Long Term Conditions Year of Care Commissioning Programme - Early Implementer Site workshop - 5 October 2015

The slides from a workshop held by the Long Term Conditions Year of Care Commissioning Programme on 5 October 2015.

1. LtC Year of Care Commissioning EIS Project Leads Workshop 5 th October 2015 Central London

2. Our Declaration, My Declaration Taking action to make person-centred care for people with long-term conditions a reality Looking at what needs to change and why we need to change Co-produced with NHS England and Coalition for Collaborative Care and developed with health and care professionals, policy makers and people with long-term conditions   What you can do: Make a commitment embedding patient-centred care in your work at www.engage.england.nhs.uk/survey/ltc-declaration Tell your teams about our work Use the hashtag # A4PCC when you see work that is relevant to person-centred care for people with LTCs Let us know of any events, activities or social media opportunities that we can join forces with you #A4PCC – Action for Person-Centred Care

3. LTC Year of care commissioning West Hampshire EIS

4. West Hampshire Clinical Commissioning Group Kate Smith – Senior Commissioning Manager West Hampshire CCG

5. WHCCG Out of Hospital Strategy; Overview Where are we now Next steps Challenges

6. Overview

7. West Hampshire Out of Hospital Model Proactive Intervention Care navigation via 111 or Care Co-ordinator; care in line with agreed plan Primary care urgent care centres Rapid access to consultant advice Rapid assessment clinics (including diagnostics); Integrated Rapid response & crisis intervention services via SPA Access to community beds (step-up), home treatment and care support including night sitting. Rapid, flexible provision of care packages to meet need End of Life – patients supported to die in place of choice Proactive management by SCAS – enhanced paramedic role Keeping Well: Early Intervention and Effective Care Co-ordination Pro-active risk profiling to identify high risk patients using predictive tools and the combined local intelligence of health and social care professionals Early diagnosis and intervention Person Centred Care Planning with patients and carers as active participants defining priorities, goals, programme implementation, coping strategies, contingency plans for crisis and outcome measures. The use of Personal Health Budgets and direct payments to enable patients greater choice, flexibility and control over their own care and treatment Care planning to include self-care and supported self-management programmes to put the patient and their carers in control of their condition. This can include the use of assisted living technology and virtual intervention tools such as telehealthcare. Utilisation of community support and third sector services , particularly where patients are isolated and have no viable carer Care Co-ordination by named Case Manager; Telephone access to support as needed Care co-ordination is a holistic model, delivered by skilled health and social care practitioners in partnership with patients, carers and their GP Admitting patients to hospital should be a last resort; with the majority of care provided in the community. Community services need to be responsive to proactively meet changing need If admission to an acute hospital is required, patients should only remain in hospital for the acute phase of their illness, with timely transfer or discharge. Patients should be supported to return home Supporting Recovery Strengthened Community Pull ; hospital in-reach supported by ‘Daily Alert’ information Community beds (step-down) with early supported discharge either within or as close to a patients home as possible; ICTs able to direct use of community beds & out of hospital services Care packages to be quickly reinstated, adapted to meet changing need or set up via pooled budget Personal care and Welcome Home services West Hampshire Out of Hospital Model

8. Eastleigh & Test Valley Parkside Boyatt Wd St Andrews Pineview Leighside Eastleigh Chandlers Ford Park & St Francis Fryern Brownhill IICTs GP Practices Eastleigh Southern Parishes Romsey Blackthorn Burseldon Hedge End West End St Lukes Alma Rd Abbey Md Night-ingale North- Baddesley Andover 1 Andover 2 Avon Valley Totton & Lyndhurst Friarsgate St Pauls St Clements Gratton Stockbridge Whitchurch Lymington Shepherd’s-Spring Derrydown Adelaide St Mary’s Charlton- Hill Andover Totton Testvale Forest Gate Lyndhurst Fording-bridge Ringwood Corner-ways New Milton Winchester Andover Totton/Waterside Sway/ Brockenhurst Chawton Wistaria & Milford Barton N.Milton Arne-wood Twin-Oaks Winchester City Winchester Rural North Winchester Rural South B . Waltham Twyford Wickham Stokewood Old Anchor Winchester Rural East Alresford Mansfield West Meon Waterside Waterside Forestside Water-front & Solent West New Forest Eastleigh A Community Based Approach to Integrated Care Community Support Integrated Care Team GP Practice Network Community based, primary care co-located model Our approach: 15 Integrated Care Teams (ICTs) covering 6 Localities Teams are co-located and work with a network of practices to foster meaningful partnerships Each Team covers a population of around 30,000 – 50,000 The core team consists of health and social care professionals including primary care, community nurses, therapists, social workers, and Older Persons Mental Health liaison workers. Each team has a named link Consultant Geriatrician The wider team consists of specialist services Integrated Care Teams are rooted in communities – they know and understand their community and actively engage local voluntary organisations and support networks. ICTs provide a continuum of care based on individual need West Hampshire Localities Specialist Services

9. National Voices definition of integrated care as meaning person centred, coordinated care: “I can plan my care with people who work together to understand me and my carer (s), allow me control, and bring together services to achieve the outcomes important to me”

10. Supporting Recovery and Maximising Independence Integrated Care Team Community Beds – Core Offer “ ERS@H is not appropriate clinically / safe” Enhanced Recovery and Support @ Home “Time limited support designed around an individual to support recovery and maximise independence” At home or Recovery Clinics Acute Trust “Patients ONLY in Acute Trust for minimal time required for acute phase” Complex Needs Assessment “Rapid assessment and diagnosis – signposting” Clinical Triage / SPA Health and Wellbeing – links with 3 rd Sector Principles of Core Delivery Model: The right care will be provided at the right time and in the right place Care will be personalised and tailored to meet individual health and social need A recovery culture , with people supported to maximise their independence Care will be delivered locally either at home or as close to home as possible No patient will be admitted to a bed who could safely be supported at home. Care at home will always be the default for care delivery Patients will only remain in an acute hospital for the acute phase of their illness Decisions about long term care needs will not be made in an acute setting Care will be delivered by integrated health and social care teams that are co-located and work with a network of Practices, with access to specialist support ‘Community Pull’

11. For Patients and Carers: Our Patient Offer

12. For GPs and Community Services Becoming more proactive in identifying people that are becoming frail and vulnerable, rather than waiting for crisis A single point of access through which to make referrals A standard approach to care planning, including the sharing of plans, of agreeing the content of plans and lead worker through structured whiteboard meetings Access to a range of services to maintain people in their own homes Improved communication and joint working with a greater understanding of each others roles Less duplication

13. Where are we now

14. Programme 1: Early Intervention and Effective Care Co-ordination Key Work Streams Description Timescales Integrated Care Team Development Programme Develop the core Integrated Care Team and understanding of each others roles and responsibilities; ensure shared understanding of integrated care and embed key components of integrated working in line with the ‘What Does Good Look Like Framework’ Delivery facilitated through bi-monthly ICT meetings & ICT workshops; All people 75 years and over to have a named accountable GP Bypass numbers established for Ambulance, A&E and care home staff Risk Stratification: Case management register established of patients identified at high risk of admission (minimum 2% registered adults); Same day telephone consultations established; Patients notified of accountable GP and care coordinator Personalised care plans developed and in place Jun 2014 Sep 2014 Transformation Fund Established to support Practices in transforming the care of older people aged 75 and over and those with complex needs. Four Transformation Fund proposals to be implemented over 12 months. Enables innovative models to be tested and if successful, embedded in integrated care delivery models Apr-15 Building Blocks to Integration (CQUINs) Care management & care co-ordination: Develop, agree, implement model Personalised Care Planning : Agree a single process, documentation and way of sharing plans (including urgent and end of life care plans) via HHR Scope implementation costs and timescales for delivery Self-management and shared decision making : Development of self-management models and processes and roll-out to ICTs Mar-15 Dec-14 Jan-15 Mar-15 Care Homes Strategy Development of Care Home Strategy (with Quality Team) Sep-15 Care Pathways Review and redesign of wound care, falls and continence pathways Sep-15 Programme 1: Early Intervention and Effective Care Co-ordination

15. Programme 2: Proactive Intervention Key Work Streams Description Timescales Integrated Rapid Response Service There are currently two rapid response services provided by health (via CCTs) and social care (CRT), with different referral routes. Development of Integrated Rapid Response model accessed via a single point of access Sep-15 Community Geriatrician To ensure greater access to consultant geriatrician advice and assessment for complex patients; recruitment to additional posts in line with agreed service specification Agree alternative models with localities where recruitment unsuccessful and timescales for delivery Nov-14 Mar-15 Rapid Assessment Units Review of current provision to ensure improved access to consultant advice and rapid assessment Mar-15 End of Life Care Development of the End of Life Care Strategy and implementation plan Implementation of End of Life Incentive Scheme – to include Clinical Leadership, patient identification and after death analysis Roll-out Marie Curie project and undertake full evaluation to inform future commissioning strategy Ensure sustained provision of Andover Hospice at Home Service and full evaluation of model to inform future commissioning strategy Jun-15 Mar-15 Mar-15 Nov-14 – Mar-15 Programme 2: Proactive Intervention

16. Programme 3: Supporting Recovery Key Work Streams Description Timescales Intermediate Care and Reablement Services Redesign of intermediate care and reablement services – enhanced support and recovery at home and universal admission criteria to community beds Consultation and phased implementation Oct-14 – Mar-15 Mar-16 Care at Home (HCC) To procure a new Care at Home Model and contractual framework. Providers to work as an integral part of ICTs who will direct resource: Develop new service specification Complete procurement framework process and award contracts New service mobilisation Dec-13 Nov-14 Apr-15 Day Care To procure a new Day Care Service model To map current provision of Day Care Centres, wound café’s, health and well-being centres and explore opportunity for co-locating services into community well-being hubs Mar-15 Mar-15 Discharge and Community Pull Move to a strengthened community pull model to facilitate timely discharge: Development of Trusted Assessment – development and roll out of implementation plan Sustained delivery of In-reach Co-ordinators and roll-out to MAU and T&O wards via winter resilience bids Review of social care discharge team and integration within ICTs; agree model and implementation plan with agreed timescales for delivery Sep-14 – Mar-15 Oct-14 – Mar-15 Jun-15 Programme 3: Supporting Recovery

17. Next steps

18. Outcomes dashboard Evaluating impact - discovery interviews ICT Peer review Workforce development – Every Community Contact Counts Proactive care models – Transformation fund Federation focus New models of care – Vanguard – Primary Care Access Centre MCP provider development

19. Monitoring Effectiveness; Demonstrating Success Strategic Aims Objectives Key performance indicators OUTCOME People receive the right care in the right place and the right time Maintain constant focus on long term quality of care and the achievement of outcomes for users Reductions in permanent admissions to residential and nursing care, per 100,000 population Reduction in non-elective emergency admissions (targeted HRGs); reduction in average LoS Reduction in the number of excess bed days Reduction in delayed transfers of care Increased numbers of discharges across 7 days Achieve long term quality outcomes Ensure fairness and equality in broader context underpins every decision we make Give service users and their families choice and control over their own outcomes Promoting greater care co-ordination Increase self sufficiency and independence, avoiding reliance on services wherever possible and improving overall experience Increased numbers of people having health and care needs met closer to or within their own home Increased use of self-directed support and use of personal health budgets Increased numbers of people dying in their preferred place of care Evidence of development of personalised care plans and that people are supported to determine options and are involved in setting and achieving their own goals Increased patient satisfaction Increased GP and staff satisfaction Ensure our services meet demand Work collaboratively to deliver integrated care services that promote independence and recovery Protect the sustainability of services to meet current and future demographic, financial and statutory requirements Minimum of 65% of service users return home after a period of rehabilitation/ reablement Ensure our system is financially sustainable Monitoring Effectiveness; Demonstrating Success

20. Challenges

21. Evaluation, measuring impact Engagement and relationships System focus Capacity and capability New models of care……..

22. Care Coordination Local approaches

23. Operational January 2015, Core Staff Recruited, Patients No increasing

24. Health 1000 Health 1000 is a new primary care provider organisation operating a new model of care as part of the Prime Minister’s Challenge Fund supporting people with 5 or more LTCs from BHR practices. It has a clinical model which includes input from BHRUT, North East London NHS Foundation Trust, Barts NHS Trust, and the social care services of the co terminus London Boroughs. The service exists in primary care but incorporates specialists “tailored” to individual needs. People consenting to take part are being de registered from their GP and registered with the Practice and receive a refreshed care plan and a tailored team (including GP, nurse, social care and consultant specialists) Age UK RBH is working as part of the Multidisciplinary team supporting a cohort of 500 people with multiple LTCs using the Age UK Integrated Care Model.

25. Project Background In developing Health 1000, the work with potential service users and their families revealed that people have difficulties in accessing services to manage their own conditions and meet their needs due to: Lack of information Fragmented options “We feel helpless trying to get the best for our mum” “I just want to be able to go fishing” “The professionals don’t understand all my needs”

26. Age UK Integrated Care Programme It operates across England and brings together voluntary organisations and health and care services in local areas to provide an innovative combination of medical and non-medical support for older people with long term conditions at risk of recurring hospital admissions. Through the programme Age UK staff and volunteers become members of primary care led multi-disciplinary teams providing care in the local community. The pathfinder for the programme has been underway in Cornwall since 2012 and early results have been highly promising.

27. Aims of the Age UK Integrated Care Programme Improve the health and wellbeing outcomes for older people with long-term conditions who experience high numbers of avoidable hospital admissions. Deliver cost savings and help alleviate financial pressures in the local health and social care economy. Support and deliver transformational whole system change by demonstrating how GPs, community care, hospitals, social care and the voluntary sector can work together with the older person at the centre.

28. BHR Care Navigator Pilot The pilot is funded for 2 years by Redbridge, Barking and Havering CCGs and Age UK. The team delivering the pilot includes one Team Leader and 3 Care Navigators. In addition, we aim to recruit 10 volunteers in the first year to support patients . The Care Navigators are fully integrated with the Health 1000 team and take part in weekly MDT meetings. The pilot has started at the end of August 2015 and so far 39 Clients have had guided conversations and have started receiving support from the project.

29. How Does it Work? Care Navigators carry out a person centred guided conversation with patients which covers aspects such as personal history, living arrangements, financial situation, support received, likes and dislikes, personal interests, etc. Client goals are identified through the guided conversation which are then translated into a support plan . The emphasis of the project is to shift the clients’ focus from their health condition to pursuing their interests, becoming more engaged with their community and developing a good network of support. Type of support for client may include referrals to other services such as befriending, arranging outings, developing new activities, peer networks, etc.

30. Early Outcomes Improving client’s wellbeing by supporting him to achieve his goal to go fly fishing. S upporting client to regain confidence in going out and increase independence by assisting them to go out shopping and attend a social club at the Punjabi Centre. Coordinating and organising day centre attendance and carer respite. Supporting clients and carers to access services such as Advice and Information, Befriending Services, Re- ablement , Community Treatment Team, Care Line, Dementia Services, disabled swimming facilities, etc. Liaising with Health 1000 Practitioners to enable referrals for OT assessments, Podiatry Services, Counselling, Dietician support, memory assessments, hearing tests, social care assessments, etc.

31. Case study continued The first patient for H ealth 1000 he is an amazing character and likes to support the practice as much as he can. He lost his wife 3 years ago which sent him into a depression and felt he was losing control. His illnesses made things worst in turn having to rely on his family to support him. His son moved in to live with him. He has lived in his community for 20+ years and felt he was losing touch of what was around him. He was feeling isolated. He used to be head Forman on building sites and was the man to know who helped everyone in the neighbourhood. His passion was fishing but as he didn’t like eating it!

32. Case study When Age UK RBH met him he was very positive about his experience with Health 1000 and wanted to do anything he could to be more involved.  This is where Fly fishing came up and the possibility of make a group led by him. We had to find out and source this which took a number of weeks but we finally contacted an organisation who could help and we arranged for to do what he loved most. He didn’t stop smiling the whole day he pushed himself and caught 4 trout. He was tried but happy and after a pub lunch he said this was the best day he had had since before his wife died. He is now getting ready to be the lead fisherman for Health 1000 fly fishing group. Patients’ son provided feedback to the patient’s GP that since using Health 1000 his father was feeling better, his medical condition had improved and he was happier and felt supported.

33. Developing Stakeholder Outcomes Martin Ware m [email protected]

34. Based on Work in Staffordshire 2011 - 2014 We wanted to answer the question: If we are commissioning for outcomes, what outcomes do we want to achieve?

35. Process – Different Perspectives Does everyone have the same view? We sought to test this through a series of 9 workshops

36. Process – Four Key Groups 1 Workshop 1 Workshop 1 Workshop 6 Workshop

37. Process – Four Key Groups Surprisingly similar outcomes Mostly quantitative Very similar themes between the six workshops and mostly qualitative in nature

38. Outcomes – Patients / Public 1 of 2 Avoid Crisis Focus on all of the ‘individuals’ needs Value and support Carers Continuity of Care Single coordinator of care (case mgt ) Proactive/Preventive planning Improved Hospital Discharge process Equality of Access for all (e.g. dDeaflinks ) Improve Community Services and links with third sector Improvements in the short term/Pace of change Improved working between all agencies

39. Outcomes – Patients / Public 2 of 2 Improved Timeliness of and access to services Improved Access to GPs (Appointments, times and services offered) Improved quality of Dom Care provision (Care, Timing and reliability) Improved access to information (method/location and type) Improved Communication around pathways Address the confidence in health and Social Care provision (media bombardment) Improve all urgent care services across the board Remove confusion over WIC/MIU service provision Improve the sharing of patient data to support the patients/Carers Contracting Innovation (e.g. providers becomes longer term) More support for those who can and want to self-manage

40. Outcomes – Health Professionals Avoid Crisis (Reduced Acute and ambulance activity) Improve Customer Experience Clear/Protocols and Experience (Ease of Referral for GPs ) Improved Strategic Reporting/System Assurance Improved Performance Management (Individual providers and whole pathways) Improve timeliness of and access to services (Right First Time) Move to 24/7 service Improved flow to reablement and Social Care Early Intervention Quality Dom Care / Quality of Residential Care Better Information Sharing of patient data across providers LHE System efficiencies (E.g. Reduction in beds utilised etc..) More Care at Home Improved Community Diagnostics Improved LHE Overall financial position

41. Next Steps Outcomes Design of Service How to measure success What Metrics? What targets? Don’t forget the qualitative aspects! Outcome based commissioning Or Commissioning for Outcomes?

42. Scott Bennett [email protected] 07769697413 [email protected]

43. Coordinated community care models Shaping care around communities in line with needs and assets

44. Video

45. A Matched Control – Our approach Match using 6 x living well key LTCs g ender age u se of services in 6months pre-guided conversation Match group specific to each Living Well cohort member Match from Penwith GP registered population only Matched GP practice activity to retain a single match group for each member of the Living Well cohort Vary age until 10 matches found max +- 5 years Compared 6 months pre intervention to up to 6 months post intervention Filtered out those without matches in the background population, and t hose without 3 months post-intervention represented in the dataset

46. Emergency Admissions Living Well Group Control Group 20.8% 3.8% Financial Impact £1,577 per patient p.a. 24.6% £35 Million

47. Elective Admissions Living Well Group Control Group 21.1 % 26.8% Financial Impact £460 per patient p.a. 5 .7% £11 Million

48. ED Attendances Living Well Group Control Group 20.8% 5.9% Financial Impact £21 per patient p.a. 26.7% £0.5 Million

49. All Admissions Living Well Group Control Group 10.7% 31.8% Financial Impact £670 per patient p.a. 21.1% £15 Million

50. Primary Care Usage Living Well Group Control Group 36.6% 49.3% Financial Impact 1.7 more practice contacts per patient p.a. 12.7%

51. Conclusions Five Year Forward View Closing the Care and Quality Gap Closing the Health Gap Closing the funding and efficiency Gap Triple Aim (IHI) Improved Health and Wellbeing Improved Experience of Care and Support Reduced cost of C are and Support

52. Conclusions Five Year Forward View Closing the Care and Quality Gap ✓ Closing the Health Gap Closing the funding and efficiency Gap Triple Aim (IHI) Improved Health and Wellbeing ✓ Improved Experience of Care and Support Reduced cost of Care and Support

53. Conclusions Five Year Forward View Closing the Care and Quality Gap ✓ Closing the Health Gap ✓ Closing the funding and efficiency Gap Triple Aim (IHI) Improved Health and Wellbeing ✓ Improved Experience of Care and Support ✓ Reduced cost of Care and Support

54. Conclusions Five Year Forward View Closing the Care and Quality Gap ✓ Closing the Health Gap ✓ Closing the funding and efficiency Gap ✓ Triple Aim (IHI) Improved Health and Wellbeing ✓ Improved Experience of Care and Support ✓ Reduced cost of Care and Support ✓