Using simulation to drive changes in health and care - long term conditions Year of Care model Bev Matthews and Claire Cordeaux Presentation from Day 1 of the Health and Care Innovation Expo 2014, Manchester Central

1. Long Term Conditions
Year of Care
Commissioning Programme
Bev Matthews - Programme Delivery Lead
Jamie Day - Healthcare Finance and Information Specialist
Claire Cordeaux - Executive Director, SIMUL8Healthcare

2. Context
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•
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15m people with Long Term Conditions
Increasing each year with ageing population
Responsible for 70% of NHS costs
Significant cause of ED attendance and urgent admission

3. Driving Policy through
Funding Instruments
• A year of care capitation fund for a person living with
multiple conditions
• Incentivizing providers and commissioners to work
effectively together
• Aligning funding flows and patient need for support
• Improving outcomes and efficiency
• Reducing emergency care activity

4. Silo treatment vs. whole person
Sir John Oldham, DH

5. What if?
• We plan care for people rather than disease?
• Are there common patterns of service use?
• Can we differentiate groups of patients by need and costs
to create an annual tariff?
• Can we work within that tariff to reduce emergencies and
manage care out of hospital?
• Where should we intervene to stop progression to multiple
long term conditions?

6. Background
 Launched in June 2012 under Dept of Health QIPP programme
 Transferred to NHS England in December 2013
 SRO is Dr Martin McShane, Director Domain 2
 7 Early Implementer Sites
 22 Fast Followers

7. 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
Kirklees
North Kirklees Emerging CCG; Greater Huddersfield CCG; Kirklees Council; NHS Calderdale; Mid Yorkshire Hospitals
Trust, Calderdale and Huddersfield FT; Local Community Partnership; South West Yorkshire Partnership; Kirkwood
Hospice.
North

8. Benefits
Improved outcomes and wellbeing:
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•
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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

9. Data Collections
Recovery, rehabilitation & Reablement clinical 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.
Costing 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

10. Early Implementer Sites Deliverables
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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 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

11. National Support Team Deliverables
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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

12. Using Simulation to Drive Changes in
Health and Social Care –
LTC Year of Care Commissioning
Programme

13. Agenda
• What is simulation?
• Why use it in
healthcare?
• Learning from the data
• Simulating long term
conditions for the Year
of Care

14. Where does simulation help?
• Modelling uncertainty
• Testing assumptions and their consistency when no
historic data
• Considering variability
• Driving thinking
• Sharing models

15. Our task
• Create a simulation model
• 7 pilot sites
• 1 national model to be used locally
Looking for common parameters

16. What is simulation and why use it?
Models a flow of events
Small scale
operations
Service
operations
Whole
system
Passing of time
Arrivals
Experimentation
Duration of What if?.... Results
treatment
Time
between
treatments
Waiting
times and
bottle
necks
No risk to
patients
through
pilots
Costs
Resource
utilisation
Waiting
times
Operating Theatre, Emergency Department, Beds, Disease
Pathways, Reconfiguration...

17. A simple simulation
Patients come into a clinic for treatment
They arrive every 5 minutes
The treatment takes 10 minutes
-
What is the likely demand?
How many clinicians do I need?
What is my revenue/cost?
How long are patients waiting?

18. A simple clinic – a typical week

19. Benefits of simulation
Risk- Free
Uses data
intelligently
More
accurate than
a
spreadsheet
Models
variability
Increases
confidence
in decision
making
Test and
compares
potential
solutions
Simulates the
passing of
time
VisualEngages
Stakeholders

20. Planning for Healthcare
How long
What is my
What are
is it
How much How much
demand
my
can I
reasonable
resource
likely to
expected
spend?
for patients
have I got?
be?
outcomes?
to wait?
Financial Winners and Losers

21. Starting to simulate a new approach
Patients at Risk
Assessment of Need
Exacerbation
Services “consumed”

22. But……
• No real correlation between risk score and level of need
Patients at Risk
Assessment of Need

23. What the data is telling us

24. Over 30% of people over 75 years
have multimorbidity
Kent whole population data

25. Multimorbidity is more common than
single morbidity
Kent whole population data

26. The total health and social care cost
is strongly related to multimorbidity
Kent whole population data

27. The main contributors to total health
& social care cost are acute nonelective admissions
Kent whole population data

28. People with complex health & social
care needs appear to demonstrate a
‘crisis curve’
Kent whole population data

29. More community, mental health and
social care services are delivered to
people following a ‘crisis’ than
before the ‘crisis’
Kent whole population data

30. Some indications that an integrated
care plan changes the pattern of
services delivered to people
BHR costing data

31. Implications
• Evidence suggests that once people with complex care needs (multimorbidity) are
identified, the services delivered to those people changes
• If people with complex care needs could be identified before the „crisis
curve‟, service changes could be put in place that may prevent some of the nonelective acute care
Year of Care currency incentives
• Providers to work together to deliver cost-effective care
• Payment based on holistic outcomes not episodes of care
LTC Year of Care programme encourages
• Integrated care for a patient-centred and seamless patient pathway
• Sharing of evidence to support service change (e.g. SIMUL8)

32. Current Simulation
• Likelihood of patients accessing services by changing
state of patients
– Level of acuity
– Increasing numbers of long term condition

33. How it works
• Patients in each “state” have
– A likelihood of accessing certain types of service
(Acute, Community, Mental Health, Social
Care), including accessing services more than once
• Costs associated with those services

34. Results
• Number of patients in each “state” by year
• Costs by state per year
• Comparison with locally determined tariff

35. Testing, testing…
• Beta being tested with site data for year 2
• Comparing patients cared for by integrated care teams or
not
• Tested by sites for usability

36. What the simulation does…
• Informs question development and data collection
• Allows experimentation and hypothesis testing where no
historic data available
• Enables research evidence to be applied to policy and
practice development
• Shares national assumptions meaningfully at local level
• Reduces risks in policy development by generating
evidence for decisions

37. @NHSIQ
enquiries@nhsiq.nhs.uk
www.nhsiq.nhs.uk
Improving health outcomes across England
by providing improvement and change expertise

38. “Integration is a means to an end;
the purpose is about better person
centred care and better outcomes –
it‟s about
privileging, autonomy, prevention
and wellbeing.”
“It‟s about two organisations
working together with the benefit for
users of the services at the heart.”
Available on NHS Improving Quality Stand