Population Health Planning in

Chronic Disease:Measuring the impact of applying a capitated budget for

people living with multi morbidity in NHS England

CMS Measures Forum

May 19, 2016

Jacquie White

Deputy Director for LTC, Older People

& End of Life Care

NHS England

Claire Cordeaux

Executive Director

SIMUL8 Corporation

Objectives

The webinar will focus on how the National Health Service (NHS) in England, UK have been implementing person-centered care for people with Long Term Conditions (LTCs) and in particular multi-morbidity.

It will cover:

• The concept and the change programme

• Whole population analysis and identification of target

populations

• Financial instruments to facilitate change

• Models of delivery to support person centred outcomes

• How simulation models have supported decision-making,

and will include a demonstration of simulation models

Who are we? NHS England

• Established 1948 to provide good healthcare to all regardless of wealth.

• Free at the point of delivery

• NHS England serves a population of 53.9 million, seeing 1 million patients

every 36 hours and employs more than 1.3 million people including the

following clinical groups:

• 40,236 primary care physicians

• 351,446 nurses

• 18576 ambulance staff

• 111,963 hospital and community health service, medical and dental staff.

• Funding for the NHS comes directly from taxation. For 2015/16, the

overall NHS budget was around £116.4 billion. NHS England is managing

£101.3 billion

• Reformed in 2013 and underpinned by the Health and Social Care Act

2012, the “Five Year Forward View” is the national strategy for healthcare

in England and sets out the system transformation required to meet the

changing needs of current and future patients. Person-centered care is a

key part of the strategy.

Who are we? SIMUL8 Corporation

• Established 1994

• Business simulation software

worldwide

• Specialists in health and social care

• Combine healthcare knowledge and software development

to create sector-wide tools

• Close working with NHS since 2008

Setting the Scene: Global Changes

Increasing demand for healthcare• Rise of long term conditions and multi-morbidity: physical

and mental

• Ageing population

• Increasing expectations: access, treatment, cure not care

Supply pressures

• Dependence on system

• Hospital and medic-centric care models

• Workforce – recruitment & retention, ageing, diversity and culture

• Fragmentation of care in health and to social care

• Crisis curve – late identification of people needing support

The Patient at the Center?

A man being treated for heart

failure in UK primary care

rejected the offer to attend a

specialist heart failure clinic to

optimise management of his

condition. He stated that in the

previous two years he had made

54 visits to specialist clinics for

consultant appointments,

diagnostic tests, and treatment.

The equivalent of one full day

every two weeks was devoted to

this work.

BMJ 2009;339:b2803

The NHS Program: the priorities

• Empowering patients and informal caretakers to be full

partners in care

• Whole person focus

• Life course approach to care needs

• Strengthening Primary and Community Care

• Older people with increasingly complex needs including

frailty

• New care models moving away from purely medical,

hospital-centric focus

• Strengthen key enablers – IT, Workforce, Technology

• Need for a new purchaser/provider/funding model

The Person at the Center: Changing the

Language Changes Culture

Patient > Person

Chronic Disease > Long Term Conditions

List of Needs > Whole Person

Integrated Care > Coordinated Care

Changing the language helped to reinforce the different behaviours

needed to implement change

Long Term Conditions (LTC):

House of Care

NHS Commissioning:

Planning and Paying for

Services for a Population

Person-centered Outcomes

Better Health for the

Population

• Access

• Clinical outcomes

• Co-ordination

• Transitions of care

• Urgent care response

Better Care for

Individuals

• Experience of care

• Quality of life and

death

• “Activation” levels

• Goal achievement

Lower Cost Through

Improvement

• Acute care

• Residential care

• Shifts in spend

Outcomes and Benefits

• More activated patients have 8% lower costs in the base year and 21%

lower costs in the following year than less activated patients

• Health coaching can yield a 63% cost saving from reduced clinical time,

giving a potential annual saving of £12,438 per FTE from a training cost

of £400

• Coaching and care co-ordination has shown to reduce emergency

admissions by 24%

• Improved medication adherence improves outcomes and yields

efficiencies, for instance in 6000 adults in the UK with Cystic Fibrosis,

could save more than £100 million over 5-years

• Between 20% and 30% of hospital admissions in over 85’s could be

prevented by proactive case finding, frailty assessment, care planning

and use of services outside of hospital

Whole Population Analysis

Identifying the population at risk, predicting

need and services required to maintain

independence

Identifying the Population

Research on People with

Multi-Morbidity

• Research shows that of people with chronic disease, a

third have more than one

• On this basis we should be planning for the needs of

the person, rather than focussing on the single disease

• The following slide shows a graph illustrating this

Multi Morbidity is Common

Current impact of people with LTCs on

healthcare resource

Current impact on Healthcare Resource

ctd.

Risk Stratification:

Selecting the cohort

• There are many techniques that

can be used to segment a

population.

• Different segmentation methods

select different people - the

method used should match the

outcomes required

• IT-based intelligence should be

supplemented with humanistic

intelligence

• People in the cohort still need to

be assessed to determine

suitability for inclusion and before

a care plan is developed and

services delivered.

Changes in risk profiling over time

Crisis Curve:

• Selected individuals with the most complex care needs demonstrate a

‘crisis curve’ (cost curve).

• They enter a period where they need more non-elective acute care, and

then their health stabilizes.

Death within 12 months:

• A large proportion of individuals selected with the most complex care

needs die within a year of selection – up to 35% of individuals with risk

scores within the top 0.5%

Both of these factors reduce when using multi-morbidity to select the cohort.

Conclusion:

• Risk scores measure historical needs, rather than future needs

• Multi-morbidity appears to select a more stable patient cohort

People with Complex Health and Care

Needs Appear to Demonstrate a ‘Crisis

Curve’

Current Situation from the Patient and

Carer’s Perspective

And…

People living longer but not always well

The larger the number of co-morbidities a patient

has, the lower their quality of life

Increasing evidence on over-treatment and

harm

Social isolation/loneliness a risk factor for

mortality in people over 75 and should be

supported as a co- morbidity

What if we set a Capitated

Budget to Facilitate Spend on

Individual Needs rather than

Healthcare Organizations?

Selecting the Service Bundle:

Emerging Delivery Models

The service models being developed by our sites are

essentially similar but differ to match local conditions.

Similarities include:

• Single point of access

• Care planning and shared care record

• Supported self management

• Care co-ordination

• Community multi-disciplinary team based around primary care,

• Wider neighborhood support including specialist practitioners, therapists

• Recovery, Rehabilitation and Reablement “services”

• Care navigators and voluntary sector as a key enabler.

Differences include:

• Whole population or selected cohorts

• Formation of new organizations

• New delivery models within and across existing organizations

Capitated Budgets

Overall aim is to include all services and total cost of care for

cohort with the purpose of incentivising providers to work

together to deliver person centred co-ordinated care

The main issue for setting credible capitated budgets is the management

of risk. Financial risk results from:

• Poor data quality – some services might not be included within the capitated budget if

data quality results in poor budget estimates

• Changes in the use of care over time by selected patients – selection method

important

• Potential for double payment – IT systems and information flows are needed to

support the capitated budget

Changes in the budget need to be managed because:

• The patient cohort will change as individuals die or leave the area and new patients

join

• The needs of individuals will change as their health and social circumstances change

• The patient cohort may grow as more individuals who may benefit from integrated

care are identified

Contracts

Contracts are more about relationships than legality.

Currently NHS organisations are constrained to use the NHS

standard contract, but alternative agreements can be used in

parallel with this contract.

There are many contracts being explored and tested by the teams. The

most common are the:

• Alliance contract – requires exceptional relationships between all stakeholder

because all decisions need to be joint decisions

• Prime provider contract – shifts control and management of relationships to

another organisation (who will then need to set up sub-contracts)

• Development of accountable care organisations – organisationally aligning care

Performance monitoring of the contract is based on outcome metrics,

developed by patients, care practitioners and finance with all organisations

accountable for all outcomes.

The Total Health and Social Care Cost is

Strongly Related to Multi-morbidity

The Role of Simulation

Whole System Impact of Change

Simulating

the Concept

and Reality

Segmenting

Patients

How the Simulation Works

How the Simulation Works – The Logic

Results from a Simulation:

What is the Cost of a Patient Each Year?

How do Patients Typically use Services,

What is the Cost and what Resource is

Needed:Emergency Department Example

Person-Centered Care Example:Extensivist Care and Enhanced Primary Care

• 1.6% of the population assessed as in need of extensive

support

• Person-centered model includes:

• All care co-ordinated by a clinician

• Regular contact with a health and wellbeing support worker to

ensure referral to relevant services

• Patient activated

• Reduces hospital emergency and planned visits

• 36% of population receiving Enhanced Primary Care,

managed by Primary Care Physician with lighter touch:

• Health and wellbeing support

• Support for high intensity users

• Care Co-ordination

Return on Investment

Extensivist Care Model only

Using Simulation Results to:

• Discuss with stakeholders across organizational

boundaries

• Agree a capitated budget for each patient type

• Test the impact of a new model of person-centered

care to:

• Understand the RoI

• Understand financial and resource impact for each

provider

Acute to Rehabilitation

RRR Audits Identify the Point in the

Acute Patient Pathway that Patients are

Medically fit for Discharge

Lesson Learned

Change the payment at the point when the

patient’s needs change –

and not when they change institution.

The Simulation

Simulation Benefits

Test before implement (no harm to patients)

Dissemination of practice and sharing of models of

care

Supports decisions where no historical data

Helps to formulate exact models of care and predict

impacts

National Roll Out and

Resources

National Support and Dissemination

• Virtual facilitation and improvement expertise

• Networking and learning...

• From each other, the early implementer sites

and national experts in various related fields

Through...

• Email updates

• Our website

• Facilitated Webinars with specialist input

• National workshops

• Coaching, facilitation and

improvement expertise

• Networking and

learning…From each other,

and national experts in

various related fields

• Programme funding to

support specific

developments e.g. data

analysis, testing delivery

models

• Simulation – capturing,

sharing and reusing

LTC Resources and Tools

NHS LTC program resources are available here:

http://www.nhsiq.nhs.uk/improvement-programmes/long-

term-conditions-and-integrated-care.aspx

Access to Simulations

Simulations and resources linked to the simulation can be

accessed at the following link.

http://www.SIMUL8Healthcare.com/chronic_disease

Contact Us

Jacquie White

Twitter:

@jaqwhite1 #A4PCC

Email:

Jacquie.white@nhs.net

https://www.england.nhs.uk/re

sources/resources-for-

ccgs/out-frwrk/dom-2/

Claire Cordeaux

Twitter:

@SIMUL8Health

Email:

Claire.c@SIMUL8.com

http://www.SIMUL8Healthcare

.com/chronic_disease