Serving the North West London Cluster

Integrated Care in North West London Innovation in care for older people and people with long term conditions Daniel Elkeles Director of Strategy NHS NW London February 2012

Serving the North West London Cluster

Aligned Incentives through an innovative financial model

Joint Governance IMB with a shared performance and evaluation

framework

Patient, user and carer engagement and involvement

1

2

4

We have focussed on overcoming the 5 major barriers to delivering integrated care in the NHS

Information sharing to access and analyse data in a timely fashion

3

Organisation and culture development

5

Serving the North West London Cluster

Serving the North West London Cluster

Local Multi-Disciplinary Groups… …working in a Multi-Disciplinary System

Patient registry

Risk stratification

Clinical protocols & care packages

Case conference

Performance review

Care plans

Care delivery

Improve the quality of patient care for patients with diabetes and the elderly

Group

Mental Health

Specialist

Sub-Group

Social care Specialist

Acute Specialist

The NWL Integrated Care Pilot

Community matron

Practice

Social care

worker

District nurse

Community Mental Health

Practice nurse

GP

1

2

3

4

5

6

7

What are we trying to achieve in NWL?

1) Improve patient outcomes and experience through collaboration and coordination care across providers (4 hospitals, 3 community providers, 93 GP practices, 5 social care organisations) with shared clinical practices and information

2) Over 5 years decrease hospital usage including emergency admissions by 30% and nursing home admissions by 10% for diabetics and frail elderly through better more proactive care

3) Reduce the cost of care for these groups by 24% over 5 years

SOURCE: NWL ICP Operations Team

Serving the North West London Cluster

Serving the North West London Cluster

3

A large number of providers taking part in this pilot

Ealing CCG Great West CCG (Hounslow) West London CCG (K&C) Westminster CCG Hammersmith and Fulham CCG

Serving the North West London Cluster

Serving the North West London Cluster

Over the last three months, the ICP partners have organised themselves into 10 multi-disciplinary groups (MDGs) that reach over 550K patients

Acton ▪ Practices: 12 ▪ Diabetes: 1,551 ▪ Elderly: 2,845 ▪ Total patients: 54,917

Chiswick ▪ Practices: 9 ▪ Diabetes: 1,015 ▪ Elderly: 2,218 ▪ Total patients: 41,630

H&F North Central ▪ Practices: 9 ▪ Diabetes: 2,134 ▪ Elderly: 2,528 ▪ Total patients: 72,486

H&F Central ▪ Practices: 5 ▪ Diabetes: 1,113 ▪ Elderly: 1,790 ▪ Total patients: 39,908

H&F South Fulham ▪ Practices: 6 ▪ Diabetes: 688 ▪ Elderly: 1,700 ▪ Total patients: 38,302

K&C South ▪ Practices: 14 ▪ Diabetes: 1,667 ▪ Elderly: 3,635 ▪ Total patients: 73,492

Victoria ▪ Practices: 8 ▪ Diabetes: 1,225 ▪ Elderly: 2,618 ▪ Total patients: 47,674

CLH ▪ Practices: 13 ▪ Diabetes: 2,723 ▪ Elderly: 3,420 ▪ Total patients: 63,636

K&C North ▪ Practices: 17 ▪ Diabetes: 2,109 ▪ Elderly: 3,407 ▪ Total patients: 74,370

X

SOURCE: NWL ICP Operations Team

H&F Small Practices ▪ Practices: 11 ▪ Diabetes: 1221 ▪ Elderly: 1325 ▪ Total patients: 37,951

Serving the North West London Cluster

Serving the North West London Cluster

5

Reduction in emergency admissions

Reduction in A&E attendances

Total reduction in emergency care

Unit of measurement across pilot

▪ Avoid 7 admissions per ~2,000 patients

▪ Avoid 28 admissions per ~8,000 patients

▪ Avoid 1,753 admissions across pilot of 506,000 population

▪ Avoid 2,080 admissions across catchment of 600,000 population

▪ Avoid 15 attendances per ~2,000 patients

▪ Avoid 59 attendances per ~8,000 patients

▪ Avoid 3,700 attendances across pilot of 506,000 population

▪ Avoid 4,390 attendance across catchment of 600,000 population

▪ Saving of £50,000 from emergency admissions and £1,250 from A&E

▪ Saving of £200,000 from emergency admissions and £5,000 from A&E

▪ Saving of £12.3m from emergency admissions and £0.2m from A&E

▪ Saving of £14.6m from emergency admissions and £0.4m from A&E

A simple way of describing the ambition

GP Practice Pilot Catchment

Serving the North West London Cluster

Serving the North West London Cluster

Emergency admissions April 2011 - September 2011 SLA base line activity 2011/12 5,561 Actual emergency admissions 5,040 Difference 521

Compared to April 2010 - September 2010 Emergency admissions across NWL -1% Emergency admissions in ICP cohort -4%

How are we doing so far? Very preliminary data

Serving the North West London Cluster

Serving the North West London Cluster

7

Joint Governance - We created a virtual organisation to run the pilot

Serving the North West London Cluster

Serving the North West London Cluster

We set out clearly the responsibilities of each service provider in the ICP

▪ Support MDGs in creating initial care plans for all diabetic patients and 50% of patients aged 75 and over (e.g., by providing seconded nurses to the MDG)

▪ Modify care plans with patients’ GPs as needed

▪ Discuss MDG performance, identify opportunities for improvement, and allocate out-of-hospital investment

▪ Identify best practice across MDGs

▪ Complete “actions” (referrals) and regularly monitor activity

▪ Collaborate with MDG partners on day-to-day basis (e.g., direct phone call to GP upon A&E attendance)

▪ Use the ICP IT tool to see range of patient data and history across multiple settings

▪ Identify and prepare patient cases for discussion (e.g., inpatients, social service users with health issues, etc.)

▪ Give specialist input on patient cases brought by other participants

▪ Be the expert for the MDG on the full range of available services and resources

▪ Follow-up on questions and actions generated through the case conference

Change how care is delivered Review performance & identify improvement

Actively participate at case conferences Support and take part in care planning

▪ Identify system gaps and opportunities

Serving the North West London Cluster

Serving the North West London Cluster

9

Aligning financial incentives – Funds flow from the Commissioner directly for guaranteed payments funded recurrently without taking from providers up front

Funding flows (2011/12)

Commissioner

Integrated Management Board allocates funding

Does the IC pilot deliver

improvements?

No Yes

Providers paid for activity using existing contracts – PbR for acute and block

for MH / Community

Infrastructure / IT

Commissioner Balance

x/2

SOURCE: Integrated Care Project Steering Group

x/2

QIPP saving

MDG Resource

70% marginal rate for emergency activity over 08/09 baseline held by SHA Readmissions top slide held by PCTs

Serving the North West London Cluster

Serving the North West London Cluster

The costs of running the pilot are £3.4m

Estimated cost, £ ‘000

1. Commissioners retained £1.2m for other work streams 2. Includes non-recurring set-up costs 3. Resource envelope available for Care Planning, Case Conference and Performance Reviews

Infrastructure2 1,800

Commissioner Retained 1,200

Total Funding 5,500

MDG Out of Hospital3 2,500

22% OOH

8% Performance reviews

18%

Case conference

51% Care planning

SOURCE: NWL ICP Operations Team

Full year cost for MDGs in the pilot will need to

increase to £2.8m

Serving the North West London Cluster

Serving the North West London Cluster

11

Patient Risk Stratification

Information - We put in place an IT solution that enables providers to work together

Care plan

Action 2

Action 3

Action 1

Plan care for patients, share these plans across settings, and monitor progress This helps better coordinate care

Identify high risk patients using population segmentation and risk stratification This enables proactive care to be planned

Track and evaluate the performance of GP’s surgeries and Multi-Disciplinary Groups This helps spread best practice in patient care

Action: Review by falls service

Action status: Completed

1 Integrated Patient Care Planning

Performance Evaluation

Patient records: GP Hospital Community

View patient medical information from multiple settings This enable integrated care to be provided

Patient Medical Information Sharing

2

3 4

Serving the North West London Cluster

Serving the North West London Cluster

Things we learnt on route…

• We are doing this because we want to improve patient care and make professional’s jobs better

• Be able to explain the concept simply and agree a single performance metric

• Identify patient cohorts which aligned to NWL PCTs clinical case for change

• Build a ‘bolt on’ to the existing NHS infrastructure and rules

• Don’t try and redesign the NHS financial payment mechanisms

• Don’t create a new organisation

• Don’t challenge existing or emergent NHS policy

• Take the minimum of funding out of providers up-front

• Invest sufficient resource to set up the pilot and deliver operationally on the ground the new ways of working

Serving the North West London Cluster

Serving the North West London Cluster

13

What’s next for integrated care in North West London?

▪ Enhance integration with local authorities and other providers

▪ Continue to develop and enhance the IT tool ▪ Conduct robust evaluation at the end of the pilot year to

understand impact ▪ Scale up within North West London

– Additional +10 practices in INWL already added, including Chelsea Pensioners

– Roll out across more Pathways in North west London – Cardiology and Respiratory

– Use methodology to redesign Mental Health provision

– Replicate in Outer North West London. Aim to have 200 practices taking part by October 2012

• Fit for the future – Work on governance structures post April 2013

– Consider new ways of funding through ‘year of care tariffs’

– Link to the development of CCGs and Out of Hospital Care strategy

SOURCE: NWL ICP Operations Team

Serving the North West London Cluster

Serving the North West London Cluster

14

Many CCG’s are thinking about organising practices in some sort of “network”, which can have different roles… Practice “Networks” can have dual roles

▪ Using the network to commission care locally that is tailored to local population needs e.g., additional elderly care needed different nursing system

▪ Using network to make sure local needs are taken into account in cross-borough commissioning

▪ Using network to ‘peer review’ referrals made by practices

▪ Your practice works with other practices in multi-disciplinary teams to enable specialist care to be provided at local level – ICP

▪ Your practice provides a service on behalf of other practices – diabetic foot service

▪ Consolidating resources in the community for your patients to readily access e.g., a hub for radiology equipment

For example….

As Providers 1

As Commissioners 2

2 JO

Serving the North West London Cluster

Serving the North West London Cluster

Across NWL, CCGs are organising their practices as providers as well as commissioners …

2 Seen as provider?

8 Hillingdon “Practice networks”

Yes

7 Ealing “Practice networks”

No

6 Hounslow “Mentoring cells”

No

5 H&F “Practice networks”

Yes

4 West London “Learning sets”

No

3 Central London Yes

2 Brent “Localities” Yes

1 Harrow “Peer

groups” Yes

JO

Serving the North West London Cluster

Serving the North West London Cluster

We have previously discussed that a significant amount of care will be delivered by GPs in future

Community hospital GP practice Home

Planned care

Unscheduled care

Long term conditions

Mental Health

▪ Complex procedure (low ASA elective surgery)

▪ MRI

▪ Plain radiography ▪ Ultrasound

▪ Close walk in centre ▪ Active diversion to

practice

▪ Telehealth

▪ Emergency assessments

▪ Minor surgery

Hub (e.g., health centre)

2

JO

Serving the North West London Cluster

Serving the North West London Cluster

17

How else could we work together? Deep Integration

Some integration

“Tier 1” e.g., Individual practices

“Tier 2” e.g., special interest

Illustrative - Complexity of OOH care

“Tier 3” e.g., MDG care

“Tier 4” e.g., UCCs

“Tier 5”

▪ Shared diagnostics ▪ OP appointments

▪ Urgent care access

▪ MDG team meetings ▪ Co-ordination of CHS services

e.g., District Nurses

▪ Inter-practice referral ▪ GPSI referrals

▪ Core primary care provision

What networks could provide…

2

TOM

Serving the North West London Cluster

Serving the North West London Cluster

What does a Multi-Disciplinary Group do?

1 Icons are illustrative only: any number of other professionals may be involved in a patient’s care, a case conference or performance review

Risk stratification 2

2

Shared clinical protocols 3

All providers in the MDG agree to provide high quality care as laid out in the Pilot’s recommended pathways and protocols

3

Community pharmacist

Practice nurse

Social care worker

District nurse

GP

Community Mental Health

Care delivery1 5

Patients receive care from a range of providers across settings, with primary care playing the crucial co-ordinating role and every body using the ICP IT tool to coordinate delivery of care

5

Performance review 7 The MDG meets regularly

to review its performance and decide how it can improve its ways of working to meet the Pilot goals

7

Case conference 6

A small number of the most complex patients will be discussed at a multi-disciplinary case conference, to help plan and coordinate care

6

Patient registry 1

Each MDG holds a register of all patients who are over the age of 75 and/or who have diabetes

1

Each patient is then given an individual integrated care plan that varies according to risk and need

4

Care planning 4

The MDG uses the ICP information tool to stratify these patients by risk of emergency admission

Serving the North West London Cluster

Serving the North West London Cluster

Why clinicians enjoy the being part of an MDT

SOURCE: NWL ICP Informatics group

▪ Improved awareness of available local services e.g. Falls service

▪ Increased awareness of the scope of other professionals’ roles and abilities, e.g. role of community matrons

▪ Shared learning about a variety of conditions, drugs and services e.g. the impact of needle length on insulin effect

▪ Highlighted areas that may need further attention, in individual patients and the overall population, e.g. the need for formal cognitive assessments in many of the elderly

▪ Valuable discussions involving all disciplines, taking a holistic view e.g. complicated diabetics with psychiatric co-morbidity & heavy drug burden

▪ Professional support, e.g. reassurance that there is no more that can be done, or alternatively, suggestions for investigations and management in complicated case

▪ Increased Coordination and collaboration with Social care, only forum where Health and social care specialists meet regularly to discuss coordinated health and well-being actions

▪ Reduction in inappropriate Outpatient referrals, through improved communication and focused care planning, inappropriate referrals should be reduced

Serving the North West London Cluster

Serving the North West London Cluster

20

What is required to build a successful Integrated Care virtual organisation ▪ Establish leadership coalition– Pathfinder leads, PCT Cluster, Hospital CE(s), Community

Health Service CE/MD, Local Authority CE/DASS ▪ Crucial to ensure buy in to vision and appetite to make #1 agenda item

Leadership

Joint governance

Clinical pathways and MDG mechanics

Financial

MDG formation, application and development

Information

Organisational development

▪ Establish Integrated Management Board with executive level leadership (CE/MD level) for participating organisations including terms of reference, voting rights

▪ Establish committee structure (e.g., pathways, info, finance, etc, co-chairs and members)

▪ Select pathway, informed by clinical evidence, best practice and local needs ▪ Establish clinical working group with leading clinicians (ie heads of relevant department in

hospital, leading GPs and community health leaders) ▪ Agree risk stratification and care package including resourcing envelope ▪ Agree key metrics for monitoring ▪ Define mechanics for multi-disciplinary working (i.e., balance time needed from specialists) ▪ Profile health economy with patient level data on activity and cost ▪ Model savings from interventions and cost of care coordination and care packages ▪ Establish scale up impact based on population in pilot, pathways in pilot and timeline ▪ Agree incentive mechanism and implication for all providers ▪ Agree how upfront investment is used to fund additional activity and operational team

▪ Establish organisation team ▪ Train frontline users on use of information tool ▪ Continue to reinforce ‘new ways of working’ via team events

▪ Identify local clinical leaders, supporting them to build clinical coalition leading to MDGs ▪ Agree on resource plan principles, content and peer-review process ▪ Define local MDG operating and financial model, and complete resource plan submissions ▪ Begin holding MDG meetings – and for into a true team ▪ Build technical requirements for sharing data, care planning, risk strat and performance ▪ Evaluate existing IT solutions, and determine scope for required bespoke IT development ▪ Design a usable ‘front-end’ clinical portal with regular interaction with clinicians ▪ Build ‘back-end’ datawarehouse by integrating all required data sets ▪ Review IG requirements and build into security rules ▪ Complete legal data sharing agreements

Serving the North West London Cluster

Serving the North West London Cluster

Each MDG must go through an intensive multi-step ‘mobilisation stage’

Formation and governance Data extraction Care planning

design & set-up Care planning roll-out

Clarify governance

Set-up & train users [GPs]

Set-up & train users [MDG]

Customise IT tool

Sign-up Authorise data extraction

Sign-off templates

Plan rate of activity

Approve resource plan

Complete data extraction

Map services

Organise support

Start care planning

Invite patients

Risk-stratify patients

Establish baseline

SOURCE: NWL ICP Operations Team