integrating predictive modelling into a whole system approach · integrating . predictive modelling...
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Virtual Wards and the
NHS Devon/NEW Devon CCG Experience
Integrating Predictive Modelling into a Whole System approach
Todd Chenore Clinical Informatics NEW Devon CCG
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Virtual Wards
Virtual Ward = P redic tive Modelling + Multi-dis c iplinary C as e-Management
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Complex Care Teams
Developed under DH POPPS Project - started October
2008 in North Devon
23 to cover NHS Devon pop. c770,000 (now c1.2 million)
Case Management core to proposed function
Integrated Health and Social Care Team
Common Geographical coverage and base
Linked to specified GP Practices (104 in total, now 161)
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Predictive modelling in Devon • Started with PARR and PARR++
• Implemented CPM in house for 2008/09 start of virtual ward pilot
• Built DPM in house for 2010/11 at very low relative cost
• Incorporated local datasets like ambulance, OOH, registration duration (deprivation, social care, etc.)
• Improved predictive power
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Number (%) patients in ‘at risk’ group predicted by the model who had an emergency admission within 12
months
‘At risk’ sub-group Combined Predictive Model (CPM)
Devon Predictive Model (DPM)
200 top-ranked patients (0·03% of registered population) 143/200 (71.5%) 173/200 (86.5%)
1000 top-ranked patients (0·13% of registered population) 605/1000 (60.5%) 733/1000 (73.3%)
3800 top-ranked patients (0·5% of registered population) 1843/3800 (48.5%) 2241/3800 (59.0%)
7000 top-ranked patients (0·92% of registered population) 2639/7000 (37.7%) 3708/7000 (53.0%)
16000 top-ranked patients (2·1% of registered population) 4896/16000 (30.6%) 6877/16000 (43.0%)
From Chenore T. et al 2013
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Devon-Wide Roll-out
Identified as QIPP plan for Urgent Care Devon-wide
Aim to integrate into CCTs
Roll-out commenced 2010/11
Stage 1- Establish (2010/11) Sign up to Devon Predictive Model
Year 1 CQUIN LES Funded
Payment to practices by volume (to limit)
Identify target patients and assign a case-manager (Read
Code)
Produce Out of Hours Special Message- active on DDOC
Adastra
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Devon-Wide Roll-out Stage 2 - Exert Control on high-risk Group (2011/12)
Sign up to Devon Predictive Model
Year 2 CQUIN LES Funded
Payment to practices by % Bed-state (of bed number limit)
Full payment- 85% High /Very High Risk and 80% Occupancy over the
year
Identify target patients and assign a case-manager (Read Code)
Produce Out of Hours Special Message- active on DDOC Adastra
Devon P redic tive Model 85%
Direc t R eferral 15%
3-4 Months Input LTC S elf-Management, E duc ation, S oc ial etc (75-80%)
P rolonged Admis s ion 12-18 months (20-25%)
Virtual Ward
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Devon-Wide Roll-out
Stage 3 - Maximise Impact & Responsiveness (2012/13) Year 3 CQUIN LES Funded
Payment to practices by % Bed-state (of bed number limit) and Top 0.5%
percentage
Ensure named Lead GP in each Practice
Monthly Bed-state meetings
Share DPM results access with CCT Team
Ensure Project Support Role in place from Locality Commissioning Team
Embed and make routine part of work and roles
Cope with changes in CCG and membership
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Next Stages
Stage 4 - Upstream targeting Evolve Model and additional functionality in the Virtual Wards to
identify those at point of take-off (Popcorn Theory)
Gaps in care
Avoidable admissions (ACS conditions)
Threshold models and those not appropriate for the service
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