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Enhancing care by Sharing Data and Information
Abraham George, Consultant in Public Health/Assistant Director of Public Health, Kent County Council
Jochen Worsley, Head of Long Term Conditions, East Kent Federation of CCGs
Bruce Pollington, Deputy Medical Director, Kent Community Health Trust/Chief Clinical Information Officer
at Kent Integration Pioneer
5%
20%
75%
The scale of the problem and the cost
45%
40%
15%
Multiple complex conditions
Single LTC/ at risk
Healthy / minor risk
Population segments Cost
Commissioning in silos
• All PbR (except YoC or
package currencies)
Acute Community Mental Health Social Care Voluntary/ Independent
Primary care
Primary care prescribing
NHS England as commissioner
• Non-PbR block contract
• PbR excl drugs• Crit. Care
Personal healthcare
budget
Specialised MH Services
Means-tested
services (incl. residential)
Within currency
Rehabilitation palliative & end of life
Maternity pathway
• Reablement• Adult Services
PbR MH clusters
Children’s services
GP services
Include if possible
Residential continuing care
(Include if possible)
Include if possible
How we created our Year of Care currency
• Risk stratification tool applied• LTC codes applied (18 in total - QoF)• List segmented by LTC currency (Bands B – E applied -
B=2,C=3-5,D=6-8,E=9), • Risk Score over time mapped (looking for rise in risk
score in last 6 mths – 4 of 6 show an increase) or • Rapid Riser in last 3 mths (mthly increase in risk score
over past 3 mths and overall increase of >15pts).• Kent – 80 GP practices, Band B = 2197, Band C= 3506,
Band D =261, Band E= 5 Total 6369 of 729, 275• Now driving increased engagement in risk stratification
Identifying patients suitable for YoC
Issues highlightedGap Identified by Date identified Action
No standard definitions for Integrated Care service across system
EK PG Jan 2014 Flag to WK and link to Integrated Care plan work
No method to share care plans once MDT completed. (Not even seen by GPs)
EK Project Group Feb 2014 Flag to SRO
Not all practices submitting data to HISBi
EK PG WK PG
April 2014 May 2014
Flag to SROOngoing
PLICS and RiO system in KMPT not flowing data correctly
KMPT when requested to submit first data submission
June 2014 Resolved by KMPT
No standard definition for integrated care within KCHT
Impact identified by Programme on YoC ability to assess impact of ITC services V’s WP
July 2014 PM worked with KCHT to standardise definition. Recording process agreed Sept 2014
Variable in recording practice of GP codes in Non –NHS data
Programme when we introduced “black box” solution
Sept 2014 Highlighted to organisations. With 3rd sector provided list to facilitate update.
The Year of Care dashboard has so far presented 4 months of activity and costs worth £57 million from 7 different provider organisations. Of this £4 million (7% of total spend) represents the proportionate costs for the YOC cohort (0.3% of total population).
YoC & the wider context• Shift from service orientated Integrated Care as
the definition to Patient focused Integrated Care Plan (ICP).
• The YoC Cohort identified in primary care for ICP• Changing behaviour to meeting patients needs
and wishes and not the services ability to deliver. • Plans shared system wide using the developing
Care Plan Management system • Developed with and visible to the patients. • Their wishes, their plan.
“Year of Care is a vital component of Kent’s Integration Pioneer Programme – with findings being used to underpin Kent’s Better Care Fund” Jo Frazer – Kent Pioneer Programme Manager
- “If this works that’s my job done”- -CCG Head of Finance
“This is the first group I have been part of that has moved so far so fast”-AD Finance Provider
“The intelligence from YOC is both informing our thinking on a more progressive contracting approach incentivising real service integration”- Hazel Carpenter, Accountable Officer CCG
“Kent have been successful in linking their transformation of services with commissioning through the LTC Year of Care programme which will make that step towards individualised care for people with complex needs.” Beverley Matthews, LTC Programme Lead, NHSIQ
“The year of care programme has been a great enabler in helping us focus upon and design a holistic ‘health and social care’ model around individual clients rather than individual disease pathways in a value added, integrated manner.”- Sanjay Singh Chief GP Commissioner West Kent CCG