SYMPHONY Person-Centred Coordinated Care

Our Aim

“to dramatically improve the way in which health and social care is delivered in South

Somerset”

The Symphony Project Board

We adopt the National Voices definition of person-centred coordinated care.

We will work to achieve person-centred coordinated care by:• Supporting people to remain independent and healthy for as long as possible.• When people do need advice or support, ensuring this is easy to obtain.• Making it as easy as possible for people to access the services they need and

ensuring that we can provide individualised care to meet their needs.• Ensuring that staff across our organisations work to do the right thing for the

people they care for at the right time, in the right place, regardless of who they work for.

• Making it easier and more rewarding for staff to do their jobs.

We believe that if we do this, not only will local people receive better care but these services will be more efficient and will make best use of our staff and our money.

Chard, Crewkerne and Ilminster Federation

Other Partners (so far)• Centre for Health Economics, York University• South Somerset Together• South Somerset Association for Voluntary and Community Action• Age UK Somerset• South Somerset MIND• Yarlington Housing Group• Yeovil College• Registered Care Providers Association• South Somerset CAB• Somerset Pharmaceutical Committee• Devon & Somerset Fire & Rescue Service

Evidence-Based Approach

Establish the right environment to allow co-ordinated care to flourish (culture, leadership, systems, processes,

incentives, information systems, governance)

Build on the approach of the Independent Living Teams to develop integrated care model across primary,

community, acute, social care and wider

SUCCESS!

Key Symphony Components1. Patient-focussed data set - evidence2. Shared outcomes3. A new way of contracting and a

shared budget4. Care model

The Data-set

Overall Aims

• To identify which group(s) of patients should be the initial focus of the Symphony Project (i.e. where there would be the most benefit from an integrated approach)

• To inform the outline business case

• To develop a methodology to calculate a shared budget for that group of patients

• To provide a baseline so the impact can be tracked

The Data-Set

• Fully pseudonymised• South Somerset GP Federation (109,000 patients)• Majority of activity and cost at patient level for:

– Primary care– Community hospitals– Mental health (community and inpatient)– Acute– Social care– Continuing health care

• Age, sex, clinical conditions, ward of residence• It’s evolving

What’s not included…yet• District nursing and health visiting• Ambulance service• Podiatry• Dietetics• Community diabetes service• Rehab• Community therapies• Tissue viability• Speech and language therapies• Continence• End of life• Voluntary sector• I’m sure there are others

Approach to Analysis

• Understand current patterns of utilisation and cost

• Understand what drives these patterns

• Develop an approach to decide which group to target

Approach to Analysis

• Develop method to calculate shared budget and impact on each organisation

• Develop approach to tracking and evaluation

Basis Rationale Analytical approachFrequency of occurrence

In developing a budget, need enough people to form the “risk pool”.

People with multiple conditions are more likely to require collaborative care arrangements.

Assess how many people have particular conditions (ETG) and combinations of conditions.

Costs of care Potential savings greater the higher are the costs of care.

Summarise total costs and setting-specific costs by ETG.

Utilisation of services across settings

People who require services across diverse settings most likely to benefit from collaborative care requirements

Summarise the number and type of settings in which patients receive care by ETG.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+

Patie

nts (

%)

Age band (Years)

Morbidity (number of ETGs) by age band

0

1

2

3

4

5

6

7+

Number ofconditions

Regression variables

Age Number of conditions

Age, Number of conditions

Variation explained

3.36% 18.76% 19.30%

People with diabetes or dementia and any number of other co-morbidities

Group Number of patients

Total cost % variation in costs

predictedDiabetes 5625 £17M 36%

Dementia 1062 £13M 15%

Diabetes + dementia

6521 £28M 38%

Total cost by setting

People with diabetes or dementia and any number of other co-morbidities

Group £

GP practice 1,163,285

Prescribing 2,778,463

Inpatient 7,456,346

Outpatient 1,543,905

AE 281,422

Mental health 2,288,199

Community health 1,504,421

Social care 6,651,990

Continuing care 4,401,048

Total 28,069,078

2. Outcomes

• Central to care model and alliance contract• To be developed by patients, carers and staff• Facilitated process culminating in workshop• Care model designed to deliver them• Alliance contract tied to them

What does “good” look like?

• One-to-one interviews with patients and carers

• Event for patients and staff• What does “good” look like for:

– Patients– Carers– Staff– “The system”

3. Alliance contract

4. Care model

• Design work starts in December• Design team:

– Lead responsible for delivery: member of Project Board– Design team oversees process and makes strategic design decisions

to recommend to project board– Expert facilitation– Project support– To deliver the agreed outcomes

• Clinician and patient-led• Learn from Independent Living Teams;• Include known effective ingredients (e.g. care co-ordination,

single assessment, shared protocols)

Timescale

SeptemberOctober

NovemberDecember

January2014 February

MarchApril

Patient & carer

interviews

Patient group

decision

“What good looks like”

agreed

Initial design process

Alliance contract negotiation

Patient and staff involvement

Alliance agreement