Jacquie White, Deputy Director of NHS England Long Term Conditions, Older People & End of Life Care and Claire Cordeaux SIMUL8 Executive Director for Health & Social Care were invited by Centers for Medicare & Medicaid Services to discuss how NHS England work in chronic disease.

1. Population Health Planning in
Chronic Disease:
Measuring the impact of applying a capitated budget for
people living with multi morbidity in NHS England
CMS Measures Forum
May 19, 2016
Jacquie White
Deputy Director for LTC, Older People
& End of Life Care
NHS England
Claire Cordeaux
Executive Director
SIMUL8 Corporation

2. Objectives
The webinar will focus on how the National Health
Service (NHS) in England, UK have been implementing
person-centered care for people with Long Term
Conditions (LTCs) and in particular multi-morbidity.
It will cover:
• The concept and the change programme
• Whole population analysis and identification of target
populations
• Financial instruments to facilitate change
• Models of delivery to support person centred outcomes
• How simulation models have supported decision-making,
and will include a demonstration of simulation models

3. Who are we? NHS England
• Established 1948 to provide good healthcare to all regardless of wealth.
• Free at the point of delivery
• NHS England serves a population of 53.9 million, seeing 1 million patients
every 36 hours and employs more than 1.3 million people including the
following clinical groups:
• 40,236 primary care physicians
• 351,446 nurses
• 18576 ambulance staff
• 111,963 hospital and community health service, medical and dental staff.
• Funding for the NHS comes directly from taxation. For 2015/16, the
overall NHS budget was around £116.4 billion. NHS England is managing
£101.3 billion
• Reformed in 2013 and underpinned by the Health and Social Care Act
2012, the “Five Year Forward View” is the national strategy for healthcare
in England and sets out the system transformation required to meet the
changing needs of current and future patients. Person-centered care is a
key part of the strategy.

4. Who are we? SIMUL8 Corporation
• Established 1994
• Business simulation software
worldwide
• Specialists in health and social care
• Combine healthcare knowledge and software development
to create sector-wide tools
• Close working with NHS since 2008

5. Setting the Scene: Global Changes
Increasing demand for healthcare
• Rise of long term conditions and multi-morbidity: physical
and mental
• Ageing population
• Increasing expectations: access, treatment, cure not care
Supply pressures
• Dependence on system
• Hospital and medic-centric care models
• Workforce – recruitment & retention, ageing, diversity and
culture
• Fragmentation of care in health and to social care
• Crisis curve – late identification of people needing support

6. The Patient at the Center?
A man being treated for heart
failure in UK primary care
rejected the offer to attend a
specialist heart failure clinic to
optimise management of his
condition. He stated that in the
previous two years he had made
54 visits to specialist clinics for
consultant appointments,
diagnostic tests, and treatment.
The equivalent of one full day
every two weeks was devoted to
this work.
BMJ 2009;339:b2803

7. The NHSProgram: the priorities
• Empowering patients and informal caretakers to be full
partners in care
• Whole person focus
• Life course approach to care needs
• Strengthening Primary and Community Care
• Older people with increasingly complex needs including
frailty
• New care models moving away from purely medical,
hospital-centric focus
• Strengthen key enablers – IT, Workforce, Technology
• Need for a new purchaser/provider/funding model

8. The Person at the Center: Changing the
Language Changes Culture
Patient > Person
Chronic Disease > Long Term Conditions
List of Needs > Whole Person
Integrated Care > Coordinated Care
Changing the language helped to reinforce the different behaviours
needed to implement change

9. Long Term Conditions (LTC):
House of Care
NHS Commissioning:
Planning and Paying for
Services for a Population

10. Person-centered Outcomes
Better Health for the
Population
• Access
• Clinical outcomes
• Co-ordination
• Transitions of care
• Urgent care response
Better Care for
Individuals
• Experience of care
• Quality of life and
death
• “Activation” levels
• Goal achievement
Lower Cost Through
Improvement
• Acute care
• Residential care
• Shifts in spend

11. Outcomes and Benefits
• More activated patients have 8% lower costs in the base year and 21%
lower costs in the following year than less activated patients
• Health coaching can yield a 63% cost saving from reduced clinical time,
giving a potential annual saving of £12,438 per FTE from a training cost
of £400
• Coaching and care co-ordination has shown to reduce emergency
admissions by 24%
• Improved medication adherence improves outcomes and yields
efficiencies, for instance in 6000 adults in the UK with Cystic Fibrosis,
could save more than £100 million over 5-years
• Between 20% and 30% of hospital admissions in over 85’s could be
prevented by proactive case finding, frailty assessment, care planning
and use of services outside of hospital

12. Whole Population Analysis
Identifying the population at risk, predicting
need and services required to maintain
independence

13. Identifying the Population

14. Research on People with
Multi-Morbidity
• Research shows that of people with chronic disease, a
third have more than one
• On this basis we should be planning for the needs of
the person, rather than focussing on the single disease
• The following slide shows a graph illustrating this

15. Multi Morbidity is Common

16. Current impact of people with LTCs on
healthcare resource

17. Current impact on Healthcare Resource
ctd.

18. Risk Stratification:
Selecting the cohort
• There are many techniques that
can be used to segment a
population.
• Different segmentation methods
select different people - the
method used should match the
outcomes required
• IT-based intelligence should be
supplemented with humanistic
intelligence
• People in the cohort still need to
be assessed to determine
suitability for inclusion and before
a care plan is developed and
services delivered.

19. Changes in risk profiling over time
Crisis Curve:
• Selected individuals with the most complex care needs demonstrate a
‘crisis curve’ (cost curve).
• They enter a period where they need more non-elective acute care, and
then their health stabilizes.
Death within 12 months:
• A large proportion of individuals selected with the most complex care
needs die within a year of selection – up to 35% of individuals with risk
scores within the top 0.5%
Both of these factors reduce when using multi-morbidity to select the cohort.
Conclusion:
• Risk scores measure historical needs, rather than future needs
• Multi-morbidity appears to select a more stable patient cohort

20. People with Complex Health and Care
Needs Appear to Demonstrate a ‘Crisis
Curve’

21. Current Situation from the Patient and
Carer’s Perspective

22. And…
People living longer but not always well
The larger the number of co-morbidities a patient
has, the lower their quality of life
Increasing evidence on over-treatment and
harm
Social isolation/loneliness a risk factor for
mortality in people over 75 and should be
supported as a co- morbidity

23. What if we set a Capitated
Budget to Facilitate Spend on
Individual Needs rather than
Healthcare Organizations?

24. Selecting the Service Bundle:

25. Emerging Delivery Models
The service models being developed by our sites are
essentially similar but differ to match local conditions.
Similarities include:
• Single point of access
• Care planning and shared care record
• Supported self management
• Care co-ordination
• Community multi-disciplinary team based around primary care,
• Wider neighborhood support including specialist practitioners, therapists
• Recovery, Rehabilitation and Reablement “services”
• Care navigators and voluntary sector as a key enabler.
Differences include:
• Whole population or selected cohorts
• Formation of new organizations
• New delivery models within and across existing organizations

26. Capitated Budgets
Overall aim is to include all services and total cost of care for
cohort with the purpose of incentivising providers to work
together to deliver person centred co-ordinated care
The main issue for setting credible capitated budgets is the management
of risk. Financial risk results from:
• Poor data quality – some services might not be included within the capitated budget if
data quality results in poor budget estimates
• Changes in the use of care over time by selected patients – selection method
important
• Potential for double payment – IT systems and information flows are needed to
support the capitated budget
Changes in the budget need to be managed because:
• The patient cohort will change as individuals die or leave the area and new patients
join
• The needs of individuals will change as their health and social circumstances change
• The patient cohort may grow as more individuals who may benefit from integrated
care are identified

27. Contracts
Contracts are more about relationships than legality.
Currently NHS organisations are constrained to use the NHS
standard contract, but alternative agreements can be used in
parallel with this contract.
There are many contracts being explored and tested by the teams. The
most common are the:
• Alliance contract – requires exceptional relationships between all stakeholder
because all decisions need to be joint decisions
• Prime provider contract – shifts control and management of relationships to
another organisation (who will then need to set up sub-contracts)
• Development of accountable care organisations – organisationally aligning care
Performance monitoring of the contract is based on outcome metrics,
developed by patients, care practitioners and finance with all organisations
accountable for all outcomes.

28. The Total Health and Social Care Cost is
Strongly Related to Multi-morbidity

29. The Role of Simulation

30. Whole System Impact of Change

31. Simulating
the Concept
and Reality

32. Segmenting
Patients

33. How the Simulation Works

34. How the Simulation Works – The Logic

35. Results from a Simulation:
What is the Cost of a Patient Each Year?

36. How do Patients Typically use Services,
What is the Cost and what Resource is
Needed:
Emergency Department Example

37. Person-Centered Care Example:
Extensivist Care and Enhanced Primary Care
• 1.6% of the population assessed as in need of extensive
support
• Person-centered model includes:
• All care co-ordinated by a clinician
• Regular contact with a health and wellbeing support worker to
ensure referral to relevant services
• Patient activated
• Reduces hospital emergency and planned visits
• 36% of population receiving Enhanced Primary Care,
managed by Primary Care Physician with lighter touch:
• Health and wellbeing support
• Support for high intensity users
• Care Co-ordination

38. Return on Investment

39. Extensivist Care Model only

40. Using Simulation Results to:
• Discuss with stakeholders across organizational
boundaries
• Agree a capitated budget for each patient type
• Test the impact of a new model of person-centered
care to:
• Understand the RoI
• Understand financial and resource impact for each
provider

41. Acute to Rehabilitation

42. RRR Audits Identify the Point in the
Acute Patient Pathway that Patients are
Medically fit for Discharge

43. Lesson Learned
Change the payment at the point when the
patient’s needs change –
and not when they change institution.

44. The Simulation

45. Simulation Benefits
 Test before implement (no harm to patients)
 Dissemination of practice and sharing of models of
care
 Supports decisions where no historical data
 Helps to formulate exact models of care and predict
impacts

46. National Roll Out and
Resources

47. National Support and Dissemination
• Virtual facilitation and improvement expertise
• Networking and learning...
• From each other, the early implementer sites
and national experts in various related fields
Through...
• Email updates
• Our website
• Facilitated Webinars with specialist input
• National workshops
• Coaching, facilitation and
improvement expertise
• Networking and
learning…From each other,
and national experts in
various related fields
• Programme funding to
support specific
developments e.g. data
analysis, testing delivery
models
• Simulation – capturing,
sharing and reusing

48. LTC Resources and Tools
NHS LTC program resources are available here:
http://www.nhsiq.nhs.uk/improvement-programmes/long-
term-conditions-and-integrated-care.aspx

49. Access to Simulations
Simulations and resources linked to the simulation can be
accessed at the following link.
http://www.SIMUL8Healthcare.com/chronic_disease

50. Contact Us
Jacquie White
Twitter:
@jaqwhite1 #A4PCC
Email:
Jacquie.white@nhs.net
https://www.england.nhs.uk/re
sources/resources-for-
ccgs/out-frwrk/dom-2/
Claire Cordeaux
Twitter:
@SIMUL8Health
Email:
Claire.c@SIMUL8.com
http://www.SIMUL8Healthcare
.com/chronic_disease