Long Term ConditionsYear of Care Commissioning Programme

Bev Matthews - Programme Delivery LeadJamie Day - Healthcare Finance and Information Specialist Claire Cordeaux - Executive Director, SIMUL8Healthcare

Context

• 15m people with Long Term Conditions• Increasing each year with ageing population• Responsible for 70% of NHS costs• Significant cause of ED attendance and urgent admission

Driving Policy through Funding Instruments

• A year of care capitation fund for a person living with multiple conditions

• Incentivizing providers and commissioners to work effectively together

• Aligning funding flows and patient need for support• Improving outcomes and efficiency• Reducing emergency care activity

Silo treatment vs. whole person

Sir John Oldham, DH

What if?

• We plan care for people rather than disease?• Are there common patterns of service use?• Can we differentiate groups of patients by need and costs

to create an annual tariff?• Can we work within that tariff to reduce emergencies and

manage care out of hospital?• Where should we intervene to stop progression to multiple

long term conditions?

Launched in June 2012 under Dept of Health QIPP programme

Transferred to NHS England in December 2013

SRO is Dr Martin McShane, Director Domain 2

7 Early Implementer Sites

22 Fast Followers

Background

Early Implementer Sites

Health Economy Early Implementer

Key Partners Regions

Leeds Leeds South and East CCG, Leeds West CCG, Leeds North CCG, North

Southend Southend CCG; Southend Council Midlands and East

Kent Kent County County (Social Services Dept), Kent Community Health Trust, East Kent University Hospital FT, Maidstone Foundation Trust, Darent Valley Hospitals FT, Canterbury CCG, Thanet CCG, Swale CCG, Ashford CCG, South Kent Coast CCG, West Kent CCG, Dartford and Gravesham and Swanley CCG.

South

North Staffordshire and Stoke on Trent

Stoke on Trent CCG, North Staffordshire CCG; Stoke on Trent Council; Staffordshire Joint Commissioning Unit; University Hospital of North Staffordshire; Staffordshire and Stoke on Trent Partnership Trust, North Staffordshire Combined Healthcare Trust; West Midlands Ambulance Trust

Midlands and East

West Hampshire West Hampshire CCG; Hampshire County Council; Hampshire Hospitals NHS FT; Southern Health NHS FT. South

Barking, Havering and Redbridge

Barking and Dagenham CCG; Havering Emerging CCG; Redbridge Emerging CCG; Barking & Dagenham Council; Redbridge Council; Havering Council; NHS Outer North East London; Barking, Dagenham and Redbridge University Hospitals Trust; North East London NHS FT.

London

Kirklees North Kirklees Emerging CCG; Greater Huddersfield CCG; Kirklees Council; NHS Calderdale; Mid Yorkshire Hospitals Trust, Calderdale and Huddersfield FT; Local Community Partnership; South West Yorkshire Partnership; Kirkwood Hospice.

North

Benefits

Improved outcomes and wellbeing:• Patients receive care that is better managed, more seamless across different care

services and more needs focused.• Reduction in acute admissions to hospital; and shorter lengths of stay when these

are required.• Clinical professionals contribute to a more holistic service for patients by working

within an integrated patient-centred care plan

 Local health & Social Care economies: • Provide care that delivers value for money and is better managed by integrated

teams.• Incentive to improve services for patients• Improved joint working and shared responsibility for outcomes

Recovery, rehabilitation & Reablement clinical audit: To support local thinking about RRR and early discharge, particularly in relation to

potential for pathway changes. To assess the appropriateness of methodology for long-term conditions (COPD,

diabetes, stroke and heart failure), particularly whether there is scope to unbundle the RRR service from the Acute Provider PbR tariff.

Costing dataset Support the development of local tariffs for LTC YoC currency Looking at longitudinal data to support the discussions/understand the impact in

changing pathways

Whole Population Gives the evidence to support the currency framework Validates the framework

Data Collections

• Stakeholder engagement and senior team ‘buy-in’ • Assessment of services to maximise the benefit of integrated care • Learn from research, eg models of care, contracting models,

weighting LTCs for local tariff• Planning for improvement in data quality and implementation of

shadow testing• Assessment of systems and processes to support YoC currency• RRR clinical audit• Local analysis and collection of data to support national analysis• Local tariff development• Share learning with other health economies and national

stakeholders

Early Implementer Sites Deliverables

• Senior team ‘buy-in’, eg NCDs• Stakeholder Engagement, eg Monitor and PbR Team• Framework for the Model and vision for future years• SIMUL8 Model for redesigning services• Data analysis and comparison • Programme Management and EI site support • Resolution of barriers, eg Information Governance

National Support Team Deliverables

Using Simulation to Drive Changes in Health and Social Care –

LTC Year of Care Commissioning Programme

Agenda

• What is simulation? • Why use it in

healthcare?• Learning from the data• Simulating long term

conditions for the Year of Care

Where does simulation help?

• Modelling uncertainty• Testing assumptions and their consistency when no

historic data• Considering variability• Driving thinking• Sharing models

Our task

• Create a simulation model• 7 pilot sites• 1 national model to be used locally

Looking for common parameters

What is simulation and why use it?

Models a flow of events

Small scale operations

Service operations

Whole system

Passing of time

Arrivals

Duration of treatment

Time between treatments

Waiting times and bottle necks

Experimentation

What if?....

No risk to patients through pilots

Results

Costs

Resource utilisation

Waiting times

Operating Theatre, Emergency Department, Beds, Disease Pathways, Reconfiguration...

Patients come into a clinic for treatment

They arrive every 5 minutes

The treatment takes 10 minutes

A simple simulation

- What is the likely demand?- How many clinicians do I need?- What is my revenue/cost?- How long are patients waiting?

A simple clinic – a typical week

Benefits of simulation

Risk- FreeUses data intelligentl

y

Increases confidenc

e in decision making

Test and compares potential solutions

More accurate than a

spreadsheet

Models variabili

ty

Simulates the

passing of time

Visual-Engages Stakehol

ders

Planning for Healthcare

How much can I spend?

How much resource

have I got?

What is my demand

likely to be?

How long is it reasonable for patients

to wait?

What are my expected

outcomes?

Financial Winners and Losers

Starting to simulate a new approach

Exacerbation

But……

• No real correlation between risk score and level of need

What the data is telling us

Over 30% of people over 75 years have multimorbidity

Kent whole population data

Multimorbidity is more common than single morbidity

Kent whole population data

The total health and social care cost is strongly related to multimorbidity

Kent whole population data

The main contributors to total health & social care cost are acute non-

elective admissions

Kent whole population data

People with complex health & social care needs appear to demonstrate a

‘crisis curve’

Kent whole population data

More community, mental health and social care services are delivered to

people following a ‘crisis’ than before the ‘crisis’

Kent whole population data

Some indications that an integrated care plan changes the pattern of

services delivered to people

BHR costing data

Implications• Evidence suggests that once people with complex care needs (multimorbidity) are

identified, the services delivered to those people changes• If people with complex care needs could be identified before the ‘crisis curve’,

service changes could be put in place that may prevent some of the non-elective acute care

Year of Care currency incentives• Providers to work together to deliver cost-effective care• Payment based on holistic outcomes not episodes of care

LTC Year of Care programme encourages• Integrated care for a patient-centred and seamless patient pathway• Sharing of evidence to support service change (e.g. SIMUL8)

Current Simulation

• Likelihood of patients accessing services by changing state of patients

– Level of acuity– Increasing numbers of long term condition

How it works

• Patients in each “state” have– A likelihood of accessing certain types of service

(Acute, Community, Mental Health, Social Care), including accessing services more than once

• Costs associated with those services

Results

• Number of patients in each “state” by year• Costs by state per year• Comparison with locally determined tariff

Testing, testing…

• Beta being tested with site data for year 2• Comparing patients cared for by integrated care teams or

not• Tested by sites for usability

What the simulation does…

• Informs question development and data collection• Allows experimentation and hypothesis testing where

no historic data available• Enables research evidence to be applied to policy and

practice development• Shares national assumptions meaningfully at local level• Reduces risks in policy development by generating

evidence for decisions

@NHSIQ

enquiries@nhsiq.nhs.uk

www.nhsiq.nhs.uk

Improving health outcomes across England

by providing improvement and change expertise

Available on NHS Improving Quality Stand

“Integration is a means to an end; the purpose is about better person centred care and better outcomes – it’s about privileging, autonomy, prevention and wellbeing.”

“It’s about two organisations working together with the benefit for users of the services at the heart.”