intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED...

49
SCHEDULE 2 – THE SERVICES A. Service Specifications Service Specification No. LCS v2 Service Anticipatory Care – Primary Care Commissioner Lead Name of CCG Provider Lead [Name of Practice / Surgery] Period April 2018 – March 2020 Date of Review April 2019 Introduction The Frimley Health and Care Integrated Care System (ICS) sets out our vision for integrated out of hospital care and anticipatory care planning for the most vulnerable individuals in our population. Our vision describes an out of hospital health and care system, led by Primary Care, with a principal focus on proactive and anticipatory care planning for individuals living with moderate to severe frailty, multiple complex co-morbidities and/or life threatening or life limiting conditions. This locally commissioned service is a step towards realising our ICS vision, by building on our existing Community Multi- Disciplinary Team approach involving GPs, nurse practitioners, therapists, mental health professionals, paramedics, pharmacists and social care professionals. This new service will foster an environment for proactive case identification and care planning. Encompassing a menu of interventions - both in routine and crisis care - aimed at maximising independence and enabling individuals to live well independently, we will avoid unplanned use of health and care services including attendance at A&E and admission to hospital or long term care. Implementing this LCS is a significant step towards delivering our ICS new model of out of hospital care, and puts Primary Care at the heart of care co-ordination in the community. This service delivers a person-centred approach and ensures that Page 1 of 49

Transcript of intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED...

Page 1: intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED CT Codes . G – Sign Up and Service and Payment Pre-Requisites (May 2018 Submission)

SCHEDULE 2 – THE SERVICES

A. Service Specifications

Service Specification No. LCS v2Service Anticipatory Care – Primary CareCommissioner Lead Name of CCGProvider Lead [Name of Practice / Surgery]Period April 2018 – March 2020Date of Review April 2019

IntroductionThe Frimley Health and Care Integrated Care System (ICS) sets out our vision for integrated out of hospital care and anticipatory care planning for the most vulnerable individuals in our population.

Our vision describes an out of hospital health and care system, led by Primary Care, with a principal focus on proactive and anticipatory care planning for individuals living with moderate to severe frailty, multiple complex co-morbidities and/or life threatening or life limiting conditions.

This locally commissioned service is a step towards realising our ICS vision, by building on our existing Community Multi-Disciplinary Team approach involving GPs, nurse practitioners, therapists, mental health professionals, paramedics, pharmacists and social care professionals. This new service will foster an environment for proactive case identification and care planning. Encompassing a menu of interventions - both in routine and crisis care - aimed at maximising independence and enabling individuals to live well independently, we will avoid unplanned use of health and care services including attendance at A&E and admission to hospital or long term care.

Implementing this LCS is a significant step towards delivering our ICS new model of out of hospital care, and puts Primary Care at the heart of care co-ordination in the community.

This service delivers a person-centred approach and ensures that individual preferences are discussed, recorded and shared among health professionals including NHS 111, the Ambulance Service, care home workforce and out of hours primary care.

List of Appendices

A – Case Finding, Assessment, Medication Reviews and Care Planning Guidance, Training, Support and Learning ResourcesB – IPA User Access Request formC – IPA Quick Reference Guide for PracticesD – Summary Care Record Toolkit for GP Practices GuideE – Payment Schedule and Monitoring InformationF – Anticipatory Care Planning LCS Read and SNOMED CT CodesG – Sign Up and Service and Payment Pre-Requisites (May 2018 Submission)H – Excel template, comprising:

Page 1 of 37

Page 2: intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED CT Codes . G – Sign Up and Service and Payment Pre-Requisites (May 2018 Submission)

1. ACP Care Plan Audit Tool2. Practice self-assessment3. Data submission

I – Word template: Practice Improvement Action Plan

All appendices and embedded documents will be available on the intranet by 8th May 2018.

1. Population Needs

1.1 National/ local context and evidence base

Anticipatory care planning is about adopting a ‘thinking ahead’ philosophy of care that allows practitioners and their teams to work with patients and their family/ carer to set and achieve common goals that will ensure the right thing is being done at the right time by the right person(s) with the right outcome.

Anticipatory care planning supports those living with multiple long term conditions and/ or frailty to plan for an expected change in health or social status. It incorporates health improvement and staying well through prevention and self-management of the person’s condition.

People who have frailty, multi-morbidities or chronic disease requiring management, have dementia, palliative care needs, are approaching the end of life or who are vulnerable as a result of medical and/ or psychiatric issues and/ or socio economic deprivation are more likely to have frequent non-elective admissions (three per year). Evidence shows that these people would benefit from the proactive planning of their care. It enables individuals with long term conditions to plan their care, have strategies in place to cope with exacerbations of their condition and have all the relevant information they need to make informed choices and decisions. Supporting people to self-care means they have more confidence and control over their condition and understand how it affects their lives.

It is estimated that across east Berkshire there are approximately 13,700 individuals who will benefit from this LCS.

This LCS compliments a wide spectrum of the CCG commissioning intentions, ambitions and outcomes including:

Integrated Care Decision Making (ICDM) Primary Care at Scale GP Transformation Integration and Better Care Fund (BCF) Self-care and Prevention Acute Frailty Liaison/ Outreach Social Prescribing Community Nursing Review

Anticipatory care planning (ACP) is a core pillar of the Integrated Care Decision Making (ICDM) model.

Page 2 of 37

Page 3: intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED CT Codes . G – Sign Up and Service and Payment Pre-Requisites (May 2018 Submission)

2. Outcomes

2.1 NHS Outcomes Framework Domains & Indicators

Domain 1 Preventing people from dying prematurelyDomain 2 Enhancing quality of life for people with long-term

conditionsDomain 3 Helping people to recover from episodes of ill-health or

following injuryDomain 4 Ensuring people have a positive experience of careDomain 5 Treating and caring for people in safe environment and

protecting them from avoidable harm

2.2 Local defined outcomes

The expected outcomes for the defined cohort over the two years of this service are:

90% of patients identified have a good quality and current anticipatory care plan agreed and in place

15% reduction in non-elective admissions (NELs)

Other anticipated outcomes are articulated in our ICS vision of integrated decision making and include:

Reduction in unplanned admissions for patients at risk Reduction in lengths of stay/ excess bed days/ delayed transfers of care Reduction in re-admission rates Reduction in ambulance conveyancing Reduction in number of planned and unplanned Primary Care appointments Increased support for patients to manage their own conditions Improved patient and carer experience and satisfaction Reduction in prescription costs Improved staff experience of care and satisfaction Improved quality of care planning and recording

3. Scope

3.1 Aims and objectives of service

The aim of this enhanced service is to improve the delivery of holistic, patient-centred care to patients who have been identified as being at risk of admission or having a high number of non-elective admissions (three or more in the last year), including patients living in care or nursing homes.

The service will introduce consistency across east Berkshire in our approach to proactive care case identification and care management. It will support the implementation of a personalised care planning approach, designed to effectively increase patients’ choice and control over their care and, as appropriate, improve the self-management of their conditions.

Page 3 of 37

Page 4: intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED CT Codes . G – Sign Up and Service and Payment Pre-Requisites (May 2018 Submission)

This enhanced primary care service:

Compliments the core frailty element of the GMS contract (which requires practices to identify patients aged 65 and over who are living with moderate or severe frailty and carry out a clinical review on these patients) https://www.england.nhs.uk/publication/supporting-routine-frailty-identification-and-frailty-through-the-gp-contract-20172018/

Promotes medicines optimisation Demonstrates quality case management Demonstrates closer integration and coordination of care between GPs and hospital

clinicians, social services and community and charitable services across the care pathway

Encourages and supports multi-disciplinary team working that has been established in practices and promotes new multi-disciplinary interventions and case management

Promotes self-management and patient empowerment Promotes preventative care in the community

The key objective of this service is the delivery of high quality care planning using an MDT approach to reviewing frequent users and high risk patients. This objective is to be fulfilled in the following elements:

1. Identification of patients appropriate for anticipatory care planning

2. Anticipatory care planning

3. Additional requirements for patients within the above list who have had three or more unplanned admissions in the last year, OR who have an unplanned admission between 01.04.2018 – 31.03.2020.

4. Care plan audits and reviews and on-going learning and feedback

The third element of the service aims to support practices to manage patients with multiple non-elective admissions (NELs), resulting in an overall reduction to NELs. These admissions are likely to be unplanned and urgent (likely via A&E). A NEL is generally understood to include at least one overnight stay on short notice because of a clinical need or because alternative care is not available.

It is expected that there will be a reduction in NELs as a result of focusing efforts on quality care planning and working with other health and social care providers. It is anticipated that some of this will be achieved through natural patient ‘churn’ with the remaining proportion to be delivered through the interventions described in this service.

3.2 Out of Scope

Additional to the interventions required by this LCS are those required the GP Contract for patients with severe frailty: deliver a clinical review providing an annual medication review and; annual falls risk identification (as clinically appropriate); and where a patient does not already have an enriched Summary Care Record (SCR)

the practice will promote this by seeking informed patient consent to activate this.

Patients who are on the End of Life Care (EoLC) register (and who are therefore Read coded 9Ng7) are excluded from this LCS and the ACP Cohort.

Page 4 of 37

Page 5: intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED CT Codes . G – Sign Up and Service and Payment Pre-Requisites (May 2018 Submission)

3.2 The Service

3.2.1 Service and Payment Pre-Requisites

Service and Payment Pre-RequisitesTo take advantage of this locally commissioned service (LCS):

1. Practices are required to identify up to three members of staff who are passionate about improving the experience of patients with long term conditions to drive forward the practice engagement with this scheme:

1. LCS lead clinician (eg GP/ practice nurse/ AHP – this individual may already lead on another related area, such as long term conditions or end of life care)

2. LCS co-ordinator (eg practice manager/ administrator)3. LCS care planner (eg GP/ Nurse Practitioner/ AHP – this individual may

also be the LCS lead clinician where appropriate)

Overall responsibilities:Lead clinician

Co-ordinator

Care planner

Attend care and support planning training As required

Run the ‘Find New ACP Patients’ report in IPA Review IPA indicative cohort, identify further patients and confirm frailty diagnosis or multi-morbidities, coding appropriately

Carry out care planning for the identified cohort As

required Arrange appointments for the patient cohort and maintain records relating to these, ensuring Read coding required by this LCS is carried out and accurate

Liaise with the Multi-Disciplinary Teams (MDTs)/ Integrated Care Teams (ICTs)/ Integrated Care Decision-Making (ICDM) Teams

As required As

required

Track progress for the cohort and collate information for MDT case conferences Participate in MDT case conferences As

required Carry out the additional requirements for patients who have had an unplanned admission (refer to page 13)

As required

Lead the care plan quality audit and reviews (refer to element 4 on page 14) Contribute to the in-year CCG level discussions and the sharing of learning across east Berkshire (refer to section 6 on page 16)

Page 5 of 37

Page 6: intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED CT Codes . G – Sign Up and Service and Payment Pre-Requisites (May 2018 Submission)

2. Care planning training is being developed by the CCG and guidance is available in Appendix A. GPs and clinical staff will need to have reviewed and discussed the care planning training and guidance and embed it within care planning at the practice or cluster. Practices are required to submit a brief action plan detailing how the training is being/ has been embedded.

Practices are required to sign up to the training. If the LCS clinician or LCS care planner have undertaken recent care and support planning training provide evidence of this (course title, content and date/s undertaken by whom) on the sign-up form.

3. Practices are required to have signed up to Insights Population Analytics (IPA) and their data sharing agreement with the CSU. Appendix B is the IPA User Access Request form or click on the icon below to access it:

4. Practices are required to have signed up to the End of Life Care LCS.

5. Health care professionals carrying out the initial assessment must have completed at least up to Tier 3 Frailty Training.

Health care professionals carrying out reviews must have completed at least up to Tier 2 Frailty Training.

Frailty training is taking place at PLTs during 2018/19, led by a Consultant Practitioner - Specialising in Frailty:

BASE – 3 May STEPS – 21 June EPIC – 24 July

Page 6 of 37

Page 7: intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED CT Codes . G – Sign Up and Service and Payment Pre-Requisites (May 2018 Submission)

3.2.2 Service description

1: Identification of Patients Appropriate for Care Planning

Page 7 of 37

Page 8: intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED CT Codes . G – Sign Up and Service and Payment Pre-Requisites (May 2018 Submission)

1.The Insights Population Analytics (IPA) system includes risk stratification tools to support the identification of patients and clinical decision making. Practices must run the report called ‘Find New ACP Patients’ in IPA to obtain an indicative list of patients who are likely to benefit from having an anticipatory care plan.

This LCS allows for practices to autonomously identify patients appropriate for this LCS, for example:

via an initial case conference specifically set up to identify patients via a profiling tool available in EMIS Web or Vision the patient is known by the practice, social care or service providers identification by acute hospitals via discharge summaries

A case finding and assessment toolkit is available in Appendix A.

This LCS will pay for up to 3% of the patient population.

Practices are required to review the indicative list generated by IPA and those identified by other means to confirm through clinical judgement those patients living with moderate or severe frailty or with multiple long term conditions. Practices must code the records of appropriately diagnosed patients using Read codes 2Jd1. (‘moderate frailty’) or 2Jd2. (‘severe frailty’) as required by the 2017/18 GMS Contract, or 2Je.. (‘multiple long term conditions’) and carry out anticipatory care planning for each patient as part of this service. These patients are referred to as the ‘ACP Cohort’.

The IPA report called ‘My ACP Cohort’ shows the patients Read coded as above.

Patients who are on the End of Life Care (EoLC) register (and who are therefore Read coded 9Ng7) are excluded from this LCS and the ACP Cohort. Practices must, therefore, Read code 9Ng7 all patients who are already on or who are added to the EoLC register during the term of this LCS. This will be compared with EoLC data.

Patients that are likely to be identified as being appropriate for anticipatory care planning include:

Patients who have had at least three non-elective admissions within the last 12 months

Patients with multiple co-morbidities for whom anticipatory care planning would be appropriate

Patients with life-threatening or life-limiting conditions Patients who need chronic disease, multi-morbidity or long term condition

management Care home residents

Practices that do not already have access to IPA should request this by completing the CSU’s IPA User Access Request form for practices (Appendix B). The IPA Quick Reference Guide for Practices is available in Appendix C.

2: Anticipatory Care Planning

As part of the care planning process for the ACP Cohort practices are required to:

Page 8 of 37

Page 9: intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED CT Codes . G – Sign Up and Service and Payment Pre-Requisites (May 2018 Submission)

1.Maintain and improve the quality of anticipatory care planning for identified patients using a multi-disciplinary approach

GPs will receive support from and collaborate with other health and social care providers, including the Primary Care Integrated Care Teams (ICTs) and the new Integrated Care Decision-Making (ICDM) programme to review patients in a multi-disciplinary forum. As part of this collaboration, the identified LCS Care Planner will actively participate in the MDT case conferences to manage patients and develop care plans in collaboration with other professionals.

GP-led MDT meetings will be established through the ICTs/ ICDM, across all localities providing a platform for multi-disciplinary review of those patients most active in the community and/ or those identified as the ACP Cohort. Monthly meetings allow for the review, management and care planning of the most complex individuals. While individuals for review in the MDT meetings will be identified from a variety of local intelligence sources (including GP clinical judgement, IPA risk stratification/ data, supported discharge, adult social care, community nursing etc) the funding for this LCS applies only to the ACP Cohort.

The following is an example of the minimum membership of the MDT:

LCS Care Planner, LCS clinical lead (as required), Community Matron, District Nurse, Adult Social Care, Social Prescriber, Community Psychiatric Nurse, voluntary sector representatives and other health and care professionals as specific cases require.

The MDT case co-ordinator will liaise with practices, supporting them in the selection of patients to be reviewed. Patients will need to provide their consent for discussion and data sharing as part of the LCS (see item 5 on page 10). The time allocated to each practice will be based on the practice size and active caseload but the intention of the ICDM programme is increase the scale and pace of the MDT patient reviews. Notes/ actions/ plans following the meeting will be shared with the appropriate organisations and the patient. Practices attend either physically or virtually at their allocated time; the upfront payment to practices provided via this LCS funds this monthly attendance.

Prioritise those patients who have had more than three NELs in the previous 12 months.

Further details on anticipatory care planning, training and learning resources can be found in Appendix A.

Page 9 of 37

Page 10: intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED CT Codes . G – Sign Up and Service and Payment Pre-Requisites (May 2018 Submission)

2. Provide regular reviews

Using an MDT approach, provide ongoing care planning to patients, ensuring that the following are included for each patient:

Month Consultation Appointment Length0 Initial assessment (LCS) 20 minutes (minimum)1 1 month review (LCS) [1] Up to 10 minutes3 3 month review (LCS) 20 minutes (minimum)6 6 month review (LCS) 20 minutes (minimum)12 Annual review (GMS contract) [2]

Note 1: the purpose of the 1 month review is to clarify the care plan with the patient. This consultation may be carried out in person or via a telephone call.

Note 2: the above LCS reviews are in addition to the annual review required as part of the core frailty element of the GMS contract (refer to p.4).

Each consultation carried out under this LCS must be a minimum of 20 minutes in duration.

It is recommended that practices combine appointments previously conducted separately and allow extra time for people who might need it, such as those with dementia or multi-morbidities. Longer consultations can improve assessment and planning, enabling a more holistic approach.

A case finding and assessment toolkit is available in Appendix A.

3.Record care plans using a single, holistic template

It is recommended that care planning is recorded using single, holistic care planning template: a template is being developed and is expected to be available in May 2018. Further developments will be produced collaboratively with the digital transformation team and practices.

Code patients with an anticipatory care plan with the Read code 8CMM. (patient ‘has anticipatory care plan’).

Should a patient on the list already have a care plan this should be reviewed, updated and coded as above.

An IPA report is available to show those patients in the ACP Cohort who do not yet have an anticipatory care plan under this LCS.

4.Falls risk identification

Carry out an annual falls risk identification assessment for all patients (this is in addition to the GMS Contract requirement) (refer to p.4).

Page 10 of 37

Page 11: intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED CT Codes . G – Sign Up and Service and Payment Pre-Requisites (May 2018 Submission)

5.Increase the number of patients with consent to share their data

Request each patient’s consent to share their information with other healthcare providers, such as Berkshire Healthcare NHS Foundation Trust (BHFT), East Berkshire Primary Care Out of Hours Service (EBPCOOH), Frimley Health NHS Foundation Trust (FHFT), South Central Ambulance Service (SCAS) etc. Record this consent on the clinical system, using the Read code 9Ndn. (‘Express consent for core and additional Summary Care Record dataset upload’).

If a patient has expressed their dissent to share their information use the Read code 9Ndo. (‘Express dissent for summary care record dataset upload’). The patient should be given further opportunities to provide consent.

Appendix D is a Summary Care Record Toolkit for GP Practices. A leaflet to support discussions with patients is available for download from the NHS Digital website at https://digital.nhs.uk/summary-care-records and should be provided to patients or their family/ carer in advance of those discussions taking place.

6. Share data as appropriate

Share new care plans and updates to care plans with the patient’s family/ carer as appropriate.

Access to care of a patient during the out of hours period (which covers approximately 2/3 of the week) is challenging. The healthcare professional seeing the patient during this time is heavily reliant on the information contained in the care plan and communicated to EBPCOOH (via Adastra) and SCAS.

Good quality care plans enable SCAS, EBPCOOH and other clinicians who are involved with the patient’s ongoing care, to support and influence clinical decisions made during an urgent or acute phase of illness.

If consent to share patient data with other professionals has been obtained, securely share an electronic version of the care plan with other relevant healthcare professionals, such as SCAS and EBPCOOH as per standard practice:

For EBPCOOH:

Log on to Adastra (for any new users or log-on issues contact Barry Spiller, Operations Manager, [email protected] or, if it’s urgent, contact the call centre on 03000 24 3333).

Complete the Special Patient Note website or directly input to Adastra. For any additional paper-based information such as the anticipatory care

plan please scan and send by email to [email protected] before 17.00 Monday to Friday to allow EBPCOOH administrators to update the system prior to the OOH period.

For SCAS:

To inform SCAS of any ‘special circumstances’ including electronic images of forms please email [email protected]

Any future changes/ updates to the care plan should also be shared in a timely manner.

Page 11 of 37

Page 12: intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED CT Codes . G – Sign Up and Service and Payment Pre-Requisites (May 2018 Submission)

7. Identify and support carers

Identify and support unpaid (family/ friend) carers as appropriate and signpost to appropriate services and support (for example, signpost to social services for carers assessments and to the Social Prescribing Team). Use Read code 918F (patient ‘has a carer’).

If the carer is also registered at the practice, record and code their carer status accordingly on their medical record on the GP system using the appropriate Read code (refer to Appendix F for carer Read codes) and ensure they are included on the Carers Register. If the carer is registered elsewhere, contact their practice to request that their carer status is recorded.

8. Carry out a medication review

Carry out a medication review, Read coding using the codes in the GMS contract pp. 33-34: http://www.nhsemployers.org/-/media/Employers/Documents/Primary-care-contracts/GMS/2017-18-Technical-requirements-for-GMS-contract-changes.pdf. It is recommended that clinicians use the STOPP/ START tool. Guidance is available in Appendix A and more details on the tool can be found in the STOPP/ START Toolkit Supporting Medication Review:

Practices can contact the Medicines Optimisation Team for advice.

9. Offer flu immunisations

Where a clinician identifies that a patient would be eligible to receive flu immunisations in the winter periods of 2018-19 and 2019-20 this should be offered in the early part of the flu season. The responsibility for administering the flu immunisation to care home patients (both residential and nursing) remains with the general practice.

10. Refer to mental health services, as appropriate

Many people with long-term physical health conditions also have mental health problems. These can lead to significantly poorer health outcomes and reduced quality of life. Therefore, consider for each patient whether they would benefit from a referral to mental health diagnostic and/ or support services.

11. Provide a full team approach

As appropriate, practice staff should be aware of patients receiving this enhanced service to ensure a full team approach when a patient contacts the surgery. If capacity allows, provide patients with a direct line telephone number where they can contact a GP at the surgery in an emergency.

Page 12 of 37

Page 13: intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED CT Codes . G – Sign Up and Service and Payment Pre-Requisites (May 2018 Submission)

12. For care homes patients (in addition to the above requirements):

Practices are encouraged to notify the CCG Care Homes Quality Programme Manager where any concerns or themes appear from within any care homes they are visiting that may require further staff training/ support.

Practices are encouraged to give consideration to providing continuity of care to care home residents by having a nominated regular GP to provide care and be the nominated GP to the care home residents.

GPs may wish to consider working collaboratively with other practices to provide this service, where there are multiple practices covering one care home.

Work collaboratively with the care home staff and other health and social care staff as relevant to develop the care plan.

Ensure a single, up-to-date copy of the care plan is held both within the care home and at the GP practice. The care plan must be one record regularly updated and shared across the practice and care home, with relevant elements uploaded to Adastra.

Provide care home staff with a direct access telephone number to the practice should they need to speak to a member of the practice team urgently. Make all practice staff aware of this requirement.

Provide care home staff with a direct access number to the EBPCOOH – East Berkshire Primary Care Out of Hours Service: 03000 243 252.

13. MDT/ ICT pathway

The MDTs/ ICTs have limited capacity and managing their portfolios is critical, therefore each practice/ cluster must develop both a referral process and step down mechanism for patients appropriate for the MDT.

For example, MDTs might agree to intensively monitor those patients with new/ developing anticipatory care plans until after their first 3-month review, after which they are periodically discussed prior as part of the review process.

14. Patient and carer feedback

The practice must actively seek and record patient and carer feedback on the experience of their care provided under this LCS. The CCG will offer support and guidance.

Discuss and evidence learning points at the practice meeting, and record them on the Practice Improvement Action Plan (Appendix I) for sharing with other stakeholders.

Page 13 of 37

Page 14: intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED CT Codes . G – Sign Up and Service and Payment Pre-Requisites (May 2018 Submission)

3: Additional requirements for patients within the list who have had three or more unplanned admissions in the last year OR who have an unplanned admission

between 01.04.2018 – 31.03.2020

1. Practice clinical team to review the patients in the ACP Cohort who have had more than three NELs in the year prior to 01.04.2018 OR who have a NEL during the term of this LCS. Discuss and analyse how the NEL admission(s) for each patient potentially could have been avoided. Learning should form part of an action plan.

GPs and appropriate clinical staff (including members of the wider MDT, ICT and ICDM as relevant) are to perform a review of each patient on the list provided and of each admission to assess:

What went well What did not go well and why not Whether interventions or support in the community could have prevented

the admission Whether having identified interventions in place could prevent future

admissions.

The review should be discussed with the patient and family/carer/significant others and advice offered on services that are available to support them.

Practices are required to collate their learning across these reviews, detailing areas for improvements, and actions taken in the form of the Practice Improvement Action Plan (Appendix I). Identified learning and recommendations will be shared with practices and other relevant providers.

3. Create a crisis management/ treatment escalation plan for each patient. Identify the most appropriate member of the team to lead on each patient’s admission avoidance work.

4. On discussion and agreement with the patient and family/ carers as appropriate the identified team member takes responsibility for ensuring the completion of the actions identified.

5. Record changes and any further identified actions which could benefit the patient on the plan. Share this information as appropriate with other providers.

6. Monitor the patient through the year, keeping a record of any changes in their condition and circumstances, including noting any admissions and whether these were potentially avoidable. The plan should be updated when any meaningful changes occur.

7. Evidence which other organisations have been involved in each patient’s care planning, such as other health and social care teams, charities and independent organisations.

8. Practice contributes to in-year CCG level discussions, basing discussions around the learning identified by the practice and any actions taken.

Page 14 of 37

Page 15: intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED CT Codes . G – Sign Up and Service and Payment Pre-Requisites (May 2018 Submission)

3.3 Population covered

This service covers patients registered with a general practice in East Berkshire CCG and who:

Are diagnosed with moderate or severe frailty Have multi-morbidities Are at risk of unplanned admissions

3.4 Any acceptance and exclusion criteria and thresholds

Practices must agree to attend regular formal training resulting from the learning expected from the enhanced service, and ensure competency and awareness of local policies, pathways and processes. Practices should be familiar with training around: Advance Communication, Safeguarding Adults Level 3, Deprivation of Liberty, Dementia Diagnosis, Falls Assessment, Advance Care Planning along with any relevant training associated with the service.

3.5 Interdependence with other services/ providers

The provider (GP Practice) must ensure they collaborate with other health and social care teams.

Practices are encouraged to collaborate, for example sharing resources to deliver the requirements of this LCS:

This LCS allows more than one practice to sign up to each contract in order to deliver on the requirements.

Page 15 of 37

4: Care Plan Audits and Reviews

1.Audit the quality of a random sample of care plans carried out using the Care Plan Audit Tool (Appendix H).

The first audit should take place in Q1 2018/19 to review care plans developed in Q1 subsequent to the care and support planning training attended in Q1 2018/19.

Carry out annual audits thereafter on a random 5% of anticipatory care plans carried out each year.

Discuss and evidence learning points at the practice meeting, and record them on the Practice Improvement Action Plan (Appendix I) for sharing with other stakeholders.

2.Review any care plans highlighted by South Central Ambulance Service (SCAS), East Berkshire Primary Care Out of Hours Service (EBPCOOH) or other providers as requiring improvement, identifying and addressing areas for improvement in these plans and in practice care planning processes generally. Discuss and evidence learning points at the practice meeting, record them on the Practice Improvement Action Plan (Appendix I) for sharing with other practices and provide feedback to the provider.

Page 16: intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED CT Codes . G – Sign Up and Service and Payment Pre-Requisites (May 2018 Submission)

This LCS allows inter-practice referrals, enabling larger practices to take on patients from smaller practices

This LCS allows each cluster to have one LCS clinical lead, co-ordinator and care planner who attend the launch event and training on the basis that they are delivering the LCS on behalf of the cluster.

Practices must consider that, when sharing resources as described above, they are also sharing the risk.

Choosing to work within local Federations or clusters to provide the LCS offers opportunities for GPs with a special interest to take a lead role on the development and delivery of the primary care role in the local integrated care model. This also enables smaller practices to take advantage by combining lists to meet the minimum threshold.

4. Applicable Service Standards

4.1 Applicable national standards (e.g. NICE)

The service must comply with the guidelines produced by the following organisations (where applicable):

Rules of Professional Conduct: http://www.csp.org.uk/professional-union/professionalism/csp-expectations-members/professional-rules

NICE Guidance and recommended pathways: Dementia : supporting people with dementia and their carers in health and social

care Clinical guideline [CG42] Dementia, disability and frailty in later life – mid-life approaches to delay or prevent

onset NICE guideline [NG16] End of life care for adults Quality standard [QS13] Multimorbidity : clinical assessment and management NICE guideline [NG56] Medicines optimisation : the safe and effective use of medicines to enable the best

possible outcomes NICE guideline [NG5]

Care Act 2014 and Care and Support Statutory Guidance (updated August 2017).

Applicable policies produced by East Berkshire CCG and any adaptations to these policies.

Care Quality Commission registration requirements.

4.2 Applicable standards set out in Guidance and/or issued by a competent body (e.g. Royal Colleges)

Not applicable.

4.3 Applicable local standards

Not applicable.

Page 16 of 37

Page 17: intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED CT Codes . G – Sign Up and Service and Payment Pre-Requisites (May 2018 Submission)

5. Monitoring and payment

Please refer to Appendix E for the Payment Schedule and Information and Monitoring Requirements for this LCS. The value of this LCS is £220 for up to 3% of the practice’s patient population over 2 years – 18/19 and 19/20:

£55 per patient in the Indicative ACP Cohort paid upfront to practices in 2018/19 based on 3% of their patient population as at 01.03.18

£55 per patient in the Indicative ACP Cohort paid upfront to practices in 2019/20 based on 3% of their patient population as at 01.03.19

In total up to £110 paid per ACP Cohort patient who has a coded anticipatory care plan (up to 3% of the patient population) on the achievement of measures outlined in Appendix E.

Practices or clusters that sign up to this LCS are expected to provide the service in full. The commissioner reserves the right to recover the up-front payment if the practice’s data does not demonstrate participation, including submitting evidence to the CCG.

Practices are required to submit the completed documentation provided by the CCG to the [email protected] email account no later than the dates outlined in the table in Appendix E. The submissions will be assessed and approved by the Project Manager and the Senior Responsible Officer (SRO) as meeting the requirements set out in the Monitoring Schedule.

6. Review and Shared LearningA vital part of this LCS is the learning that the CCG can gather from our healthcare colleagues and how this can be used to shape future services to help improve patient care and outcomes.

As part of the care plan audit and action plan practices are asked to evidence that they have taken part in discussions around care planning, efforts made to reduce NELs and the outcomes of this work for patients and the practice. Sharing key themes that are discovered through this work means that further targeted admission prevention work can be planned for the future.

Each practice will contribute to in-year CCG level discussions, basing discussions around details within the Care Plan Audit (Appendix H) and the Practice Improvement Action Plan (Appendix I). The CCG will share the learning identified by practices for the purpose of service improvement and to identify key themes and trends in the area.

Page 17 of 37

Page 18: intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED CT Codes . G – Sign Up and Service and Payment Pre-Requisites (May 2018 Submission)

Appendix A

CASE FINDING, ASSESSMENT, MEDICATION REVIEW AND CARE PLANNING GUIDANCE, TRAINING, SUPPORT AND LEARNING RESOURCES

All appendices and embedded documents will be available on the intranet by 8th May 2018.

CONTENTS

1 - Training and support2 - Case Finding and Assessment Toolkit – including medication reviews3 - Guide to delivering personalised care and support planning4 - Care planning learning resources5 - Care plan principles6 - Interventions and coding required by this Locally Commissioned Service

1TRAINING AND SUPPORT

Academic Half Days

Training is taking place at PLTs during 2018/19 BASE – 3 May STEPS – 21 June EPIC – 24 July

The training comprises:

Frailty, led by a Consultant Practitioner - Specialising in Frailty Prescribing, led by a Pharmacist

Note: PLT training may differ between localities.

Care and Support Planning Training

Training is being developed by the CCG. Dates will be confirmed following the sign-up period.

Implementation Support

The CCG will carry out practice visits to provide support on:

The LCS and returns documentation Using IPA Implementation and developing a local approach: Case finding, effective MDT

meetings, care and support planning, MDT discharge and step up/ step down.

Page 18 of 37

Page 19: intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED CT Codes . G – Sign Up and Service and Payment Pre-Requisites (May 2018 Submission)

2CASE FINDING AND ASSESSMENT TOOLKIT

NHS England has published a toolkit for general practice in supporting older people living with frailty. The aim of this toolkit is to provide GPs, practice nurses and the wider primary care workforce with a suite of tools to support the case finding, assessment and case management of older people living with frailty.

The toolkit’s appendices comprise:

Clinical Frailty Scale Gait speed test PRISMA7 questions Initial Comprehensive Geriatric Assessment (CGA) form STOPP START Medication Review Tool

Medication Reviews

The use of multiple medications by older people living with frailty and multi-morbidity is likely to increase the risk of falls, adverse side effects and interactions. The STOPP/ START Toolkit Supporting Medication Review is based on a medication review tool designed to identify medication where the risks outweigh the benefits in the elderly and vice versa.

3A GUIDE TO DELIVERING PERSONALISED CARE AND SUPPORT PLANNING

National Voices, in collaboration with a wide range of partners and people who use services, has developed a common understanding about what is meant by care and support planning. They highlight the four main steps of the care and support planning process and have identified a number of principles to help ensure that the process is truly person-centred. These principles are the basis for the guidance on delivering personalised care and support planning.

1. Prepare Starts from the point of view of the person and their carer or family member Gathers necessary information and makes it available upfront to the person Builds in time to reflect and consider options

Individuals will need time, support and information to help them prepare for a discussion about their care and support. This might include being able to view test results; having

Page 19 of 37

Page 20: intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED CT Codes . G – Sign Up and Service and Payment Pre-Requisites (May 2018 Submission)

access to accessible, relevant information to aid decision making; or time to identify and discuss their preferences with family, carers, advocates or peers.

Health and care practitioners will also need to prepare for care and support planning discussions. This might include liaising with other care professionals, and building a better understanding of local services and support which might benefit patients and carers in their local area.

2. Discuss Takes a partnership approach Focuses on staying well and living well (and for some, it will also mean dying

well) Identifies the actions that a person can take Identifies what care and/or support might be needed from others

Discussion relies on both parties being able to contribute equally, and in some cases, individuals may lead their own planning discussion. For others, for example individuals lacking in confidence, with lower levels of health literacy or activation, language or communication barriers, additional support may be needed. Individuals who lack capacity, as defined by the Mental Capacity Act 2005, can benefit from personalised care and support planning with the right support and considerations.

Conversations should be flexible and not dictated by set questions. There should be open questions and active listening and the discussion should be broad enough to cover what is important to the person and the wider holistic needs that might be impacting on their health and wellbeing.

A key part of personalised care and support planning is setting goals which are important and relevant to the individual and discussing realistic and tangible actions for achieving these. This will include planning for the future and contingency planning. Strategies for achieving goals might rely on self-management; support from peers, carers or local community services; or support from health, care or other public services.

3. Document The main points from discussions are written up, Read or SNOMED coded

appropriately, included as part of the person’s health and/ or social care records, and owned by the person and shared, with explicit consent.

When documenting the care and support planning discussion, consideration needs to be given to how this is presented. The individual and their carer need to have a copy and this should be written in plain English. The plan should also be saved as part of the individual’s healthcare record and be shared with others. Services will need to determine their approach, for example whether they will use paper or electronic formats, whether templates or datasets will be used, and how data can be shared. Consent from the individual to share any information must be discussed and recorded.

4. Review Considers options for follow up and sets a date for review

The frequency of the review of personalised care and support plans should be agreed with the individual and their carer and may depend upon factors such as unplanned hospital admissions, deterioration in health, changes in circumstances, carer concerns. Some

Page 20 of 37

Page 21: intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED CT Codes . G – Sign Up and Service and Payment Pre-Requisites (May 2018 Submission)

people may only require an annual review, for others reviews may be needed every three months, or more often.

Reviews should reflect on what is working well and what is not, progress against goals and actions, and whether any changes are needed. This information will help determine whether the individual is receiving the right care and support but can also help inform decisions at a population level about commissioning or de-commissioning services.

4CARE PLANNING LEARNING RESOURCES

British Geriatrics Society Personalised Care and Support Planning - This webpage provides a quick reference guide to care planning for primary care and community clinicians with emphasis on the care of older people living with frailty. It provides the following information:

What is personalised care and support planning? The recommended components of a care plan Tips for developing a care plan A list of useful resources to help clinicians and patients engage in personalised care

and support planning.

National Voices Care and Support Planning Guide - This guide is designed for anyone who has health and care needs over time, or cares for someone who does.

5CARE PLAN PRINCIPLES

The plan is focused and written in language that is clear and person-centred (for example, maximising positives, strengths, the patient's choices and involvement, minimising weaknesses and disability)

Records patient's and/ or carer's involvement in care planning (e.g. patient’s determined goals, agreed treatment options, patient’s views)

The plan clearly shows a description of the action to be taken and by whom, including the provision of information and guidance.

Evidence that mental capacity has been considered Plan supports or encourages the patient to self-care/ self-manage their condition/s Plan is outcomes focused and demonstrate goals that show progress Encompasses all needs identified with clear outcomes to be achieved; identifies any

unmet needs The care plan is given to the patient or their NOK and shared with other professionals

with consent

Page 21 of 37

Page 22: intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED CT Codes . G – Sign Up and Service and Payment Pre-Requisites (May 2018 Submission)

The reviewing GP and/ or other appropriate clinician could use the 7Cs approach:

Condition ...any change?Consequences

...of any changes?

Consent ...to discuss with carers?Change ...in medications?Coping ...practical matters to adjust?Care place ...home, hospital or care home?Community ...are District Nurses/ social care team informed/ MDT involved?

A good quality anticipatory care plan should include:

Patient’s wishes/ place of care Resuscitation status/ DNACPR in place? Risks to responders Patient profile/ insight Health history Social history Diagnosed conditions Normal or usual presentations Normal observations Medications Risks for patient and allergies Safeguarding requirements Existing care and provision, including unpaid family carers Specific treatment plan/ regime EOL plan/ just in case medication Recommended referral route/ pathway if presenting ‘normally’ List of names, contacts, phone numbers and providers involved in care Is there a lasting power of attorney for health and wellbeing?

The inclusion of meaningful free text information is crucial. See examples of good practice below in relation to free text information:

Example 1JB is a retired aircraft engineer, lives with wife (mild dementia) in isolated country cottage. He is now 97, has AF, COPD, mild CCF. Poor mobility with OA, walks with frame. Carers X2 /day. Son lives in Windsor, helps him with showering three times a week. Independently shops on internet. 2 dogs, they are well behaved and cause no trouble. Wants to be admitted for acute chest infections, if he gets very SOB or goes into CCF. If O2 below 88% he usually needs admission. If better than that then ABs and nebulising may avoid admission. He is a falls risk, has alarm pendant. Still on anticoagulant Pradaxa. If he has to be in bed or immobile (ie LRTI or musculoskeletal problem) then call care agency xxx (Tel xxxxx xxxxxx) have agreed to provide 24hr care privately as necessary.Example 2Patient lives with supportive husband, she has had worsening MS for 30 years. Has now decided that she does not want hospital admission, wishes to have treatment at home only. Letter received by SCAS stating that if she gets a life-threatening condition she does NOT want to receive IV antibiotics even though her life may be at risk. She will however take oral antibiotics for any infection if advised. Palliative Care Consultant has advised how to change to syringe driver for meds prn, see Current Situation.Example 3Does not wish to be admitted to acute hospital if becomes acutely unwell. Please consider keeping him at home and palliating symptoms or possible xxx admission.

Page 22 of 37

Page 23: intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED CT Codes . G – Sign Up and Service and Payment Pre-Requisites (May 2018 Submission)

6SUMMARY OF CARE PLANNING INTERVENTIONS AND CODING REQUIRED BY THIS

LOCALLY COMMISSIONED SERVICE

Code patients within the ACP Cohort as follows: moderate frailty - Read code 2Jd1 severe frailty - Read code 2Jd2 Multiple long term conditions – 2Je.

Use the MDT approach to care planning

Each patient to receive 4 contacts plus an annual review (refer to the LCS p9)

Record care plans using a single, holistic template

Falls risk identification

Code patients with an anticipatory care plan using Read code 8CMM.Ask patients to give consent to share their data. Record this using the Read code 9Ndn.

(Express consent for core and additional Summary Care Record dataset upload)Patients who do not wish to share their data should have their records updated using the

Read code 9Ndo. (Express dissent for summary care record dataset upload)Identify carers and record this using Read code 918F (patient ‘has a carer’). Signpost

carers to the appropriate services and supportUpdate carers’ records with the appropriate ‘is a carer’ Read code and add them to the

Carers Register

Carry out a medication reviewCode patients added to the End of Life Register using the Read code 9Ng7.Offer eligible patients a flu immunisationRefer appropriate patients to mental health servicesCarry out tasks specific to care homes patients as per the LCS p12Actively seek and record patient and carer feedback relevant to this service, LCS p12Carry out tasks specific to patients who have unplanned admissions as per the LCS p13

Page 23 of 37

Page 24: intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED CT Codes . G – Sign Up and Service and Payment Pre-Requisites (May 2018 Submission)

All appendices and embedded documents will be available on the intranet by 8th May 2018.

Appendix B

IPA USER ACCESS REQUEST FORM

IPA QUICK REFERENCE GUIDE FOR PRACTICES

CARE RECORDS WITH ADDITIONAL INFORMATION:

TOOLKIT FOR GP PRACTICES

Page 24 of 37

Appendix D

Appendix C

Page 25: intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED CT Codes . G – Sign Up and Service and Payment Pre-Requisites (May 2018 Submission)

APPENDIX E: Payment Schedule and Information and Monitoring Requirements

Bracknell and Ascot Locality

Slough Locality

Page 25 of 37

Page 26: intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED CT Codes . G – Sign Up and Service and Payment Pre-Requisites (May 2018 Submission)

Windsor, Ascot and Maidenhead Locality

Page 26 of 37

Page 27: intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED CT Codes . G – Sign Up and Service and Payment Pre-Requisites (May 2018 Submission)

The table below outlines the reporting requirements from practices and associated planned payments:

Page 27 of 37

Page 28: intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED CT Codes . G – Sign Up and Service and Payment Pre-Requisites (May 2018 Submission)

Anticipatory Care Locally Commissioned Service (LCS)

The value of this LCS is £220 for up to 3% of the practice’s patient population over 2 years – 18/19 and 19/20: £55 per patient in the Indicative ACP Cohort paid upfront to practices in 2018/19 based on 3% of their patient population as at 01.03.18 £55 per patient in the Indicative ACP Cohort paid upfront to practices in 2019/20 based on 3% of their patient population as at 01.03.19 In total up to £110 paid per ACP Cohort patient who has a coded anticipatory care plan (up to 3% of the patient population) on the achievement of measures

outlined below.

Payment Reporting Requirement Reporting Period Format of ReportDeadline for Delivery of

ReturnsInvoice Payment

Date

Year 1Upfront payment£55 per patient in the Indicative ACP Cohort – based on 3% of the practice’s registered population

Sign up to the LCS, confirming:1. Care planning training has been attended,

discussed and is being/ will be embedded in practice (action plan)

2. That the practice has signed up to IPA and returned its data sharing agreement to the CSU

3. The names of the LCS lead clinician, care planner and co-ordinator and their commitment to the responsibilities outlined in paragraph 3.2.1 above, which includes attendance at monthly MDTs funded through this LCS (refer also to p.8)

4. That HCPs carrying out care planning have the appropriate level of frailty training

Refer to 3.2.1 Service and Payment Pre-Requisites (p. 5) for details.

It is expected that 3% of the practice’s registered population will be identified as appropriate for this service. Identify, assess and code the ACP Cohort by 1 November 2018 (refer to 3.2.2 Service description, p. 7)

n/a Submission of Sign Up and Service and Payment Pre-Requisites (May 2018 Submission) - Excel template (Appendix G).

No report required; patients must be coded within the GP record system.

Submission of sign up for the period: 1st April 2018 to 31st

March 2019 (to be submitted no later than 31st May 2018)

Invoice template to be issued and paid following approval of the first submission.

Page 28 of 37

Page 29: intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED CT Codes . G – Sign Up and Service and Payment Pre-Requisites (May 2018 Submission)

Anticipatory Care Locally Commissioned Service (LCS)

The value of this LCS is £220 for up to 3% of the practice’s patient population over 2 years – 18/19 and 19/20: £55 per patient in the Indicative ACP Cohort paid upfront to practices in 2018/19 based on 3% of their patient population as at 01.03.18 £55 per patient in the Indicative ACP Cohort paid upfront to practices in 2019/20 based on 3% of their patient population as at 01.03.19 In total up to £110 paid per ACP Cohort patient who has a coded anticipatory care plan (up to 3% of the patient population) on the achievement of measures

outlined below.

Payment Reporting Requirement Reporting Period Format of ReportDeadline for Delivery of

ReturnsInvoice Payment

Date

Practice Self-Assessment.

Submission of Practice Self-Assessment - Excel template (Appendix H).

Performance payment £55 per ACP Cohort patient with a coded anticipatory care plan.

At least 45%* of the ACP Cohort have a care plan.

Patients to be coded with moderate or severe frailty or multiple long term conditions (refer to p.7) and have a coded anticipatory care plan (refer to p. 9).

1st April 2018 - 31st March 2019

Data submission - Excel template (Appendix H).

End of Year submission: 1st April 2018 to 31st March 2019 (to be submitted no later than 17th May 2019)

Invoice template to be issued and paid following approval of the end of year submission.

Performance payment £33 per ACP Cohort patient with a coded anticipatory care plan.

Submission of two satisfactory ACP Care Plan Audits and Practice Improvement Action Plan in year 1 of this LCS

1st April 2018 – 30th September 2018

1st October 2018 –

Q1 ACP Care Plan Audit on 5% of anticipatory care plans carried out between 1st April 2018 – 30th September 2018 - Excel template (Appendix H) and Practice Improvement Action Plan – Word document (Appendix I).

End of Year submission: 1st April 2018 to 31st March 2019 (to be submitted no later than 17th May 2019)

Invoice template to be issued and paid following approval of the end of year submission.

Page 29 of 37

Page 30: intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED CT Codes . G – Sign Up and Service and Payment Pre-Requisites (May 2018 Submission)

Anticipatory Care Locally Commissioned Service (LCS)

The value of this LCS is £220 for up to 3% of the practice’s patient population over 2 years – 18/19 and 19/20: £55 per patient in the Indicative ACP Cohort paid upfront to practices in 2018/19 based on 3% of their patient population as at 01.03.18 £55 per patient in the Indicative ACP Cohort paid upfront to practices in 2019/20 based on 3% of their patient population as at 01.03.19 In total up to £110 paid per ACP Cohort patient who has a coded anticipatory care plan (up to 3% of the patient population) on the achievement of measures

outlined below.

Payment Reporting Requirement Reporting Period Format of ReportDeadline for Delivery of

ReturnsInvoice Payment

Date

31st March 2019 Year 1 ACP Care Plan Audit on 5% of anticipatory care plans carried out between 1st October 2018 – 31st March 2019 - Excel template (Appendix H) and Practice Improvement Action Plan – Word document (Appendix I).

Performance payment £22 per ACP Cohort patient with a coded anticipatory care plan.

By the end of year 1 of this LCS achieve a reduction** of 15% in NELs activity for the ACP Cohort.

1st April 2018 - 31st March 2019.Measured at 31st March 2019

NELs data provided by the CSU

N/A Invoice template to be issued and paid following approval of the achievement measure.

Payment Reporting Requirement Reporting Period Format of ReportDeadline for Delivery of

ReturnsInvoice Payment

Date

Year 2Upfront payment£55 per patient in

Practice Self-Assessment – Year 1 review. Submission of Practice Self-Assessment - Excel

Submission of sign up for the period: 1st April 2019 to 31st

Invoice template to be issued and paid following

Page 30 of 37

Page 31: intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED CT Codes . G – Sign Up and Service and Payment Pre-Requisites (May 2018 Submission)

Payment Reporting Requirement Reporting Period Format of ReportDeadline for Delivery of

ReturnsInvoice Payment

Date

the Indicative ACP Cohort – based on 3% of the practice’s registered population

Practice Self-Assessment – Year 2 review.

template (Appendix H).

Submission of Practice Self-Assessment - Excel template (Appendix H).

March 2020 (to be submitted no later than 29th March 2018)

approval of the first submission

Performance payment £55 per ACP Cohort patient with a coded anticipatory care plan***.

At least 90%* of the ACP Cohort have a care plan.Patients to be coded with moderate or severe frailty or multiple long term conditions (refer to p.7) and have a coded anticipatory care plan (refer to p. 9).

1st April 2019 - 31st March 2020

Data submission - Excel template (Appendix H).

End of Year submission: 1st April 2019 to 31st March 2020 (to be submitted no later than 15th May 2020

Invoice template to be issued and paid following approval of the end of year submission.

Performance payment £33 per ACP Cohort patient with a coded anticipatory care plan***.

Submission of a satisfactory ACP Care Plan Audit and Practice Improvement Action Plan in year 2 of this LCS

1st April 2019 - 31st March 2020

Year 2 ACP Care Plan Audit on 5% of anticipatory care plans carried out in 2019/20 - Excel template (Appendix H) and Practice Improvement Action Plan – Word document (Appendix I).

End of Year submission: 1st April 2019 to 31st March 2020 (to be submitted no later than 15th May 2020

Invoice template to be issued and paid following approval of the end of year submission.

Performance payment £22 per ACP Cohort patient with a coded anticipatory care plan***.

By the end of year 2 of this LCS achieve a reduction** of 15% in NELs activity for the ACP Cohort.

1st April 2019 - 31st March 2020.Measured at 31st March 2020

NELs data provided by the CSU

N/A Invoice template to be issued and paid following approval of the achievement measure.

Page 31 of 37

Page 32: intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED CT Codes . G – Sign Up and Service and Payment Pre-Requisites (May 2018 Submission)

* For those patients who do not engage with the care planning consultations, payment will be made if practices can evidence via that they have made every effort to engage with non-responding patients.

** Reduction in NELs will be evaluated on the practices signed up to each LCS contract. For example:

A single practice may sign up to this LCS and must achieve 15% reduction in NELs for the practice’s ACP Cohort. A cluster of practices may sign up to this LCS together and must achieve 15% reduction in NELs for the combined ACP Cohorts of all

practices in the cluster

*** Not inclusive of patients with coded care plans this LCS paid for in 2018/19: each patient in the ACP Cohort will be paid for once during this LCS.

Practices may be asked to submit a random selection of care plans to audit for quality purposes.

Submit returns to [email protected] no later than the dates outlined in the table above.

Please email any queries or issues regarding measures and payments to [email protected]

Page 32 of 37

Page 33: intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED CT Codes . G – Sign Up and Service and Payment Pre-Requisites (May 2018 Submission)

All appendices and embedded documents will be available on the intranet by 8th May 2018.Appendix F

Anticipatory Care Planning LCS Read and SNOMED CT Codes

Below is a list of Read codes relevant to this LCS and referred to in the specification. Using these codes will enable accurate reporting of the ACP Cohort activity.

Description Read Code SNOMED CT CodeModerate frailty 2Jd1. 925831000000107Severe frailty 2Jd2. 925861000000102Multiple long term conditions 2Je.. 934471000000109On End of Life Care (EoLC) register 9Ng7 526631000000108Has anticipatory care plan 8CMM. 792871000000101Express consent for core and additional Summary Care Record dataset upload

9Ndn. 773051000000102

Express dissent for summary care record dataset upload

9Ndo. 777441000000102

Has a carer 918F 184156005Is a carer 918G 224484003

Carer Read Codes

Read codes are used to identify carers and carers of patients with various conditions. Running regular audit searches to monitor identification of carers, a new diagnosis that would likely give rise to a household member becoming a carer, is crossed referenced with early contact to the family of offer support.

Carer identification:

Is a carer 918GNo longer a carer 918f

Carer of person with:

Dementia 918yTerminal Illness 918mAlcohol Misuse 918bChronic disease 918cPhysical disability 918XSensory impairment 918YLearning disability 918WSubstance misuse 918aMental Health Problems 918dMotor Neurone disease EMISNQCA1099

Codes used to identify referrals for Carers Services:

Referral for Voluntary Support Service (Signal4Carers) 8HHNOReferral sent for Social Services Carer Assessment 8HKB

Page 33 of 37

Page 34: intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED CT Codes . G – Sign Up and Service and Payment Pre-Requisites (May 2018 Submission)

Appendix G

Sign Up and Service and Payment Pre-Requisites(May 2018 Submission)

Upon sign up to the Anticipatory Care Planning LCS practices are required to complete the declaration below and return to [email protected] no later than 31st May 2018.

Practice Name:

Practice Code:

Practice Manager Name:

Anticipatory Care Planning LCS - Sign Up Declaration

Name of LCS clinical lead:Email address of LCS clinical lead:Name of LCS co-ordinator:Email address of LCS co-ordinator:Name of LCS care planner:Email address of LCS care planner:Clinicians have reviewed and discussed the care planning guidance to embed it within care planning at the practice.

Y/N

The practice has signed up to Integrated Population Analytics (IPA) and has submitted its data sharing agreement with the CSU.

Y/N

The practice or has signed up to the End Of Life Care Locally Commissioned Service (LCS).

Y/N

Health care professionals carrying out the initial assessments have completed at least up to Level 3 Frailty Training and those carrying out reviews have completed up to at least Level 2 Frailty Training.

Y/N

The practice (care planner and clinical lead as required) commits to leading and attending monthly MDT meetings (ICTs/ ICDMs)

Y/N

The LCS resources commit to attending at least one in-year CCG level discussions and to participating in the regular sharing of learning across East Berkshire.

Y/N

Action Plan for Embedding Care Planning Training into Practice

Provide details of how the care planning training and guidance is being/ has been implemented into practice:

Baselining Data

Page 34 of 37

Page 35: intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED CT Codes . G – Sign Up and Service and Payment Pre-Requisites (May 2018 Submission)

Item Data Request Data

1 No. patients identified by IPA on 01.06.18

Data supplied by CSU

2No. patients Read coded 2Jd1, 2Jd2 or 2Je. on 01.04.18

3

No. patients Read coded as per 2 above with an anticipatory care plan on 01.04.18

4

No. carers of patients in the ACP Cohort (Read coded as per 2 above) on 01.04.18 (search Read code 918F)

5

No. patients in the ACP Cohort (Read coded as per 2 above) with consent to share their data on 01.04.18 (search Read code 9Ndn.)

6

No. patients in the ACP Cohort (Read coded as per 2 above) who do not consent to share their data on 01.04.18 (search Read code 9Ndo.)

All appendices and embedded documents will be available on the intranet by 8th May 2018.

Page 35 of 37

Page 36: intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED CT Codes . G – Sign Up and Service and Payment Pre-Requisites (May 2018 Submission)

All appendices and embedded documents will be available on the intranet by 8th May 2018.

Appendix H

Excel template, comprising:1. ACP Care Plan Audit Tool2. Practice self-assessment 3. Data submission

Page 36 of 37

Page 37: intranet.eastberkshireccg.nhs.uk  · Web viewF – Anticipatory Care Planning LCS Read and SNOMED CT Codes . G – Sign Up and Service and Payment Pre-Requisites (May 2018 Submission)

Appendix I

Practice Improvement Action Plan(September 2018 Submission)

Learning identified for on-going in-house/ CCG discussion, discussion with other providers/ MDTs and to feed back to other stakeholders

Practice Name:

Practice Code:

Practice Manager Name:

Include learning and identified actions/ improvements from: Practice Self-Assessment; care plan audits; reviews of patients who have had a non-elective admission; patient and carer feedback; any other source relevant to this service.

Provide evidence that the practice has taken part in discussions around care planning, efforts made to reduce NELs and the outcomes of this work for patients, the practice and the partners in the cluster MDTs/ ICTs.

Include owners of actions and completed actions. Do not include patient identifiable data.

What went well/ what works well?

What did not go well/ doesn't work well?

What could have been done differently, and by whom?

What changes to practice are being implemented and by when?

All appendices and embedded documents will be available on the intranet by 8th May 2018.

Page 37 of 37