LTC Year of Care Commissioning Model Lesley A Callow, Delivery Support Manager - Long Term Conditions Year of Care Commissioning Model NHSIQ Fionuala Bonnar, Year of Care Programme Manager LTC Year of Care benefits: Improved outcomes and wellbeing: Patients receive care that is better managed, more seamless across different care services and more needs focused. Reduction in acute admissions to hospital; and shorter lengths of stay when these are required. Clinical professionals contribute to a more holistic service for patients by working within an integrated patient-centred care plan   Local health and Social Care economies: Provide care that delivers value for money and is better managed by integrated teams. Incentive to improve services for patients Improved joint working and shared responsibility for outcomes

1. Improving health outcomes across England by providing improvement and change expertise
LTC Year of Care
Commissioning Model
Lesley A Callow
Delivery Support Manager
LTC Year of Care Commissioning Model
NHSIQ
Fionuala Bonnar
Year of Care Programme Manager

2.  Launched in W/C 19th April 2012 with EOI under Dept of Health LTC QIPP
workstream
 Transferred to NHS England in December 2012 to Martin Mc Shane and he
is SRO as Director Domain 2
 Integration with the ICSP Pioneers
 22 Fast Followers
 6 Early Implementer Sites
LTC Year of Care: Background

3. LTC Year of Care: Early Implementer Sites
Health Economy Early
Implementer
Key Partners Regions
Leeds Leeds South and East CCG, Leeds West CCG, Leeds North CCG, North
Southend Southend CCG; Southend Council Midlands and
East
Kent Kent County County (Social Services Dept), Kent Community Health Trust, East Kent University
Hospital FT, Maidstone Foundation Trust, Darent Valley Hospitals FT, Canterbury CCG, Thanet
CCG, Swale CCG, Ashford CCG, South Kent Coast CCG, West Kent CCG, Dartford and
Gravesham and Swanley CCG.
South
North Staffordshire and
Stoke on Trent
Stoke on Trent CCG, North Staffordshire CCG; Stoke on Trent Council; Staffordshire Joint
Commissioning Unit; University Hospital of North Staffordshire; Staffordshire and Stoke on Trent
Partnership Trust, North Staffordshire Combined Healthcare Trust; West Midlands Ambulance
Trust
Midlands and
East
West Hampshire West Hampshire CCG; Hampshire County Council; Hampshire Hospitals NHS FT; Southern Health
NHS FT.
South
Barking, Havering and
Redbridge
Barking and Dagenham CCG; Havering Emerging CCG; Redbridge Emerging CCG; Barking &
Dagenham Council; Redbridge Council; Havering Council; NHS Outer North East London; Barking,
Dagenham and Redbridge University Hospitals Trust; North East London NHS FT.
London

4. The House of Care
Engaged,
informed
individuals &
carers
Commissioning
Organisational
& clinical processes
Person-
centred,
coordinated
care
Health & care
professionals
committed to
partnership
working
Plan
Study
Do
Act

5. The House of Care

6. LTC Year of Care Benefits:
Improved outcomes and wellbeing:
• Patients receive care that is better managed, more seamless across
different care services and more needs focused.
• Reduction in acute admissions to hospital; and shorter lengths of stay
when these are required.
• Clinical professionals contribute to a more holistic service for patients by
working within an integrated patient-centred care plan
Local health & Social Care economies:
• Provide care that delivers value for money and is better managed by
integrated teams.
• Incentive to improve services for patients
• Improved joint working and shared responsibility for outcomes

7. LTC Year of Care Currency:
• All PbR
(except YoC or
package
currencies)
Acute Community Mental Health Social Care Voluntary/
Independent
Primary care
Primary care
prescribing
NHS England
as commissioner
• Non-PbR block
contract
• PbR excl drugs
• Crit. Care
Personal
healthcare
budget
Specialised MH
Services
Means-
tested
services (incl.
residential)
Within currency
Rehabilitation
palliative &
end of life
Maternity pathway
• Reablement
• Adult Services
PbR MH
clusters
Children’s
services
GP services
Include if possible
Residential
continuing
care (Include if
possible)
Include if
possible

8. RRR audit:
 To support local thinking about RRR and early discharge, particularly in
relation to potential for pathway changes.
 To assess the appropriateness of methodology for long-term conditions
(COPD, diabetes, stroke and heart failure), particularly whether there is
scope to unbundle the RRR service from the Acute Provider PbR tariff.
Health and social care resource utilisation dataset
 Support the development of local tariffs for LTC YoC currency
 Looking at longitudinal data to support the discussions/understand the
impact in changing pathways
Whole Population
 Gives the evidence to support the currency framework
 Validates the framework
LTC Year of Care: Data Collections

9. • Stakeholder engagement and senior team ‘buy-in’
• Assessment of services to maximise the benefit of integrated care
• Learn from research, eg models of care, contracting models,
weighting LTCs for local tariff
• Planning for improvement in data quality and implementation of
shadow testing
• Assessment of systems and processes to support LTC YoC currency
• RRR clinical audit
• Local analysis and collection of data to support national analysis
• Local tariff development
• Share learning with other health economies and national
stakeholders
LTC Year of Care:
Early Implementer Sites Deliverables

10. • Senior team ‘buy-in’, eg NCDs
• Stakeholder Engagement, eg Monitor and PbR Team
• Framework for the Model and vision for future years
• Simul8 Model for redesigning services
• Data analysis and comparison
• Programme Management and EI site support
• Resolution of barriers, eg Information Governance
LTC Year of Care:
National Support Team Deliverables

11. GPs
Community &
Social Care
Assessment
Integrated
Care Team
GP datasets
Acute datasets
Mental
Health
datasets
KMHIS2
GPs
Community
Trust1
Acute Trust1
Mental Health
Trust1
Social Care
Independent sector
& voluntary
PHE3
NHSIQ
A) Referral B) Selecting
patient cohort &
risk stratification
C) Sharing
patient cohort
(patient register)
D) Collecting
data/financial
monitoring
E) National
reporting
Person ID
Referral reason
Person ID
Client, Clinical & QOF
Demographic
Pseudo. Person ID only
(i.e. single data item shared)
Pseudo. Person ID
Client, Clinical & QOF
Demographic
Costs
Pseudonymised Person ID
Client, Clinical & QOF
Demographic
Costs
Early Implementer team – LTC Year of Care programme
Information Governance
May include national datasets
(CMDS, MHMDS, CIDS, QOF)
May include national datasets
(CMDS, MHMDS, CIDS, QOF)
Processstep
description
ProcessdataflowsMajordata
items
Non-NHS
organisations
1 Includes both Foundation and non-Foundation Trusts
2 Kent and Medway Health Informatics Service (Interim Safe Haven)
3 PHE – Public Health England safe haven
Population List
KMHIS2P
P
P
P
P
P
P
P
P
P
P
P
Costing dataset – A, B, C, D & E
Shadow testing – A, B, C & D
Whole population dataset – D & E

12. EARLY FINDINGS

13. Starting with the models for the most complex
individuals with multi morbidity
5%
20%
75%
45%
40%
15%
Multiple complex
conditions
Single LTC/ at risk
Healthy / minor
risk
Population segments Cost

16. Relationship between number of long-
term conditions and cost

17. Distribution of cost between
Providers
Provider type £ %
Acute £7,827 67.3%
Community £1,083 9.3%
Mental Health £1,028 8.8%
Social Care £1,690 14.5%
Total £11,628

18. Risk stratification versus no. of LTCs –
do they select the same patients?

19. Do Integrated Care teams change
service delivery?

20. RRR audit – are some patients in
hospital when they need not be?

21. What happens to patients assessed
as having an RRR need?

22. Percentage of admission length
for RRR phase

23. Implementing Year of Care
programme in Kent
Dr Abraham P George
Consultant in Public Health
Lead for Kent YOC programme

24. The journey so far
• Profile of Kent
• Background and work before YOC
• Governance of programme
• RRR audit
• Data sharing arrangements
• Costing analysis
• Plan for shadow testing
• Our vision for integrated intelligence

25. Profile of Kent
• 1.5 million popn
• 1 County Council, 7
CCGs, 12 districts, 4
acute trusts, 1
community health trust,
mental health trust, >200
practices
• Governance of
commissioning at
multiple levels
• Different integrated
models of care

26. Background to YOC
• Whole population
profiling using risk
stratification
• Impact of multiple
morbidities on service
utilisation - ‘Crisis curve’
• Modelling how benefits
of integrated care could
be realised
• www.kmpho.nhs.uk/jsna

27. Governance of programme
• All providers and commissioners involved
• 2/7 CCGs are the sponsor orgns
• KCC Public Health manages programme on behalf of
whole county
• Implementation at sub Kent level – NK EK & WK
• East Kent Federation group of CCGs first to take part
and now finalising shadow testing arrangements
• Ensure all stakeholders are involved – commissioner,
finance, informatics, etc.
• Use of risk stratification for costing analysis and
shadow testing

28. RRR audit – key results
• > 80 EK patients followed up over 3 months in
• Short stay admissions excluded
• >80% had morbidity
• Average LOS and average length of RRR phase
were much higher than the other audit sites
• Stroke patients contributed much of the bed days
– if excluded LOS would have been reduced by
half Kent BHR Leeds Stoke
All conditions Excluding
stroke
Average length of stay
(days)
19.72 13.93 5.62 6.71 4.46
Average length RRR
phase (days)
6.28 3.29 0.19 3.23 0.69

29. Data sharing arrangements
• Strong historical relationship between KMPHO and
intelligence teams
• Local data warehouse containing hospital, community
health data
• Social care data obtained directly from provider
• Whole Kent population risk stratified using local tool
• Datasets were de-identified at source & and
pseudonymised using same encryption method and key
• Public Health linked data sets - ‘hub and spoke’ before
sending to national team for analysis
‘Whole population person level linked datasets’
• Cannot be re-identified

30. • Whole population person level linked datasets
containing 4 years of activity sent to national team
• Cohort of 1650 (of high intensive users) selected
for detailed analysis in 13-14
• Report produced which provided us with evidence
for indicative tariff
• Data used to develop currency and selection
criteria
Costing analysis

31. East Kent – total cost (reference or unit) for patient cohort (552 patients)
Patient selection date = (May 2012)
Crude tariffs and trends

32. East Kent – total cost for patient cohort (552 patients)
2012_13 Trend
cost % cost %
Acute £6,595 56.2% £4,671 43.7%
Community £1,361 11.6% £1,323 12.4%
Mental Health £1,535 13.1% £1,791 16.8%
Social Care £2,170 18.5% £2,891 27.1%
Total £11,743 £10,676
Crude tariffs and trends

33. Selecting shadow currencies

34. Currency No LTCs New Counts
B 2 1042
C 3 822
C 4 449
C 5 197
D 6 80
D 7 31
D 8 5
E 9 1
E 10 1
Selecting YOC cohort
(using current whole popn dashboard)
• Risk stratification tool applied
• GP practice and CCG identified
• Checked to ensure GP data is active
(ie. each practice has submitted data
within the last 3 months)
• Risk stratification popn profile selected
• YoC currency (using QOF LTC codes)
is then applied which outlines the
following:
– Under 18s excluded & Patients
with 1 LTC notionally excluded,
– List segmented by LTC currency
• Risk Score over time mapped (looking
for rise in risk score in last 6 mths or
rapid riser in last 3 mths (mthly
increase in risk score over past 3 mths
and overall increase of >15pts)

37. • Agree a tariff for each of the currency categories-
finance subgroup to agree costing data.
• Track the activity and cost over the next 12mths –
informatics group.
• Identify data issues- definitions and gaps
• Increase engagement of system and link to
existing initiatives
• Evaluate information – dashboard.
• Communication
Next steps

38. To deliver the evidence for Integrated Commissioning
Building on the Kent approach to Integrated Intelligence
Primary
Care
Urgent
Care
OOH Care
Secondary
Care
Adult
Social
Care
3rd Sector
Mental
Health
Community
Health
Kent are collecting activity and actual cost data from all of the above using a cross system pseudonymisation tool. Data
pseudonymised/anonymised at source and linked and analysed by Public Health. MONITOR are currently developing
guidance on how to develop a person level linked data sets, using Kent’s approach as a case example of best practice.
•
• We have developed a systematized method for selecting multi – morbidity people at risk
and suitable to be included in the Year of Care approach
• The selection includes a subjective consent/opt in to facilitate patient choice and clinician
intelligence at point of service delivery.
• It builds on the whole population data set analysis due to be published by the Year of Care
team and distributed nationally at the end of April.
• This focus on the integrated intelligence by commissioners enables best practice to flourish
and identifies areas for improvement within different provider models of integrated care.
• Implementing in Kent across the 3 systems at pace and scale. East Kent leading the way and
building consensus across the other systems.
• Next steps include agreeing an indicative tariff for year of Care to shadow test in 14/15 – we
have sign off in principle to the approach.
• We have agreed the metrics to develop a dashboard which systematically reports the
results/outcomes at both system and patient level, using existing metrics and data
collection. This will be used to jointly measure the impact of YoC on both the individual and
the system.
Identify cross-
system opportunities
and barriers to
change
Collect the data
with the support of
the system to
challenge status
quo.
Identify opportunity
for integrated
incentives/penalties
across provider
organisations.
Commission across
the system to
incentivise the
outcomes desired.
Commissioners and
providers jointly
measure impact on
individuals and cost
of system

39. @NHSIQ
iCASE - http://www.icase.org.uk/pg/groups/88229/
lesley.callow@NHSIQ.nhs.uk
Abraham.george@kent.gov.uk
Fionuala.Bonnar@kent.gov.uk
Improving health outcomes across England
by providing improvement and change expertise.