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Commissioning Services Working across Health & Social Care

Julie Wilkinson

Rochelle Morris

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Why Long TermConditions Management Agenda

� Background and overview to the contracts for Integrated Care with:

North East Lincolnshire Care Trust Plus

Erewash Clinical Commissioning Group

Hardwick Clinical Commissioning Group

Others

� We will cover the process followed and the tools used during the:

- Scoping phase

- Implementation phase

� Improve user/carer/professional experience and care through multi organisational working

� Better outcomes for users/carers

� VfM

� Support the Sir John Oldham National LTC QIPP agenda

The Department of Health has agreed three fundamental features of best practice LTC care programmes:

– Using risk profiling to ensure that commissioners understand the needs of their population and manage those at risk. This will assist in preventing disease progression and will allow for interventions to be targeted and prioritised.

– The creation of integrated health and social care teams to provide joined up and personalised services. Each individual has a key worker within this team who co-ordinates their care and acts as the point of contact.

– Self care / shared decision

Overall Aims:

� Scoping phase:– Current state assessment

– Stakeholder engagement

– Develop Integrated Care Model

– Create Service Specification

� Implementation phase:– Case Management across health and social care and links with intermediate

care and acute trust

– Community Delivery Teams/Virtual Ward Teams

– Review in-reach discharge process for individuals with complex needs for secondary, intermediate and short stay

– Integrated Care Plan booklets for individuals to record personal goals and develop contingency plans for their care

– Developing Reporting tools

– HealthNumerics-RISC to identify individuals with high risk of admission to hospital and developed an adult social care risk assessment tool for high risk of care home admission

Approach:

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Project Aims

Defined under 3 key principles:

• Joined Up

• Personalised

• Prevention and Early Intervention

Joined Up• Coordination of multidisciplinary

assessment/care in the home

• In-reach to Secondary Care and

Intermediate Care stays

• Linking to Primary Care

• Effective information and case

sharing

Personalised• Effective person centred assessment

• Supporting self assessment and goal planning

• Supporting the views, strengths and wishes of the individual

• Use of Personal Budgets

• Advocacy / brokerage in assisting individuals to plan to meet

their goals

Prevention and Early Intervention• Using skills, knowledge & experience of

condition(s) to effectively plan to mitigate

exacerbations and deterioration pro-actively

• Possible use of systematic methods of LTC

care such as telehealth, telephonic coaching,

self management planning, etc.

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Programme Management Structure – NEL

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Programme Management Structure – Erewash

Erewash Clinical Commissioning Group

Commissioning & Quality Board

Work Stream Leads

Integrated Care Programme

Lead

Senior Responsible OfficerIntegrated Care Programme

Board Members

Integrated Care Project

Group

Members

Work Stream LeadsIntegrated Care Programme

Lead and Clinical Lead

South Derbyshire CCG Integrated

Care Programme Board

South Derbyshire Integrated Care

for Frail & Elderly Implementation

Group

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Work StreamsSingle Point of

Access

� Leadership

� Criterias

� Resource Planning

� Rollout of Clinical Navigation Service to SPA?

Community Delivery

� Process Mapping

� OOH

� In reach

� Reablement

� Leadership

� Resource Planning

� Home Care Services

� Integrated Care Plan

� Criterias (CCM)

� Inclusion

� Exclusion

� Voluntary Sector

� Implementation of Virtual Working

Performance Tools

� Outcomes

� SystmOne & Alerts

� Savings

� Risk – health, social care

� Resourcing

� Acute alerts

� Telehealth

� IT

Communication/Engagement

� Patient engagement

� Staff engagement

� Other stakeholder engagement

� Model rollout

� Launch

Integrated Care Model - NEL

IT

Performance

What is it?• An approach to delivering a ‘fit for

purpose’ joined up system that

ensures all providers work

together to benefit users

Benefits • Seamless service for users

• Integrated care pathways

• Improved communications

• Increased co-operation and

understanding between services

and providers

• Improve quality of services

• Facilitate appropriate changes to

culture

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Integrated Care

Model

for

Erewash CCG

4 new elements:

-Single Point Access

-Rapid Response

-Community Delivery Teams

-Risk Stratification

Manage for up to 6 weeks

Nomination Criteria Score

determines bias

Referrer

SPA

Community

Delivery Team

Role of CC

- Case finding

- Risk strat

- MDT co-ord

Colour code

Decision point

Tool/Criteria

Services

Supporting services

Non Critical

Social Care

Rapid

Response

and Intermediate

Care/Reablement

Acute

TrustPractice

Appropriate for Case Management?

NOYES

Case

ManagerReferrer

DN

team

NO NO

Specialist LD teamTelehealth

Mental Health

(to incl. in model for Community

Delivery, RR and IC teams)

Specialist Nurses

DN Team Intermediate Care at HomeVoluntary Sector

Place of SafetySocial Care

Personalised budgetsSelf Care ProgrammesEquipment store

Hospital DischargeDieteticsTelecare

Short Stay/Respite

Falls Service

Safeguarding AdultsCHC

GP OOH

(DHU)

Navigator

Care Co-ordinator

Therapists

Referral Criteria Nomination Criteria

Continual Assessment Secondary Screening

Routine Task

DN

team

Critical <2hrs

Manage for

required period

Personalised

Budgets

If regular tasks

required

YES

Triage

Health

Unplanned Planned

Social

Care

Complex long-term

management or

safeguarding

Discharge/Refer

Social

Care

Community

Delivery Team

Personalised

Budgets

For

assessmentOr

signposting?

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Overview of Complex Case Management & RISC� Process started in Spring 2009

� ICEC – savings cabinet with one element CCM

� Project group created – Community Matrons and Adult Social Workers – later a wider

group

� How do you define complexity in an integrated manner?

� How do we determine case loads, who is seeing whom?

� Resource requirements to ‘Complex Case Manage’ patients?

� What does CCM mean to health and social care teams? What is currently being delivered?

� Is vertical and horizontal integration in place? – GPs, Secondary Care, Intermediate Tier, etc.

� How do you currently take referrals? Is there a nomination criteria?

� How do you reduce unplanned chronic admissions to hospital?

� How do you bring care closer to the user?

� How do you improve joined up care and communications across teams?

� How to embed the chosen risk stratification tool for health?

� What is an integrated care plan?

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Establishing Caseloads

Stratifying Caseloads

1. Defining a set of criteria for “complexity” across health

and social care. UHUK RISC tool was basis for

stratification in Health with a paper based tool created for ASC

2. Analysing all existing caseloads against criteria and checked

against RISC list (6-16%, partly due to unclear definition of CM

role and lack of resources)

3. Allocating cases to complex case managers and

redistributing other cases as required across available

resources

In Adult Social Care: A3 (L1)

Locality Teams (L2 + L3)

In Health: Initially level 3

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Maintaining Caseloads

1. Development of a nomination criteria to support referral into Case & Complex Case

Management;

2. Agreed secondary assessment tool for both H and ASC;

3. Developed referral processes;

4. Ongoing clinical decisions made on who was appropriate for Complex Case Management

based on case review and on available case management resources;

5. Using the RISC tool and ASC scores, cross reference caseloads & ensure most

appropriate complex case manager is allocated – where is the bias? (60% same list);

6. On-going use of a RISC tool to continually monitor list.

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• Allowed CMs to compare current workload to a predictive list and agree criteria for

inclusion on new caseload.

• Provided the basis for discussion and comparison with ASC lists and allocation of

appropriate case manager.

• Offered opportunity to ‘push back’ some inappropriate referrals.

• Helped determine resource requirements for community nurse provider.

• Created opportunity to consider a formal process for in-reach.

• Led to sharing of case loads with wider teams

� intermediate care (specifically SPA and RR teams) - essential to share case lists

with SPA and RR team (handovers, snow 2011).

� acute trust – alert system.

• Led to MDT meetings being prepared for thoroughly and relevant staff invited to attend

only when required.

� created speedier MDT/practice meetings – all information required to initially judge

appropriateness for secondary screening was all in one place.

The Influence of RISC

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Intermediate Tier

Re-ablement

Rehabilitation

( 6 wks )

SPA

Complex

Caseload

• Personal enquiry to A3

• Professional enquiry to A3 based on nomination criteria

• Professional enquiry to Community Matron from Primary Care team

A3 L1

caseload

DN/AHP

caseload

Nominated for CCM- Assessment for

complexity completed

Professionals

ASC & Health

Public

Service Users

& Carers

Routes In – New Case in Crisis

Low Score

High Score

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PAS alertfrom CTP

list ofComplexCaseload

CTP list ofComplexCaseload

Intermediate TierDPoW

In-reach Actions:

• CCM provides coordination of discharge planning on behalf of the individual

• Contact with Acute Trust/Intermediate Care bed unit made

• Decision on visits and who needs to be involved

• Decision on need to attend MDT

• Coordination with all professionals on

• services required for discharge

In Reach – Admission Alert

Central Case Lists for IT

Notify bytelephone call to contact number

provided

NotificationReference

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Goals set by

individual (plus

carer) used to build

care plans

*Completed by the

Service User

(or carer/family)*

Goals/Wishes

Important

information

Contingency

Plans

Individual’s

commitment

Schedule

of care

Contacts

Initially

for all

level 3

cases

Kept in the home but

taken to other services

(intermediate care and

acute trust, etc.)

Integrated Care Plan“My Care, My Way”

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CCM Ongoing

Recording

Monthly

Collection &

Collation

Audit Supervision

AIOD

Performance &Outcomes

Measurement

Evidencing PreventativeInterventions

Identify blocks & Issues and inform

servicedevelopment

Activity, Interventions & Outcomes Dashboard (AIOD)

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Staff Training� Training delivered to RR and CCM team on principles of case management and to share

new models and developments to date

� Once all tools ready, delivered training for 70 staff on following:

� 3 key principles = co-ordination, personalisation, prevention & early intervention

� Case list maintenance

� Integrated Care Plans

� Outcomes recording – AIOD tool

� In-reach process and responsibilities – DPoW and Beacon

� Other services - interaction with and referral to – processes set up

� Running effective MDT meetings

� Shadowing of CMs by UHUK Nurse Practitioner and sharing of best practice in

conducting assessments

� Assistance with delivery of and coaching of CMs for 1st MDT meeting

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Lessons Learned

� Started with small project team – later realised need for a full programme management

approach

� Behavioural /cultural change was a significant issue – long established teams,

processes and practices - geography and skills had impact

� Underestimated time required to realise savings – needed watertight systems and

processes in place first – both horizontally and vertically

� Required some form of outcomes recording to make commissioning decisions and have

contracting levers

CUMULATIVE Rapid Response Complex Case Management Total Saved

Type of saving Volume Unit Cost Total Saving Volume Unit Cost Total Saving

Avoided A&E attendance 1,076 £77 £82,852 215 £77 £16,555 £99,407

Avoided emergency admission 315 £2,110 £664,650 189 £2,110 £398,790 £1,063,440

Avoided use of place of

safety/72hr stay/carer respite

22 £375 £8,250 60 £375 £22,500 £30,750

Avoided placement in

residential/nursing beds

284 £792 £224,928 62 £792 £49,104 £274,032

Avoided GP home visit 0 £104 £0 290 £104 £30,160 £30,160

Avoided multiple daily care calls 0 £16,128 £0 11 £16,128 £177,408 £177,408

Avoided single daily care call 0 £6,048 £0 3 £6,048 £18,144 £18,144

Avoided ambulance call out 0 £221 £0 144 £221 £31,824 £31,824

Prevented GP appointment 0 £96 £0 7 £96 £672 £672

DISCHARGE Avoided excess bed

days

0 £177 £0 38 £177 £6,726 £6,726

PROVIDED place of safety/72hr

stay/carer respite

38 -£375 -£14,250 25 -£375 -£9,375 -£23,625

1,735 £966,430 1,044 £742,508 £1,708,938

NE Lincolnshire outcomes for RR & Case Management teams

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One Year On…Recorded outcomes for RR and CCM teams for first full year 2011/12 reflected savings of £4.8m

Acute:

� Total of £5m taken out of unplanned care - 3 years 2010/11 thro’ 2012/13

� Achieved -0.8% vs. national average +4% unplanned care growth from 2009 to now

� In year 11/12 saw very small growth back – believe this is due to reaching community capacity. So now have 3 year planned step rise in community capacity of 250 people per year. This will assist in containing the expected growth.

� Front end A&E work successful – over 34 recorded weeks, 78% of admissions avoided (304 or 387, of which 202 were >65years). Team includes GP, RR team (health care, social care and therapist), plus lower level Social Care team provision

Social Care

� 8% below average for long term care home placements

� Further £500k savings from support at home

� 60% returned home from re-enablement with no care package, 22% with reduced care package

� Additional £750k investment in prevention

� £1.8m investment in intermediate tier

� Further percentage of reduction in readmissions from long term care homes

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One Year On…Other legacies

� HealthNumeric’s RISC and the Social Care Complex Case risk tool, both help provide

the basis for further segmentation of the population into 4 levels (including high to low

cost) with clearly defined responsibilities for these levels across the area

� North East Lincolnshire are in the 1st wave for authorisation and are the only

organisation to remain integrated – to become NEL CCG and Care Trust

� The work UHUK did in helping NEL CTP prepare for World Class Commissioning

(moving up from 55th to 5th place) has helped them diligently prepare for the

authorisation process with all documents now submitted

SPA:

• Criteria

• Hours and planned hours

• SLA/Spec

• Briefing

RR:

• Review of current provision

• Agree team - Therapists, DNs, CMs

• Consultation with staffCDT:

• Agreed team – CC, CM, GP, AC, Snr DN, MH, PN

• Appoint CC

• Develop spec

• Create toolkit

• Agree reporting

Risk stratification:

• Procurement

• Training

• Caseload – remove duplication

Erewash:It was clear from the model that we needed to focus as an integrated team on

these 4 NEW areas:

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Care Co-ordinator RoleIdentification:• Admission & discharge plus OOH

calls collation

• Manage risk list - identify high

climbers & new patients using a risk

stratification tool

• Referrals – check criteria

• Local intelligence

Casework discussion:• Attend Virtual Ward meeting with core

team

• Manage clinical meetings – ensure

others invited as required

• Present information

• Take minutes & distribute

Care Planning:

• Update records (including template)

• Record action plans

Care Delivery:

• Follow through any actions required

tests/referrals etc

• Follow through with patient/others involved to

ensure all services/care arrangements in place

• Keep everyone informed/updated

Other:

• Co-ordinate response and

build relationships

• Deal with public and local

professionals

• Ability to set up packages of

care

• Refer complex cases to MDT

• Access to hospital systems

and some GP systems

Solution Objective Key Components

Milestones & Deliverables

Delivery and implementation of Integrated Care across Erewash

To “weave together” the separate strands of integrated working

� To implement a programme management structure

� Introduce systems and processes for joint integrated working

� Bring together innovation, evidence-based thinking

Phase 3

� Implementation of risk stratification tool (allowing

for implementation period)

� Training of risk stratification tool to GPs,

Community Matrons and Care Co-ordinators

� Ongoing training, mentoring and coaching for all

staff in both referral streams – SPA/Intermediate

Care and Community Delivery

� Initial training for all staff in both referral

streams – SPA/Intermediate Care and

Community Delivery

� DCHS to implement the SPA as per

implementation plan

� Reallocate staff into new roles e.g. Care Co-

ordinator, Navigator, Rapid Responder roles

� Review Case Lists for Health and Social Care

� Continue development of assessment tools

and criterias

� Implementation of virtual working for

Community Delivery

Implementation Plan

December 2012October 2012 November 2012

Phase 4

Phase 5

� Develop Activity and Outcomes reporting tool

� Develop Integrated Care Plan (Self Care) for

individuals if needed

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"The work undertaken by UnitedHealth UK to develop a fully integrated health and social care functional model for both rapid response and complex care management has been innovative and challenging. It has included developing a model of patient stratification that incorporates a common 'definition' and recognition of the holistic needs of individuals that give rise to understanding complexity from the differing perspectives of both health and social care professionals."

Geoff Lake, Director of Integrated Commissioning, North East Lincolnshire Care Trust Plus

HSJ supp 22/3/12 Commissioning support Case study (re North East Lincolnshire):

“UnitedHealth UK’s independent and objective programme management work was crucial to the partnership’s success, given the multidisciplinary nature of the work and the fact that it had funding from the NHS and adult social care”.

Today they have a complex case management tool which integrates means testing in adult social care with identifying high resource users with long term conditions.

“It enabled us to develop a single system that brought two ideologies together,” says Mr. Lake. “We’re still adapting that to understand who the most vulnerable on the practice list are and then to concentrate resource from both parties on the same people.”

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