Working with the people of Camdento achieve the best health for all

A view from Across the Pond

Dorothy Blundell, Chief Officer & Charlotte Mullins, Director of Sustainable Insights

Away from the past to a sustainable future?

A National Challenge…… A Local Response

From Clinical Commissioning to Accountable Care via Population Health Management & Integration

Time after Time* — Health Policy Implications of a Three-Generation Case Study (*Sayer and Lee, NEJM Oct 2014)

Three key messages

• Reorganize care aroundachieving value forpatients – and that wehave to do it in morethoughtful and strategicways

• Plan and deliver onwider system than justtraditional healthboundaries

• Think about the longerterm investments

Strategic Intent: clinically led, innovative service re-design focused on an integrated model of care, planned and co-ordinated around the needs of patients and families.

Within Camden there are many influencing factors that impact on the health of our population.

Understanding our population health: a managed approach

Our response: An integrated system underpinned Population Health Management Tools

Source: SUS, Disease Register Flag

Key Messages

• Data available to health planners is available in aggregate

form or shared by patients with individual clinicians.

• Our Population Health Management toolset describes

service utilisation as a proxy for health needs of the local

population by developing groupings based on similar health

needs that can influence pathway redesign.

• This helped bridge the gap between aggregate and patient

level information to drive down variation in the quality of

care and costs, while improving outcomes.

• The most complex segment (most right) comprises of only

1.21% of the population for 13% of overall spend.

Benefit to the patient:

Increased time spent at home

72% of patients spent the same amount or more time at home following MDT case management.

Benefit to the Provider:

Fewer emergency beddays

An 18% reduction in emergency beddays for these patients. This extra capacity can be used to treat elective patients who actually need to be in hospital.

Benefit to the CCG:

Secondary care savings

An estimated £560k has been realised in secondary care savings since the MDT began.

A&E average monthly saving 2014 is

£1140

Emergency admissions average monthly

saving 2014 is £25,770

Value and the

MDT

Putting the information to work: value of the health and social care MDT approach

Sayer-NEJM Catalyst 2016

Impact: How has the outcome landscape changed?

2011/122014/15

Source: NHS Right Care, CCG Spend and Outcome tool

Impact: Patient experience measures

A wide range of patient experienceoutcome measures are monitored inthe toolset.

From our work, it is clear thatexperience most patients are directlyaffected by is their experience ofprimary care where most healthcarecontacts take place

The data taken from the latest GPsurvey shows most practices inCamden meeting or exceedingEngland’s performance.

Population Health Management Planning

Ambulatory Care Sensitive Conditions – Potential Savings

Over the last three years the cost to Camden CCG for admissionsrelating to Ambulatory Care Sensitive (ACS) conditions was £55.8million.

The patients that were admitted for ACS fall into 3 of the segmentswithin the population health management tool;

• LTC patients who need regular management and / or monitoring• Patients without LTC with limited potential to use secondary care• LTC patients with high potential to use secondary care – most

complex

Costs vary from £442 per admission for the least complex to £5,796for the most complex patients.

Of the most complex patients :• 74% had at least one admissions for an ACS condition• 44% had two or more admissions

*List of Ambulatory care conditions can be found herehttps://indicators.hscic.gov.uk/download/Impact%20on%20NHS%20resources/Specification/19_ACS.pdf

Main Segment Population in this segment

Total Cost of Emergency ACS conditions

Admissions per patient

Cost ACS admissions per person in the segment

LTC patients who need regular management and / or monitoring

4,609 £2,036,278 1.2 £442

Patients without LTC with limited potential to use secondary care

50,903 £35,862,151 1.8 £705

LTC patients with high potential to use secondary care – most complex

3,001 £17,395,263 2.7 £5,796

The response to our local population health

challenge was to implement the Camden Diabetes

Integrated Practice Unit (IPU).

Our local monitoring measures the impact of keymetrics. The data shows prevalence increasing andthe number of unplanned admissions decreasing.

This impact can also be seen at a national level withCamden falling within the top performing category inthe recently published clinical indicators.

Whole system approach: Diabetes Value Based Contract

No. of Adults Diagnosed with Diabetes

No. of unplanned admissions for Hypo/Hyperglycaemia

CCTop Performing

Towards Accountable Care – delivering the Camden Local Care Strategy

Partnership aim: “Health and care services will work together with local people to provide coordinated, proactive, accessible, good quality care in order to improve the health and well being of people in Camden.”

Shared outcomes: Reduce health inequalities, prevent early death, improve service users’ access to care, improve service users’ experience of care, enhance residents’ quality of care

Enablers: Integrated Digital Health and Care Records

Camden’s model of care emphasises the importance of care coordination and integrated multidisciplinary working. An accountable care entity is well placed to deliver such a model of care.