integrating predictive modelling into a whole system approach · integrating . predictive modelling...

Virtual Wards and the

NHS Devon/NEW Devon CCG Experience

Integrating Predictive Modelling into a Whole System approach

Todd Chenore Clinical Informatics NEW Devon CCG

Virtual Wards

Virtual Ward = P redic tive Modelling + Multi-dis c iplinary C as e-Management

Complex Care Teams

Developed under DH POPPS Project - started October

2008 in North Devon

23 to cover NHS Devon pop. c770,000 (now c1.2 million)

Case Management core to proposed function

Integrated Health and Social Care Team

Common Geographical coverage and base

Linked to specified GP Practices (104 in total, now 161)

Predictive modelling in Devon • Started with PARR and PARR++

• Implemented CPM in house for 2008/09 start of virtual ward pilot

• Built DPM in house for 2010/11 at very low relative cost

• Incorporated local datasets like ambulance, OOH, registration duration (deprivation, social care, etc.)

• Improved predictive power

Number (%) patients in ‘at risk’ group predicted by the model who had an emergency admission within 12

months

‘At risk’ sub-group Combined Predictive Model (CPM)

Devon Predictive Model (DPM)

200 top-ranked patients (0·03% of registered population) 143/200 (71.5%) 173/200 (86.5%)





From Chenore T. et al 2013

Devon-Wide Roll-out

Identified as QIPP plan for Urgent Care Devon-wide

Aim to integrate into CCTs

Roll-out commenced 2010/11

Stage 1- Establish (2010/11) Sign up to Devon Predictive Model

Year 1 CQUIN LES Funded

Payment to practices by volume (to limit)

Identify target patients and assign a case-manager (Read

Code)

Produce Out of Hours Special Message- active on DDOC

Adastra

Devon-Wide Roll-out Stage 2 - Exert Control on high-risk Group (2011/12)

Sign up to Devon Predictive Model

Year 2 CQUIN LES Funded

Payment to practices by % Bed-state (of bed number limit)

Full payment- 85% High /Very High Risk and 80% Occupancy over the

year

Identify target patients and assign a case-manager (Read Code)

Produce Out of Hours Special Message- active on DDOC Adastra

Devon P redic tive Model 85%

Direc t R eferral 15%

3-4 Months Input LTC S elf-Management, E duc ation, S oc ial etc (75-80%)

P rolonged Admis s ion 12-18 months (20-25%)

Virtual Ward

Devon-Wide Roll-out

Stage 3 - Maximise Impact & Responsiveness (2012/13) Year 3 CQUIN LES Funded

Payment to practices by % Bed-state (of bed number limit) and Top 0.5%

percentage

Ensure named Lead GP in each Practice

Monthly Bed-state meetings

Share DPM results access with CCT Team

Ensure Project Support Role in place from Locality Commissioning Team

Embed and make routine part of work and roles

Cope with changes in CCG and membership

Next Stages

Stage 4 - Upstream targeting Evolve Model and additional functionality in the Virtual Wards to

identify those at point of take-off (Popcorn Theory)

Gaps in care

Avoidable admissions (ACS conditions)

Threshold models and those not appropriate for the service

A B

integrating predictive modelling into a whole system approach · integrating . predictive modelling...

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