The LTC QIPP Development programme &Year of Care Funding Model

3

Annual HC spending per capita by age group2004, USD thousand

Aging populations

Source:UN population database, US Centers for Medicare and Medical services reproduced with kind permission of Novartis

1.5

0.4

2000 2050

+252%

WORLD

Aging Population Billion people >65 years

US

3

3

5

8

11

16

2685+

75–84

65–74

55–64

45–54

19–44

0–18

All ages = 5

– The majority of over-65s have 2 or more conditions, and the majority of over-75s have 3 or more conditions

– More people have 2 or more conditions than only have 1

Multimorbidity is common in Scotland

Records of 1.7 million patients showed

• Only 19% of patients with COPD have just COPD

• Only 14% of patients with Diabetes have just Diabetes

• Only 5% of patients with Dementia have just Dementia

• etc

Mercer Guthrie and Wyke Univ of Glasgow 2011

Team A

Team B

Team C

Team D

?

Integrated neighbourhood Care Team

Primary drivers

• Systematic risk profiling of population

• Integrated locality care teams including social care, community services, allied health professionals and general practice

• Maximising number of patients who can self manage through systematic transfer of knowledge, and care planning

Risk stratification

•Better targeted services improves outcomes

•Enhanced targeted assessment was associated with improved mortality and physical function after one year1

•Targeted activities to activate patients have the greatest impact when targeted a specific high risk groups2

•When integrated stroke care was targeted at highest risk, this increase survival and reduced need for institutional care3

Source: (1) Stuck, Siu, Whieland et al. “Comprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet 1992; 342: 1032-6Source: (2) Conn, Valentine & Cooper “Interventions to increase physical activity among aging adults: a meta-analysis”. Ann Behav Med 2002; 24(3): 190-200Source: (3) Fagerberg, et al. “Effect of acute stroke unit care integrated with care continuum versus conventional treatment. Stroke 2000; 31(11): 2578-84

Integrated teams

• Improved health status, reduced weight and improved diet.1,4 • People were most likely to be alive, living independently at

home.6

• Improved symptoms and behaviours.5

• Improved health status & mental well-being. Outcomes for lower cost.3,7

• Source: (1) Kasper “A Randomized Trial of the Efficacy of Multidisciplinary Care in Heart Failure Outpatients at High Risk of Hospital Readmission”. Journal of the American College of Cardiology Vol. 39, No. 3, 2002

• Source: (2) Griffiths. “Cost effectiveness of an outpatient multidisciplinary pulmonary rehabilitation programme”. Thorax 2001;56:779–784

• Source: (3) van den Hout “Patient team care nurse specialist care, inpatient team care, and day arthritis: a randomised comparison of clinical multidisciplinary care in patients with rheumatoid”. Ann Rheum Dis 2003 62: 308-315

• Source: (4) Capomolla et al. “Cost/utility ratio in chronic heart failure: comparison between heart failure management programme delivered by day-hospital and usual care” J Am Coll Cardiol 2002; 40: 1259-66

• Source: (5) Opie, Doyle & O’Connor “Challenging behaviours in nursing home residents with dementia: a RCT of multidisciplinary interventions” Int J Geriatr Psychiatry 2002; 17(1):6-13

• Source: (6) Stroke Unit Trialists’ collaboration “Organised inpatient care for stroke” Cochrane Library, issue 2, 2004

• Source: (7) Ahlmen et al “Team vrs non-team outpatient care in rheumatoid arthritis” Arthritis Rheum 1988; 31(4): 471-9

Self Management

• reduce number of GP visits

• help to prevent unnecessary admissions to hospital

• reduce length of stay of necessary hospital admissions

• improve health status and self efficacy

• enable patients to remain in their homes and communities

• improve feeling of control in their condition

• increase choice for patients

• improve end of life care

• integrate all elements of care

• deliver better glycaemic control for diabetic patients

• lead to reduced stress for people with mental health conditions• 1 http://www.crd.york.ac.uk/CRDWeb/ShowRecord.asp?View=Full&ID=32006001556

Other literature

• 20% patients identified by risk stratification could not be identified in any other way

• Improving access to care for these people improves quality of care

• Large RCT in US (Boult) showed this approach reduced inpatient days (52%), Aand E visits (17%) and readmissions (49%)

• 16 other studies showed significant reductions in length of stay, admissions and Aand E visits

In other words ..

You need to do them all

.. And status quo is not an option

Risk Profiling

Milestone Two - By ....20% of practices covering a minimum 50% of the population within the CCG or cluster have committed to implementing a risk profiling tool and have a plan to systematically use the data with the integrated neighbourhood team

Milestone Three - By ....All practices that have implemented a risk profiling tool are systematically using the data with the integrated neighbourhood team to pro-actively manage patients identified 'at risk

National Average – Risk Profiling

Milestone 2 Achieved 56.35%Milestone 2 Date set 43.65%

Milestone 3 Achieved 18.54%Milestone 3 Date set 57.60%

Integrated Care Teams

Milestone Three - By....The implementation team have identified and engaged all relevant stakeholders/ clinicians and developed an action plan to embed the integrated neighbourhood team model in a minimum 20% of practices covering a minimum of 50% of the population within the CCG/ locality.Milestone Four - By....All integrated neighbourhood care teams attached to every practice / locality are using risk profiling data to case manage patients identified' at risk '

National Averages – Integrated Care Teams

Milestone 3 Achieved 50.73%Milestone 3 Date set 38.98%

Milestone 4 Achieved 11.00%Milestone 4 Date set 55.90%

Devon CCG -Rolling impact top cohort

Other European LTC financial models

• Alzira model Valencia; capitated payments single integrated provider. Significant shift from hospital to community 25% less cost – but

• CREG project Lombardy; multiple providers but common risk adjusted pathways developed reinforced by capitated contractual model ; still in pilot stage

• Netherlands; bundled payments but disease specific orientation, costs increased

• Gesundes Kinzigtal Germany; multiple providers and insurers, bundled capitation payments since 2007 but as part of care change; reduction in morbidity and mortality, morbidity adjusted efficiency gain 16%

Gesundes Kinzigtal Integrated Care: improving population health by a shared health gain approach and a shared savings contract, H. Hildebrandt, C. Hermann, R. Knittel, M. Richter-Reichhelm, A. Siegel, W. Witzenrath

Money for value: the Kinzigital -way to measure the produced value and health gain in a local area

Helmut Hildebrandt, CEO OptiMedis AG and CEO Gesundes Kinzigital GmbH, Germany

 

Scope of the Year of Care Funding Model

• PbR TIA• PbR same-

day EM• EL Medicine

Acute Community Mental Health Social Care Voluntary/ Independent

Primary care

GP services

• Special Serv• Surgery

• Cancer??• PbR excl drugs

• Crit. Care

Personal healthcare

budget

Specialised Services

Means-tested

services

Within tariff

Residential continuing healthcare

Palliative & end of life

• Alcohol-related care• Yearly cost > £50k

• Reablement• Adult Services

PbR MH clusters

Selection of Services

GP. prescribing

4 key elements

• Identifying and supporting people with LTCs

• Developing costed pathways of need

• Commissioning and contracting of the model

• Systems architecture

What LTCs Should be IncludedThe National Project Team Propose that the LTCs included should be based on the Scottish School of Primary Cares Multimorbidity Research Programme (excluding schizophrenia.)

These LTCs are: Coronary Heart Disease Hypertension Heart Failure Stroke/TIA Diabetes COPD Cancer as LTC (not chemo/radiotherapy) Depression Dementia

Achieving the future state – Primary Drivers

LTC Year of Care

Funding Model

Define the Year of Care Budget and Costing Pathways

Identifying and supporting patients

Systems architecture

Commissioning & Contracting

Define current spend on

LTCs

Agree an integrated needs led assessment framework

Agree categories of support

Define and agree a set of locally owned outcomes

Needs Assessment

Define Year of Care budget according to agreed scope of patient cohort and services

Costings Information

Integration for care co-

ordination

Practical Implementation

Identify population that would benefit from this model

Develop commissioning

mechanism

Developing contracting mechanism

Data Quality

Define typical pathways per category of support

Define methodologies and currencies to establish costs

Cost future pathway

Secure and Maintain agreement to test the implementation of the

Year of Care Funding Model

Identify and agree a model for effective stakeholder collaboration

Agree a high level strategic vision and direction