www.england.nhs.uk

Integrated data to support service redesign decision making

Leeds LTC Year of Care Commissioning Early Implementer Site

Tricia Cable, Year of Care LeadAlison Phiri, Business Intelligence ManagerMohini Chauhan, Year of Care Commissioning Manager

Julie Renfrew, LTC Programme NHS England

LTC Community of PracticeTuesday 19 January 2016

www.england.nhs.uk

LTC Framework

Commitment to Carers

Frailty

Health AgeingGuide

Fire Service as an asset

Care Homes Quick Guides

Care & Support Planning

Navigating Health& Social Care

Self Care

Ambitions for End of Life Care

Our Declaration

Delivery Models

Planning for Change:• Capitated Budget• Contracting• Simulation Modelling

Patient and Service Selection

Planning for Change:Workforce

Whole Population Analysis;Understanding your population

LTC Dashboard LTC Toolkit

www.england.nhs.uk

Long term conditions resources

Simulation modelUnbundling recovery simulation model

www.england.nhs.uk

7

Using behavioural change to open

minds

#A4PCC – Action for Person-Centred Care

Person with long term

condition

o Make a declaration at www.engage.england.nhs.uk/survey/ltc-declaration

o Tell your teams about our worko Encourage them to make a declarationo Ask them to feed back thoughts and

ideaso Use our hashtag – #A4PCC – when

you see work that is relevant to person-centred care for people with LTCs

o Let us know of any events, activities or social media opportunities that we can join forces with you

www.england.nhs.uk

Date Topic Led by and details of session Venue

20 January

12.30pm

Implementing the six Quick Guides to bring clarity on how best to work with the care sector. www.nhs.uk/quickguides

Nicola Spencer and Emily Carter NHS England

Guest speakers: • Angela Dempsey, - Baker Tilly on

the Quest4care tool• Dawn Moody – North Staffs on

MDT working and a model implemented in a CCG

Via WebEx

10 February11.30am

Health Coaching in the community - the role of non-clinical staff and people with lived experience as coaches

Anya De Iongh & Jim Phillips Via WebEx

TBC Self-management in the community and on the Internet

Peter Moore, The Pain Toolkit Via WebEx

LTC Virtual Learning Community Lunch & Learn webinars: Sharing and Learning …

www.england.nhs.uk

Date Topic Led by and details of session Venue

4 February10.30 – 3.30

LTC Community of Practice Workshop Please save the date for this workshop - details to follow

Central London

11 February

12.30 – 1.30

Commissioning Integrated models of care:- The South Kent model of care (what it looks like) - Roadmap to delivery - Contracting models and evaluation.

Alison Davis, Integration Programme Health and Social Care, Working on behalf of Kent County Council and South Kent Coast and Thanet CCG'sKent LTC Year of Care Commissioning Early Implementer Site

Via WebEx

Click here to register

22 February

12.30 – 1.30

Information Sharing to Support Service Integration:- Centre of Excellence for Information Sharing- Information Sharing user framework- Blueprint for sharing information for integrated care

Mark Golledge, Programme Manager, Health and Care Informatics, Local Gov Association

Via WebEx

Click here to register

LTC Community of Practice webinars and workshop: Scan, Focus, Act …

LTC Community of Practice webinar

Leeds EIS

Tricia Cable – YoC leadAlison Phiri - Business Intelligence ManagerMohini Chauhan - YoC Commissioning Manager

Developing integrated data to support service redesign decision making

Developing the data setWhat?

• Review of current Information Assets

• Gap analysis

• Developed Leeds Data Model

• Tailored Leeds Data Model for specific purposes.

What?

Leeds Integrated Health & Social

Care Data Model

Datasets linked on a common patient identifier

GP Practice Data Notional costs assigned

Community Dataset Notional costs assigned

Mental Health Data Cost per unit assigned

Inpatient Data

Adult Social Care Data No costs assigned

Outpatient Data

A&E Data

Year of Care Combined Dataset

ACG Grouper

Linked data processed through

the ACG Grouper to create risk scores

Input Dataset

Used for production of

capitated budgets

Output Dataset

Used for cohort

identification

To be defined

Dataset for shadow

monitoring

Key:

How did we use the dataset?

So what?

• Cohort identification – pivot table hell!

• Created a tool that enabled us to get the best out of the data

Introduction to data packs

• Data packs were developed to create an impact and so they could be easily distributed to stakeholders across the system.

• Inspiration taken from commissioning for value data packs.

• A visual and engaging way of presenting data.

• The data packs do not provide the answers to which cohorts should be selected. Their purpose is to generate discussion and to support stakeholders to make a more informed decision around which cohorts they would like to focus on.

Now What?

CASE MANAGEMENT

DISEASE MANAGEMENT

SUPPORTED SELF CARE

POPULATION WIDE PREVENTION

Which populations do we want to target?

Reducing unplanned admissions?

Reducing total costs?

Health outcomes/potential years of life lost (PYLL)?

Multimorbidity?

Age?

Risk of high healthcare utilisation?

Focus on now or the future?

Frailty?

Prevalence of CHD, COPD and Diabetes is higher than the rest of the city Around 40% of the NHS

Leeds South and East CCG population has one or more

LTC

Emergency readmissions are significantly higher than the national averageThe biggest cause of years of life lost is due to cardiovascular disease cancer and respiratory disease

More people have mental health problems than in the rest of the city, above the national average

Health related

quality of life for people

with LTC’s is

significantly lower than the national average

25% of the CCG population have an existing

health problem, which is above the England average

More people are living with 2 or 3 LTC’s, compared to the rest of the city By 18/19 PYLL

to be improved by 26.6%

Please note: the data on this slide was taken from a number of sources including; public health profiles, the LSE CCG 2 year plan, NHS England commissioning for value packs and the NHS England long term condition dashboard.

NHS Leeds South and East CCG

Whole population dataset

Analysis of Leeds city wide data involved testing the following methodologies to understand utilisation of healthcare services, over a two year period:

a. Patients who had three or more A&E attendancesb. All patients aged 85 and over c. All patients with a Frailty Index of seven or more d. All patients with 4 or more long-term conditions e. All patients in the top 2% by risk of unplanned hospitalisation in the

next 12 months (based on the Kings Fund’s Combined Predictive Model algorithm).

The analysis demonstrated an increased use of healthcare services over the subsequent two years when moving from (a) to (e) and points towards a multimorbidity model.

18-34 35-44 45-54 55-64 65-74 75-84 85+0

2000

4000

6000

8000

10000

12000

14000

16000

18000

Number of LTC’s, by age, for people with at least one LTC*

13+

12

11

10

9

87

6

5

4

3

2

1

Age category

Num

ber o

f pat

ient

s

*NHS Leeds South and East CCG

GP

Community

Mental Health

Outpatients

A&E

Inpatients

£0 £5,000,000 £10,000,000 £15,000,000 £20,000,000 £25,000,000 £30,000,000 £35,000,000 £40,000,000 £45,000,000 £50,000,000

£12,297,218

£11,947,166

£6,591,526

£12,381,539

£2,439,706

£43,220,633

Total costs of services, for people with at least one LTC*

Total costs (£)

Serv

ice

area 14%

13%

7%

14%3%

49%

% total costs of services

GP

Community

Mental Health

Outpatients

A&E

Inpatients

*NHS Leeds North CCG

1 2 3 4 5 6 7 8 9 10 11 12 13+ -

5,000,000

10,000,000

15,000,000

20,000,000

25,000,000

Total costs of services, by number of LTC’s, for people with at least one LTC*

Inpatient

A&E

Outpatient

Mental Health

Community

GP

Number of LTC/s

Tota

l cos

ts (£

)

*NHS Leeds South and East CCG

1 2 3 4 5 6 7 8 9 10 11 12 13+ -

2,000.00

4,000.00

6,000.00

8,000.00

10,000.00

12,000.00

14,000.00 Average costs of services, by number of LTC’s, for people with at least one LTC*

Inpatient

A&E

Outpatient

Mental Health

Community

GP

Number of LTC/s

Aver

age

cost

s (£

)

*NHS Leeds South and East CCG

Patterns of multimorbidity*

*NHS Leeds West CCG

Ischemic heart diseaseCOPD

Depression(+any other conditions)

1028 people affected of which 47%

are male

Average costs per person, over a one year period £5,399

8.6 average number of LTC’s per person

Total costs, over a one year period £5,550,474

GP costs £439,814

Inpatient costs £3,277,790

A&E costs£199,067

Outpatient costs £438,993

Mental Health costs£155,436

Community costs£1,039,082

*NHS Leeds South and East CCG

18-34 35-44 45-54 55-64 65-69 70-74 75-79 80-84 85+0

50

100

150

200

250

0

10

65

205

153 152

182

150

111

Age split of patients who have IHD, COPD and depression (+any other conditions)*

Age category

Num

ber o

f pat

ient

s

*NHS Leeds South and East CCG

1 2 3 4 5 6 7 8 9 10 11 12 13 14 150

50

100

150

200

250

0 0 1

11

36

119

171

203

153

121112

51

37

103

Numbers of multiple LTC’s for patients with IHD, COPD and depression (+any

other conditions)*

Number of long term conditions

Num

ber o

f pat

ient

s

*NHS Leeds South and East CCG

NHS Leeds South and East CCG

Beeston Chapeltown Kippax Middleton Seacroft0

5000

10000

15000

20000

25000

12472

22856

14955

21171

14757

Neighbourhood teams

Num

ber o

f pat

ient

s

Neighbourhood team breakdown, for patients with at least one LTC*

*NHS Leeds South and East CCG

Leed

s C

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ice

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shan

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ark

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Beeston Chapeltown Kippax Middleton Seacroft

0

1000

2000

3000

4000

5000

6000

7000

GP breakdown, by neighbourhood team, for patients with at least one LTC

Neighbourhood team

Num

ber o

f pat

ient

s

*NHS Leeds South and East CCG

Coronary heart disease (n= 1801)

Hypertension (n=8267)

Heart failure (n= 1122)

Stroke/ TIA (n= 1009)

Diabetes (n= 2314)

COPD (n= 1283)

Depression (n=8646)

Dementia (n= 399)

1632

1001

789

1766

791

2702

326

533

1001

204

361

277

404

120

279

789

204

242

160

391

143

520

1766

361

242

236

746

86

329

791

277

160

236

510

64

591

2702

404

391

746

510

194

138

326

120

143

86

64

194

1632

533

279

520

329

591

138

Coronary heart disease

Hypertension

Heart failure

Stroke/ TIA

Diabetes

COPD

Depression

Dementia

Multimorbidity analysis at NT level

COPDHypertention

Lipid Metabolism Disorders

Cardiac Arrhythmia

Ischemic Heart Disease

Heart Failure

Peripheral Vascular Disease

Renal Failure

Cerebrovascular Disease

Osteoporosis

Rheumatoid ArthritisEpilepsy

Parkinsons

Multiple Sclerosis

Hypothroidism

Chronic Pancreatitis

Chronic Liver Disease

Cancer

Depression

Bipolar Disorder

Schizophrenia

Dementia and Delirium

-

5,000

10,000

Prevalence of other conditions for pa-tients who have Diabetes (n=10654)*

*NHS Leeds North CCG

I visited my GP 35 times, in the past year

My name is Bob. I suffer from COPD, IHD,

rheumatoid arthritis, high blood pressure, high cholesterol and

depression

The total cost for my healthcare, over the

year, was around £9500

I was admitted to hospital 8 times, which

cost £6000

I was seen by a number of health professionals

and visited the outpatient clinic 19 times

I am between 45-54 years old

Having a care plan will help me feel more

supported to manage my condition

I want to feel more empowered to

manage my condition

Where can I find out about self help courses for people who have long-term conditions?

I want to find out more about my condition. Where are the

best places to do this?

Are there any lifestyle changes I should make to

help my health?

What do our service users say?How do I meet other people

who have the same condition as me? Is there a

local or national support group?I feel I cannot manage my

condition due to lack of information and support

How can I make my condition easier on my family and

friends?

LTC Community of Practice

Integrated Data to Support Service Redesign Decision Making

Leeds LTC YoC Commissioning team

Tricia Cable Mohini Chauhan Alison PhiriYOC Lead YoC Commissioning Manager Business Intelligence Manager

Questions and discussion

www.england.nhs.uk

Date Topic Led by and details of session Venue

4 February10.30 – 3.30

LTC Community of Practice Workshop Please save the date for this workshop - details to follow

Central London

11 February

12.30 – 1.30

Commissioning Integrated models of care:- The South Kent model of care (what it looks like) - Roadmap to delivery - Contracting models and evaluation.

Alison Davis, Integration Programme Health and Social Care, Working on behalf of Kent County Council and South Kent Coast and Thanet CCG'sKent LTC Year of Care Commissioning Early Implementer Site

Via Webex

Click here to register

22 February

12.30 – 1.30

Information Sharing to Support Service Integration:- Centre of Excellence for Information Sharing- Information Sharing user framework- Blueprint for sharing information for integrated care

Mark Golledge, Programme Manager, Health and Care Informatics, Local Gov Association

Via Webex

Click here to register

LTC Community of Practice webinars and workshop: Scan, Focus, Act …

www.england.nhs.uk

Integrated data to support service redesign decision making

Leeds LTC Year of Care Commissioning Early Implementer Site

Tricia Cable, Year of Care LeadAlison Phiri, Business Intelligence ManagerMohini Chauhan, Year of Care Commissioning Manager

Julie Renfrew, LTC Programme NHS England

LTC Community of PracticeTuesday 19 January 2016