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North West London Whole Systems Integrated Care Meeting with New Zealand Health Economies 4 th April 2014. Whole Systems Integrated Care Pioneer Programme. Our shared vision of whole systems integrated care…. “. … supported by 3 key principles. 1. 2. 3. - PowerPoint PPT Presentation
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Whole Systems Integrated Care
Living longer and living well
North West London Whole Systems Integrated Care
Meeting with New Zealand Health Economies4th April 2014
Living longer and living well 2
Whole Systems Integrated Care Pioneer Programme
We want to improve the
quality of care for individuals, carers and families,
empowering and supporting people to maintain independence
and to lead full lives as active participants in their community
“
”
People will be empowered to direct their care and support and to receive the care they need in their homes or local community.
GPs will be at the centre of organising and coordinating people’s care.
Our systems will enable and not hinder the provision of integrated care.
… supported by 3 key principles
1
2
3
Our shared vision of whole systems integrated care…
Living longer and living well
Our track record of working together to design and implement joined up careWe have a strong history of genuine partnerships between health, social care, third sector and patient and user-led organisations across 8 boroughs.
Providers working together & with patients
• Involves community, primary, secondary and social care, mental health, community pharmacy, specialist nursing and third sector (eg. Age UK and Diabetes UK)
• Providers come together to co-create integrated, proactive and personalised care plans
• Monthly multi-disciplinary groups with aim to improve the care of individuals with complex needs
• Active involvement of patients, service users, carers
NW London Integrated Care Pilots
Commissioners working together with providers to change the commissioning framework and delivery model
• Working in partnership with national partners and across Tri-borough
• Business case identified steps to achieving integrated care, such as aligned financial incentives, integrated provider networks, shared information and joint accountability
• Tri-borough and West London Alliance continue to work with Public Service Transformation Network
Tri-borough Whole Place Community Budget Pilot
Outcomes
Evaluation by Imperial College and the Nuffield Trust of the initial stage showed :• 69% of patients felt they had increased involvement in
decision making; • 77% of GPs felt MDGs had improved their knowledge
of patient care
Outcomes
• Estimated potential net acute savings of £38m a year by Yr 5.
• This is primarily driven by a reduction in acute hospital activity, through investment in community and social care services.
Living longer and living well 4
Next steps - what is whole systems integrated care?
• Joined up health and social care
• Organise around people’s needs not historic organisational structures
• There is one set of records shared across organisations
• Multidisciplinary home care teams
• Fewer people are treated in hospital, and those that are leave sooner
• More specialist support for management of people in the community
• More investment in primary and community care
• Social care and mental health needs considered holistically with physical health and care needs
• Less spending on acute hospital based care
Care is provided
in the most appropriate
setting
Funding flows to
where it is needed
Care is coordinated around the individual
Living longer and living well 5
How will we get there – our ten step plan for North West London
Living longer and living well 6
Co-design framework
centrally once
Expressions of interest in being early adopters
and plan locally
All NWL prepares for implementation
and learns from early adopters
Roll out Whole Systems
approach
1 3 42 Whole Systems
integrated care
business as usual
How we get from where we are today to where we want to be in 2015/16
Oct 2013 – Jan 2014
Apr 2014 – Mar 2015
Apr 2015 –
Jan 2014 – Apr 2014
TODAY
Living longer and living well 7
Co-design phase – October 2013 to January 2014
This has not been a typical programme!
• 31 partners support our transition towards whole systems integrated care
• Over 150 people engaged in developing and discussing the content
• The programme is organised across five module working groups which collectively have met over 30 times
Living longer and living well 8
Embedding Partnerships: Co-design with people and partners as our guiding principle
“Co-production means delivering public services in an equal and reciprocal relationship between professionals, people using services, their families and neighbours… both services and neighbourhoods become far more effective agents of change.”
Nesta & new economics foundation
Our commitment to working co-productively in North West London means:1. Commitment to agreed ways of working – everyone is valued as equal partners, we will
capitalise on lived experience as well as professional learning
2. Supporting development and learning
3. Fostering a supportive environment – developing collective resilience and acknowledging that mistakes will be made along the journey
4. Working towards shared goals – promoting local voice and enabling people to be involved in the delivery of their care and support
Living longer and living well 9
We have been working together within the working groups below to tackle the tough questions for integrated care framed around the ten step plan
Population and outcomes
Mostly healthy
Defined episode of care Single LTC
Multiple LTC
Serious and enduring mental illness
Advanced stage organic disordersCancer
Learning disability
Age
0-15 (Children)
Socially excluded groups
16-74
75+
Mostly healthy adults Adults with one or more long term conditions
Adults and elderly people with cancer
Elderly people with one or more long term conditions
1 3 5
4
Adults and elderly people with SEMI
6
Adults and elderly people with learning disabilities
7
Adults and elderly people advanced stage organic disorders
8
Homeless people, alcoholics, drug users
9
2
Mostly healthy elderly people
▪ The programme is not currently focused on integrated care for children▪ There may be innovative care models that we could trial but this would
probably be the focus of a future phase
• Instead of organisations or diseases, which groups of people should we organise care around?
• What are the opportunities to improve care for these people?
• What goals do people in these groups want to achieve?
GP networks
Hospital
CommunityHealth
Social Care
PracticePractice
PracticePractice
Practice Mental Health
Third SectorIntermediate
care
• What services could groups of practices provide better for people if they work together?
• How can these GP groups work with other care providers to deliver better services?
Provider networks
Contracting options
Horizontal governance
Hierarchical governance
Description
Providers come together as equals, requiring some form of multilateral decision-making
An organisation is commissioned to provide services and subcontracts with other providers as needed
No formal contracting
Shared funding for integration activities but no formal ties between providers
Unincorporated ‘club’1
Alliance contracting2
Joint venture model (hub and spoke consortium)
3
Third party broker model
4
Prime contractor model
5
Fully integrated provider organisation
6One organisation
A single organisation is commissioned to provide all services
• What services could groups of providers provide better for people if they work together?
• How can incentives for providers make the right thing to do the easy thing to do?
• How do different providers of care decide to spend money in new ways without damaging existing care?
Commissioningand finance
Sources of financing
Contracting with provider networksLocal authority Pooled
budgets
Evaluating care deliveryCCGs Needs
identification
Sharing risks and savingsNHS England Prioritisation
Contracting with providersPricing and resource allocation
• How can people get better care by not having different organisations paying for care with separate budgets?
• If there were one pot of money how do different commissioners make sure that people are getting the care they want?
Informatics
• What information is needed to provide better services to people?
• What information do commissioners need to make sure people are getting the care they need?
• What do we have and what is missing today?
Embedding Partnerships
Living longer and living well 10
Co-design used three ways to group the population of North West London around similar needs
Health and social care commissioners, clinicians, public health experts, the ASHN and lay partners have collaborated to provide professional judgement, statistical data analysis and a review of other models globally.
Review of internationally applied segmentation models
Judgement of multiple professionals and lay partners
In-depth analysis of integrated health and social care data set
Living longerand living well 1
US example of population segmentation
Segment Prevalence Priorities
Healthy~32% Maintenance of health (e.g., prevention,
screening)
Healthy with acute illness
Variable Diagnosis, treatment, early detection of complications
At risk~18% Prevention of disease and complications
Chronically ill~45% Prevention, detection, and treatment of
secondary complications
Complex~5% Prevention of complications, coordinaton
of care
Root Cost:1385.2 N:153687 SD:8.718609e+11
LTCs< 1.5 Cost:798.0117 N:138962 SD:8.718609e+11
LTCs>=1.5 Cost:6926.585 N:14725 SD:6.773154e+11
LTCs< 0.5 Cost:547.0933 N:123338 SD:6.296122e+11
LTCs< 3.5 Cost:5900.64 N:12474 SD:3.766181e+11
LTCs>=3.5 Cost:12611.9 N:2251 SD:2.148090e+11
LTCs>=0.5 Cost:2778.796 N:15624 SD:1.731825e+11
Age< 74.5 Cost:464.8282 N:120584 SD:3.649281e+11
Age>=74.5 Cost:4149.072 N:2754 SD:2.281369e+11
Age< 77.5Cost:2619.463 N:14884 SD:1.044416e+11
Age>=77.5 Cost:5983.555 N:740 SD:6.076288e+10
Dementia_yn=n Cost:5723.384 N:12279 SD:2.833689e+11
LTCs< 5.5 Cost:11790.78 N:1988 SD:1.615568e+11
Dementia_yn=y Cost:17062.27 N:195 SD:6.856999e+10
LTCs>=5.5 Cost:18818.71 N:263 SD:4.177988e+10
LTC
LTC
LTC
Age
Deme-ntia
LTC
Age
Learndisab_yn=n Cost:450.2067 N:120367 SD:3.065684e+11
Learndisab_yn=y Cost:8575.203 N:217 SD:4.406015e+10
Age< 84.5 Cost:3286.481 N:1741 SD:1.040154e+11
Age>=84.5 Cost:5631.572 N:1013 SD:1.205997e+11
LTCs< 2.5 Cost:4929.639 N:8427 SD:1.465033e+11
LTCs>=2.5 Cost:7459.856 N:3852 SD:1.199412e+11
Age>=78.5 Cost:14018.81 N:585 SD:7.842639e+10
Cancer_yn=n Cost:2530.153 N:14478 SD:9.091432e+10
Cancer_yn=y Cost:5804.239 N:406 SD:9.293829e+09
Age< 78.5 Cost:10861.77 N:1403 SD:7.901548e+10
Age< 86.5 Cost:4937.704 N:561 SD:2.891769e+10
Age>=86.5 Cost:9261.335 N:179 SD:2.930843e+10
Age
LD
Cancer
Age
LTC
Age
Cancer_yn=y Cost:3488.164 N:831 SD:1.447678e+10
Cancer_yn=n Cost:429.0872 N:119536 SD:2.843688e+11
Cancer_yn=n Cost:4767.833 N:7996 SD:1.301565e+11
Cancer_yn=y Cost:10519.78 N:273 SD:1.057677e+10
Cancer_yn=n Cost:7226.45 N:3579 SD:1.066133e+11
LTCs>=4.5 Cost:13077.32 N:357 SD:2.449066e+10
LTCs< 4.5 Cost:10105.6 N:1046 SD:5.217435e+10
Cancer
Cancer
Cancer
LTC
Cancer_yn=y Cost:7931.51 N:431 SD:1.225361e+10
1 2 3
Living longer and living well 11
Whole Systems approach to population grouping for people with similar needs
Serious and enduring mental illness
Mostly healthy
Defined episode of care
Single LTC
Multiple LTC
Advanced stageorganic brain disordersCancerAge
0-15 Children
16-74
75+
Mostly healthy adults
Adults with one or more long term conditions
Adults and elderly people with cancer
Elderly people with one or more long term conditions
1 3 5
4
Adults and elderly people with SEMI
6Adults and elderly people advanced stage organic disorders
7
2
Mostly healthy elderly people
Socially excluded groups
Homeless people, alcohol and drug depende-ncies
10
Learning disability
Adults and elderly people with learning disabilities
8
Severe physical disability
Adults and elderly people with severe physicaldisabilities
9
▪ The programme is currently not focused on integrated care for children
• Only primary need shown, other needs are also treated• A group has broadly similar needs but care is tailored further• Some services common to all, some unique to group
1 Severe and enduring mental illness2 For example, the homeless, people with alcohol and drug dependenciesSource: Whole Systems Integrated Care module working group
Living longer and living well 12
Number of reviews showing positive evidence Additional insight from evidence baseIntervention Average impact1
2. Multi-disciplinary teams
Hospitalisations reduced by 15-30% (inter-quartile range)
81% (13 of 16 reviews) assessed MDTs and found a positive impact
All reviews have concluded that specialised follow up of patients by a multidisciplinary team can reduce hospitalisationHolland et al, Heart, 2005, 91, 899-906
1. Self- empowerment and education
Hospitalisations reduced by 25-30% (inter-quartile range)
83% (20 of 24 reviews) assessed patient support for self-care and found a positive impact
Supported self-management has the strongest effect on clinical outcomes of all IC components when estimated at component-levelTsai et al, Am J Manag Care, 2005 (August), 11(8), 478-88 (Table 4)
3. Care coordination
Hospitalisations reduced by ~37% (pooled estimate only reported in 2 relevant reviews)
57% (8 of 13 reviews) assessed care coordination and found a positive impact
Interventions involving case management reduce HbA1c [in patients with diabetes] by 22% more than interventions without case management.Shojana et al, JAMA, 2006, 296(4), 427-440
4. Individualised care plans2
Hospitalisations reduced by ~23% (pooled estimate only reported in 2 relevant reviews)
64% (7 of 11) reviews) assessed care plans and found a positive impact
Personalised approaches using tailored information influence health behaviour more than uniform approachesGraffy et al, Primary Health Care Research & Development, 2009, 10(3), 210-222
Intervention inclusion criteria Strong, consistent
published evidence of efficacy
Also used in the overwhelming majority of the 13 case studies looked at
1 Impact measured from systematic reviews, including relevant interventions and containing meta-analyses of hospitalisation rate2 Cochrane review of the evidence for personalised care planning (Coulter et al.) currently in processSource: Richardson, Dorling – Global Integrated Care Case Compendium (McKinsey)
Four interventions are based on strong evidence and widely tested
Living longer and living well 13
We are now moving into the implementation phase for all of NWL and early adopters
A. ALL OF NWL
B. EARLY ADOPTERS
Pioneer principles Who will complete this
1 People will be empowered to direct their care and support and to receive the care they need in their homes or local community.
2 GPs will be at the centre of organising and coordinating people’s care.
3 Our systems will enable and not hinder the provision of integrated care. Our providers will assume joint accountability for achieving a person’s outcomes and goals and will be required to show how this delivers efficiencies across the system
A
B
Living longer and living well 14
Criteria for Whole Systems and “Early Adopters”
Putting people at the centre of care
Embedding Partnerships
Population and Outcomes
Provider networks
Commissioning governance & finance
Information
Use co-production to develop plansCommitment to move to personalisation, self care and use of community capital
Organise care models around people with similar needs
Pool health and social care budgetsOperate shadow capitated budgets
Reallocate money across a care pathway to fund innovative models of care regardless of setting
Establish governance for networks, bringing together different types of providers around a GP registered population
Generate significant savings to system
Identify outcomes to be delivered
Information governance to support this across all providers
Ensure the flow of information to support care delivery, performance management and payment
Agree binding performance management
Agree binding performance management
Early adopters will move further and faster and share learning across NWL and must plan to implement the following criteria for Whole Systems
Living longer and living well 15
GP Networks are essential as part of an integrated care system
CommunityCare home
GP practice GP practice
111
999Electivehospital
Local hospital
Major hospital
Hubs & GP networks
HomeCare plan1.…2.…service user
Living longer and living well 16
Primary care in the UK is under significant strain…
Living longer and living well 17
… and is unable to meet increasing pressures
SOURCE: The Kings Fund
Risingpatient
expectations
Competitionand
procurementlaw
New medical
technologies
Undertakingclinicalcommi-ssioning
Risingprevalenceof chronicdisease
Workforcepressures
Constrainedfundinggrowth
ITdevelopments
Primarycare
Living longer and living well 18SOURCE: GP Patient Survey 2011-12
‘…significant variation in quality and outcomes’
Particular challenges in London
Access to care
Continuity of care
Patient engagement and involve-
ment
Overall patient
experience
1 2
3 4
These challenges are affecting patient experience of primary care services in London
Living longer and living well 19
There are many benefits of GPs working in networks
Improved Care Offering
Focus on population health across a geographic region will enable inequalities in health to be addressed
Able to offer extended range of services including new forms of care for groups with the highest need (e.g., elderly with multi-morbidity) and seven day working▪ Freeing up time spent on administration for direct patient care
Economies of Scale
Allows for efficiency gains from sufficient scale such as access to:▪ Specialist skills (e.g., diabetes nurse, consultant geriatrician)▪ Specialist resources (e.g., diagnostic equipment, information systems)▪ Capacity and capability building (e.g. contract bidding)▪ Shared investments (e.g., IT) or joint premises
Coordination with other partners
Build collaborative relationships with wide range of partners (e.g., local government agencies, schools, and charities)
Serve as basis to coordinate with other providers:▪ Acute sector (e.g., for consultants to work in community)▪ Community health and social care services (e.g., for coordination of field-deployed staff)
Opportunities to spread learning e.g., through peer review and joint education activities
Living longer and living well 20
Organisational options for GP networks
Horizontal governance: Federated (and Integrated)
One organi-sation: Integrated only
Contracting optionsDescription Service or case example
No formal contracting
Collaboration1▪ GPs do not have formal contracts or organisational structures but agree to cooperate when there are benefits for their population
▪ Nearby GPs opening at different times
Formal cooperation agreements
2▪ GPs come together as equals, and have a contract that sets out how they will work together
▪ Referring patients between practices to specialist GPs
Shared services3▪ GPs set up new and separate organisation, that then provides services to all the member practices
▪ Network funds shared services such as case conferences or diagnostics
4 Practice merger▪ GP Practices merge to create larger scale organisations
▪ Practices merge completely and co-locate their services
Fully integrated primary care company
5▪ A single organisation is commissioned to provide all services, and employs GPs on a salary basis
▪ ChenMed
Living longer and living well 21
New networks must think about their purpose, size and membership when deciding on an organisational structure
E.g., networks for education, audit and governance purposes will require a simpler (informal) structure than networks aiming to bid for extended services, out of hours etc. which will require formal legal models e.g. limited company, partnership
1 Purpose
Larger networks will require more complex operating models to manage things such as governance, service delivery, risk, communication, accountability, decision making, engagement, involvement etc.
2 Size
The differing characteristics of individual member practices and there location will affect form – how much discretion, autonomy and choice is required, how much standardisation is possible?
3 Membership
Things to consider
Living longer and living well 22
How can GPs legally collaborate and enter into contracts to provide out of hospital services? (1/2)
GP practices are legally independent entities Key question
What is the contract form that is used to commission out of hospital services, as if the GPs are collaborat-ing to provide services, they will need to ensure that the form of collaboration is one that is eligible to enter into the relevant contract?
▪ GP practices in England are usually set up as sole traders, partnerships or companies limited by guarantee or shares
▪ They are independent of the NHS, but are subject to certain eligibility criteria that they must fulfill to hold GMS, PMS or APMS list based primary care contracts
▪ The eligibility criteria differs between the different types of contract, but in broad terms, GP practices are independent organisations with differing legal structures
▪ They are not "NHS bodies" and therefore, unlike NHS provider trusts and Foundation Trusts, are not established by statute or subject to the constraints on their powers of being a statutory body. They are of course subject to external regulation.
Living longer and living well 23
How can GPs legally collaborate and enter into contracts to provide out of hospital services? (2/2)
There are three main options for organising contracts between GP practices
1 2 3
Contractual joint ventures
▪ This could be as simple as a light touch agreement between the parties setting out how they will work together to provide certain services (e.g. including sharing premises and staff)
▪ It could also be a more detailed (and more robust) arrangement with details of how the parties will collaborate to provide services, how financial liabilities will be shared and how decisions will be taken by the collaboration
▪ It is possible for GP practices to agree that one GP practice will be the lead provider of certain services, and other GP practices will essentially be sub contractors of the lead provider. The detail of how this lead provider GP network would operate practically could be set out within a contract
Practice Mergers
▪ GP practices could seek to formally merge with each other in order to create larger scale organisations
▪ This would include full operational and management merging, as well as possible co-location of services
▪ Would include merged support staff
Corporate joint ventures
▪ GP practices could seek to set up a new corporate entity that they are all responsible for (either by way of shareholding or membership, for example).
▪ There are a number of different legal forms that this new corporate entity could take, with suitability of the form largely depending on the function and purpose of the new entity.
Any of these forms would enable the GP collaboration to tender collectively for out of hospital services. In each case, the governing documents for the joint venture would set out how the participating practices could refer patients between themselves.
Living longer and living well
Evolution of a model in practice
Patient Registry
3 axis triangulation
Case management
Ongoing reviews
Cu
rren
t M
od
el
New
Mo
del
Continuous Patient
Improvement
Patient Selection based on known need (by practice)
Care Plan completed once over a year (one off event)
Complex patients brought for case review to an MDG
• Select patient
• Initiate care plan
• Review at MDG
Key New Features3
Living longer and living well
Updated Structure
Integrated Management Board (IMB)
Harrow Integrated
Management Group (IMG)
Brent Integrated
Management Group (IMG)
Hillingdon Integrated
Management Group (IMG)
Ealing Integrated
Management Group (IMG)
6 Provider Networks
BasedMDGs
4 Provider Networks
Based MDGs
4-6 Provider Networks
Based MDGs
4-7 Provider Networks
Based MDGs
Patient Care Plans
Regional Strategy
CCG Delivery
Locality Delivery
Practice Delivery
• >1 Million
• >300,000
• 50,000
• 2,000 – 20,000
1. Patient Registry
2. Risk Stratification
3. Care Pathways
4. WorkPlanning
5. Care Delivery
6. Case Conferencing
7.Performance Review
High Risk Population
Updated Structure
Total Number• 348,000Community Ward• 6,960
Per NetworkMDG plans• 1740Per Month• 145
Per NetworkMDG annual• 174Per Month• 15
4
Living longer and living well
1. Patient Registry2. Risk
Stratification
• There is a defined list of who the patients are• From the list, patients are segmented based on need (and history/predicted
utilization)
Patient Registry and Risk Stratification
• Practice defined populations (≈2-3%)
• 3 axis triangulation: BIRT2, Practice and Provider
• Audit those whom they can have an impact on
• Set up a community ward (practice & MDG profile)
• Monitor delivery against agreed patients throughout the year
• Practice self-selected by pathway only
• Frequent flyer information sent to practices
• No risk stratification tool
• Single one off care plan
• MDG meetings twice a month
Cu
rren
t M
od
el
New
Mo
del
Community Ward Evaluation Patient 3 Axis Stratification
Very High Risk (0.5%)
High risk (0.5-5%)
Moderate risk (5-20%)
Low risk (20-50%)
Very low risk (50-100%)
Very High Risk (0.5%)
High risk (0.5-5%)
Moderate risk (5-20%)
Low risk (20-50%)
Very low risk (50-100%)
• >1 LTCs• MH• Dementia• LD• >75• Cancer• ….
Specific changes5
Living longer and living well
3. Care Pathways4. Work Planning
• An agreed care pathway across multiple professionals based on best evidence• A care plan can be agreed with the patient for targeted support
Care Pathways and Work Planning
• Risk based care plan
• Updated at least 4 times a year
• Incorporates multi-morbidity
• Increase use of SPNs/CMC for 111
• Accessible electronically out of surgery hours
• Pathway specific care plan
• Relies on clinician prioritization of pathway
• No direct interaction with other services
• Care plan accessible only to patient
• No regular review and in-hours access only
Cu
rren
t M
od
el
New
Mo
del
Patient records: GPHospitalCommunity
Patient Medical Information Sharing: include Unscheduled Access
111
Care Plan
1. ….2. ….
Specific changes6
Living longer and living well
5. Care Delivery6. Case Conferencing
• The defined care delivery providers in the community, e.g. GP and other providers• A means of seeking advice and support for complex patients amongst this cohort
Care Delivery and Case Conferencing
• Risk based delivery of care based on GP network
• Relies on all providers
• MDGs as Community Ward reviews once a month: trigger use of coordinators
• Impact on Ward patients monitored
• Health and Social Care Coordinators supporting patient delivery provide updates to MDGs
• Pathway specific delivery of care
• Relies mainly on the practice and GP
• MDGs happen up to 2 times a month
• Unclear about impact on complex patients
• Minutes noting review and updates only
Cu
rren
t M
od
el
New
Mo
del
Care plan
Action 2
Action 3
Action 1
Action: Review by falls service
Action status: Completed
Integrated Patient Care Planning
Health & Social Care Coordinators
Community Ward MDG
PatientClinician/Provider
MDG
Patient
Clinician/Provider
Care Plan
1. ….
2. ….
Specific changes7
Living longer and living well
7. Performance Review
• Review of the process looking at standard outcome measures
Performance Review
• Metrics from BIRT2, Practice and other sources
• Practice, MDG and Borough based
• Data on actions from H&SC coordinators
• Reviewed at Community Ward levels
• Metrics from SUS
• Borough based data
• Data input based solely on care planning
• Reviewed at IMG and CCG only
Cu
rren
t M
od
el
New
Mo
del
GP PRACTICE
HUBS AND GP NETWORKS
BOROUGH
BOROUGH
Specific changes8