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Developing Networks of Care:
throughLong Term Conditions Year of Care Commissioning
&
Long Term Conditions Improvement Programmes
Bev MatthewsProgramme Lead for Long Term Conditions29th October 2014
2008 – Polysystems & Person Centred Care
2009 – Risk Stratification
2010 – Integrated data
2011 – LTC management, & The Year of Care
2012 – Integrated Case Management
2013 – Rapid Response & Community Treatment Teams
2014 – Complex Primary Care Practice
2015 – 5 Year Forward View
Drivers for Improvement:
5%
20%
75%
The scale of the problem and the cost:
45%
40%
15%
Multiple complex conditions
Single LTC/ at risk
Healthy / minor risk
Population segments Cost
Commissioning in silos:
• 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
• Risk stratification tool applied• LTC codes applied (18 in total - QoF)• List segmented by LTC currency (Bands B – E applied - B=2,C=3-5,D=6-
8,E=9), • Risk Score over time mapped (looking for rise in risk score in
last 6 mths – 4 of 6 show an increase) or • Rapid Riser in last 3 mths (mthly increase in risk score over
past 3 mths and overall increase of >15pts).• Kent – 80 GP practices, Band B = 2197, Band C= 3506, Band D
=261, Band E= 5 Total 6369 of 729, 275• Now driving increased engagement in risk stratification
Identifying patients:
LTC Year of Care CommissioningImplementation Guide
Over 30% of people over 75 years have multimorbidity
Population Level Commissioning for the Future:
Population Level Commissioning for the Future:
The total health and social care cost is strongly related to multimorbidity
Population Level Commissioning for the Future:
The main contributors to total health & social care cost are acute non-elective admissions
Population Level Commissioning for the Future:
People with complex health & social care needs appear to demonstrate a ‘crisis curve’
Population Level Commissioning for the Future:
More community, mental health and social care services are delivered to people following a ‘crisis’ than before the ‘crisis’
Population Level Commissioning for the Future:
Some indications that an integrated care plan changes the pattern of services delivered to people
LTC Year of Care Commissioning ModelImplementation Guide
SIMUL8 Corporation | SIMUL8.com | [email protected]
• A service and system redesign• Understanding the impact of changing service
utilization on:– Flow– Cost– Capacity/Resource
• No historic data• Different impacts on organizations, costs and
patients
Why simulation?
SIMUL8 Corporation | SIMUL8.com | [email protected]
• Use local data to test assumptions
• Ability to update and review
LTC Year of Care Simulation Model
SIMUL8 Corporation | SIMUL8.com | [email protected]
How it works:
• Patients in each “state” have– A likelihood of accessing certain types of service, including
accessing services more than once• Acute, • Community, • Mental Health, • Social Care),
• Costs associated with those services
SIMUL8 Corporation | SIMUL8.com | [email protected]
Results:
• Cost by each area of service/organisation
SIMUL8 Corporation | SIMUL8.com | [email protected]
• Costs by state per year• Average cost per patient
• Comparison with tariff
Results:
LTC Year of Care Commissioning ModelImplementation Guide
Next Chapter:RRR Clinical Audit:
• Report• Simulation Model, • How to Guide
Long Term Conditions House of Care:
• The 15 million people in England with long term conditions have the greatest needs of the population
• People living with long term conditions report that they require person centred coordinated care.
• The House of Care provides framework for this to be delivered
The House of Care: value to the personThis House supports National Voices ‘I’ statements:
My goals/outcomes e.g.• All my needs as a person were
assessed and taken into account.
Communication e.g.• I always knew who was the
main person in charge of my care.
Information e.g.• I could see my health and
care records at any time to check what was going on
Decision-making e.g.• I was as involved in
discussions and decisions about my care and treatment as I wanted to be. Care planning e.g.
• I had regular reviews of my care and treatment, and of my care plan.
Transitions e.g.• When I went to a new
service, they knew who I was, and about my own views, preferences and circumstances.
Emergencies e.g.• I had systems in place so that
I could get help at an early stage to avoid a crisis.
The House of Carein value to NHS: £1.2bn:
Avoid ambulatory care sensitive admissions though e.g. following NICE guidelines (1)
£0.8bn:Reduction of hospital admissions for common LTCs through integrated care esp frailty, comorbid (2)
£0.8-1.2bn:Reduce use of low value drugs, devices and elective procedures using commissioning analytics and clinician education (3)
£0.2-0.4bn:Empower people in supportive self-management (4)
£1-1.6bn:Shift activity to cost effective settings e.g. pharmacy minor ailments (5)
£0.4-0.6bn:Avoidance of drug errors e.g. through electronic records/e-prescribing (7)
@NHSIQ@bev_j_matthews ICASE LTC Community
LTC Year of Care Community
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