whole systems integrated care pioneer programme

Whole Systems Integrated Care

Living longer and living well

North West London Whole Systems Integrated Care

Meeting with New Zealand Health Economies4th April 2014

Living longer and living well 2

Whole Systems Integrated Care Pioneer Programme

We want to improve the

quality of care for individuals, carers and families,

empowering and supporting people to maintain independence

and to lead full lives as active participants in their community

“

”

People will be empowered to direct their care and support and to receive the care they need in their homes or local community.

GPs will be at the centre of organising and coordinating people’s care.

Our systems will enable and not hinder the provision of integrated care.

… supported by 3 key principles

1

2

3

Our shared vision of whole systems integrated care…


Our track record of working together to design and implement joined up careWe have a strong history of genuine partnerships between health, social care, third sector and patient and user-led organisations across 8 boroughs.

Providers working together & with patients

• Involves community, primary, secondary and social care, mental health, community pharmacy, specialist nursing and third sector (eg. Age UK and Diabetes UK)

• Providers come together to co-create integrated, proactive and personalised care plans

• Monthly multi-disciplinary groups with aim to improve the care of individuals with complex needs

• Active involvement of patients, service users, carers

NW London Integrated Care Pilots

Commissioners working together with providers to change the commissioning framework and delivery model

• Working in partnership with national partners and across Tri-borough

• Business case identified steps to achieving integrated care, such as aligned financial incentives, integrated provider networks, shared information and joint accountability

• Tri-borough and West London Alliance continue to work with Public Service Transformation Network

Tri-borough Whole Place Community Budget Pilot

Outcomes

Evaluation by Imperial College and the Nuffield Trust of the initial stage showed :• 69% of patients felt they had increased involvement in

decision making; • 77% of GPs felt MDGs had improved their knowledge

of patient care

Outcomes

• Estimated potential net acute savings of £38m a year by Yr 5.

• This is primarily driven by a reduction in acute hospital activity, through investment in community and social care services.


Next steps - what is whole systems integrated care?

• Joined up health and social care

• Organise around people’s needs not historic organisational structures

• There is one set of records shared across organisations

• Multidisciplinary home care teams

• Fewer people are treated in hospital, and those that are leave sooner

• More specialist support for management of people in the community

• More investment in primary and community care

• Social care and mental health needs considered holistically with physical health and care needs

• Less spending on acute hospital based care

Care is provided

in the most appropriate

setting

Funding flows to

where it is needed

Care is coordinated around the individual


How will we get there – our ten step plan for North West London


Co-design framework

centrally once

Expressions of interest in being early adopters

and plan locally

All NWL prepares for implementation

and learns from early adopters

Roll out Whole Systems

approach

1 3 42 Whole Systems

integrated care

business as usual

How we get from where we are today to where we want to be in 2015/16

Oct 2013 – Jan 2014

Apr 2014 – Mar 2015

Apr 2015 –

Jan 2014 – Apr 2014

TODAY


Co-design phase – October 2013 to January 2014

This has not been a typical programme!

• 31 partners support our transition towards whole systems integrated care

• Over 150 people engaged in developing and discussing the content

• The programme is organised across five module working groups which collectively have met over 30 times


Embedding Partnerships: Co-design with people and partners as our guiding principle

“Co-production means delivering public services in an equal and reciprocal relationship between professionals, people using services, their families and neighbours… both services and neighbourhoods become far more effective agents of change.”

Nesta & new economics foundation

Our commitment to working co-productively in North West London means:1. Commitment to agreed ways of working – everyone is valued as equal partners, we will

capitalise on lived experience as well as professional learning

2. Supporting development and learning

3. Fostering a supportive environment – developing collective resilience and acknowledging that mistakes will be made along the journey

4. Working towards shared goals – promoting local voice and enabling people to be involved in the delivery of their care and support


We have been working together within the working groups below to tackle the tough questions for integrated care framed around the ten step plan

Population and outcomes

Mostly healthy

Defined episode of care Single LTC

Multiple LTC

Serious and enduring mental illness

Advanced stage organic disordersCancer

Learning disability

Age

0-15 (Children)

Socially excluded groups

16-74

75+

Mostly healthy adults Adults with one or more long term conditions

Adults and elderly people with cancer

Elderly people with one or more long term conditions

1 3 5

4

Adults and elderly people with SEMI

6

Adults and elderly people with learning disabilities

7

Adults and elderly people advanced stage organic disorders

8

Homeless people, alcoholics, drug users

9

2

Mostly healthy elderly people

▪ The programme is not currently focused on integrated care for children▪ There may be innovative care models that we could trial but this would

probably be the focus of a future phase

• Instead of organisations or diseases, which groups of people should we organise care around?

• What are the opportunities to improve care for these people?

• What goals do people in these groups want to achieve?

GP networks

Hospital

CommunityHealth

Social Care

PracticePractice

PracticePractice

Practice Mental Health

Third SectorIntermediate

care

• What services could groups of practices provide better for people if they work together?

• How can these GP groups work with other care providers to deliver better services?

Provider networks

Contracting options

Horizontal governance

Hierarchical governance

Description

Providers come together as equals, requiring some form of multilateral decision-making

An organisation is commissioned to provide services and subcontracts with other providers as needed

No formal contracting

Shared funding for integration activities but no formal ties between providers

Unincorporated ‘club’1

Alliance contracting2

Joint venture model (hub and spoke consortium)

3

Third party broker model

4

Prime contractor model

5

Fully integrated provider organisation

6One organisation

A single organisation is commissioned to provide all services

• What services could groups of providers provide better for people if they work together?

• How can incentives for providers make the right thing to do the easy thing to do?

• How do different providers of care decide to spend money in new ways without damaging existing care?

Commissioningand finance

Sources of financing

Contracting with provider networksLocal authority Pooled

budgets

Evaluating care deliveryCCGs Needs

identification

Sharing risks and savingsNHS England Prioritisation

Contracting with providersPricing and resource allocation

• How can people get better care by not having different organisations paying for care with separate budgets?

• If there were one pot of money how do different commissioners make sure that people are getting the care they want?

Informatics

• What information is needed to provide better services to people?

• What information do commissioners need to make sure people are getting the care they need?

• What do we have and what is missing today?

Embedding Partnerships


Co-design used three ways to group the population of North West London around similar needs

Health and social care commissioners, clinicians, public health experts, the ASHN and lay partners have collaborated to provide professional judgement, statistical data analysis and a review of other models globally.

Review of internationally applied segmentation models

Judgement of multiple professionals and lay partners

In-depth analysis of integrated health and social care data set

Living longerand living well 1

US example of population segmentation

Segment Prevalence Priorities

Healthy~32% Maintenance of health (e.g., prevention,

screening)

Healthy with acute illness

Variable Diagnosis, treatment, early detection of complications

At risk~18% Prevention of disease and complications

Chronically ill~45% Prevention, detection, and treatment of

secondary complications

Complex~5% Prevention of complications, coordinaton

of care

Root Cost:1385.2 N:153687 SD:8.718609e+11

LTCs< 1.5 Cost:798.0117 N:138962 SD:8.718609e+11

LTCs>=1.5 Cost:6926.585 N:14725 SD:6.773154e+11

LTCs< 0.5 Cost:547.0933 N:123338 SD:6.296122e+11

LTCs< 3.5 Cost:5900.64 N:12474 SD:3.766181e+11

LTCs>=3.5 Cost:12611.9 N:2251 SD:2.148090e+11

LTCs>=0.5 Cost:2778.796 N:15624 SD:1.731825e+11

Age< 74.5 Cost:464.8282 N:120584 SD:3.649281e+11

Age>=74.5 Cost:4149.072 N:2754 SD:2.281369e+11

Age< 77.5Cost:2619.463 N:14884 SD:1.044416e+11

Age>=77.5 Cost:5983.555 N:740 SD:6.076288e+10

Dementia_yn=n Cost:5723.384 N:12279 SD:2.833689e+11

LTCs< 5.5 Cost:11790.78 N:1988 SD:1.615568e+11

Dementia_yn=y Cost:17062.27 N:195 SD:6.856999e+10

LTCs>=5.5 Cost:18818.71 N:263 SD:4.177988e+10

LTC

LTC

LTC

Age

Deme-ntia

LTC

Age

Learndisab_yn=n Cost:450.2067 N:120367 SD:3.065684e+11

Learndisab_yn=y Cost:8575.203 N:217 SD:4.406015e+10

Age< 84.5 Cost:3286.481 N:1741 SD:1.040154e+11

Age>=84.5 Cost:5631.572 N:1013 SD:1.205997e+11

LTCs< 2.5 Cost:4929.639 N:8427 SD:1.465033e+11

LTCs>=2.5 Cost:7459.856 N:3852 SD:1.199412e+11

Age>=78.5 Cost:14018.81 N:585 SD:7.842639e+10

Cancer_yn=n Cost:2530.153 N:14478 SD:9.091432e+10

Cancer_yn=y Cost:5804.239 N:406 SD:9.293829e+09

Age< 78.5 Cost:10861.77 N:1403 SD:7.901548e+10

Age< 86.5 Cost:4937.704 N:561 SD:2.891769e+10

Age>=86.5 Cost:9261.335 N:179 SD:2.930843e+10

Age

LD

Cancer

Age

LTC

Age






LTCs>=4.5 Cost:13077.32 N:357 SD:2.449066e+10

LTCs< 4.5 Cost:10105.6 N:1046 SD:5.217435e+10

Cancer

Cancer

Cancer

LTC


1 2 3


Whole Systems approach to population grouping for people with similar needs

Serious and enduring mental illness

Mostly healthy

Defined episode of care

Single LTC

Multiple LTC

Advanced stageorganic brain disordersCancerAge

0-15 Children

16-74

75+

Mostly healthy adults

Adults with one or more long term conditions

Adults and elderly people with cancer

Elderly people with one or more long term conditions

1 3 5

4

Adults and elderly people with SEMI

6Adults and elderly people advanced stage organic disorders

7

2

Mostly healthy elderly people

Socially excluded groups

Homeless people, alcohol and drug depende-ncies

10

Learning disability

Adults and elderly people with learning disabilities

8

Severe physical disability

Adults and elderly people with severe physicaldisabilities

9

▪ The programme is currently not focused on integrated care for children

• Only primary need shown, other needs are also treated• A group has broadly similar needs but care is tailored further• Some services common to all, some unique to group

1 Severe and enduring mental illness2 For example, the homeless, people with alcohol and drug dependenciesSource: Whole Systems Integrated Care module working group


Number of reviews showing positive evidence Additional insight from evidence baseIntervention Average impact1

2. Multi-disciplinary teams

Hospitalisations reduced by 15-30% (inter-quartile range)

81% (13 of 16 reviews) assessed MDTs and found a positive impact

All reviews have concluded that specialised follow up of patients by a multidisciplinary team can reduce hospitalisationHolland et al, Heart, 2005, 91, 899-906

1. Self- empowerment and education

Hospitalisations reduced by 25-30% (inter-quartile range)

83% (20 of 24 reviews) assessed patient support for self-care and found a positive impact

Supported self-management has the strongest effect on clinical outcomes of all IC components when estimated at component-levelTsai et al, Am J Manag Care, 2005 (August), 11(8), 478-88 (Table 4)

3. Care coordination

Hospitalisations reduced by ~37% (pooled estimate only reported in 2 relevant reviews)

57% (8 of 13 reviews) assessed care coordination and found a positive impact

Interventions involving case management reduce HbA1c [in patients with diabetes] by 22% more than interventions without case management.Shojana et al, JAMA, 2006, 296(4), 427-440

4. Individualised care plans2

Hospitalisations reduced by ~23% (pooled estimate only reported in 2 relevant reviews)

64% (7 of 11) reviews) assessed care plans and found a positive impact

Personalised approaches using tailored information influence health behaviour more than uniform approachesGraffy et al, Primary Health Care Research & Development, 2009, 10(3), 210-222

Intervention inclusion criteria Strong, consistent

published evidence of efficacy

Also used in the overwhelming majority of the 13 case studies looked at

1 Impact measured from systematic reviews, including relevant interventions and containing meta-analyses of hospitalisation rate2 Cochrane review of the evidence for personalised care planning (Coulter et al.) currently in processSource: Richardson, Dorling – Global Integrated Care Case Compendium (McKinsey)

Four interventions are based on strong evidence and widely tested


We are now moving into the implementation phase for all of NWL and early adopters

A. ALL OF NWL

B. EARLY ADOPTERS

Pioneer principles Who will complete this

1 People will be empowered to direct their care and support and to receive the care they need in their homes or local community.

2 GPs will be at the centre of organising and coordinating people’s care.

3 Our systems will enable and not hinder the provision of integrated care. Our providers will assume joint accountability for achieving a person’s outcomes and goals and will be required to show how this delivers efficiencies across the system

A

B


Criteria for Whole Systems and “Early Adopters”

Putting people at the centre of care

Embedding Partnerships

Population and Outcomes

Provider networks

Commissioning governance & finance

Information

Use co-production to develop plansCommitment to move to personalisation, self care and use of community capital

Organise care models around people with similar needs

Pool health and social care budgetsOperate shadow capitated budgets

Reallocate money across a care pathway to fund innovative models of care regardless of setting

Establish governance for networks, bringing together different types of providers around a GP registered population

Generate significant savings to system

Identify outcomes to be delivered

Information governance to support this across all providers

Ensure the flow of information to support care delivery, performance management and payment

Agree binding performance management

Agree binding performance management

Early adopters will move further and faster and share learning across NWL and must plan to implement the following criteria for Whole Systems


GP Networks are essential as part of an integrated care system

CommunityCare home

GP practice GP practice

111

999Electivehospital

Local hospital

Major hospital

Hubs & GP networks

HomeCare plan1.…2.…service user


Primary care in the UK is under significant strain…


… and is unable to meet increasing pressures

SOURCE: The Kings Fund

Risingpatient

expectations

Competitionand

procurementlaw

New medical

technologies

Undertakingclinicalcommi-ssioning

Risingprevalenceof chronicdisease

Workforcepressures

Constrainedfundinggrowth

ITdevelopments

Primarycare

Living longer and living well 18SOURCE: GP Patient Survey 2011-12

‘…significant variation in quality and outcomes’

Particular challenges in London

Access to care

Continuity of care

Patient engagement and involve-

ment

Overall patient

experience

1 2

3 4

These challenges are affecting patient experience of primary care services in London


There are many benefits of GPs working in networks

Improved Care Offering

Focus on population health across a geographic region will enable inequalities in health to be addressed

Able to offer extended range of services including new forms of care for groups with the highest need (e.g., elderly with multi-morbidity) and seven day working▪ Freeing up time spent on administration for direct patient care

Economies of Scale

Allows for efficiency gains from sufficient scale such as access to:▪ Specialist skills (e.g., diabetes nurse, consultant geriatrician)▪ Specialist resources (e.g., diagnostic equipment, information systems)▪ Capacity and capability building (e.g. contract bidding)▪ Shared investments (e.g., IT) or joint premises

Coordination with other partners

Build collaborative relationships with wide range of partners (e.g., local government agencies, schools, and charities)

Serve as basis to coordinate with other providers:▪ Acute sector (e.g., for consultants to work in community)▪ Community health and social care services (e.g., for coordination of field-deployed staff)

Opportunities to spread learning e.g., through peer review and joint education activities


Organisational options for GP networks

Horizontal governance: Federated (and Integrated)

One organi-sation: Integrated only

Contracting optionsDescription Service or case example

No formal contracting

Collaboration1▪ GPs do not have formal contracts or organisational structures but agree to cooperate when there are benefits for their population

▪ Nearby GPs opening at different times

Formal cooperation agreements

2▪ GPs come together as equals, and have a contract that sets out how they will work together

▪ Referring patients between practices to specialist GPs

Shared services3▪ GPs set up new and separate organisation, that then provides services to all the member practices

▪ Network funds shared services such as case conferences or diagnostics

4 Practice merger▪ GP Practices merge to create larger scale organisations

▪ Practices merge completely and co-locate their services

Fully integrated primary care company

5▪ A single organisation is commissioned to provide all services, and employs GPs on a salary basis

▪ ChenMed


New networks must think about their purpose, size and membership when deciding on an organisational structure

E.g., networks for education, audit and governance purposes will require a simpler (informal) structure than networks aiming to bid for extended services, out of hours etc. which will require formal legal models e.g. limited company, partnership

1 Purpose

Larger networks will require more complex operating models to manage things such as governance, service delivery, risk, communication, accountability, decision making, engagement, involvement etc.

2 Size

The differing characteristics of individual member practices and there location will affect form – how much discretion, autonomy and choice is required, how much standardisation is possible?

3 Membership

Things to consider


How can GPs legally collaborate and enter into contracts to provide out of hospital services? (1/2)

GP practices are legally independent entities Key question

What is the contract form that is used to commission out of hospital services, as if the GPs are collaborat-ing to provide services, they will need to ensure that the form of collaboration is one that is eligible to enter into the relevant contract?

▪ GP practices in England are usually set up as sole traders, partnerships or companies limited by guarantee or shares

▪ They are independent of the NHS, but are subject to certain eligibility criteria that they must fulfill to hold GMS, PMS or APMS list based primary care contracts

▪ The eligibility criteria differs between the different types of contract, but in broad terms, GP practices are independent organisations with differing legal structures

▪ They are not "NHS bodies" and therefore, unlike NHS provider trusts and Foundation Trusts, are not established by statute or subject to the constraints on their powers of being a statutory body. They are of course subject to external regulation.


How can GPs legally collaborate and enter into contracts to provide out of hospital services? (2/2)

There are three main options for organising contracts between GP practices

1 2 3

Contractual joint ventures

▪ This could be as simple as a light touch agreement between the parties setting out how they will work together to provide certain services (e.g. including sharing premises and staff)

▪ It could also be a more detailed (and more robust) arrangement with details of how the parties will collaborate to provide services, how financial liabilities will be shared and how decisions will be taken by the collaboration

▪ It is possible for GP practices to agree that one GP practice will be the lead provider of certain services, and other GP practices will essentially be sub contractors of the lead provider. The detail of how this lead provider GP network would operate practically could be set out within a contract

Practice Mergers

▪ GP practices could seek to formally merge with each other in order to create larger scale organisations

▪ This would include full operational and management merging, as well as possible co-location of services

▪ Would include merged support staff

Corporate joint ventures

▪ GP practices could seek to set up a new corporate entity that they are all responsible for (either by way of shareholding or membership, for example).

▪ There are a number of different legal forms that this new corporate entity could take, with suitability of the form largely depending on the function and purpose of the new entity.

Any of these forms would enable the GP collaboration to tender collectively for out of hospital services. In each case, the governing documents for the joint venture would set out how the participating practices could refer patients between themselves.


Evolution of a model in practice

Patient Registry

3 axis triangulation

Case management

Ongoing reviews

Cu

rren

t M

od

el

New

Mo

del

Continuous Patient

Improvement

Patient Selection based on known need (by practice)

Care Plan completed once over a year (one off event)

Complex patients brought for case review to an MDG

• Select patient

• Initiate care plan

• Review at MDG

Key New Features3


Updated Structure

Integrated Management Board (IMB)

Harrow Integrated

Management Group (IMG)

Brent Integrated


Hillingdon Integrated


Ealing Integrated


6 Provider Networks

BasedMDGs

4 Provider Networks

Based MDGs

4-6 Provider Networks

Based MDGs

4-7 Provider Networks

Based MDGs

Patient Care Plans

Regional Strategy

CCG Delivery

Locality Delivery

Practice Delivery

• >1 Million

• >300,000

• 50,000

• 2,000 – 20,000

1. Patient Registry

2. Risk Stratification

3. Care Pathways

4. WorkPlanning

5. Care Delivery

6. Case Conferencing

7.Performance Review

High Risk Population

Updated Structure

Total Number• 348,000Community Ward• 6,960

Per NetworkMDG plans• 1740Per Month• 145

Per NetworkMDG annual• 174Per Month• 15

4


1. Patient Registry2. Risk

Stratification

• There is a defined list of who the patients are• From the list, patients are segmented based on need (and history/predicted

utilization)

Patient Registry and Risk Stratification

• Practice defined populations (≈2-3%)

• 3 axis triangulation: BIRT2, Practice and Provider

• Audit those whom they can have an impact on

• Set up a community ward (practice & MDG profile)

• Monitor delivery against agreed patients throughout the year

• Practice self-selected by pathway only

• Frequent flyer information sent to practices

• No risk stratification tool

• Single one off care plan

• MDG meetings twice a month

Cu

rren

t M

od

el

New

Mo

del

Community Ward Evaluation Patient 3 Axis Stratification

Very High Risk (0.5%)

High risk (0.5-5%)

Moderate risk (5-20%)

Low risk (20-50%)

Very low risk (50-100%)

Very High Risk (0.5%)

High risk (0.5-5%)

Moderate risk (5-20%)

Low risk (20-50%)

Very low risk (50-100%)

• >1 LTCs• MH• Dementia• LD• >75• Cancer• ….

Specific changes5


3. Care Pathways4. Work Planning

• An agreed care pathway across multiple professionals based on best evidence• A care plan can be agreed with the patient for targeted support

Care Pathways and Work Planning

• Risk based care plan

• Updated at least 4 times a year

• Incorporates multi-morbidity

• Increase use of SPNs/CMC for 111

• Accessible electronically out of surgery hours

• Pathway specific care plan

• Relies on clinician prioritization of pathway

• No direct interaction with other services

• Care plan accessible only to patient

• No regular review and in-hours access only

Cu

rren

t M

od

el

New

Mo

del

Patient records: GPHospitalCommunity

Patient Medical Information Sharing: include Unscheduled Access

111

Care Plan

1. ….2. ….

Specific changes6


5. Care Delivery6. Case Conferencing

• The defined care delivery providers in the community, e.g. GP and other providers• A means of seeking advice and support for complex patients amongst this cohort

Care Delivery and Case Conferencing

• Risk based delivery of care based on GP network

• Relies on all providers

• MDGs as Community Ward reviews once a month: trigger use of coordinators

• Impact on Ward patients monitored

• Health and Social Care Coordinators supporting patient delivery provide updates to MDGs

• Pathway specific delivery of care

• Relies mainly on the practice and GP

• MDGs happen up to 2 times a month

• Unclear about impact on complex patients

• Minutes noting review and updates only

Cu

rren

t M

od

el

New

Mo

del

Care plan

Action 2

Action 3

Action 1

Action: Review by falls service

Action status: Completed

Integrated Patient Care Planning

Health & Social Care Coordinators

Community Ward MDG

PatientClinician/Provider

MDG

Patient

Clinician/Provider

Care Plan

1. ….

2. ….

Specific changes7


7. Performance Review

• Review of the process looking at standard outcome measures

Performance Review

• Metrics from BIRT2, Practice and other sources

• Practice, MDG and Borough based

• Data on actions from H&SC coordinators

• Reviewed at Community Ward levels

• Metrics from SUS

• Borough based data

• Data input based solely on care planning

• Reviewed at IMG and CCG only

Cu

rren

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od

el

New

Mo

del

GP PRACTICE

HUBS AND GP NETWORKS

BOROUGH

BOROUGH

Specific changes8

whole systems integrated care pioneer programme

Documents

care of individuals

provision of integrated

quality of care

peoples care

social care services

gmt standard timeprinted

personalised care plans

gmt standard timeliving