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Commissioning Services Working across Health & Social Care
Julie Wilkinson
Rochelle Morris
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Why Long TermConditions Management Agenda
� Background and overview to the contracts for Integrated Care with:
North East Lincolnshire Care Trust Plus
Erewash Clinical Commissioning Group
Hardwick Clinical Commissioning Group
Others
� We will cover the process followed and the tools used during the:
- Scoping phase
- Implementation phase
� Improve user/carer/professional experience and care through multi organisational working
� Better outcomes for users/carers
� VfM
� Support the Sir John Oldham National LTC QIPP agenda
The Department of Health has agreed three fundamental features of best practice LTC care programmes:
– Using risk profiling to ensure that commissioners understand the needs of their population and manage those at risk. This will assist in preventing disease progression and will allow for interventions to be targeted and prioritised.
– The creation of integrated health and social care teams to provide joined up and personalised services. Each individual has a key worker within this team who co-ordinates their care and acts as the point of contact.
– Self care / shared decision
Overall Aims:
� Scoping phase:– Current state assessment
– Stakeholder engagement
– Develop Integrated Care Model
– Create Service Specification
� Implementation phase:– Case Management across health and social care and links with intermediate
care and acute trust
– Community Delivery Teams/Virtual Ward Teams
– Review in-reach discharge process for individuals with complex needs for secondary, intermediate and short stay
– Integrated Care Plan booklets for individuals to record personal goals and develop contingency plans for their care
– Developing Reporting tools
– HealthNumerics-RISC to identify individuals with high risk of admission to hospital and developed an adult social care risk assessment tool for high risk of care home admission
Approach:
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Project Aims
Defined under 3 key principles:
• Joined Up
• Personalised
• Prevention and Early Intervention
Joined Up• Coordination of multidisciplinary
assessment/care in the home
• In-reach to Secondary Care and
Intermediate Care stays
• Linking to Primary Care
• Effective information and case
sharing
Personalised• Effective person centred assessment
• Supporting self assessment and goal planning
• Supporting the views, strengths and wishes of the individual
• Use of Personal Budgets
• Advocacy / brokerage in assisting individuals to plan to meet
their goals
Prevention and Early Intervention• Using skills, knowledge & experience of
condition(s) to effectively plan to mitigate
exacerbations and deterioration pro-actively
• Possible use of systematic methods of LTC
care such as telehealth, telephonic coaching,
self management planning, etc.
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Programme Management Structure – NEL
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Programme Management Structure – Erewash
Erewash Clinical Commissioning Group
Commissioning & Quality Board
Work Stream Leads
Integrated Care Programme
Lead
Senior Responsible OfficerIntegrated Care Programme
Board Members
Integrated Care Project
Group
Members
Work Stream LeadsIntegrated Care Programme
Lead and Clinical Lead
South Derbyshire CCG Integrated
Care Programme Board
South Derbyshire Integrated Care
for Frail & Elderly Implementation
Group
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Work StreamsSingle Point of
Access
� Leadership
� Criterias
� Resource Planning
� Rollout of Clinical Navigation Service to SPA?
Community Delivery
� Process Mapping
� OOH
� In reach
� Reablement
� Leadership
� Resource Planning
� Home Care Services
� Integrated Care Plan
� Criterias (CCM)
� Inclusion
� Exclusion
� Voluntary Sector
� Implementation of Virtual Working
Performance Tools
� Outcomes
� SystmOne & Alerts
� Savings
� Risk – health, social care
� Resourcing
� Acute alerts
� Telehealth
� IT
Communication/Engagement
� Patient engagement
� Staff engagement
� Other stakeholder engagement
� Model rollout
� Launch
Integrated Care Model - NEL
IT
Performance
What is it?• An approach to delivering a ‘fit for
purpose’ joined up system that
ensures all providers work
together to benefit users
Benefits • Seamless service for users
• Integrated care pathways
• Improved communications
• Increased co-operation and
understanding between services
and providers
• Improve quality of services
• Facilitate appropriate changes to
culture
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Integrated Care
Model
for
Erewash CCG
4 new elements:
-Single Point Access
-Rapid Response
-Community Delivery Teams
-Risk Stratification
Manage for up to 6 weeks
Nomination Criteria Score
determines bias
Referrer
SPA
Community
Delivery Team
Role of CC
- Case finding
- Risk strat
- MDT co-ord
Colour code
Decision point
Tool/Criteria
Services
Supporting services
Non Critical
Social Care
Rapid
Response
and Intermediate
Care/Reablement
Acute
TrustPractice
Appropriate for Case Management?
NOYES
Case
ManagerReferrer
DN
team
NO NO
Specialist LD teamTelehealth
Mental Health
(to incl. in model for Community
Delivery, RR and IC teams)
Specialist Nurses
DN Team Intermediate Care at HomeVoluntary Sector
Place of SafetySocial Care
Personalised budgetsSelf Care ProgrammesEquipment store
Hospital DischargeDieteticsTelecare
Short Stay/Respite
Falls Service
Safeguarding AdultsCHC
GP OOH
(DHU)
Navigator
Care Co-ordinator
Therapists
Referral Criteria Nomination Criteria
Continual Assessment Secondary Screening
Routine Task
DN
team
Critical <2hrs
Manage for
required period
Personalised
Budgets
If regular tasks
required
YES
Triage
Health
Unplanned Planned
Social
Care
Complex long-term
management or
safeguarding
Discharge/Refer
Social
Care
Community
Delivery Team
Personalised
Budgets
For
assessmentOr
signposting?
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Overview of Complex Case Management & RISC� Process started in Spring 2009
� ICEC – savings cabinet with one element CCM
� Project group created – Community Matrons and Adult Social Workers – later a wider
group
� How do you define complexity in an integrated manner?
� How do we determine case loads, who is seeing whom?
� Resource requirements to ‘Complex Case Manage’ patients?
� What does CCM mean to health and social care teams? What is currently being delivered?
� Is vertical and horizontal integration in place? – GPs, Secondary Care, Intermediate Tier, etc.
� How do you currently take referrals? Is there a nomination criteria?
� How do you reduce unplanned chronic admissions to hospital?
� How do you bring care closer to the user?
� How do you improve joined up care and communications across teams?
� How to embed the chosen risk stratification tool for health?
� What is an integrated care plan?
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Establishing Caseloads
Stratifying Caseloads
1. Defining a set of criteria for “complexity” across health
and social care. UHUK RISC tool was basis for
stratification in Health with a paper based tool created for ASC
2. Analysing all existing caseloads against criteria and checked
against RISC list (6-16%, partly due to unclear definition of CM
role and lack of resources)
3. Allocating cases to complex case managers and
redistributing other cases as required across available
resources
In Adult Social Care: A3 (L1)
Locality Teams (L2 + L3)
In Health: Initially level 3
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Maintaining Caseloads
1. Development of a nomination criteria to support referral into Case & Complex Case
Management;
2. Agreed secondary assessment tool for both H and ASC;
3. Developed referral processes;
4. Ongoing clinical decisions made on who was appropriate for Complex Case Management
based on case review and on available case management resources;
5. Using the RISC tool and ASC scores, cross reference caseloads & ensure most
appropriate complex case manager is allocated – where is the bias? (60% same list);
6. On-going use of a RISC tool to continually monitor list.
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• Allowed CMs to compare current workload to a predictive list and agree criteria for
inclusion on new caseload.
• Provided the basis for discussion and comparison with ASC lists and allocation of
appropriate case manager.
• Offered opportunity to ‘push back’ some inappropriate referrals.
• Helped determine resource requirements for community nurse provider.
• Created opportunity to consider a formal process for in-reach.
• Led to sharing of case loads with wider teams
� intermediate care (specifically SPA and RR teams) - essential to share case lists
with SPA and RR team (handovers, snow 2011).
� acute trust – alert system.
• Led to MDT meetings being prepared for thoroughly and relevant staff invited to attend
only when required.
� created speedier MDT/practice meetings – all information required to initially judge
appropriateness for secondary screening was all in one place.
The Influence of RISC
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Intermediate Tier
Re-ablement
Rehabilitation
( 6 wks )
SPA
Complex
Caseload
• Personal enquiry to A3
• Professional enquiry to A3 based on nomination criteria
• Professional enquiry to Community Matron from Primary Care team
A3 L1
caseload
DN/AHP
caseload
Nominated for CCM- Assessment for
complexity completed
Professionals
ASC & Health
Public
Service Users
& Carers
Routes In – New Case in Crisis
Low Score
High Score
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PAS alertfrom CTP
list ofComplexCaseload
CTP list ofComplexCaseload
Intermediate TierDPoW
In-reach Actions:
• CCM provides coordination of discharge planning on behalf of the individual
• Contact with Acute Trust/Intermediate Care bed unit made
• Decision on visits and who needs to be involved
• Decision on need to attend MDT
• Coordination with all professionals on
• services required for discharge
In Reach – Admission Alert
Central Case Lists for IT
Notify bytelephone call to contact number
provided
NotificationReference
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Goals set by
individual (plus
carer) used to build
care plans
*Completed by the
Service User
(or carer/family)*
Goals/Wishes
Important
information
Contingency
Plans
Individual’s
commitment
Schedule
of care
Contacts
Initially
for all
level 3
cases
Kept in the home but
taken to other services
(intermediate care and
acute trust, etc.)
Integrated Care Plan“My Care, My Way”
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CCM Ongoing
Recording
Monthly
Collection &
Collation
Audit Supervision
AIOD
Performance &Outcomes
Measurement
Evidencing PreventativeInterventions
Identify blocks & Issues and inform
servicedevelopment
Activity, Interventions & Outcomes Dashboard (AIOD)
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Staff Training� Training delivered to RR and CCM team on principles of case management and to share
new models and developments to date
� Once all tools ready, delivered training for 70 staff on following:
� 3 key principles = co-ordination, personalisation, prevention & early intervention
� Case list maintenance
� Integrated Care Plans
� Outcomes recording – AIOD tool
� In-reach process and responsibilities – DPoW and Beacon
� Other services - interaction with and referral to – processes set up
� Running effective MDT meetings
� Shadowing of CMs by UHUK Nurse Practitioner and sharing of best practice in
conducting assessments
� Assistance with delivery of and coaching of CMs for 1st MDT meeting
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Lessons Learned
� Started with small project team – later realised need for a full programme management
approach
� Behavioural /cultural change was a significant issue – long established teams,
processes and practices - geography and skills had impact
� Underestimated time required to realise savings – needed watertight systems and
processes in place first – both horizontally and vertically
� Required some form of outcomes recording to make commissioning decisions and have
contracting levers
CUMULATIVE Rapid Response Complex Case Management Total Saved
Type of saving Volume Unit Cost Total Saving Volume Unit Cost Total Saving
Avoided A&E attendance 1,076 £77 £82,852 215 £77 £16,555 £99,407
Avoided emergency admission 315 £2,110 £664,650 189 £2,110 £398,790 £1,063,440
Avoided use of place of
safety/72hr stay/carer respite
22 £375 £8,250 60 £375 £22,500 £30,750
Avoided placement in
residential/nursing beds
284 £792 £224,928 62 £792 £49,104 £274,032
Avoided GP home visit 0 £104 £0 290 £104 £30,160 £30,160
Avoided multiple daily care calls 0 £16,128 £0 11 £16,128 £177,408 £177,408
Avoided single daily care call 0 £6,048 £0 3 £6,048 £18,144 £18,144
Avoided ambulance call out 0 £221 £0 144 £221 £31,824 £31,824
Prevented GP appointment 0 £96 £0 7 £96 £672 £672
DISCHARGE Avoided excess bed
days
0 £177 £0 38 £177 £6,726 £6,726
PROVIDED place of safety/72hr
stay/carer respite
38 -£375 -£14,250 25 -£375 -£9,375 -£23,625
1,735 £966,430 1,044 £742,508 £1,708,938
NE Lincolnshire outcomes for RR & Case Management teams
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One Year On…Recorded outcomes for RR and CCM teams for first full year 2011/12 reflected savings of £4.8m
Acute:
� Total of £5m taken out of unplanned care - 3 years 2010/11 thro’ 2012/13
� Achieved -0.8% vs. national average +4% unplanned care growth from 2009 to now
� In year 11/12 saw very small growth back – believe this is due to reaching community capacity. So now have 3 year planned step rise in community capacity of 250 people per year. This will assist in containing the expected growth.
� Front end A&E work successful – over 34 recorded weeks, 78% of admissions avoided (304 or 387, of which 202 were >65years). Team includes GP, RR team (health care, social care and therapist), plus lower level Social Care team provision
Social Care
� 8% below average for long term care home placements
� Further £500k savings from support at home
� 60% returned home from re-enablement with no care package, 22% with reduced care package
� Additional £750k investment in prevention
� £1.8m investment in intermediate tier
� Further percentage of reduction in readmissions from long term care homes
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One Year On…Other legacies
� HealthNumeric’s RISC and the Social Care Complex Case risk tool, both help provide
the basis for further segmentation of the population into 4 levels (including high to low
cost) with clearly defined responsibilities for these levels across the area
� North East Lincolnshire are in the 1st wave for authorisation and are the only
organisation to remain integrated – to become NEL CCG and Care Trust
� The work UHUK did in helping NEL CTP prepare for World Class Commissioning
(moving up from 55th to 5th place) has helped them diligently prepare for the
authorisation process with all documents now submitted
SPA:
• Criteria
• Hours and planned hours
• SLA/Spec
• Briefing
RR:
• Review of current provision
• Agree team - Therapists, DNs, CMs
• Consultation with staffCDT:
• Agreed team – CC, CM, GP, AC, Snr DN, MH, PN
• Appoint CC
• Develop spec
• Create toolkit
• Agree reporting
Risk stratification:
• Procurement
• Training
• Caseload – remove duplication
Erewash:It was clear from the model that we needed to focus as an integrated team on
these 4 NEW areas:
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Care Co-ordinator RoleIdentification:• Admission & discharge plus OOH
calls collation
• Manage risk list - identify high
climbers & new patients using a risk
stratification tool
• Referrals – check criteria
• Local intelligence
Casework discussion:• Attend Virtual Ward meeting with core
team
• Manage clinical meetings – ensure
others invited as required
• Present information
• Take minutes & distribute
Care Planning:
• Update records (including template)
• Record action plans
Care Delivery:
• Follow through any actions required
tests/referrals etc
• Follow through with patient/others involved to
ensure all services/care arrangements in place
• Keep everyone informed/updated
Other:
• Co-ordinate response and
build relationships
• Deal with public and local
professionals
• Ability to set up packages of
care
• Refer complex cases to MDT
• Access to hospital systems
and some GP systems
Solution Objective Key Components
Milestones & Deliverables
Delivery and implementation of Integrated Care across Erewash
To “weave together” the separate strands of integrated working
� To implement a programme management structure
� Introduce systems and processes for joint integrated working
� Bring together innovation, evidence-based thinking
Phase 3
� Implementation of risk stratification tool (allowing
for implementation period)
� Training of risk stratification tool to GPs,
Community Matrons and Care Co-ordinators
� Ongoing training, mentoring and coaching for all
staff in both referral streams – SPA/Intermediate
Care and Community Delivery
� Initial training for all staff in both referral
streams – SPA/Intermediate Care and
Community Delivery
� DCHS to implement the SPA as per
implementation plan
� Reallocate staff into new roles e.g. Care Co-
ordinator, Navigator, Rapid Responder roles
� Review Case Lists for Health and Social Care
� Continue development of assessment tools
and criterias
� Implementation of virtual working for
Community Delivery
Implementation Plan
December 2012October 2012 November 2012
Phase 4
Phase 5
� Develop Activity and Outcomes reporting tool
� Develop Integrated Care Plan (Self Care) for
individuals if needed
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"The work undertaken by UnitedHealth UK to develop a fully integrated health and social care functional model for both rapid response and complex care management has been innovative and challenging. It has included developing a model of patient stratification that incorporates a common 'definition' and recognition of the holistic needs of individuals that give rise to understanding complexity from the differing perspectives of both health and social care professionals."
Geoff Lake, Director of Integrated Commissioning, North East Lincolnshire Care Trust Plus
HSJ supp 22/3/12 Commissioning support Case study (re North East Lincolnshire):
“UnitedHealth UK’s independent and objective programme management work was crucial to the partnership’s success, given the multidisciplinary nature of the work and the fact that it had funding from the NHS and adult social care”.
Today they have a complex case management tool which integrates means testing in adult social care with identifying high resource users with long term conditions.
“It enabled us to develop a single system that brought two ideologies together,” says Mr. Lake. “We’re still adapting that to understand who the most vulnerable on the practice list are and then to concentrate resource from both parties on the same people.”
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