care staff can produce the FACE assessment as an output. The Community

Information System recently procured by KCHT will also have this capability as

implementation progresses. MTW will be looking to populate FACE from their Patient

Administrative System, however, this does not provide the systems architecture required to

share information and at this stage sharing between organisations will be a paper based

process until the MIG is fully functional.

Understanding how FACE toolset complements the other assessment processes

FACE tool set does not seek to replace existing approaches to Single Assessment Process,

Care Programme Approach and other specialist assessment, but to deliver a framework for

sharing the common information they collect. Thus there will be a consistent format in

collection of assessment information, and will person centred. However, assessment is only

as good as the person completing the form. Staff will have to find workarounds to avoid

having to complete additional forms and keep separate copies back at base.

Using FACE to price the risk adjusted capitation budget

This has been explained in Section 4


FACE toolset will be used by the integrated team for case management and will contribute

towards calculating personal health budgets as per Year of Care Funding model (see section

4).

53

Note: While Medway are moving towards a Single Assessment Framework they are exploring alternative solutions

other than FACE.

OTHER IMPORTANT CONSIDERATIONS

16 APPLYING THE LTC MODEL OF APPROACH TOWARDS THE END OF LIFE CARE AGENDA

While risk stratification has been used to identify patients at high risk of admission to hospital,

it has perhaps only recently be been recognised that risk stratification has significant potential

to help identifying the patients who would benefit from the EoL pathway noting that during the

last year of life patients have an average of 3 admissions to hospital. A tailored approach is

required to answer the ‘risk of death’ question in order to achieve higher predictive value.

Therefore when developing risk stratification capability, strong consideration should be given

to tools that are able to answer the specific questions required and not rely on surrogate

measures, and certainly not in the medium to long term.

Looking at rate of change of risk

One of the limitations of the snap shot approach to risk stratification is that in a certain sense

it is somewhat a little late for those at the highest risk. By frequently running risk tools it is

quite possible however to determine the rate of change of risk, which identifies individuals as

they rise up through the rankings before they reach their peak in risk, this in effect buys time

for intervention. This holds true for any rate of change of risk model so that it is applicable to

models looking at risk of admission or risk of mortality, with interventions being directed

appropriately, whether this is putting in places strategies to avoid hospital admission or

preparing for death or both.

The integrated care team and symptom control

As part of the LTC workstream, the output of risk stratification is to support case finding of

complex patients who may benefit from management by Integrated Care teams. To

complement hospital avoidance strategies, the integrated care team needs to be able to

access appropriate skills to systematically assess and treat patient’s symptoms from a holistic

perspective, recognising that psycho-social factors have a dramatic magnifying factor upon

physical symptomatology. Patients call ambulances out of hours because of a deterioration in

symptoms not issues in relation to disease management.

The question is how many patients with multiple LTC do not have symptoms that effect their

functional status and general well being and that their quality of lives could not be improved

should we systematise our approach to managing their symptoms?

54

Self Care & Tailoring Escalation Care Plans

All complex LTC and EoL patients will have a deterioration in their functional status and

control of their symptoms but it is not known exactly when. Therefore escalation care plans

need to be put in place and tailored to the individuals needs and developed alongside patients

and their carers (where this is the wish of the patient), so that their wishes are integral to the

plan. In EoL these are partly captured in Advance Care Plans. The first tier of any Escalation

Care Plan should be self care.

17 IDENTIFYING AND MANAGING THOSE AT RISK OF LONG TERM CONDITIONS

Vision

While complex chronic illness is driven to a degree by broad shifts in demographics and

disease status it also a fact that significant amounts of chronic disease can be averted

through primary prevention programmes. It makes sense, therefore, to incorporate the

existing effect of these programmes into the overall programmes and the evaluation of their

impacts. The recent agreement on the use of Audit + across K & M will enable CCGs to adopt

a simultaneous dual approach in not only managing LTCs effectively but also preventing them

and / or identifying them earlier.

Potential benefits

The use of a uniform system such as Audit + can have several benefits:

o It can improve the quality of data entry in primary care which in turn improves the

quality of reporting particularly on QOF indicators

o Following the successful implementation of the LTC Model of Care programme, we

may start to see a decline in overall use of hospital services and so the input of data

from primary care information systems like audit + will become more significant

towards the risk stratification and predictive modelling.

Audit + and its impact on health inequalities

Use of Audit + could have a positive impact on our local Health Inequalities Action

Plan based on the framework / commissioning model developed by the National Support

Team. (The model) is designed to ensure that primary care interventions impact positively on

health inequalities, identifying key populations that would benefit most from early detection

and diagnosis of potential long-term conditions, those that are least likely to present

themselves to practices or other medical facilities to take up screening and other

opportunities. It enables interventions to be targeted to those most at risk so that conditions

are prevented or better managed to avoid more extensive and expensive treatments. The

importance of primary care in addressing health inequalities should not be under-estimated.

55

Whilst the wider social and economic determinants of health are critically important their

impact takes several years to become apparent. Earlier detection, diagnosis and treatment of

long-term conditions in primary care will result in the quickest potential improvement to health

inequalities in the affected population.

Improving Public Health support to CCGs

The impact of primary care on health inequalities is dependent upon accurate and

reliable information about the population being served and their health needs. Public health

should be able to provide detailed population analysis of the local demography and the health

deficits it contains. In other words who lives in the area and what conditions they will be

susceptible to, or are suffering from. If this does not correspond to those known to be

presenting for intervention programmes it should trigger further consideration and analysis to

locate the “missing patients”. For example: are NHS Health Checks being given to those in

the local population most likely to suffer from heart disease? Public health should also be able

to provide expertise within communities to reach those previously reluctant to engage in

relevant programmes and to assist in the design of services to make them more effective. In

this way any disparity between the take up of early detection and treatment services and the

needs of the local population, particularly those that will be most susceptible to the conditions

we would wish to prevent, could be identified and addressed

18 TRANSFORMING SOCIAL CARE – LINKING PERSONALISED HEALTH AND SOCIAL CARE BUDGETS TO ENABLE THE LTC MODEL OF CARE APPROACH

Vision

By 2015 it is anticipated that as well as delivering significantly improved services through

integration and a changed investment profile, the transformation programme will also release

the savings that the local authority is committed to achieving. The management of long term

conditions is expected to play a major part in this. It is anticipated that the comprehensive

implementation of all three elements of the LTC strategy will deliver significant savings to both

health and social care as well as a more coordinated and improved service for patients.

Whilst some of the detailed planning for the work-stream projects is still being developed,

some of the broader principles about how the savings and improvements could be achieved

may have become clearer through the DH ‘Year of Care Funding Model’ explained in section

4.

How do we do it?

Based on this guidance the following initiatives should be explored within social care:

o The initiatives explored in section 3 around payment mechanisms for creating health

budgets could also be applied in social care.

56

o Establishing a joint health and social care commissioning approach (and potentially

pooled budgets) to develop the pattern of services required in the community, including

primary, community health, social care and services from the voluntary sector and

housing.

o Taking forward the LTC strategy will require the development of integrated health and

social care commissioning at CCG level and potentially neighbourhood levels. The

methodology for this will need to evolve as the formal planning for LTC by health and

social care becomes established. The work of the Kent Health Commission is currently

exploring how integrated commissioning can be developed at locality level and may

provide some helpful guidance for the future.

o It is anticipated that the detailed adult social care transformation programme and

guidance on locality commissioning will have become clearer by September 2012 in time

for the revised LTC guidance.


o Social care data will be actively used for risk stratification and clinical dashboard

reporting.

o Social care records will be accessible via MIG by the integrated teams

o Personal social care budgets will be linked with health budgets co-managed by the

integrated teams and the patients for the top 0.5% of the population.

19 EVALUATION OF WHOLE SYSTEMS CHANGE

Discussions have been initiated with Kent Health (a collaboration between the 3 local

universities) exploring how funding could be applied via NIHR bid supporting the LTC model

of care development in K&M on a number of issues. Development of the bid is expected to

commence after June 2012 on the following:

o Long term R&D support towards development of the risk stratification tool by the K&M

HIS exploring how and what other data can improving the predicting power and other core

functionalities. This could include the development of a quality assurance framework

(mentioned in section 3) looking at the quality and rigor of data being supplied by

providers especially primary care.

o Development of a patient database which, among other things, form the basis for future

monitoring and evaluation of the LTC model of care over the next 3 to 5 years.

o A mixed methods approach towards evaluation of the neighbourhood integrated teams as

well as the other interdependencies mentioned above.

o It is possible that the evaluation may link or include the academic support provided for the

Kent and Medway Technology programme (mentioned earlier as part of the benefits

realisation workstream).

57

o How the LTC programme will impact on other important programme areas such as

dementia, falls prevention, mental health and end of life.

o Support for the Utilization Review as mentioned in section 2.

o Based OECD recommendations described in the introduction, links with the future Local

Education & Training Boards will need to be set up as to how medical and nursing

professional training could be transformed to promoting proactive integrated case

management, the use of and sharing information systems and shifting care closer to

home towards self care self management.

20 COMMUNICATIONS AND ENGAGEMENT

Change of this scale requires excellent communications and engagement. This is already the

approach across Kent and Medway, having benefitted from patient engagement and research

that was undertaken previously. As progress continues in this area, all parts of the NHS and

social care system must ensure that they have adequate mechanisms to co-design with

patients and to keep the public informed where necessary of new ways of working. In

addition, because this is a whole-system challenge, we must all ensure that we are

communicating with CCGs, providers and local authority colleagues to make sure that our

work is co-ordinated and that we are all benefitting from best practice.

58

59

HOW DO WE GET THERE? The following table is a suggested plan, summarising the action required by CCGs

and provider organisations that they will need to outline in CCG mobilization plans by end of

July 2012, thus moving towards a consistent approach for programme implementation and

whole systems change.

Key Interdependencies

CCGs Acute Trusts

Kent and Medway Councils

Kent & Medway Partnership Trust

Kent and Medway Community Health orgns

SECAMB and South East Health

1. Ensuring robust CCG led governance arrangements

Arrangements required to deliver LTC Model of care and quality assured robust monitoring system

Provider organisations should work with CCGs ensuring that governance arrangements are robust enough to acknowledge their responsibilities and minimum standards required for the effective delivery of the LTC programme

2. Understanding of population need

CCGs and provider organisations will need to work closely with Public Health and business intelligence (KMCS in future) to design and create a robust JSNA and constituent CCG health profiles using the risk stratification approach to describe population need. Central to this relationship is the need (for Public Health) to access linked pseudonymised datasets (particularly primary care) so that future IG arrangements for data sharing, need to reflect this

3. The importance of a robust minimum dataset

Participate in county wide quality assurance process for practices to improve maintain data quality and accessibility linked to risk stratification and clinical dashboard

Participate in county wide quality assurance process for information systems and clinical coding to improve maintain data quality and accessibility linked to risk stratification and clinical dashboard

Participate in county wide quality assurance process for information systems and clinical coding to improve maintain data quality and accessibility linked to risk stratification and clinical dashboard Both Kent and Medway Social Services need to agree a common framework for a minimum data set to be used for the above

Preparation underway for move to PbR for mental health services in April 2013. New system requires significant fine tuning to to link cost and activity data with care pathway information at patient level. Participate in county wide quality assurance process to improve maintain data quality and accessibility linked to risk stratification and clinical dashboard

Participate in county wide quality assurance process to improve maintain data quality and accessibility linked to risk stratification and clinical dashboard

(SECAMB) Need to develop dataset linking NHS number with ambulance callout information Participate in county wide quality assurance process to improve maintain data quality and accessibility linked to risk stratification and clinical dashboard

60


CCGs Acute Trusts





4. Achieving financial balance and transforming payment systems based on Year of Care funding model

Work with Councils around developing health and social care orgns in developing risk adjusted budgets for high risk patients. This should be linked to contract renegotiation with providers around reducing bed and other overhead capacity

Work with CCGs around contract renegotiation using risk stratification analysis as a benchmark to implement LTC programme

Work with CCGs around developing health and social care risk adjusted budgets for high risk Contract renegotiation with acute trusts and other provider agencies around reducing beds and other overhead capacity




5. Information governance

Work with information governance leads around: 1. Arrangements for member practices towards sharing and collation of primary care data with the K&M HIS 2. Arrangement of member practices for sharing of care records via MIG

Work with information governance leads around sharing of care records via MIG

Work with information governance leads around: 1. Arrangements for sharing and collation of social care data with the K&M HIS 2. Arrangement for sharing of care records via MIG

Work with information governance leads around: 1. Arrangements for sharing and collation of mental health care data with the K&M HIS 2. Arrangement for sharing of care records via MIG

Work with information governance leads around: 1. Arrangements for sharing and collation of community health data with the K&M HIS 2. Arrangement for sharing of care records via MIG

Work with information governance leads around: 1. Arrangements for sharing and collation of ambulance call out data with the K&M HIS 2. Arrangement for sharing of care records via MIG

6. A common data repository / warehouse

Assuming IG arrangements are in place, primary care data can be shared with K&M HIS

No further action as SUS data is already available to K&M HIS

Assuming IG arrangements are in place, social care data can be shared with K&M HIS

Assuming IG arrangements are in place, mental health care data can be shared with K&M HIS

No further action as community health data is already available to K&M HIS

Assuming IG arrangements are in place, ambulance call out data can be shared with K&M HIS

7. Decision management system

Already work in progress among some CCGs, data should come from K&M HIS

Work with CCGs in ensuring appropriate reporting of activity data via K&M HIS from CCG to patient level

8. Making information accessible

Organisations should work with Information governance and IT programme leads (for eg. regular participation in Kent & Medway Technology Programme) in the development of MIG, and other technologies to enable

9. The use of telemedicine and

61


CCGs Acute Trusts





interactive care

integrated working and, more importantly, identify clinical champions who can take forward and promote them. The audit of clinical systems across Kent & Medway will provide valuable information

10. The use of technology for staff

11. The use of technology for the patient

12. Choosing the ideal risk stratification / risk profiling tool

All CCGs should work with LTC team to ensure the development of a robust consistent tool across K&M

Provider organisations need to ensure that their minimum datasets comply with the prescribed standards for risk stratification. This is expected to be part of a rolling programme for quality assurance

13. Developing and operating integrated health and social care teams

Evaluation of pilots and review of best practice will be used to shape commissioning intentions

Provider organisations will need set about transformation the work plans of their staff including specialists for their regular and active participation of the integrated teams and link this with the wider IG arrangements for sharing of care records as mentioned earlier.

14. Empowering patients to self care and self manage

Awareness raising among practices around what resources are available outside NHS (eg. third sector voluntary orgns)

Awareness raising required around the principles of self care self management and what local resources available



Ensure adequate capacity and training for health trainers for effective participation in the integrated case management


15. Single assessment framework

All organisation should ensure the timely roll out and uptake of the assessment framework by the integrated teams

16. End of Life Care

Awareness raising required to extend end of life care services to non cancer patients by setting advance care plans for appropriate patients as soon as possible

Awareness raising required to extend end of life care services to non cancer patients by setting advance care plans for appropriate patients as soon as possible Acute trusts also need to link the LTC / EoL





62


CCGs Acute Trusts





programme with their existing plans around reduction of hospital mortality rates

17. Preventing Long Term Conditions

Ensure roll out of audit + across constituent practices, link with Public Health to support poorer performing practices

NA NA NA NA NA

18. Transforming Social Care – developing pooled health and social care budgets to enable the LTC model of care approach

CCGs should engage with Councils to ensure robust transformation change

NA Detailed (Kent) social care transformation plan is expected by September linking with recommendations mentioned in this guidance

NA NA NA

19. Robust evaluation of whole systems change

Participate in the county wide innovation study (TBC) supported by Kent Health, to develop an iterative process of transformation change across all organisations and programme areas

20. Communications and Engagement

LTC team will work with comms and engagement to ensure appropriate cascading and dissemination of best practice not only to CCGs and providers but also to patient representative groups.

63

REFERENCES Audit Commission (2004) Information and data quality in the NHS Key messages from three years of independent review Department of Health (2005) Supporting People with Long Term Conditions: An NHS and Social Care Model to Support Department of Health (2006) Supporting people with long term conditions to self care – A guide to developing local strategies and good practice Department of Health (2011) Assessment of need and managing risk – improving care for people with long term conditions, an ‘at a glance’ guide for health care professionals Department of Health (2012) QIPP Long Term Conditions Supporting the local implementation of the Year of Care Funding Model for people with long-term conditions Department of Health (2012a) The power of information: Putting all of us in control of the health and care information we need Kent County Council Families and Social Care OP/PD and LD/MH (2011) Support Planning Policy and Practice Guidance Kings Fund (2012) Long-term conditions and mental health: The cost of co-morbidities NHS Connecting For Health (2012) Background and Overview http://www.connectingforhealth.nhs.uk/systemsandservices/interop/overview NHS Networks (2011) The Urgent Care Clinical Dashboard Implementation Guide - Supporting your team to develop and implement locally NHS ONEL (2011) Implementation of an integrated case management virtual team A guide for provider services on frequently asked questions NHS Kent & Medway, Kent County Council (2011) Locality Based Integrated Health & Social Care Service - An Operational Framework Nuffield Trust (2011) Choosing a predictive risk model: a guide for commissioners in England OECD (2011) Health Reform: Meeting the Challenge of Ageing and Multiple Morbidities RAND Europe, Ernst & Young (2012) National Evaluation of the Department of Health’s Integrated Care Pilots QIPP Digital Technology (2012) Technical Guidance on Selecting and Implementing Predictive Modelling Solutions QIPP Digital Technology (2012) (Technical Guidance for Sharing Care Plans QIPP Long Term Conditions Workstream (2011) Commissioning Development Programme Operational Phase MEMBERS’ GUIDE Tribal (2008) Tools assessment University of Dundee (2011) Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study

64

APPENDIX 1

Risk stratification Analysis Risk stratification Analysis

A Patient Master Index as at 04.04.2011 extracted from the Exeter patient registration database has been used to

generate a risk score for re-admission to hospital.

The list contained 1,768,073 patients registered with Kent and Medway GPs. The risk scores for this population

ranged from 0 to 71.24.

• Number of records with a risk score of 0 = 2,724

Data are presented in 4 bandings. The numbers within each band are as follows.

The proportion of people dying is greater in Band 1 [those with the higher risk scores] as would be expected. Band 1

represents 0.5% of the total Kent and Medway registered practice population.

Risk Band Number of patients Number of Deaths Proportion of Deaths*

1 8,840 1,441 16.3%

2 79,563 5,056 6.4%

3 265,211 4,244 1.6%

4 1,414,459 4,580 0.3%

*all deaths from all causes – data linked to primary care mortality database [via open Exeter]

Age and Sex profile of Band 1 patients

There are more males (52%) in band 1 than females (48%). The majority of patients are over the age of 60.

Proportion of Band 1 patients by 5 year age groups and gender

Deaths as a proportion of Band 1 patents by age and gender

65

Of the 1,441 deaths in the Band 1 group 861 (59.8%) were for an LTC1 [See Appendix X for list of ICD 10 codes]

Deaths by Long Term Condition

Deaths

Condition Number %

Asthma 5 0.6%

CAD 202 23.5%

Cancer 317 36.8%

CHF 28 3.3%

COPD 157 18.2%

Dementia 109 12.7%

Depression 1 0.1%

Diabetes 33 3.8%

Hypertension 9 1.0%

All LTC deaths 861 59.8%

Other reason 580 40.2%

All Deaths 1441

Band 1: 2011-12 Activity

All Admissions Outpatients A&E attendances Total Cost

Number Cost Number Cost Number Cost Number Cost

Band 1 20,399 £28,963,658 49,236 £4,495,614 13,492 £1,256,826 83,127 £34,716,098

Kent and Medway Total

255,966 £341,903,435 2,196,369 £194,589,399 486,696 £40,726,518

2,939,031 £577,219,352

Proportion of Kent and Medway

8.0% 8.5% 2.2% 2.3% 2.8% 3.1% 2.8% 6.0%

Spell by type

1 Based on underlying cause of death

66

All Admissions Non-Elective Elective Day Case Total Bed

days

Number

Cost Number

Cost Number

Cost Number

Cost LOS Beds

Band 1 20,39

9 £28,963,6

58 10,11

3 £21,194,3

75 6,040

£4,657,940

4,246 £3,111,3

43 76,29

1 208.

9


255,966

£341,903,435

118,683

£194,497,223

53,244

£81,341,737

78,229

£63,894,018

613,524

1,680


7.97% 8.47% 8.52% 10.90% 11.34

% 5.73%

5.43%

4.87% 12.43

%

Average number of admissions, outpatient and A&E attendance’s

Activity Number Cost

Outpatients 5.6 £508.55

All Admissions 2.3 £3,276.43

Non Elective Admissions 1.1 £2,397.55

A&E attendances 1.5 £142.17

Total 9.4 £3,927.16

Band 1 2010-11 Activity


Number

Cost Number Cost Number

Cost Number Cost

Band 1 30,978 £58,068,92

6 62,214 £5,180,992 22,700 £2,079,543 115,892

£63,365,810


247,288

£353,005,654

2,178,090

£180,817,033

487,286

£41,031,008

2,912,664

£536,735,351


12.5% 16.4% 2.9% 2.9% 4.7% 5.1% 4.0% 11.8%

Spell by type

All Admissions Non-Elective Elective Day Case Total Bed days

Number

Cost Number

Cost Number

Cost Number

Cost LOS Beds

Band 1 30,97

8 £58,068,9

26 18,84

4 £44,514,9

29 6,476

£9,074,339

5,658 £4,479,6

58 1736

84 475.5

2


247,288

£353,005,654

118,941

£208,114,472

53,244

£81,341,737

75,103

£63,549,445

695380

1903.85


12.5%

16.4% 15.8

% 21.4% 2.9% 2.9% 4.7% 7.0%

25.0%

Average number of admissions, outpatient and A&E attendance’s

Activity Number Cost

Outpatients 7.04 £586.09

All Admissions 3.50 £6,568.88

Non Elective Admissions 2.13 £5,035.63

A&E attendances 2.57 £235.24

67

Total 13.11 £7,390.21

Band 1 2009-10 Activity


Number

Cost Number Cost Number

Cost Number Cost

Band 1 16,484 £27,339,76

6 44,931 £2,948,335 11,234 £944,034 72,649

£31,232,135


232,049

£324,505,332

1,985,971

£132,884,174

417,586

£32,569,876

2,635,606

£489,959,382


7.1% 8.4% 2.3% 2.2% 2.7% 2.9% 2.8% 6.4%

Spell by Type

All Admissions Non-Elective Elective Day Case Total Bed days

Number

Cost Number

Cost Number

Cost Number

Cost LOS Beds

Band 1 16,48

4 £27,339,7

66 9,272

£19,157,699

3,346 £5,461,4

05 3,866

£2,720,662

78,832

215.8


232,049

£324,505,332

114,169

£195,372,944

49,384

£77,573,097

68,496

£51,559,291

675,397

1,849.1


7.10%

8.43% 8.12

% 9.81%

6.78%

7.04% 5.64

% 5.28%

11.67%

Data extraction methodology

Data extracted on the basis on NHS Linked to NHS Number in tables for Band 1 patients.

Inpatients - dbo_APC_Provider_Spell_SUS_PBR

Contract Admissions Year = 20102011

Commissioner code original = like 5P9* or like 5QA* or like 5L3*

PBR Final Tariff / PBR_Total_Payment_For_Spells

Spell Type

Outpatients - dbo_Outpatient_Appointment_SUS_PBR

Contract year = 20102011


Total Tariff / PBF_Final_Tariff

Accident and Emergency Attendances - dbo_AE_Attendances_SUS_PBR

A&E contract year = 20102011


68

APPENDIX 2

HISBi Dashboards and Reports

The following dashboards and reports are a selection of what is available on the HISbi

system. The reports are constantly being developed and we work closely with our users to

make sure that HISbi provides them with the essential information they need using data that,

in most cases, is local.

Real Time Reporting Dashboard

This dashboard shows acute activity from the four Kent and Medway acute hospitals. The

data is extracted on a daily basis and can be viewed as a monthly, weekly or daily trend. The

most recent data is the previous day and for weekly and daily views the graphs can be drilled

down to patient level.

69

CHADS (Cardiac, Hypertension, Age, Diabetes and Stroke) Dashboard

The CHADS dashboard uses data extracted from the GP systems and provides an overview

of care for patients at risk of stroke. Charts summarise the patients by CHADS scores, risk

factors, demographics and use of anti-coagulation therapy. It allows the user to quickly

review the care of these patients including enabling immediate identification of those who are

most at risk by a drill down to patient level.

Heart Failure Dashboard

Thi

s dashboard uses data extracted from GP systems and allows the user to monitor the care of

patients with heart failure. It displays NYHA (New York Health Authority) scores,

Echocardiogram results, drug regimens, and results of regular tests such as Haemoglobin

and Creatinine levels as well as providing links to a set of detailed reports. There are drill-

down reports to patient level and to recent blood pressure graphs showing trends.

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DMARD Dashboard

The DMARD dashboard uses data extracted from GP systems and reports on usage of the

class of drugs used to treat rheumatoid arthritis and other autoimmune conditions. It provides

a set of graphs for each of the eight commonly used DMARD drugs showing test results and

monitoring adherence to test schedules. It includes links to detailed reports of patients who

are due for, or are overdue, a test.

Statin Dashboard

This dashboard uses data extracted from the GP systems and monitors those patients who

have been prescribed a statin. It enables the user to review statin prescribing within the

practice as well as monitoring the total cholesterol, HDL/LDL levels and liver function of those

receiving statins.

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A&E Reporting

There are a range of A&E reports using data from the Secondary Uses Service or from data

supplied directly by the acute trusts. This reports shows A&E attendances by the top 20 care

homes for the previous six weeks or six months. The information can be viewed in various

ways such as by admission status, by practice or as a standardised rate.

A&E reports, such as this one, can show patients who have had multiple A&E attendances

and what their disposal was. Where there are costs available these can also be seen. Other

A&E reports show trends for patients arriving by ambulance and whether they were admitted

or not.

72

SHREWD

73

APPENDIX 3

Table to show current status of development of integrated health and social care teams v1.0 29.5.12

CCG

Location Locality steering group

Operational description

Team composition

Related projects supporting integration

Key enablers Limiting factors

Risk Risk mitigation

Timescales Status

South Kent Coast

Dover / Deal

Yes, strategic group for SKC CCG area with GP rep (joint with Shepway). Separate locality operational implementation group (joint with Thanet)

Aims to have integrated co-located teams in place. There will be 1 Short term team for Dover/Deal and 2 GP practice linked teams for Dover and 1 for Deal focussing on LTCs.

CCG have agreed Model A* (but may change to Model C).

1. Integrated Personal Budget pilot 2. Integrated health and social care senior manager pilot

1. One manager across health and social care co-ordinating activity 2. Have already identified accommodation 3. Real drive from CCG. Locality director and GPs actively engaged 4. Kent Health Commission work focussing on this CCG area, with KCC and District Councils 5. Good local engagement with staff at manager and practitioner level – there is a will to make

1. Accommodation agreements needed 2. Dependent on revised Information Sharing Agreement between KCC and KCHT. 3. KMPT staff not part of these teams at this point. 4. Acute hospital not involved

1.Staff will not be able to share patient data between health and social care. 2. Resources to staff the Single Point of Access are not available from within KCHT. 3. Resources to divert KCC staff from KCAS to the SPA cannot be achieved. 4. Lack of integrated management at team level could result in fragmented

1. Revised Information governance being developed; Consent module to be developed for KCC system; secure email to be arranged for KCC staff 2. Work in progress to understand resource requirements for SPA – may need to open dialogue with CCG when complete. Interim referral management solution to be developed. 3. KCC to have internal dialogue to resolve. 4. Review

June – July ’12 – PCNT and matron team combine and co-locate where possible. KCC teams ready in shadow. October ’12 – Co-located primary care MDTs and referral management system. Dates for Single Point of Access and integrated rapid response/ intermediate care to be determined. Work plan being reviewed now.

Amber

74

CCG



Team composition




Timescales Status

this happen decisions, lack of co-ordination of care. 5. Dementia services will continue to be delivered in silos. 6. Integrated teams may not deliver anticipated savings or reduce acute admissions. 7. Use of separate IT systems by practitioners could hinder better co-ordination of care

management arrangements as programme progresses. 5. Commission integrated teams that do include health related dementia services. 6. Performance monitor and attend to any negative consequences of way integrated teams are implemented 7. Scope who should access health and KCC systems to link patient / service use information and better inform decisions. Provide training.

South Kent Coast

Shepway district

Yes, strategic group with GP rep (joint with Dover). Separate locality operational

Model likely to be as per Dove/Deal but configuration of teams to be agreed

CCG have agreed Model A* (but may change to Model C).

Pro-Active care pilot

1. Real drive from CCG. Locality director and GPs actively engaged 2. Kent Health

1. Accommodation requirements need to be scoped and buildings identified

As per South Kent Coast – Dover/Deal above.


Pro-Active care pilot started April 2012. No timescale for integrated teams yet

Amber

75

CCG



Team composition




Timescales Status

implementation group

(proposal available now).

Commission work focussing on this CCG area, with KCC and District Councils 3. Pro-active care pilot operating in Folkestone incorporating risk stratification, MDT working in health/social care and self management

2. Dependent on revised Information Sharing Agreement between KCC and KCHT. 3. KMPT staff not part of these teams at this point. 4. Acute hospital not involved

Thanet Thanet district

Yes with GP rep. New TOR for Thanet strategic group drafted and group to include KMPT and EKHUFT. Operational steering group established (jint with Dover/Deal).

Aims to have integrated co-located teams in place. There will be 1 Rapid response and 1 community assessment and rehabilitation team for the locality. Configuration of teams to be determined.

CCG have agreed Model C*

Integrated health and social care senior manager pilot

1. One manager across health and social care co-ordinating activity 2. CCG engaged and want to shape the model locally.

1. Accommodation requirements need to be scoped and buildings identified 2. Dependent on revised Information Sharing Agreement between KCC and KCHT. 3. KMPT staff not part of these teams at this point. 4. Acute hospital not involved

As per South Kent Coast – Dover/Deal above. No Thanet specific risks identified.

As per South Kent Coast – Dover/Deal above. Suggest this needs further development with local managers and clinicians.

To be confirmed – likely to be by autumn 2012. Consultation with PCNT and Matrons commenced and will run across June. Staff workshops planned for this period. Aiming for co-location where possible during July ’12. Dates for Single Point of Access and integrated rapid response/ intermediate care to be determined. Work plan being reviewed now.

Amber

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CCG



Team composition




Timescales Status

5. Intention to keep primary care nurses based in practices (this should not be seen negatively, but could limit the level of multidisciplinary integration that could be achieved through co-location).

Ashford

Ashford district

Yes with GP rep

Configuration of teams to be agreed, but could mirror the Thanet model.

CCG have agreed Model B, with some flexibility to adopt Model A as an interim step.

Dedicated project manager to be employed by CCG GP very engaged and sits on Locality Steering Group

1. Accommodation requirements need to be scoped and buildings identified for longer term. Identified an interim solution to house ICT/enablement and SPA (N3 in place). This will be clearer mid June, details to be scoped. This will allow a timely approach to

As per South Kent Coast – Dover/Deal above. No Ashford specific risks identified.

As per South Kent Coast – Dover/Deal above. Suggest this needs further development with local managers and clinicians.

KCHT/KCC/Commissioner Workshop held on 15

th

May when model was agreed in draft to take to CCG Board meeting on 31

st May.

Workplan agreed around team configurations to be completed mid June. Implementation dates to be agreed.

Amber

77

CCG



Team composition




Timescales Status

the longer term solution. 2. Dependent on revised Information Sharing Agreement between KCC and KCHT. 3. KMPT staff not part of these teams at this point. 4. Acute hospital not involved

C4G Canterbury, Faversham, coastal area

Yes with GP rep

Configuration of teams to be determined.

To be developed – likely to be more akin to model B

Dedicated project manager in post, employed by CCG 2 GPs sit on Locality Steering Group Acute trust to have rep on the locality steering group

Accommodation options for co-location not yet known Secure IT connections not available HR consideration needs to be factored (may impact time to implement) Contracting and procurement rules KMPT redesign and Payment by Results work may

Geography overlaps with other KCC/KCHT localities: CCG also covers Ash, Sandwich, Faversham CCG overlaps several district council areas – impact re: OTs and Disabled Facilities Grants? Cost of SPA

KCC and KCHT to review integrated management arrangements and consider boundary issues re: coterminosity Review how social care OTs may need to operate within integrated teams Develop SPA option appraisal with cosings to guide decision

To be confirmed by Locality Steering Group

Amber

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CCG



Team composition




Timescales Status

impact on what can be achieved

for this CCG may be prohibitive Cost of implementing preferred risk stratification tool Engagement of GPs and other organisations may not be easy Acute trust not yet engaged

making Consider as part of EK Federation / at Kent and Medway level to ensure financially sustainable Discuss and agree communications and engagement plan at local level EKHUFT have been invited to have a rep on the group. Engage EKHUFT in dialogue / use Care of Elderly clinical peer group forums to discuss

Swale Swale district

Yes, there has been a GP rep for this group. There will be a new GP representative on this group from June – lead GP TBC

Configuration of teams to be determined.

Model A originally agreed, however focus of CCG is to ensure integrated working between teams as

Pilot use of integrated posts x3 – Health and Social Care co-ordinators (who will be aligned to GP practice

Case manager and assessment officer funded by health in ICT already Direct access by health professionals to social care Enablement

Size of Swale is small in comparison to other areas – lose economy of scale advantages MDT meetings with GPs do not currently take place –

Stand alone SPA might not be economically viable Other cost risks due to size 1. Other

risks as per

Pooled / sharing of budgets and resources across more than one CCG area Gain engagement from leading GPs

No timescale available for integrated teams or SPA (not before September 2012) Expect Health and Social Care Co-ordinators to be in post by end August 2012.

Amber

79

CCG



Team composition




Timescales Status

soon as possible. Establishing a SPA should not hold this process up.

clusters) service Starting joint management meetings Matrons / PCNs already co-located in Sittingbourne, space for other staff to join KMPT involved and engaged in locality steering group Funding for new Health and Social Care Co-ordinators – 3 posts to be recruited to MDT meetings will be established to enable identification and case management to support risk stratification - H&SC teams key to their function

could in part be due to high number of single handed GP practices - reason for this needs to be understood

South Kent Coast above

Need to understand low referral rates for community matron, primary care nursing and intermediate care services Local discussions at CCG level to determine how to provide the necessary GP clinical leadership

South of West Kent

Maidstone and Malling Sevenoaks, Tonbridge, Tunbridge

Yes. Paper presented to CCG board inviting a GP to Chair, awaiting confirmation. KMPT representation secured.

Aim to have integrated co-located teams in place.

CCG agreed Model A

1. Integrated teams 2. Integrated

Real drive from CCG, locality director actively

1.Accommodation to be scoped and identified 2.Dependent on revised ISA


As per South Kent Coast – Dover/Deal above. Suggest this

Comprehensive implementation programme with project action plans and timelines agreed – aim to

Amber

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Wells, the Weald

Monthly operational implementation group in place.

acute care support 3. Integrated therapies pathway 4. SPA

engaged Excellent staff engagement with two workshops held – further workshops scheduled Key processes and pathways mapped High level resource mapping completed Accommodation mapping in progress Detailed process mapping for SPA workshops scheduled Comprehensive joint action plans developed and agreed Piloting Trusted Assessor

between KCC and KCHT 3. Acute Hospital not involved

needs further development with local managers and clinicians.

implement integrated teams by Septemember 2012. Single Point of Access to be determined.

Dartford, Gravesham and Swanley

DGS Yes, Locality Steering Group is in place. GP attends and chairs the meeting in turn with KCC Head of Service. PA support agreed via HOS. The group meets every 6 weeks. Project Officer to provide ongoing support.

Integrated Model supported by the Clinicl Cabinet. The model proposes to have integrated co-located

CCG have agreed Model C* Supported by the Clinical Cabinet and GP group on 17 May 2012

Digital Pen Pilot in one area of Gravesend. Risk stratification for LTCs – HISBI work

A social care case manager is already allocated/based with the Impact Team. Real drive from KCC, KCHT and CCG to include and consult with

Dependent on revised Information Sharing Agreement between KCC and KCHT. KMPT staff not part of these teams at present.



Timescales to be agreed and monitored via the Steering group’s local project plan.

Amber

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teams across the two sites in locality. Likely that There will be 1 GP practice linked team for Gravesend and 1 for Dartford and Swanley.

local GP practices and wider stakeholders. Good local engagement with staff, managers and practitioners across all stake holders. 4.Project Officer already closely working with the Steering group to progress the project plan. 5. Acute Trust have been involved in SHA event and consultant geriatrician has been invited to be part of the locality steering group.

3. Acute Trust not yet involved. 4 Accommodation still an issue. Accommodation still under review as Joynes House lease ceases in 2014. Accommodation options at Gravesham Hospital and Joynes House being considered. 5 Staff terms and conditions

Medway Medway Awaiting

information

from Medway

Council

Awaiting

information

from Medway

Council

Awaiting

information

from Medway

Council

Awaiting

information

from Medway

Council

Awaiting

information

from Medway

Council

Awaiting

information

from Medway

Council

Awaiting

information

from Medway

Council

Awaiting

information

from Medway

Council

Awaiting

information

from Medway

Council

Awaiting

information

from Medway

Council

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APPENDIX 4

What is telecare?

� A remote monitoring system.

� A hub and sensors

� Sensors are environmental and personal

� The hub receives alerts from the sensors and dials the monitoring centre

� The monitoring centre is a 24/7/365 service. It actions the appropriate response:

~ Relative ~ Friend ~ Neighbour ~ Formal responders ~ Emergency services.

� Telecare requires a robust infrastructure

What are the principles?

� Supports independence

� Supports carers

� A tool in the care management plan

� Person centric

� Potentially delays residential or nursing home placements

What is telehealth?

� Its an enabling tool

� A hub and peripherals

� It collects and stores data and sends it to a secure server, web site or cloud.

…...It is not a 24 hour monitoring service

What are the principles?

� Move data not the patient

� Frequency and richness of data

� Embeds the principles of self management - Know your numbers

� Supports clinical plan

� Supports independence and empowers patients

� Person centric

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� Processes, procedures, infrastructure

� Clear and consistent messaging and communications

� Target the correct participants

� Having the right staff in place with the right competencies and attitude.

� Easy to use technology

� The patient regularly lays data and clinical staff regularly monitor.

� Active support for the patient.

Telehealth success criteria

CitizenCarers, families,

networks

Integrated

teams

Statutorytechnology

Riskstratification

Personal

technology

3 Million lives

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Technology to support self management and self care

Benefits

Potential applications

Current Technology

Technology currently in use

Brief Description Current application

Secondary tier stratification

Third tier stratification

Lowest tier

Newly diagnosed undiagnosed Specific social care asessed needs

Telehealth Remote monitoring technology consists hub and peripherals. Situated in the home environment. Not transportable. Back office system accessed by community matrons and specialist nurses.

Communtiy matron and specialist nurse case load. Typically top 0.5% of risk stratified population

For short term application to embed good self management techniques

Telecare Remote monitoring of individuals using environmental and personal sensors to support independent living. Monitored 24/7 and linked to a variety of response services.

People who meet KCC eligibility criteria of Mdoerate FACS (Fair Access to Care Services)

Dementia Dementia Dementia Those identified as at risk of falls. Carer support. Risk of wandering. Activity monitoring as part or enablement

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Proactive Care Programme

The use of remote monitoring linked to intense support and patient education to patients with LTC.

Through the Intergrated team model



Apps

My Asthma Use of App to support self management and self care for adults and children with Asthma

Initiated by patient Patients not linked to care pathways

Diabetes UK app

Use of App to support self management and self care for adults with Diabetes


Web based solutions

Met Office Health Outlook COPD service

Early warning of weather conditions that may affect people with COPD linked to simple care plan the individual can refer to.


Finerhealth Web based community solution for sharing health based information


Supports carers

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Patient knows Best

Patient controlled information sharing mechanism to support integrated team working

has relevant use for this group






Just Checking Activity monitoring sensor which enables carers and professionals to monitor and understand activity patterns and plan care accordingly.






Supports independence and carers. Reelvent use for this group

Rally Round Allows for the development of informal care networks around individuals with LTC/ disability/ dementia

Has relevant use for this group





Supports independence and carers. Relevant use for this group

Finerday & our Yesterday

A web based secure site following the principles of social networking, sharing photos, memories and discussion for older and vulnerable people. Offers a secure gift and shopping solution.






Supports independence and carers. Relevant use for this group especially dementia and community settings such as residential and nursing homes.

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APPENDIX 5 - AUDIT +

Primary Prevention

- Alcohol screening for adults over 15 using the AUDIT C & AUDIT questionnaires

- BMI screening for adults over 15 every 27 months

- Tobacco screening for adults over 15 every 27 months

- Missed bowel, breast or aneurysm screening

- Targeted aneurysm screening to high risk groups

- Immunisation programmes

Secondary Prevention / early diagnosis

- Atrial fibrillation prompts for diagnosis and management

- COPD prompts for diagnosis and management

- Hypertension prompts for diagnosis and management

- CKD prompts for diagnosis and management

- Heart Failure prompts for management

- Familial Hypercholesterolaemia prompts for diagnosis and management

- Professor Hamilton risk assessment for tools for lung and colorectal cancer

- Depression screening for depression in all LTCs (not just QOF defined IHD & DM)

Niche conditions such as Marfans, Nail Patel syndrome, Polycystic kidney disease, Alports

syndrome, Myotonic dystrophy

Better management

- Lithium monitoring

- Learning Disabilities

- End of Life

- LARC

Other benchmarking indicators

- Recording of ethnicity, main language spoken, family history both positive and negative

- Enhanced service claims

- National audits e.g. National Diabetes Audit

- Immunisation uptake reports and prompts for those who’ve missed or are due

immunisations

- NSF compliance CHD & DM

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Improved prevalence recording

For those LTCs within QOF having the condition diagnosed and coded on a GPs clinical

system triggers the appropriate management prompts and the ability to monitor and compare

practice performance via QMAS.

NHS Healthchecks

A module which works on the same principles has been developed to work in primary care

which identifies patients who are eligible for NHS healthchecks and can then run the call &

recall system as well as supporting the Healthcheck being performed without duplicating

information already known about the patient.

Prescribing +

A module (due for launch May 2012) which will make the warnings about drug usage relevant

to the individual patient. Monitoring both drug to drug interactions and drug patient

interactions providing warnings or prompts that relate to the individuals diagnoses and clinical

condition. For example rather than a blanket warning not to use a drug, or to use a drug at

reduced dosages in patients with renal impairment it will also warn specific to the patients

diagnosis of CKD and last e GFR. It will also add warnings when the clinical condition

deteriorates and this may suggest a change in medication.

Alerts +

A module that will allow all alerts relevant to primary care to appear electronically so that

practices will have an audit trail showing they have acted or responded appropriately. Where

the alert applies to particular cohorts of patients the audit to identify those patients will be run

automatically e.g. those on a particular drug or combination.

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Snapshot showing prompts displayed for a particular patient

Little practice variation showing recorded smoking status

90

Significant practice variation for recorded alcohol consumption

91

92

APPENDIX 6

STANDARD OPERATING PROCEDURE TEMPLATE

This Template provides advice (in red) and the standard format and

words (in black) to assist staff preparing a Standard Operating Procedure (SOP) document. (See live examples in Appendix C)

Type of Agreement

This SOP is to be read in conjunction with the Kent & Medway Information Sharing Agreement and Method XX (Description to be inserted). There is the option to include more than one Method. Personnel involved in the information sharing process must be fully aware of the requirements of Agreement Method XX.

Parties to this Agreement and contact number to identify Primary Designated Officer (PDO)

List the parties to the specific agreement and contact numbers as indicated above. The details are to include the job roles as well of the names of the individuals currently holding those positions. A list of regular PDO and Designated Officer (DO) contacts is to be maintained for easy reference and is to be attached to this document (electronic and paper version). If there is any doubt about the contact or the information requested check with your supervisor before disclosing information.

Purpose

List the purpose and the reason for considering the disclosure of information e.g. targeting/investigating crime and disorder incidents, notices seeking possession or eviction, child curfew notices or noise abatement investigations and notices.

Administration/Process

List specific administration/processes that are relevant to the particular SOP, such as the response times. There is always a need to specify how each partner will keep a record of decisions and the reasons, whether it is to share or not (see Golden Rules item 5, above). Apart from this requirement, there may not be a need to add more text if the standard wording provided in the Information Sharing Agreement (ISA) is sufficient. For example, the requirement for PDOs, a standard information sharing form and the need to keep records are all specified in the ISA, but if there is a need to identify other roles, vetting levels if required, or be specific about the format of a meeting/minutes additional information will need to be inserted here.

Information Disclosure Types (Examples)

Disclosure for the following relevant areas for each partner will be considered. Specific exclusions are also listed. List information for which disclosure will be considered for each partner. Specific exclusions are also to be listed, if required (e.g. evidence in council led court cases will not be disclosed until the conclusion of the hearing). Signatory partners recognise that any data shared must be justified on the merits of each case.

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APPENDIX 7

Principles for choosing metrics to display on the

Clinical Dashboards

o Dashboards should cover the full range of clinical quality areas (safety, effectiveness

(clinical, outcome and cost), patient experience etc). o Dashboards should include a range of metrics so that at least some are relevant across

all aspects of the multidisciplinary team. o The metrics should be locally requested and chosen by the appropriate clinical teams and

will not be limited to those nationally defined. o The metrics displayed should be locally actionable, and must be more than just

interesting and available information. o The metrics should be as near real time as is useful. The metrics should be displayed

from raw data feeds and there will be no delays for data cleansing. o Presentation of information should be as instinctively understandable, and as visually

stimulating as possible. o Where similar metrics exist (eg on other sites or with national definitions), a consistent

approach should be used as far as possible to allow high quality local solutions, whilst maintaining compatibility and comparability.

List of Urgent Care metrics based on Bolton Urgent Care Dashboard

The numbers of patient events at each of the various local, unscheduled care services yesterday and for the last seven days Urgent Contacts: Activity Time Series

The numbers of patient events at various local, unscheduled care services over time

Urgent Contacts: disease registers and frequent attenders

The numbers of patient events at various local, unscheduled care services who are on a disease register, and those with more than one contact in last 30 days (both covering yesterday and the last seven days).

Urgent Contacts: Patient List A list of patient details for those patients who have attended various local, unscheduled care services, who are on a disease register, and those with more than one contact in last 30 days

Urgent Contacts: 14 Days Patient List

A list of patient details for those patients who have attended various local, unscheduled care services, in the last 14 days

Urgent Contacts Patient Contact List

A list of a single patient's details who has attended various local, unscheduled care services

Urgent Contacts: Contact Type List

A list of patient details with the selected type of unscheduled care service contact, occurring in the last 30 days

Urgent Contacts: Contact Date List

A list of patient details for all patients attending unscheduled care on a chosen date

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APPENDIX 8

Source: 2012 QIPP Digital Technology Team ‘Technical Approaches to Sharing a Care Plan’

A care plan is a document that has the following characteristics:

- It relates to a single individual

- It supports future care for an individual

- It aids decision making about future care

- It may also record decisions made about care

It also clarifies that a care plan is not:

- An electronic patient record (although the care plan is part of the overall electronic

patient record for a patient).

- A record of all activities and encounters a patient has with services

- A personal health budget

- Detailed “measurements” (either manual or from a Telehealth device)

- eConsultation (although care planning activities may be delivered over an electronic

channel in some cases)

- A care “pathway”

There are no standardised or agreed definitions for the types of care plans, however the

following diagram suggest a broad generalisation into the following types:

Types of Care Plans

Source: QIPP Digital Technology 2012

Personalised Care Plan

It is the output of a collaborative “care planning” process, giving an overall view of activities

which aim to maximise the patient's capacity to self-care. It should be structured around a

minimum core set of information – Problems, Needs and Goals.

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Treatment Plan

This is a clinically driven plan, covering prescribed procedures, therapy or medication for a

certain condition and may include goals and actions, but these are generally clinical activities

only.

Support Plan

This is a plan created by social care teams, and is generally driven by the output of formal

assessments as part of a common assessment framework. It is often linked to a personal

budget that supports the individual�s support needs.

Escalation Plan

This is arguably the most important part of care planning and often overlaps or is combined

with the treatment plan and/or the end of life care preferences / Advanced Care Plan. They

are intended to help support the patient in managing potential future crises (to avoid hospital

or care home admission) which will include:

- Instructions for emergency care professionals

- Symptoms to look out for, additional medication or actions to take to manage the

exacerbation.

- Treatment advice for the patient.

- Contact details for carers, next of kin, and emergency clinical contacts

End of Life Care Preferences / Advanced Care Plan

This is developed through a voluntary process of discussion with the patient captures details

about his / her preferences, choices and decisions regarding their care at the end of their life.

This plan may need to change rapidly if a patient starts to deteriorate, and it is important that

unscheduled care services have up-to-date information to support any emergency situations.

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APPENDIX 9

The QIPP evidence-based long term conditions model describes self care/shared decision

making as empowering patients to maximise self-care, self-management and choice, through

shared decision making and motivational interviewing.

This includes ensuring that:

• Patients engage in shared decision making to co-produce a care plan

• Both patients and their carers have access to the appropriate information about how to

manage their condition.

• Patients are active participants in all decisions about their care (‘no decision about me

without me’)

• Patients have access to their medical records.

A self care resource pack produced by the South West Development Centre, describes self

care as both self care and self management. It involves an individual taking responsibility for

their own health and well-being, making the most of their lives whilst potentially coping with

difficulties; and managing or minimising the way conditions limit their lives.

As the model below suggests this is an approach which needs to be applied across whole

systems.

However it is recognised that many of the behavioural patterns which exist amongst people

with long term conditions around their own health management are complex and multi-

97

faceted. Physical well-being and motivation to self care are significantly impacted by the

individual’s psychological state – depression and anxiety are commonly experienced by

people living with long term conditions - and their social context – people with long term

conditions and carers often experience reduced social interaction due to the nature of the

condition, with consequent negative impact on their psychological welfare and so on….

They will therefore require personalised, individually responsive services, that recognise and

respond to physical, psychological and social needs - the cost of focusing on just the physical

can be significant. The most effective services to meet all of these needs are based on co-

ordination and collaboration between many agencies in both the private and public sector.

Kings Fund reported on the Department of Health findings, published in March 2012, of a two-

year independent study of 16 integrated care pilots. The 16 initiatives varied greatly in the

populations and/or the diseases and conditions they sought to influence and in the

development of the organisations/teams.

Generally, the staff reported positive experiences – for example, improved team working and

greater job interest. They also thought patients’ quality of care had improved.

However, although patients reported receiving care plans more frequently and most felt care

was better co-ordinated after discharge from hospital, they also found it much more difficult to

see a doctor/nurse of their choice, were less involved in decisions about their care, and were

listened to less frequently. The findings suggest that typically the focus was on ‘doing’

the integration rather than the care experience.

From their recent work on the experiences of older patients in hospital and of people with

long-term physical and mental health needs Kings Fund reinforces that continuity of care

and personal relationships affect people’s life chances and that the experiences of patients

and service users must be captured and acted on. This would help ensure that new

approaches to care – which might involve shaking up the way patients interact with care

professionals – focus on developing continuity of care with service users.

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APPENDIX 10

EQ5D questionnaire

99

EQ5D results Proactive Care Pilot, Anfield, Liverpool 2010

100

101

APPENDIX 11

FACE – Functional Analysis of Care Environments

The FACE toolset is designed to integrate the requirements of Common Assessment

Framework (DH 2010) and personalisation (Putting people First 2007 and subsequent

papers. The toolset provides a combination of core and specialist tools which facilitate high

quality and proportionate assessment, planning and review processes across community,

residential and hospital settings.

The toolset provides

• Comprehensive

• Person-centred

• Proportional

• Acceptable across health and social care

• Outcomes-focussed

• Evidence-based

• Integrated

• Policy-compliant

• Supporting electronic use

The assessment information is gathered to inform care planning, decision making and review

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APPENDIX 12

COPD case conferencing / Intensive Case reviews The case conference is a tool for coordinating care across a multidisciplinary team. It

is used by team members to identify and discuss the care needs and goals of patients with

chronic or complex conditions and to assign interventions to particular members of the team.

National and international literature shows adequate evidence of case conferencing can help

improve patient outcomes such as experience of quality of care, improved prescribing and

reduction in unscheduled care activity.

In Stockport, based on the recommendations from an earlier hospital readmissions

audit, 2 case conference pilots were held in May and July 2010 to discuss the management of

8 COPD complex elderly patients. Apart from demonstrating reduction in unscheduled care

activity, anecdotal evidence indicates considerable interest and positive feedback from the

participants. The pilots demonstrated the following:

o Each patient case conference lasted approximately half an hour divided into:

o A short 5 minute presentation by the community matron of the patient’s key

health and social care needs

o Followed by 10 to 15 minutes discussion by the case conference participants

from public health, commissioning, primary care, community urgent care, social

care and pharmacy. Hospital and community case notes were brought to the

session for reference.

o A 5 to 10 minute discussion summing up and agreement of actions to be taken by

each stakeholder

o Approximately 4 out of the 8 patients were found to be in an end of life stage and referred

for palliative care services.

o All the patients had their medication reviewed and optimised.

o In at least one patient, referrals for future specialist outpatient referrals (made prior to the

case conference) were cancelled as they were deemed not necessary after case

conference discussions.

o Informal feedback from the some of the stakeholders, including GPs, highlighted

significant benefits of using the case conference as a opportunity for sharing learning

ensuring good clinical practice and quality of care.

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Excerpts of discussions and notes taken during and after the case conference for 2 COPD patients:

Patient A Background

• 82 years old, Female

• Lives with husband in ground floor flat

• Son lives nearby and visits regularly

• Ex-smoker

• Has wheelchair to go out

• Day care every Monday

• Had home based PR

• Spirometry - FEV1 71% pred. in 2004

• R CVA

• Anaemia

• Paroxysmal AF

• Echo showed mod /severe MR

• Angina

• Gastric ulcer

• Osteoarthritis Medication • SBOT • Nebulised salbutamol 2.5mg qds • Nebulised ipratropium 500mcg qds • Salbutamol inhaler 2 puffs prn • Seretide 250 evohaler 1 puff bd • Theophylline S/R 200mg bd • Ferrous sulphate 200mg od • Pantoprazole 20mg od • Paracetamol 1000mg bd Issues/ problems

•Frequent exacerbations resulting in emergency short stay admissions at least once a month

•Episodes of AF- was on amiodarone now stopped

•Confusion re medication changes after each admission plus issues of concordance

•Visited EIS (Urgent Care Centre) but unsure about attending in future

•Long overdue for spirometry testing.

•Earlier review found patient suitable for Pulmonary Rehabilitation but she has not attended yet. Actions taken and outcomes

•Spirometry testing finally carried out.

•Drug medication optimised.

•GP agreed to arrange transport to Pulmonary rehabilitation

•Patient persuaded to come along without her wheelchair

•Patient delighted with Pulmonary rehab experience

•No further re-admissions in 2 months following case conference.

104

Patient B Background • 69 year old female • Lives with husband and daughter in four bedroom house • Husband is main carer • One son lives close by but daughter is main support • Ex-smoker - 40pk yrs • Was fully mobile in Dec 09 for eg. going out shopping etc. • Recent marked decline in exercise tolerance now housebound, confined to upstairs. • Often requires assistance from family for personal hygiene • Never been well enough to start pulmonary rehabilitation • Spirometry - Severe FEV1 28% pred. • Bronchiectasis and bronchiolectasis diagnosed April 2008. • Severe tremors • Recurrent sinus tachycardia, cause unknown. • Awaiting cardiology review. • Hypertension. • 6 admissions April 09- Feb10 Medication • LTOT 2 Lmin / 16 hrs • Nebulised Ipatropium 500mg qds • (Unable to tolerate Salbutamol or Bricanyl nebs due to tachycardia and tremor) • Seretide Accuhaler 500 b/d • Ventolin Accuhaler - prn (for rescue therapy only) • Prednisolone reducing dose until back to maintenance dose of 5mg • Carbocisteine caps 375mg x2 T.D.S. • Co-amoxiclav TDS for 2 weeks (Allergic to Azithromycin) for long term antibiotics for

Bronchiectasis • Diltiazem • Trial of Sertraline – stopped recently because of no benefit Issues / Problems • Frequent admissions for tachycardia and dyspnoea. Infections excluded - cardiac cause

still not fully investigated. • Recurrent episodes of sinus tachycardia. Rate > than 120 bpm on minimal exertion. • Confusion re: diagnosis / prognosis. Unaware of severity of diagnosis, COPD severity

has been discussed by COPD team. Bronchiectasis not yet fully discussed/explained by consultant.

• Chest physician unable to bring clinic appointment forward, advised COPD team to discuss with GP the need for GSF / end of life discussions.

• Though referred, still awaiting echo and cardiology opinion. • Unrealistic expectations - Rosemary still hoping for cardiac cause to be identified in the

hope she can receive some treatment in order to improve. • Depression / anxiety / social isolation are all issues. Actions taken and outcomes � GP has initiated EoL discussions with patient taken place about end of life. � Tachycardia found to be physiological response to increased breathing effort. � Patient explained in detail about this. This openness appears to have lifted a lot of her

anxiety and she has expressed a desire to stay at home. � Patient now on GSF. � No further admissions in two months following readmissions.

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Implementing the LTC Model of Care across Kent & Medway ... · PDF filestratification is independent of diagnosis and so will address the difficulty in identifying non-cancer patients