Embed Size (px)
Citation preview
LtC Year of Care CommissioningEIS Project Leads Workshop
5th October 2015Central London
Our Declaration, My Declaration
o Taking action to make person-centred care for people with long-term conditions a reality
o Looking at what needs to change and why we need to change
o Co-produced with NHS England and Coalition for Collaborative Care and developed with health and care professionals, policy makers and people with long-term conditions
o What you can do:o Make a commitment embedding patient-
centred care in your work at www.engage.england.nhs.uk/survey/ltc-declaration
o Tell your teams about our worko Use the hashtag #A4PCC when you see
work that is relevant to person-centred care for people with LTCs
o Let us know of any events, activities or social media opportunities that we can join forces with you
#A4PCC – Action for Person-Centred Care
LTC Year of care commissioning
West Hampshire EIS
West Hampshire Clinical Commissioning Group
Kate Smith – Senior Commissioning Manager West Hampshire CCG
• WHCCG Out of Hospital Strategy;• Overview• Where are we now• Next steps• Challenges
Overview
West Hampshire Out of Hospital Model
Proactive Intervention Care navigation via 111 or Care Co-
ordinator; care in line with agreed plan Primary care urgent care centres Rapid access to consultant advice Rapid assessment clinics (including
diagnostics); Integrated Rapid response & crisis intervention services via SPA Access to community beds (step-up), home treatment and care support including night sitting. Rapid, flexible provision of care packages to meet need
End of Life – patients supported to die in place of choice
Proactive management by SCAS – enhanced paramedic role
Keeping Well: Early Intervention and Effective Care Co-ordination Pro-active risk profiling to identify high risk patients using predictive tools and the combined local
intelligence of health and social care professionals Early diagnosis and intervention Person Centred Care Planning with patients and carers as active participants defining priorities, goals,
programme implementation, coping strategies, contingency plans for crisis and outcome measures. The use of Personal Health Budgets and direct payments to enable patients greater choice, flexibility and control over their own care and treatment
Care planning to include self-care and supported self-management programmes to put the patient and their carers in control of their condition. This can include the use of assisted living technology and virtual intervention tools such as telehealthcare. Utilisation of community support and third sector services, particularly where patients are isolated and have no viable carer
Care Co-ordination by named Case Manager; Telephone access to support as needed
Care co-ordination is a holistic model, delivered by skilled health and social care practitioners in partnership with patients, carers and their GP
Admitting patients to hospital should be a last resort; with the majority of care provided in the community. Community services need to be responsive to proactively meet changing need
If admission to an acute hospital is required, patients should only remain in hospital for the acute phase of their illness, with timely transfer or discharge. Patients should be supported to return home
Supporting Recovery Strengthened Community Pull;
hospital in-reach supported by ‘Daily Alert’ information
Community beds (step-down) with early supported discharge either within or as close to a patients home as possible; ICTs able to direct use of community beds & out of hospital services
Care packages to be quickly reinstated, adapted to meet changing need or set up via pooled budget
Personal care and Welcome Home services
West Hampshire Out of Hospital Model
Eastleigh & Test Valley
ParksideBoyatt WdSt AndrewsPineview Leighside
Eastleigh Chandlers
Ford
Park & St FrancisFryern Brownhill
IICTs
GP
Prac
tices
EastleighSouthern Parishes
Romsey
Blackthorn BurseldonHedge End West End St Lukes
Alma RdAbbey Md Night-ingaleNorth- Baddesley
Andover 1
Andover 2
Avon Valley
Totton & Lyndhurst
FriarsgateSt PaulsSt Clements
GrattonStockbridgeWhitchurch
Lymington
Shepherd’s-SpringDerrydownAdelaide St Mary’s
Charlton- HillAndover
Totton TestvaleForest GateLyndhurst
Fording-bridgeRingwoodCorner-ways
New Milton
Winchester Andover Totton/Waterside
Sway/BrockenhurstChawton Wistaria &Milford
BartonN.MiltonArne-wood Twin-Oaks
Winchester City
Winchester Rural North
Winchester Rural South
B. WalthamTwyfordWickhamStokewoodOld Anchor
Winchester Rural East
AlresfordMansfieldWest Meon
Waterside
WatersideForestsideWater-front &Solent
West New Forest Eastleigh
A Community Based Approach to Integrated Care
Community Support
Integrated Care Team
GP Practice Network
Community based, primary care co-located model
Our approach: 15 Integrated Care Teams (ICTs) covering 6 Localities Teams are co-located and work with a network of practices to foster
meaningful partnerships Each Team covers a population of around 30,000 – 50,000 The core team consists of health and social care professionals
including primary care, community nurses, therapists, social workers, and Older Persons Mental Health liaison workers. Each team has a named link Consultant Geriatrician
The wider team consists of specialist services Integrated Care Teams are rooted in communities – they know and
understand their community and actively engage local voluntary organisations and support networks. ICTs provide a continuum of care based on individual need
West Hampshire Localities
Specialist Services
National Voices definition of integrated care as meaning person centred, coordinated care:“I can plan my care with people who work together to understand me and my carer (s), allow me control, and bring together services to achieve the outcomes important to me”
Supporting Recovery and Maximising Independence
Integrated Care Team
Community Beds – Core Offer
“ ERS@H is not appropriate clinically / safe”
Enhanced Recovery and Support @ Home
“Time limited support designed around an individual to support recovery and maximise independence”
At home orRecovery Clinics
Acute Trust
“Patients ONLY in Acute
Trust for minimal time required for acute phase”
Complex Needs Assessment
“Rapid assessment and diagnosis –
signposting”
Clinical Triage / SPA
Health and Wellbeing – links with 3rd Sector
Principles of Core Delivery Model: The right care will be provided at the right time and in the
right place Care will be personalised and tailored to meet individual
health and social need A recovery culture, with people supported to maximise their
independence Care will be delivered locally either at home or as close to
home as possible No patient will be admitted to a bed who could safely be
supported at home. Care at home will always be the default for care delivery
Patients will only remain in an acute hospital for the acute phase of their illness
Decisions about long term care needs will not be made in an acute setting
Care will be delivered by integrated health and social care teams that are co-located and work with a network of Practices, with access to specialist support
‘Community Pull’
I am supported to look after myself
My carers are supported
My environment is suitable for
my needs
I am able to live the full life I want
My mental health, physical
health and social care needs are addressed
I know what to do and
expect when I'm unwell
The Patient Offer 6 pillars of community support
I understand my condition I know how to manage it
and have the appropriate equipment and medication
I am confident and in control
I have set my own goals I know who to contact
when I need support
My carer understands my condition and knows who to contact when I need help
My carers needs are identified and they are supported
My carer feels confident and in control
The place I live is suitable
for my needs I have the appropriate
equipment to support me in my home
I have had the appropriate adaptations made to my home to allow me to stay in it
My community supports me
I know who and where my self-help groups are
I know which groups can help me achieve my goals
My life feels enriched by my social networks
I have an agreed plan of care that addresses my physical, mental health and social care needs
My care feels coordinated
I know who my care coordinator is, what they can do to help support me and how to contact them
I know I will receive rapid help when I need it
I know I will be helped and supported to get home as soon as I am well
Everyone involved in my care knows about my goals and care plan
For Patients and Carers: Our Patient Offer
For GPs and Community Services
Becoming more proactive in identifying people that are becoming frail and vulnerable, rather than waiting for crisis
A single point of access through which to make referrals A standard approach to care planning, including the sharing of plans, of
agreeing the content of plans and lead worker through structured whiteboard meetings
Access to a range of services to maintain people in their own homes Improved communication and joint working with a greater understanding
of each others roles Less duplication
Where are we now
Programme 1: Early Intervention and Effective Care Co-ordination
Key Work Streams Description Timescales
Integrated Care Team Development Programme
Develop the core Integrated Care Team and understanding of each others roles and responsibilities; ensure shared understanding of integrated care and embed key components of integrated working in line with the ‘What Does Good Look Like Framework’Delivery facilitated through bi-monthly ICT meetings & ICT workshops;All people 75 years and over to have a named accountable GP Bypass numbers established for Ambulance, A&E and care home staffRisk Stratification: Case management register established of patients identified at high risk of admission (minimum 2% registered adults); Same day telephone consultations established; Patients notified of accountable GP and care coordinator Personalised care plans developed and in place
Jun 2014
Sep 2014
Transformation Fund Established to support Practices in transforming the care of older people aged 75 and over and those with complex needs. Four Transformation Fund proposals to be implemented over 12 months. Enables innovative models to be tested and if successful, embedded in integrated care delivery models
Apr-15
Building Blocks to Integration (CQUINs)
Care management & care co-ordination: Develop, agree, implement modelPersonalised Care Planning: Agree a single process, documentation and way of sharing plans (including urgent and end of life care plans) via HHR Scope implementation costs and timescales for delivery Self-management and shared decision making: Development of self-management models and processes and roll-out to ICTs
Mar-15
Dec-14Jan-15Mar-15
Care Homes Strategy Development of Care Home Strategy (with Quality Team) Sep-15
Care Pathways Review and redesign of wound care, falls and continence pathways Sep-15
Programme 1: Early Intervention and Effective Care Co-ordination
Programme 2: Proactive Intervention
Key Work Streams Description Timescales
Integrated Rapid Response Service
There are currently two rapid response services provided by health (via CCTs) and social care (CRT), with different referral routes. Development of Integrated Rapid Response model accessed via a single point of access Sep-15
Community Geriatrician
To ensure greater access to consultant geriatrician advice and assessment for complex patients; recruitment to additional posts in line with agreed service specification Agree alternative models with localities where recruitment unsuccessful and timescales for delivery
Nov-14
Mar-15
Rapid Assessment Units
Review of current provision to ensure improved access to consultant advice and rapid assessment
Mar-15
End of Life Care Development of the End of Life Care Strategy and implementation plan Implementation of End of Life Incentive Scheme – to include Clinical Leadership, patient identification and after death analysis Roll-out Marie Curie project and undertake full evaluation to inform future commissioning strategy Ensure sustained provision of Andover Hospice at Home Service and full evaluation of model to inform future commissioning strategy
Jun-15Mar-15
Mar-15
Nov-14 – Mar-15
Programme 2: Proactive Intervention
Programme 3: Supporting Recovery
Key Work Streams Description Timescales
Intermediate Care and Reablement Services
Redesign of intermediate care and reablement services – enhanced support and recovery at home and universal admission criteria to community beds Consultation and phased implementation
Oct-14 – Mar-15Mar-16
Care at Home (HCC) To procure a new Care at Home Model and contractual framework. Providers to work as an integral part of ICTs who will direct resource: Develop new service specification Complete procurement framework process and award contracts New service mobilisation
Dec-13Nov-14Apr-15
Day Care To procure a new Day Care Service model
To map current provision of Day Care Centres, wound café’s, health and well-being centres and explore opportunity for co-locating services into community well-being hubs
Mar-15
Mar-15
Discharge and Community Pull
Move to a strengthened community pull model to facilitate timely discharge:Development of Trusted Assessment – development and roll out of implementation plan Sustained delivery of In-reach Co-ordinators and roll-out to MAU and T&O wards via winter resilience bids Review of social care discharge team and integration within ICTs; agree model and implementation plan with agreed timescales for delivery
Sep-14 – Mar-15Oct-14 – Mar-15Jun-15
Programme 3: Supporting Recovery
Next steps
• Outcomes dashboard• Evaluating impact - discovery interviews• ICT Peer review• Workforce development – Every Community Contact
Counts• Proactive care models – Transformation fund• Federation focus• New models of care – Vanguard – Primary Care
Access Centre• MCP provider development
Monitoring Effectiveness; Demonstrating Success
Strategic Aims Objectives Key performance indicators OUTCOMEPeople receive the right care in the right place and the right time
Maintain constant focus on long term quality of care and the achievement of outcomes for users
Reductions in permanent admissions to residential and nursing care, per 100,000 population
Reduction in non-elective emergency admissions (targeted HRGs); reduction in average LoS
Reduction in the number of excess bed days Reduction in delayed transfers of care Increased numbers of discharges across 7 days
Achieve long term quality outcomes
Ensure fairness and equality in broader context underpins every decision we make
Give service users and their families choice and control over their own outcomes
Promoting greater care co-ordination
Increase self sufficiency and independence, avoiding reliance on services wherever possible and improving overall experience
Increased numbers of people having health and care needs met closer to or within their own home
Increased use of self-directed support and use of personal health budgets
Increased numbers of people dying in their preferred place of care
Evidence of development of personalised care plans and that people are supported to determine options and are involved in setting and achieving their own goals
Increased patient satisfaction Increased GP and staff satisfaction
Ensure our services meet demand
Work collaboratively to deliver integrated care services that promote independence and recovery
Protect the sustainability of services to meet current and future demographic, financial and statutory requirements
Minimum of 65% of service users return home after a period of rehabilitation/reablement
Ensure our system is financially sustainable
Monitoring Effectiveness; Demonstrating Success
Challenges
• Evaluation, measuring impact• Engagement and relationships• System focus• Capacity and capability• New models of care……..
Care CoordinationLocal approaches
Operational January 2015, Core Staff Recruited, Patients No increasing
Health 1000• Health 1000 is a new primary care provider organisation operating a new
model of care as part of the Prime Minister’s Challenge Fund supporting people with 5 or more LTCs from BHR practices.
• It has a clinical model which includes input from BHRUT, North East London NHS Foundation Trust, Barts NHS Trust, and the social care services of the co terminus London Boroughs.
• The service exists in primary care but incorporates specialists “tailored” to individual needs.
• People consenting to take part are being de registered from their GP and registered with the Practice and receive a refreshed care plan and a tailored team (including GP, nurse, social care and consultant specialists)
• Age UK RBH is working as part of the Multidisciplinary team supporting a cohort of 500 people with multiple LTCs using the Age UK Integrated Care Model.
Project Background
In developing Health 1000, the work with potential service users and their families revealed that people have difficulties in accessing services to manage their own conditions and meet their needs due to:• Lack of information• Fragmented options“We feel helpless trying to get the best for our mum”“I just want to be able to go fishing”“The professionals don’t understand all my needs”
Age UK Integrated Care Programme
• It operates across England and brings together voluntary organisations and health and care services in local areas to provide an innovative combination of medical and non-medical support for older people with long term conditions at risk of recurring hospital admissions.
• Through the programme Age UK staff and volunteers become members of primary care led multi-disciplinary teams providing care in the local community.
• The pathfinder for the programme has been underway in Cornwall since 2012 and early results have been highly promising.
Aims of the Age UK Integrated Care Programme
• Improve the health and wellbeing outcomes for older people with long-term conditions who experience high numbers of avoidable hospital admissions.
• Deliver cost savings and help alleviate financial pressures in the local health and social care economy.
• Support and deliver transformational whole system change by demonstrating how GPs, community care, hospitals, social care and the voluntary sector can work together with the older person at the centre.
Slide:29
BHR Care Navigator Pilot
• The pilot is funded for 2 years by Redbridge, Barking and Havering CCGs and Age UK.
• The team delivering the pilot includes one Team Leader and 3 Care Navigators. In addition, we aim to recruit 10 volunteers in the first year to support patients.
• The Care Navigators are fully integrated with the Health 1000 team and take part in weekly MDT meetings.
• The pilot has started at the end of August 2015 and so far 39 Clients have had guided conversations and have started receiving support from the project.
How Does it Work?• Care Navigators carry out a person centred guided conversation
with patients which covers aspects such as personal history, living arrangements, financial situation, support received, likes and dislikes, personal interests, etc.
• Client goals are identified through the guided conversation which are then translated into a support plan.
• The emphasis of the project is to shift the clients’ focus from their health condition to pursuing their interests, becoming more engaged with their community and developing a good network of support.
• Type of support for client may include referrals to other services such as befriending, arranging outings, developing new activities, peer networks, etc.
Early Outcomes • Improving client’s wellbeing by supporting him to achieve his goal to
go fly fishing.• Supporting client to regain confidence in going out and increase
independence by assisting them to go out shopping and attend a social club at the Punjabi Centre.
• Coordinating and organising day centre attendance and carer respite.• Supporting clients and carers to access services such as Advice and
Information, Befriending Services, Re-ablement, Community Treatment Team, Care Line, Dementia Services, disabled swimming facilities, etc.
• Liaising with Health 1000 Practitioners to enable referrals for OT assessments, Podiatry Services, Counselling, Dietician support, memory assessments, hearing tests, social care assessments, etc.
Case study continued• The first patient for Health 1000 he is an amazing character
and likes to support the practice as much as he can. He lost his wife 3 years ago which sent him into a depression and felt he was losing control. His illnesses made things worst in turn having to rely on his family to support him. His son moved in to live with him.
• He has lived in his community for 20+ years and felt he was losing touch of what was around him. He was feeling isolated. He used to be head Forman on building sites and was the man to know who helped everyone in the neighbourhood. His passion was fishing but as he didn’t like eating it!
Case study• When Age UK RBH met him he was very positive about his experience
with Health 1000 and wanted to do anything he could to be more involved. This is where Fly fishing came up and the possibility of make a group led by him. We had to find out and source this which took a number of weeks but we finally contacted an organisation who could help and we arranged for to do what he loved most.
• He didn’t stop smiling the whole day he pushed himself and caught 4 trout. He was tried but happy and after a pub lunch he said this was the best day he had had since before his wife died. He is now getting ready to be the lead fisherman for Health 1000 fly fishing group.
• Patients’ son provided feedback to the patient’s GP that since using Health 1000 his father was feeling better, his medical condition had improved and he was happier and felt supported.
Based on Work in Staffordshire2011 - 2014
We wanted to answer the question:
If we are commissioning for outcomes, what outcomes do we want to achieve?
Process – Different Perspectives
• Does everyone have the same view?• We sought to test this through a series of 9 workshops
Process – Four Key Groups
Patient / Public Primary Care
Commissioners Providers1
Workshop
1 Workshop
1 Workshop
6 Workshop
Process – Four Key Groups
Patient / Public Primary Care
Commissioners Providers
Patient / Public Primary Care
Commissioners Providers
Surprisingly similar outcomesMostly quantitative
Very similar themes between the six workshops and mostly qualitative in nature
Outcomes – Patients / Public 1 of 2
• Avoid Crisis• Focus on all of the ‘individuals’ needs• Value and support Carers• Continuity of Care • Single coordinator of care (case mgt) • Proactive/Preventive planning • Improved Hospital Discharge process• Equality of Access for all (e.g. dDeaflinks) • Improve Community Services and links with third sector• Improvements in the short term/Pace of change• Improved working between all agencies
Outcomes – Patients / Public 2 of 2
• Improved Timeliness of and access to services• Improved Access to GPs (Appointments, times and services offered)• Improved quality of Dom Care provision (Care, Timing and reliability)• Improved access to information (method/location and type)• Improved Communication around pathways• Address the confidence in health and Social Care provision (media
bombardment)• Improve all urgent care services across the board• Remove confusion over WIC/MIU service provision• Improve the sharing of patient data to support the patients/Carers• Contracting Innovation (e.g. providers becomes longer term)• More support for those who can and want to self-manage
Outcomes – Health Professionals• Avoid Crisis (Reduced Acute and ambulance activity)• Improve Customer Experience • Clear/Protocols and Experience (Ease of Referral for GPs)• Improved Strategic Reporting/System Assurance• Improved Performance Management (Individual providers and whole
pathways)• Improve timeliness of and access to services (Right First Time)• Move to 24/7 service • Improved flow to reablement and Social Care Early Intervention• Quality Dom Care / Quality of Residential Care• Better Information Sharing of patient data across providers• LHE System efficiencies (E.g. Reduction in beds utilised etc..)• More Care at Home• Improved Community Diagnostics• Improved LHE Overall financial position
Next Steps
Outcomes Design of Service
How to measure success
What Metrics?What targets?Don’t forget the qualitative aspects!
Outcome based commissioningOrCommissioning for Outcomes?
Coordinated community care modelsShaping care around communities in line with needs and assets
Video
A Matched Control – Our approach Match using
• 6 x living well key LTCs• gender• age• use of services in 6months pre-guided conversation
Match group specific to each Living Well cohort memberMatch from Penwith GP registered population onlyMatched GP practice activity to retain a single match group for each member of the Living Well cohortVary age until 10 matches found max +- 5 yearsCompared 6 months pre intervention to up to 6 months post interventionFiltered out
• those without matches in the background population, and• those without 3 months post-intervention represented in the dataset
Emergency AdmissionsLiving Well Group Control Group
20.8%3.8%
Financial Impact
£1,577 per
patient p.a.
24.6%
£35 Million
Elective AdmissionsLiving Well Group Control Group
21.1%26.8%
Financial Impact
£460 per patient
p.a.
5.7% £11 Million
ED AttendancesLiving Well Group Control Group
20.8%
5.9%
Financial Impact
£21 per patient
p.a.
26.7%
£0.5 Million
All AdmissionsLiving Well Group Control Group
10.7%
31.8%
Financial Impact
£670 per
patient p.a.
21.1% £15 Million
Primary Care UsageLiving Well Group Control Group
36.6%
49.3%
Financial Impact
1.7 more practice contacts
per patient
p.a.
12.7%
ConclusionsFive Year Forward View
Closing the Care and Quality Gap
Closing the Health Gap
Closing the funding and efficiency Gap
Triple Aim (IHI)
Improved Health and Wellbeing
Improved Experience of Care and Support
Reduced cost of Care and Support
ConclusionsFive Year Forward View
Closing the Care and Quality Gap ✓
Closing the Health Gap
Closing the funding and efficiency Gap
Triple Aim (IHI)
Improved Health and Wellbeing ✓
Improved Experience of Care and Support
Reduced cost of Care and Support
ConclusionsFive Year Forward View
Closing the Care and Quality Gap ✓
Closing the Health Gap ✓
Closing the funding and efficiency Gap
Triple Aim (IHI)
Improved Health and Wellbeing ✓
Improved Experience of Care and Support ✓
Reduced cost of Care and Support
ConclusionsFive Year Forward View
Closing the Care and Quality Gap ✓
Closing the Health Gap ✓
Closing the funding and efficiency Gap ✓
Triple Aim (IHI)
Improved Health and Wellbeing ✓
Improved Experience of Care and Support ✓
Reduced cost of Care and Support ✓
