Enhancing care by Sharing Data and Information

Abraham George, Consultant in Public Health/Assistant Director of Public Health, Kent County Council

Jochen Worsley, Head of Long Term Conditions, East Kent Federation of CCGs

Bruce Pollington, Deputy Medical Director, Kent Community Health Trust/Chief Clinical Information Officer

at Kent Integration Pioneer

5%

20%

75%

The scale of the problem and the cost

45%

40%

15%

Multiple complex conditions

Single LTC/ at risk

Healthy / minor risk

Population segments Cost

Commissioning in silos

• All PbR (except YoC or

package currencies)

Acute Community Mental Health Social Care Voluntary/ Independent

Primary care

Primary care prescribing

NHS England as commissioner

• Non-PbR block contract

• PbR excl drugs• Crit. Care

Personal healthcare

budget

Specialised MH Services

Means-tested

services (incl. residential)

Within currency

Rehabilitation palliative & end of life

Maternity pathway

• Reablement• Adult Services

PbR MH clusters

Children’s services

GP services

Include if possible

Residential continuing care

(Include if possible)

Include if possible

How we created our Year of Care currency

• Risk stratification tool applied• LTC codes applied (18 in total - QoF)• List segmented by LTC currency (Bands B – E applied -

B=2,C=3-5,D=6-8,E=9), • Risk Score over time mapped (looking for rise in risk

score in last 6 mths – 4 of 6 show an increase) or • Rapid Riser in last 3 mths (mthly increase in risk score

over past 3 mths and overall increase of >15pts).• Kent – 80 GP practices, Band B = 2197, Band C= 3506,

Band D =261, Band E= 5 Total 6369 of 729, 275• Now driving increased engagement in risk stratification

Identifying patients suitable for YoC

Issues highlightedGap Identified by Date identified Action

No standard definitions for Integrated Care service across system

EK PG Jan 2014 Flag to WK and link to Integrated Care plan work

No method to share care plans once MDT completed. (Not even seen by GPs)

EK Project Group Feb 2014 Flag to SRO

Not all practices submitting data to HISBi

EK PG WK PG

April 2014 May 2014

Flag to SROOngoing

PLICS and RiO system in KMPT not flowing data correctly

KMPT when requested to submit first data submission

June 2014 Resolved by KMPT

No standard definition for integrated care within KCHT

Impact identified by Programme on YoC ability to assess impact of ITC services V’s WP

July 2014 PM worked with KCHT to standardise definition. Recording process agreed Sept 2014

Variable in recording practice of GP codes in Non –NHS data

Programme when we introduced “black box” solution

Sept 2014 Highlighted to organisations. With 3rd sector provided list to facilitate update.

The Year of Care dashboard has so far presented 4 months of activity and costs worth £57 million from 7 different provider organisations. Of this £4 million (7% of total spend) represents the proportionate costs for the YOC cohort (0.3% of total population).

YoC & the wider context• Shift from service orientated Integrated Care as

the definition to Patient focused Integrated Care Plan (ICP).

• The YoC Cohort identified in primary care for ICP• Changing behaviour to meeting patients needs

and wishes and not the services ability to deliver. • Plans shared system wide using the developing

Care Plan Management system • Developed with and visible to the patients. • Their wishes, their plan.

“Year of Care is a vital component of Kent’s Integration Pioneer Programme – with findings being used to underpin Kent’s Better Care Fund” Jo Frazer – Kent Pioneer Programme Manager

- “If this works that’s my job done”- -CCG Head of Finance

“This is the first group I have been part of that has moved so far so fast”-AD Finance Provider

“The intelligence from YOC is both informing our thinking on a more progressive contracting approach incentivising real service integration”- Hazel Carpenter, Accountable Officer CCG

“Kent have been successful in linking their transformation of services with commissioning through the LTC Year of Care programme which will make that step towards individualised care for people with complex needs.” Beverley Matthews, LTC Programme Lead, NHSIQ

“The year of care programme has been a great enabler in helping us focus upon and design a holistic ‘health and social care’ model around individual clients rather than individual disease pathways in a value added, integrated manner.”- Sanjay Singh Chief GP Commissioner West Kent CCG