Andrew Webster: person-centred co-ordinated care - London's progress and learning
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Andrew Webster looks at integrated care in the tri-borough of Westminster, Hammersmith and Fulham and Kensington and Chelsea . The councils are one of four areas in the country to be given special `Community Budget pilot' status by the government to develop radical plans for public service redesign.
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Andrew Webster: person-centred co-ordinated care - London's progress and learning
- 1. Person-centred, co-ordinated care London’s progress and learning
- 2. |McKinsey & Company London is developing integrated care systems that serve whole populations 2 Bromley Croydon Barking and Dagenham Barnet Bexley Brent Camden Ealing Enfield Greenwich City & Hackney H&F Haringey Harrow Havering Hounslow Islington K&C Lambeth Lewisham Newham Redbridge Richmond Tower Hamlets Waltham Forest Wandsworth Westminster Southwark Hillingdon Kingston Merton Sutton Waltham Forest and East London • 3 Clinical Commissioning Groups • 3 local authorities • 1 acute trust • 3 community providers • 193 GP practices • Population: 910,000 Barking and Dagenham, Havering and Redbridge • 3 Clinical Commissioning Groups • 3 local authorities • 2 acute trusts • 1 mental health and community provider • 142 GP practices • Population: 660,000 Outer North West London • 4 Clinical Commissioning Groups • 4 local authorities • 3 acute trusts • 2 mental health trusts • 2 community provider • 231 GP practices (193 co- opted) • Population: 1.2million (whole population covered, with 113k receiving specific interventions) Croydon •1 Clinical Commissioning Group •1 local authority • 1 acute trust • 1 mental health trusts • 1 community providers • 61 GP practices • Population: 381,010 Greenwich • 1 Clinical Commissioning Groups • 1 local authority • 1 acute trust • 1 mental health/community provider • 47 GP practices • Population: 277,710 Inner North West London • 4 Clinical Commissioning Groups • 4 local authorities • 2 acute trusts • 2 mental health trusts • 2 community providers • 184 GP practices (92 co- opted) • Population: 889k (470k covered, 21k with a care plan) Kings Health Partners • 2 Clinical Commissioning Groups • 2 local authorities • 2 acute trusts • 1 mental health trusts •1 community provider • 95 GP practices (56 co-opted) • Population: 600k (400k covered in full, remaining 200k by CMDTs London Cancer N&E • 12 Clinical Commissioning Groups • 12 Acute Trusts • Population: 3.3m London Cancer Alliance S&W • 20 Clinical Commissioning Groups • 17 Acute Trusts • Population: 3.9m Borough-level projects
- 3. |McKinsey & Company Our proposal for whole system integration gives health and social care commissioners the opportunity to define a new joint commissioning framework and to transform the way providers work together to deliver high quality integrated care 3 Potential feature Carer Multi-skilled health and social care worker (for high risk/dependence)Family Personalised patient care Personalised patient care Multi-agency provider coordination Multi-agency provider coordination Information systems Information systems Reimburse- ment Governanc e GP Practice Impact Capitated budget Capitated budget ▪ Incentivises proactive and preventative care to avoid unnecessary admissions Pooled health and social care resources Pooled health and social care resources ▪ Creates flexibility to redesign delivery model to make doing the right thing the right thing to do Provider networks Provider networks ▪ Encourages joint decision making based on shared systems, records and governance Care coordinators Care coordinators ▪ Manages patient care plan, out of hospital support and discharge from hospitals Shared staffingShared staffing ▪ Allows new specialist roles shared across providers, e.g., health and social care workers Micro- commissioning Micro- commissioning ▪ Ensures rapid, targeted response to patient/users need rather than delays triggering admissions Personalised response Personalised response ▪ Tailors care to individual, e.g., 30 minutes with the same GP each month, not 10 minutes a week Care Coordinator Community care Specialist care Mental health Third sector Housing Employment Probation Patient/ User Education Reablement Assistive technology Support services Care at home Supporting platform
- 4. |McKinsey & Company Contracted on casemix based on client needs/complexity Provider Network level “provision entities” Community care Social care Mental health Primary care practices …into out of hospital provider networks… Reimbursement Fee Management services …with a fixed capitation for all out of hospital services, acute and management costs. Capitation allocated to cover provider activity Community care Social care Mental health Primary care - - = Provider savings (or risk) Block contract or network agreed tariff Outpatient / A&E / UCC / Dx Any planned acute admissions PbR tariff Scope Focus on top three highest risk cohorts… Overall population ▪ 466,921population ▪ Approx £413m healthcare spend ▪ Approx £177m social care spend ▪ Average per capita spend £1,090 Focus ▪ 103,000 people ▪ £454m total spend ▪ Average per capita spend £4,407 Out of focus ▪ 364,000 people ▪ £136m total spend ▪ Average per capita spend £374 Commissioning Local Authority CCGs ▪ Pooled budget net of LA/CCG savings for whole system IC paid as capitation (average £145m per borough) ▪ Locks in required savings for commissioner balance and lower future growth rate ▪ £154m social care funding for target population ▪ Average £51m per borough ▪ Top sliced by 4% for reducing ASC budget £147m ▪ £300m health care funding for target population ▪ Average £100m per CCG ▪ Top sliced by 4% leaves £288m …pooling budgets from health and social care… Example figures for each JV/LLP (if 10 across tri- borough as example) • 10,300 target population from Network size of approx 50,000 Total revenues ▪ £28,8m health care ▪ £14.7m social care Budget per capita ▪ £2,796 health care ▪ £1,427 social care - Integrated long term care at home packages Acute: A&E,NEL, specialist Residential/ Nursing Home (PBR Tariff)
- 5. Who are we doing this for? Joan Lives on her own and has a personality disorder Frank Recently bereaved, suffers from chronic obstructive pulmonary disease
- 6. 6 Care for people with manageable long term conditions “Care at short notice” for this population Care for people with very complex needs Low risk (20-50%) Very low risk (50-100%) Very high risk High risk (0.5-5%) Moderate risk (5-20%) Description ▪ Ask the top 0.5% of the population (10 people per GP, 250 people per network, ~4,400 people across the patch) to opt into a special programme that focuses explicitly on delivering coordinated controlled care for the very complex needs of this population (typically, at the end-of-life stage) ▪ Ask the next 20% of the population (400 people per GP, 10k people per network, ~175k people across the patch) to opt into a special programme delivering more proactive/responsive, better coordinated, more consistent care ▪ 4-5 centres with critical mass for multidisciplinary staff teams - a 1:5 GP-to-support staff ratio and with consultants on hand to provide specialist opinion ▪ Retain the remaining 80% of the population utilising the current “care at short notice” model of GP care ▪ With more than 50% of GP contacts coming from the top 3 strata, we would expect “mainstay” GP services to have more than half of capacity released Example: 50,000 population 12-13 practices with ~4k people each These take a whole population perspective and focus on those at highest risk 1
- 9. © 2013 Deloitte MCS Limited. Private and confidential. Key facts about 111 in London so far Patient stories gathered to date indicate a range of patient experiences 9 NHS England - London Region: 111 Easter Review Health Advisor provided patient with reassurance Quickly accessed the right service, swiftly Assessment of patient took too long Required service was not available Insufficient clinical knowledge https://www.patientopinion.org.uk/
- 10. A whole population approach, to identify risks early; interventions tailored to levels of risk and the individual Specific goals and investment for falls, dementia, nutrition and infection pathways 50,000 Older People: All risk stratified 25,000 proactively assessed annually 5,000 case managed Generic approach based on level of risk Prioritises action for those interacting heavily with the system Picks up issues for those not yet interacting heavily with the system Coordination of care for those with multiple needs
- 11. Preventative model of care
- 13. | 13 Patient Risk Stratification The ICP IT supports 4 key processes Care plan Action 2 Action 3 Action 1 Plan care for patients, share these plans across settings, and monitor progress This helps better coordinate care Identify high risk patients using population segmentation and risk stratification This enables proactive care to be planned Track and evaluate the performance of GP’s surgeries and Multi-Disciplinary Groups This helps spread best practice in patient care Action: Review by falls service Action status: Completed 1 Integrated Patient Care Planning Performance Evaluation Patient records: GP Hospital Community View patient medical information from multiple settings This enable integrated care to be provided Patient Medical Information Sharing 2 43
- 14. | 14 Integrated Care Plans help coordinate the care for patients within the Pilot Text The Portal can be used to create and manage Integrated Care Plans for patients Standard care packages can be selected by clicking on any of the template buttons, the actions in this care plan will then be selected Individual actions can then be added or removed from the care plan
Hinweis der Redaktion
- North West London: significant progress has been made in establishing an integrated care pilot for a population of more than 500,000 that delivers proactive integrated care through a case management approach for older people and people with diabetes. The pilot is now being extended to adults with COPD, or CHD, and the operating model being developed for a whole system integrated care system. North Central London: Whittington Health has redesigned services to maximise the potential for integrating acute and community services. It is now working with GPs and local authorities in Haringey, Islington and Enfield to develop multidisciplinary groups that will offer integrated care. NHS London is providing funding and support to further develop this pilot into a comprehensive integrated care system including the development of a partial capitation model of funding.North East London: individual boroughs have a strong track record of initiatives to integrate care including working with GPs to develop packages of integrated care; quality improvement through clinical audit and risk stratification. Plans are being developed to establish integrated care system(s), covering a large geographical area, and at least one acute trust. South West London: Croydon is planning an integrated care system jointly with the local authority and this has the potential to make a major contribution to the cost-savings required by this health care economy. South East London: Kings Health Partners (KHP) integrated care pilot in Lambeth and Southwark has been planned jointly with the local authority and will be operational from April 2012. KHP is working closely with Lewisham and Croydon to share learning and operate single systems where appropriate.