Virtual Wards and the

NHS Devon Experience

Integrating Predictive Modelling into a Whole System approach

Dr Paul Lovell East Street Surgery, South Molton NHS Devon / North Devon Locality Urgent Care Lead

Todd Chenore Clinical Informatics

NHS Devon, Torbay and Plymouth

Rapid Response

Complex Care Team District Nursing, CRT, Therapy

MIU

Primary Care

Devon Doctors

Community Hospital

Medical Assessment Unit

Emergency Department

SWAST

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Acute Admission

ED Self Referral £

PbR Non-Elective

ED GP Referral £

Day 0 Admission £

Full Admission £

‘Fixed’ Costs

Community Services £

SWAST £

Primary Care £

DDOC £

End-of-Life £0 £0

IP and © Dr Paul Lovell

Marie Curie / Night sitters

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ED Self Referral £

PbR Non-Elective

ED GP Referral £

Day 0 Admission £

Full Admission £

‘Fixed’ Costs

Community Services £

SWAST £

Primary Care £

DDOC £

£0 £0

Flow and Discharge

Rapid Response

Complex Care Team District Nursing, CRT, Therapy

MIU

Primary Care

Devon Doctors

Community Hospital

Medical Assessment Unit

Emergency Department

SWAST

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Acute Admission

End-of-Life

IP and © Dr Paul Lovell

Marie Curie / Night sitters

IP and © Dr Paul Lovell

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Robust alternatives to hospital admission

Risk stratification and Case Management

Excellent end of life care

Smooth flow and discharge of patients through the

system

Specialist rehabilitation

5 Key Whole System Principles

Rapid Response 7d Pathfinder Service

Complex Care Team District Nursing, CRT, Therapy

MIU

Primary Care

Devon Doctors

Community Hospital

Medical Assessment Unit

Emergency Department

SWAST

Com

mun

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ion

EHR

/ Sh

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e, D

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are

Prov

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n

Acute Admission

ED Self Referral £

PbR Non-Elective

ED GP Referral £

Day 0 Admission £

Full Admission £

‘Fixed’ Costs

Community Services £

SWAST £

Primary Care £

DDOC £

End-of-Life £0

Community Virtual Wards

Falls Team

Special Messages

Consultant Support

Direct Access

GP Team GP Team

TeleMonitoring

Mental Health Liaison

Discharge Planning and Co-ordination of Community Services Discharge Support

24 / 7 Nursing

Early Supported Discharge

Intensive Rehabilitation

£0

Urgent Care Service Model

IP and © Dr Paul Lovell

Marie Curie / Night sitters

Voluntary Sector

Special Messages

IP and © Dr Paul Lovell

Complex Care Teams Developed under DH POPPS Project - started October

2008

23 to cover NHS Devon pop. c750,000

Case Management core to proposed function

Integrated Health and Social Care Team

Vertically Integrated in North Devon from outset

Common Geographical coverage and base

Linked to specified GP Practices (105 in total)

Post-TCS now provided by NDHT and TCT

Community Nursing

Therapy Services

Community Hospitals

OPMH Health Services

Voluntary Sector

Primary Care

Practice

Social Workers /OT

/Community Care

Practice Manager

Vol. Sector Co-ordinator

Community Nurse Team

Leader

Community Nurse Team

Manager ACS Practice Manager

Modern Matron

Therapy Manager

Practices

Complex Care Teams

PLUS: •Cluster Pharmacists •CoE Consultants •Social Care Reablement

Complex Care Teams Evaluation

Virtual Wards

Virtual Ward = Predictive Modelling + Multi-disciplinary Case-Management (Hospital at Home)

Predictive modelling in Devon • Started with PARR and PARR++

• Implemented CPM in house for 2008/09 start of virtual ward pilot

• Built DPM in house for 2010/11 at very low relative cost

• Incorporated local datasets like ambulance, OOH, registration duration, deprivation, etc.

• Improved predictive power

Number (%) patients in ‘at risk’ group predicted by the model who had an emergency admission within 12

months

‘At risk’ sub-group Combined Predictive Model (CPM)

Devon Predictive Model (DPM)

200 top-ranked patients (0·03% of registered population) 143/200 (71.5%) 173/200 (86.5%)

1000 top-ranked patients (0·13% of registered population) 605/1000 (60.5%) 742/1000 (74.2%)

3800 top-ranked patients (0·5% of registered population) 1843/3800 (48.5%) 2286/3800 (60.2%)

7000 top-ranked patients (0·92% of registered population) 2639/7000 (37.7%) 3708/7000 (53.0%)

16000 top-ranked patients (2·1% of registered population) 4896/16000 (30.6%) 6877/16000 (43.1%)

Community Specialist

Nurse Service

Consultant Outreach

Out-patient Review

Ward Assessment

Acute Admission

COPD

ACS Social Worker

ACS OT

ACS CCW

Community Matron

District Nurses

Voluntary Services

Rep

CCT Co-ordinator (VW Ward Clerk)

Mental Health

CRT Nurse

CRT Physio

CRT OT

Practice Nurses

GP

PATIENT

Case Manager

Monthly Devon Predictive Model

Primary Care and Complex Care Team

Joint Meetings

Admit to Virtual Ward

Virtual Ward Staff CCT and

Primary Care

Exacerbation Pathways

Monthly DPM report and VW Bed-state reviews

Daily interactions within team, Regular VW Ward Rounds and Reviews ( Weekly Core Group

Meetings)

Very High and High-Risk Patients Identified

Housing Charities (3rd sector)

Virtual Ward

Enhancing function and co-ordination

Community Services Virtual Ward

Devon Predictive Model

Primary Care

Promoting Integrated, whole system approach

Enhancing function and co-ordination Community-based Integrated Management

Primary Care Community Services Virtual Ward

Devon Predictive Model

CQUIN LES Service Specification & Investment CQUIN LES

Devon-Wide Roll-out Identified as QIPP plan for Urgent Care Devon-wide

Aim to integrate into 23 CCTs to cover Devon pop. c750,000

Roll-out commenced yc 2010/11

Stage 1- Establish (2010/11) • Year 1 CQUIN LES Funded

• Payment to practices by volume (to limit)

Sign up to Devon Predictive Model

Identify target patients and assign a case-manager (Read

Code)

Produce Out of Hours Special Message- active on DDOC

Adastra

Devon-Wide Roll-out Stage 2 - Exert Control on high-risk Group (2011/12)

Year 2 CQUIN LES Funded

Payment to practices by % Bed-state (of bed number limit)

Sign up to Combined Predictive Model

Identify target patients and assign a case-manager (Read Code)

Produce Out of Hours Special Message- active on DDOC Adastra

Full payment- 85% High /Very High Risk and 80% Occupancy over the

year

Devon (Combined) Predictive Model 85%

Direct Referral 15%

3-4 Months Input LTC Self-Management, Education, Social etc (75-80%)

Prolonged Admission 12-18 months (20-25%)

Virtual Ward

Characteristic Locality A Locality B Locality C

Access to Monthly DPM Y Y Y

Complex Care Teams Y Y Y

Full Year LES Y Y N

Designated Project Support Y N N

Locality Leads Buy-in Y Y/N N

Population Size 220,434 165,408 379,682

CCT Provider SDHT NDHT NDHT

CQUIN LES Investment 11/12 £ £ £

Fair Shares Funding Above Below Above

Devon Evaluation (1) The Locality Differences

Locality Average VW occupancy

Average VW occupancy

chosen from top 0.5% risk

Average VW occupancy

chosen from low risk

Percentage of practices

hitting 2011 DPM LES targets

First quarter net admission change 2009 to

2011 for top 0.5% cohort*

Change in actual PbR cost associated with net admission

change*

Locality A 107.4% 45.2% 15.5% 65.5% -22.06% -£845,310

Locality B 98.8% 37.8% 21.6% 42.9% -14.24% -£210,758

Locality C 90.3% 28.7% 26.4% 19.2% 3.91% £151,742

Devon Evaluation (2)

Devon Evaluation (3) Population Profile Changes

DPM Risk Scores - Distribution of risk across the

population when separated into Risk-Buckets (Kaiser

Pyramids)

A

B

C

Devon-Wide Roll-out Stage 3 - Maximise Impact & Responsiveness (2012/13)

Year 3 CQUIN LES Funded

Payment to practices by % Bed-state (of bed number limit) and Top 0.5%

percentage

Ensure named Lead GP in each Practice

Monthly Bed-state meetings

Share DPM results access with CCT Team

Ensure Project Support Role in place from Locality Commissioning Team

Embed and make routine part of work and roles

Community CQUIN -> TIFA, Initial Assessment Summary and Discharge

Summary

Cope with changes in CCG and membership

Next Stages Stage 4 - Upstream targeting

Evolve Model and additional functionality in the Virtual Wards to

identify those at point of take-off (Popcorn Theory)

Increase impact with lower level measures and integrate into LTC

management and whole system approaches e.g. PEAR-Resp

development, Screening, EPP etc

Interoperability of IT systems and communication

A B