#hcaqofq berge balian
Post on 07-Apr-2017
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SYMPHONY Person-Centred, Co-ordinated Care
The Symphony ProgrammeA New Vision forSouth Somerset
Dr Berge Balian, Programme Board Chair
Our demographics are changing
Proportion of the Somerset population aged 65+ by LSOA - 2003
Proportion of the population aged 65+ by LSOA - 2013
Proportion of the population aged 65+ by LSOA - 2023
Proportion of the population aged 65+ by LSOA - 2033
Unscheduled Care Complex Co-morbidities Discharge Planning Generalised Vs. Specialist Services Integrated Care Comprehensive Care closer to home Resources: Space; Finance; Time; Workforce
Key Challenges for Secondary Care
Patient Demand Long Term Conditions Seamless Care Competition Vs. Continuity of Care Autonomy Vs. Scrutiny Call For Action Resources: Time; Finance; Workforce
Key Challenges for Primary Care
Demographic changes are driving up costs in the local health economy and across the NHS
NHS Plan: Five year Forward View
New care models are being piloted at ‘vanguard’ sites sponsored by NHSE
PACS Joint Venture (JV) between GPs and YDH.
Capitated Outcome Based Commissioning (OBC) contracts in Somerset
Integrated Accountable Care Organisation (IACO) holding the OBC contract
IACO = JV + other health and social care providers, including Public Health and Third Sector
Alignment of incentives and integration of care for all health and social care provision
Shift of work and resources from 2’ to 1’ to preventative care
Shared budgets and incentives reduce costs. Savings reinvested where need is greatest.
Patient Centred Care: Right care by the right person in the right place at the right time. This improves care and cost-effectiveness
The Case for Change
Outcomes-based commissioningSomerset CCG have confirmed their desire to move to a capitated, outcome-based contract in South Somerset by April 2016
Outcomes-based commissioning in practice Definition of outcomes-based commissioning
• “The results people care about most when seeking treatment, including functional improvement and the ability to live normal, productive lives” (ICHOM, 2013)
• Starts from the perspective of the patient
• Challenges the culture not the structures
• Aims to makes best use of capped resources
Multiple commissioner and provider relationships
Lead provider(s) and simpler commissioning relationships
Potential impact on GP financials: average1 South Somerset practiceControl over larger budget is an opportunity for GPs to improve care and benefit from shared savings
AC: I/P
elect
AC: O/P
GP income
Gain share
Prescribing
£m
AC: I/P
urgent
SC:Home+Day
MH: O/P
SC: Resi
SC: other
CC: other
CC: IP
AC: A&E
MH: I/P
Socialcare
Mentalhealth
Acutecare
List size 6,380 4,340 660 1,990 630 490 70 30 130 120 10 30 1,010
Cost per patient
£160 £210 £140 £340 £1,940 £2,770 £5,100 £12,500 £2,550 £2,230 £20,600 £9,790 £250
Communitycare
Pres
crib
ing2
1. Mean figures averaging across 19 South Somerset GPs.2. Prescribing cost is extrapolated from Mar 2015 (HSCIC), with prescribing list for 2013-14 (Symphony data)
0
1
2
3
4
5
6
7
8
Pote
ntial
ben
efit f
or G
Ps v
ia sa
ving
s
Total: £1.02m £0.93m £3.35m £1.02m £0.48m £0.58m £7.38m
37 Vanguards across the countryWe are one of 9 PACS Vanguards (Primary and Acute Care
System)Two years of funding for new care and organisational models.Leading Vanguard for Organisational Forms.Funding for programme costs, primary care staff and
remodelling, three Complex Care hubs.CCG also funded to develop OBC.National team working with us to break down barriers to
innovation and overcome national issues
Vanguard programme
SYMPHONYPERSON-CENTRED, CO-ORDINATED CARE
SYMPHONYPERSON-CENTRED, CO-ORDINATED CARE
‘Leading innovation and integration for a healthier, more independent
population.’Objectives:
Informed people, empowered to take responsibility for their health and
wellbeing.
An ambitious and adaptive workforce, working creatively to deliver
exceptional care.
A seamless, integrated and responsive network of care services, working
together to do the right thing for patients.
Vision:
Our Vision
A sustainable health and social care systemHelping people and their carers to manage
their own health and achieve their goalsSupported by a joined-up system including the
NHS, local authorities, the voluntary sector and the communities in which they live
Where staff enjoy their jobs and want to work.Focus on community and preventative care
Participating practices
developmentKaren Lashly
Programme Structure: Overview
Symphony Programme Board
Dr Berge Balian
EPC ModelDr Steve Edgar
• Develop EPC model
A2OpCo/Integrated
practices development
Mandy Seymour Hanbury
IACO stand up& OBC
John Kelly• Develop
detailed design, structure & governance
B1 B2
PMOAdvisory Group
IT and Technology Patient Safety& Quality
Comms & Engagement
ElectiveDr Jon Howes
• Orthopaedic pathway improvements
A3
Workforce
Urgent Care
Dr David Cripps
A4
• Develop and refine urgent care initiatives
Cross-Care Model Forum – Dr Berge Balian• Identify themes and ‘quick wins’ across new care models• Small Action Team to implement quick win initiatives
Core JV groupDr Berge Balian
Vol sector/Public health Paediatrics
B3
Technical group
Complex Care Model
Dr Ian Wyer• Refine model
& plan roll out
A1
Working Groups
Cross-CuttingThemes
(feed in as required)
78%~90k
18%~20k
4%~5k
~15%~£20m
~35%~£55m
~50%~£75m
% of population % of cost
Complex patients with many conditions
Less complex patientswith fewer conditions
Mainly healthy patients
Population segmentationand new care models
Complex care hubs
Enhanced primary care
Proactive health and wellbeing support
Complex Care: Extensivist care modelThe patient is assigned a care coordinator and offered more proactive care, support and attention through a number of services
Complex, Poly-chronic Patients Key Worker
Expert Generalist
Extended Care TeamTherapies e.g. Physio
Mental Health
Social Care
• Diabetes• Respiratory• CHF• Dementia• Other…
Network of Services
Care HomeAdvanced Diagnostics
Core Care Team Key Elements
Comprehensive assessment of physical, mental health and social care needs
Support and coaching for patients and carers
Co-ordination of integrated pathway
Routine contact and monitoring of patient’s health and care needs
Proactive development of personalised health and social care escalation plans
Rapid crisis response
Care Programmes
Care Coordinator
GP
FOPAS (Crisis
Support)
Enhanced primary care
New model of primary careBroader team (Physios, CPNs, pharmacists)New triage systemGPs focus on people with complex long term
conditionsHealth coaches to support patients 18 out of 19 practices involved in EPC and CC
Enhanced primary care modelThe patient and key worker are supported by the wider care team and a number of care programmes and services
Patient with Chronic
Condition
Key Worker / Health Coach
GP
Care Programmes
and Specialists
Other programmes…
Extended Care Team
Therapies e.g. Physio
Mental Health
Social Care
CHF
Respiratory
Diabetes
Dementia
Network of Services
Care HomeAcute Care
Advanced Diagnostics
InterfaceCore Care Team Key Elements
Team Working and Huddle
Triage
Stratification and Proactive Outreach
Care Planning and Coordination
Defined Workflows and Programme Integration
Aligned Resources and Incentives
Shared Clinical Data and Population Health Analytics
Practice Nurse
Other services…
Working with voluntary organisations and communities
Helping people to access support in their areas
Directory of servicesSupporting communities to support their
residents
Project area statistics Population:
– 2,172 (Experian), 932 households– 45% of Martock’s total
Comprises Martock East LSOA:– outside of Yeovil and Chard this area is
the most deprived in South Somerset– nationally in the lowest 40% across all
IMD areas and in the lowest 25% for education and skills, income and employment
Key Statistics:– 24% aged 65 and over– 36% one person households– 19% long term sick or disabled– 34% no qualifications (age 16+)– 23% household income <£15k pa– 22% no car or van in household
Largest proportion of social housing in Martock (34% live in social rented homes)
Over 90% of Martock’s free school meal entitlement
NHS and social service costs:– £4.48m per annum– consumption per head 1.8 x South
Somerset average
Volunteers
Resourcing
Community Youth Project
Youth Workers
Youth Services
Community Services Coordinator
Job Club Coordinator
Employability Service
Seniors Services
Coordinator
Befriending Service
Martock Parish ClerkInformatio
n Governanc
e
Information Centre
Martock Parish Council£125,000 pa investment
IACO JV Organisational Structure
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