Improving health outcomes across England by providing improvement and change expertise

LTC Year of Care Commissioning Model

Lesley A Callow Delivery Support Manager

LTC Year of Care Commissioning ModelNHSIQ

Fionuala BonnarYear of Care Programme Manager

 

Launched in W/C 19th April 2012 with EOI under Dept of Health LTC QIPP workstream 

Transferred to NHS England in December 2012 to Martin Mc Shane and he is SRO as Director Domain 2

Integration with the ICSP Pioneers

22 Fast Followers

6 Early Implementer Sites

LTC Year of Care: Background

LTC Year of Care: Early Implementer Sites

Health Economy Early Implementer

Key Partners Regions

Leeds Leeds South and East CCG, Leeds West CCG, Leeds North CCG, North

Southend Southend CCG; Southend Council Midlands and East

Kent Kent County County (Social Services Dept), Kent Community Health Trust, East Kent University Hospital FT, Maidstone Foundation Trust, Darent Valley Hospitals FT, Canterbury CCG, Thanet CCG, Swale CCG, Ashford CCG, South Kent Coast CCG, West Kent CCG, Dartford and Gravesham and Swanley CCG.

South

North Staffordshire and Stoke on Trent

Stoke on Trent CCG, North Staffordshire CCG; Stoke on Trent Council; Staffordshire Joint Commissioning Unit; University Hospital of North Staffordshire; Staffordshire and Stoke on Trent Partnership Trust, North Staffordshire Combined Healthcare Trust; West Midlands Ambulance Trust

Midlands and East

West Hampshire West Hampshire CCG; Hampshire County Council; Hampshire Hospitals NHS FT; Southern Health NHS FT.

South

Barking, Havering and Redbridge

Barking and Dagenham CCG; Havering Emerging CCG; Redbridge Emerging CCG; Barking & Dagenham Council; Redbridge Council; Havering Council; NHS Outer North East London; Barking, Dagenham and Redbridge University Hospitals Trust; North East London NHS FT.

London

The House of Care

Engaged, informed

individuals & carers

Commissioning

Organisational & clinical processes

Person-centred,

coordinated care

Health & care professionals committed to partnership

working

Plan

Study

Do

Act

The House of Care

LTC Year of Care Benefits:

Improved outcomes and wellbeing:• Patients receive care that is better managed, more seamless across

different care services and more needs focused.

• Reduction in acute admissions to hospital; and shorter lengths of stay when these are required.

• Clinical professionals contribute to a more holistic service for patients by working within an integrated patient-centred care plan

Local health & Social Care economies: 

• Provide care that delivers value for money and is better managed by integrated teams.

• Incentive to improve services for patients

• Improved joint working and shared responsibility for outcomes

LTC Year of Care Currency:

• 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

RRR audit:

To support local thinking about RRR and early discharge, particularly in relation to potential for pathway changes.

To assess the appropriateness of methodology for long-term conditions (COPD, diabetes, stroke and heart failure), particularly whether there is scope to unbundle the RRR service from the Acute Provider PbR tariff.

Health and social care resource utilisation dataset Support the development of local tariffs for LTC YoC currency

Looking at longitudinal data to support the discussions/understand the impact in changing pathways

Whole Population Gives the evidence to support the currency framework Validates the framework

LTC Year of Care: Data Collections

• Stakeholder engagement and senior team ‘buy-in’ • Assessment of services to maximise the benefit of integrated care • Learn from research, eg models of care, contracting models,

weighting LTCs for local tariff• Planning for improvement in data quality and implementation of

shadow testing• Assessment of systems and processes to support LTC YoC currency• RRR clinical audit• Local analysis and collection of data to support national analysis• Local tariff development• Share learning with other health economies and national

stakeholders

LTC Year of Care: Early Implementer Sites Deliverables

• Senior team ‘buy-in’, eg NCDs• Stakeholder Engagement, eg Monitor and PbR Team• Framework for the Model and vision for future years• Simul8 Model for redesigning services• Data analysis and comparison • Programme Management and EI site support • Resolution of barriers, eg Information Governance

LTC Year of Care: National Support Team Deliverables

GPs

Community &Social CareAssessment

Integrated Care Team

GP datasets

Acute datasets

Mental Health

datasets

KMHIS2

GPs

CommunityTrust1

Acute Trust1

Mental HealthTrust1

Social Care

Independent sector& voluntary

PHE3

NHSIQ

A) Referral B) Selectingpatient cohort & risk stratification

C) Sharing patient cohort

(patient register)

D) Collecting data/financial

monitoring

E) Nationalreporting

Person IDReferral reason

Person IDClient, Clinical & QOF

Demographic

Pseudo. Person ID only(i.e. single data item shared)

Pseudo. Person IDClient, Clinical & QOF

DemographicCosts

Pseudonymised Person IDClient, Clinical & QOF

DemographicCosts

Early Implementer team – LTC Year of Care programmeInformation Governance

May include national datasets(CMDS, MHMDS, CIDS, QOF)

May include national datasets(CMDS, MHMDS, CIDS, QOF)

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step

desc

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Maj

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Non-NHS organisations

1 Includes both Foundation and non-Foundation Trusts2 Kent and Medway Health Informatics Service (Interim Safe Haven)3 PHE – Public Health England safe haven

Population List

KMHIS2P

P

P

P

P

P

P

P

P

P

PP

Costing dataset – A, B, C, D & EShadow testing – A, B, C & D

Whole population dataset – D & E

EARLY FINDINGS

Starting with the models for the most complex individuals with multi morbidity

5%

20%

75%

45%

40%

15%

Multiple complex conditions

Single LTC/ at risk

Healthy / minor risk

Population segments Cost

Relationship between number of long-term conditions and cost

Distribution of cost between Providers

Provider type £ %Acute £7,827 67.3%Community £1,083 9.3%Mental Health £1,028 8.8%Social Care £1,690 14.5%Total £11,628  

Risk stratification versus no. of LTCs – do they select the same patients?

Do Integrated Care teams change service delivery?

RRR audit – are some patients in hospital when they need not be?

What happens to patients assessed as having an RRR need?

Percentage of admission length for RRR phase

Implementing Year of Care programme in Kent

Dr Abraham P GeorgeConsultant in Public Health

Lead for Kent YOC programme

The journey so far

• Profile of Kent• Background and work before YOC• Governance of programme• RRR audit• Data sharing arrangements• Costing analysis• Plan for shadow testing• Our vision for integrated intelligence

Profile of Kent

• 1.5 million popn• 1 County Council, 7

CCGs, 12 districts, 4 acute trusts, 1 community health trust, mental health trust, >200 practices

• Governance of commissioning at multiple levels

• Different integrated models of care

Background to YOC

• Whole population profiling using risk stratification

• Impact of multiple morbidities on service utilisation - ‘Crisis curve’

• Modelling how benefits of integrated care could be realised

• www.kmpho.nhs.uk/jsna

Governance of programme

• All providers and commissioners involved• 2/7 CCGs are the sponsor orgns• KCC Public Health manages programme on behalf of

whole county• Implementation at sub Kent level – NK EK & WK• East Kent Federation group of CCGs first to take part

and now finalising shadow testing arrangements• Ensure all stakeholders are involved – commissioner,

finance, informatics, etc.• Use of risk stratification for costing analysis and

shadow testing

RRR audit – key results

• > 80 EK patients followed up over 3 months in• Short stay admissions excluded• >80% had morbidity• Average LOS and average length of RRR phase

were much higher than the other audit sites • Stroke patients contributed much of the bed days

– if excluded LOS would have been reduced by half   Kent BHR Leeds Stoke

  All conditions Excluding stroke

Average length of stay (days)

19.72 13.93 5.62 6.71 4.46

Average length RRR phase (days)

6.28 3.29 0.19 3.23 0.69

Data sharing arrangements

• Strong historical relationship between KMPHO and intelligence teams

• Local data warehouse containing hospital, community health data

• Social care data obtained directly from provider• Whole Kent population risk stratified using local tool • Datasets were de-identified at source & and

pseudonymised using same encryption method and key• Public Health linked data sets - ‘hub and spoke’ before

sending to national team for analysis

‘Whole population person level linked datasets’• Cannot be re-identified

• Whole population person level linked datasets containing 4 years of activity sent to national team

• Cohort of 1650 (of high intensive users) selected for detailed analysis in 13-14

• Report produced which provided us with evidence for indicative tariff

• Data used to develop currency and selection criteria

Costing analysis

East Kent – total cost (reference or unit) for patient cohort (552 patients)Patient selection date = (May 2012)

Crude tariffs and trends

East Kent – total cost for patient cohort (552 patients)

  2012_13 Trend

  cost % cost %

Acute £6,595 56.2% £4,671 43.7%

Community £1,361 11.6% £1,323 12.4%

Mental Health £1,535 13.1% £1,791 16.8%

Social Care £2,170 18.5% £2,891 27.1%

Total £11,743  £10,676 

Crude tariffs and trends

Selecting shadow currencies

Currency No LTCs New CountsB 2 1042C 3 822C 4 449C 5 197D 6 80D 7 31D 8 5E 9 1

E 10 1

Selecting YOC cohort (using current whole popn dashboard)

• Risk stratification tool applied• GP practice and CCG identified• Checked to ensure GP data is active

(ie. each practice has submitted data within the last 3 months)

• Risk stratification popn profile selected• YoC currency (using QOF LTC codes)

is then applied which outlines the following:

– Under 18s excluded & Patients with 1 LTC notionally excluded,

– List segmented by LTC currency • Risk Score over time mapped (looking

for rise in risk score in last 6 mths or rapid riser in last 3 mths (mthly increase in risk score over past 3 mths and overall increase of >15pts)

• Agree a tariff for each of the currency categories- finance subgroup to agree costing data.

• Track the activity and cost over the next 12mths – informatics group.

• Identify data issues- definitions and gaps• Increase engagement of system and link to

existing initiatives• Evaluate information – dashboard. • Communication

Next steps

To deliver the evidence for Integrated Commissioning

Building on the Kent approach to Integrated Intelligence

Primary Care

Urgent Care OOH Care

Secondary Care

Adult Social Care

3rd SectorMental Health

Community Health

Kent are collecting activity and actual cost data from all of the above using a cross system pseudonymisation tool. Data pseudonymised/anonymised at source and linked and analysed by Public Health. MONITOR are currently developing guidance on how to develop a person level linked data sets, using Kent’s approach as a case example of best practice.

•

• We have developed a systematized method for selecting multi – morbidity people at risk and suitable to be included in the Year of Care approach

• The selection includes a subjective consent/opt in to facilitate patient choice and clinician intelligence at point of service delivery.

• It builds on the whole population data set analysis due to be published by the Year of Care team and distributed nationally at the end of April.

• This focus on the integrated intelligence by commissioners enables best practice to flourish and identifies areas for improvement within different provider models of integrated care.

• Implementing in Kent across the 3 systems at pace and scale. East Kent leading the way and building consensus across the other systems.

• Next steps include agreeing an indicative tariff for year of Care to shadow test in 14/15 – we have sign off in principle to the approach.

• We have agreed the metrics to develop a dashboard which systematically reports the results/outcomes at both system and patient level, using existing metrics and data collection. This will be used to jointly measure the impact of YoC on both the individual and the system.

 Identify cross-system opportunities and barriers to 

change 

 Collect the data  with the support of the system to  challenge status 

quo.

Identify opportunity for integrated  

incentives/penalties  across  provider organisations.

Commission across the system  to incentivise the  

outcomes  desired. 

Commissioners and providers jointly measure impact on individuals and cost 

of system

@NHSIQ

iCASE - http://www.icase.org.uk/pg/groups/88229/

lesley.callow@NHSIQ.nhs.uk

Abraham.george@kent.gov.uk

Fionuala.Bonnar@kent.gov.uk 

Improving health outcomes across England

by providing improvement and change expertise.