Launching an integrated care organisation for Northcare organisation for North West London

Integrated Care in London GP Specialist collaboration

Wednesday 9th February 2011

Integrated Care in London: GP – Specialist collaboration and ‘Teams Without Walls’

Dr Mark Spencer & Dr Rebecca Rawesh

There are five things we want to this afternoon

Overview of IC pilot and what we’re trying to achieve

1

2 Structure, governance and organisation design for the IC pilot

Fi i l t d i li ti f3

Clinical engagement strategy4

Financial arrangements and implications of the IC pilot

3

g g gy

Integrating clinical relationships and creating multi-disciplinary systems5

1

The NWL integrated care pilot brings providers together to work across organisational boundaries to improve care cost-effectively

OVERVIEW OF IC PILOT

Why integrated care?

▪ C t t iBrent: 37,000 ▪ Current outcomes in

care for the elderly and people with diabetes in NWL leave room for improvement

Westminster: 122,000

patientsEaling: 25,000 patients

improvement▪ Locally there is much

enthusiasm for integrated working and improving collaboration

,patients

1) Become a ‘beacon’ for delivering integrated care to the local population

improving collaboration across clinicians

Hounslow: 33,000 patients

Kensington and Chelsea: 62,000

patients

Hammersmith and Fulham: 101,000

patients

What are we trying to achieve

1) Become a beacon for delivering integrated care to the local population involving primary, secondary, community, social and mental health sectors

2) Decrease emergency admissions by 30% and nursing home admissions by 10% for diabetics and frail elderly

2

in NWL? 3) To overall reduce cost of these groups by 24% over 5 years4) Significantly improve patient experience

The NWL integrated care pilot will remove barriers to enable the system to implement whole system change across care pathways

3

Clinical changes

Aligned incentives Joint governance

Clinical enablersOverview

▪ The 8 PCTs and providers in NWL face a £1bn funding gap by 2015

▪ GPs from across 5 PCTs, Imperial College Healthcare, social services and central

Organisational development

Diabetes & the ElderlyMDTs manage the health of a population, and specific programmes I f ti h i

Outcomes incentives will be aligned across providers, and providers will share a pool of funding

Representatives from each provider organisation will be part of a joint governing, decision-making body that monitors and acts on issues

services and central London Community health have worked together to design a pilot

▪ This has been supported by Kaiser Organisational development

and culturespecific programmes target patients based on need and risk stratification

Oth t iti

Information sharingsupported by Kaiser Permanente, Nuffield Trust, King’s Fund and McKinsey and Co.

▪ The pilot will have major Other opportunitiesA group creates overall coordination across providers to improve care and meet commissioning intentions (e g reduce LOS)

Leaders and clinical teams spanning provider organisations will undertake joint training and development, and will begin to develop their own team

A mechanism for sharing that aggregates patient-level data so that it can be analysed and accessed in a timely, seamless way

jclinical and financial benefits

3

(e.g., reduce LOS) g pcultures

y y

SOURCE: NWL Integrated care working team (Aug 2010)

Mission statement created by TIMB

1) Deliver high quality care for patients that makes an improvement in patient outcomes and satisfaction

2) Increase the level of trust, coordination and collaboration across clinicians with2) Increase the level of trust, coordination and collaboration across clinicians with GPs, consultants and other providers working together towards better patient care

3) Become a ‘beacon’ for delivering integrated care to the local population

4) Create a vehicle for delivering productivity and efficiency improvements within4) Create a vehicle for delivering productivity and efficiency improvements within and across the various providers

5) Improve the satisfaction of clinicians and healthcare workers across the sectorthrough their ability to deliver proactive care

6) Make the IMB, as a representative group of providers, accountable for ensuring the successful and timely launch of the IC pilot

7) Ensure all providers are on-board and signed-up to pilot by giving ample ) p g p p y g g popportunity to engage in the project and shape the IC

8) Ensure that all stakeholders are engaged including third sector, users of services and carers of those users

4SOURCE: Interviews, Transitional IMB

Governance modelSTRUCTURE AND GOVERNANCE OF IC PILOT

IC pilot

▪ The IC pilot will establish new relationships between providers in NWL

PCTs LA commisACV1

CLCH Imperial LA providersMental

Patients & Public

Third Sector▪ These will be based on contractual relationships rather than a new organisation

▪ The IC pilot will establish

CLCH Imperial LA providers

GP practice

Health Third Sector

IC

pmechanism for co-ordination and funding flows amongst providers

▪ The Management Board (IMB) will agree resource

GP practice

GP practice

GP IC leadership

IC Pilot

(IMB) will agree resource plans, funds sharing, membership, etc

▪ Decision making will be by consensus

GP practiceIMB

Providers

▪ The IC pilot will include GPs, Imperial, CLCH, Local Authorities and Mental Health trusts

▪ GP practices elect leaders to represent primary care in the IC pilot.F di fl

CommissionersProviders

Joint vehiclesLEGEND

Providers

5

▪ Providers will pool a small amount of funds into the IC pilot to cover costs of more activity and mgmt

Funding flowPooling of funds

1 Sector Acute Commissioning VehicleSOURCE: NWL Integrated care working team (Aug 2010)

Integrated Management BoardSTRUCTURE AND GOVERNANCE OF IC PILOT

IMB Board (Chair: Prof. Elisabeth Paice)

GP Practices (11 votes)Imperial (5 votes) Central London C it

Local Authorities (1 t )

Third Sector (2 t )

Mental Health (1 t )Community

Healthcare (2 votes)vote)

Claire Perry, Managing Director

Brent: Dr Mandy Craig

votes)

Benn Keaveney, Lead, Age UK

Geoff Alltimes, Chief Executive Officer, London Borough

Claire Holloway / (James Reilly)Chief Executive Officer

vote)

Peter Cubbon, Chief Executive Officer

Ealing: Dr Jennifer Durandt

Hounslow: Dr Liz Morris

Roz Rosenblatt, Diabetes UK

Borough Hammersmith & FulhamJane Clegg,

Director of Operations

Tony Graff, Chief Finance Officer

Josip Car, Clinical Programme Director, PH

Marian Harrington, Director of Adult

Hammersmith & Fulham: Dr Tim Spicer, Dr Simon Edwards and Dr Peter FermieJonathan Valabhji,

Clinical Lead -

Julian Redhead, Director of Medicine

Services, Westminster City Council

Kensington & Chelsea: Dr Tahir, Dr Simon Ramsden

Westminster: Dr Ruth

Diabetes

David Taube, Medical Director

Edward Dickinson,

6

O'Hare, Peter Crutchfield, 1 TBC

,Clinical Lead -Elderly

Financial modelling suggests that £10m can be saved from emergency admissions; with a proportion split across the various providers

F di h f i d il (2011/12) F di fl (2011/12)

Amount (£m)

187Commissioners in NWL currently spend a disproportionate amount on diabetes and the elderly. For a pilot of 380,000 the spend on these groups is

£187

Funding approach for integrated care pilot year (2011/12)

1

Funding flows (2011/12)

£10*m comes out of acute care due to IC pilot

Incentive PaymentAdditional ResourceInfrastructure CostQIPP Payment

£m (based on high-level analysis)2£m (based on high-level analysis)2

IC pilot providers agree the care pathways and targets for diabetes and the elderly and propose these to commissionersCommissioners reflect outcomes in provider SLAs and other contracts, expecting a decrease of activity they

10*

-6.7

~£187

2

3

Commissioner1.60

2.10Commissioner

Balance

3.30

Commissioners keep the balance as part of its QIPP contribution

p g y yprovide in 2011/12 for the diabetes and elderly pilot1population

3.34

IC Joint Venture allocates funding

Does the IC pilot deliver

improvements?

Balance

The £6.7m that will be contributed by commissioners via contracts (CQUIN and LES) is divided as follows:▪ Additional out of hospital resource for more proactive

care (guaranteed payment) ▪ Infrastructure costs to run the pilot (guaranteed

payment)▪ Incentive payment for outcomes (dependent on

5-2.1

3 0

-1.6

No Yes

3.003.00▪ Incentive payment for outcomes (dependent on

achieving goals)

Any additional savings made by the IC pilot will be kept

If outcomes are not delivered by the IC pilot, the £3 million of incentive funding will not be paid

6

5

-3.0

Split of incentive payments and additional resource to be

Payment for acute over-performance

7

1 Figures are calculated as a best estimate of the commissioning intentions specific to diabetes and elderly based on a pilot population of 380,0002 Analysis being further developed in current phase of work moving from top-down analysis to bottom-up modelling* Assumes actiivity removed at full PbR tariff from provider – in reality 30% marginal rate applies for activity reduction in 2011/12

y g y p pby the providers6 Split of incentive payments and additional resource to be

recommended by finance group via detailed modeling

Lots of work to be done in the next few months – 7 working groups set up

W k t R ibilitiW ki

OVERVIEW OF IC PILOT

Workstream Responsibilities

Governance and Finance

Governance▪ Design the new governance structure for sign-off by IMB including

roles, responsibilities, processes and various enablers required for collaborating

Working group

and Finance

Clinical Working G

▪ Define clinical interventions for both Diabetes and Elderly Care (in separate groups) and set protocols and set core clinical agenda

Finance▪ Discuss and problem-solve the various contractual and financial

implications of the IC pilot and how various providers will come together to deliver the change required

ClinicalGroups separate groups) and set protocols and set core clinical agenda

MDT Mechanics▪ Define the ‘solution space’ for local MDT design (e.g., size, duration,

frequency of interaction etc.) and develop a general toolkit to support local implementation

Evaluation and Research

Evaluation and Research

▪ Create and design an evaluation platform with metrics for the patient experience, financial impact, clinical outcomes and change management to be used during the pilot

▪ Identify various research opportunities within integrated care and discuss possible work and undertake research agreed upon within

Information

discuss possible work and undertake research agreed upon within the group

Information▪ Form ‘technical design group’ to decide how to implement the

required IT solutions and ‘functional design group’ to decide what the IT will need to look like

8

Co-chairs (one GP and one Imperial Consultant) have been appointed for each working group

We have already detailed and begun an intensive engagement strategy…

Key datesy

IMB

January February March April

1Kick-Off

2 3 4 5

Dates

▪ Page 26

MDT Support Forum (all Clinicians)

1 2 3

▪ 8th Feb ▪ 1st Mar ▪ 23rd Mar▪ 13th Apr

4 5Clinicians)

1111 1112

13 Apr▪ 27th Apr

▪ VariousGP Road-shows

GP Practice-by-Practice Visits

One-on-one Interviews ▪ Various1111 1112

2 ▪ Various

Imperial Engagement

Other Provider

Fortnightly Imperial internal IC pilot meetings (when invited)<Best approach to be defined with Imperial > ▪ TBC

9

Other Provider Engagement <Various mechanisms depending on provider> ▪ TBC

We have agreed the care pathways for frail elderly and diabetic patients3

The clinical working group for the elderly identified priority areas to improve care in the pilot elderly population through integration

The clinical working group for diabetes agreed roles and quality standards, and so the pilot will remove barriers to this

Segments # of patients in pilot1

Support neededIn care

3 3372,462

Intermediate needs

High needs

Segments

3 9691,976

# of patients in pilot1

Programme elementsImpact evidence▪ 30% reduction in bed

Impact evidenceShort term

Independent and wellIndependent but at riskSupport needed

10,5992,8503,337 Intermediate needs

Low needs

Newly diagnosed 1,1069,4543,969

Early identification of elderly frail people/risk stratification1

Risk stratification

Case management

Diabeticregistry

Telemonitoring & telephone support

▪ 30% reduction in bed days

▪ 20-80% reduction in emergency admissions over time

▪ Reduction in readmissions

Short term▪ Higher % with BP

under 140/80 and cholesterol under 4.5

▪ Improved HbA1c control (<7.5)

▪ 100% uncontrolled and

Prevention programmes (falls, medicine management)

Pro-active care planning and delivery by community team

frail people/risk stratification

2

3

Improved screening

Patient education programmes

Multi-disciplinary team meetings

Patient-held records

readmissions▪ 40-70% reduction in

falls▪ Improved satisfaction▪ People getting the

“right care” across social and health

%complex patients on care plans

Longer term▪ 20-25% reductions in

admissions▪ 40% Reduction in bed

delivery by community team

Pro-active case management of complex patients

Appropriate emergency responses4

5

Both pathways are based on individually case managing patients through

Care planning Clinical education

social and health days▪ 80% Reduction in

amputations

of complex patients

Improved information flows6

10SOURCE: NWL Integrated care working team (Aug 2010)

1 Pilot population estimated to be 380,000

p y y g g p gpathway-based MDTs and applying a risk-stratified set of interventions based on individual needs

Our vision for a multi-disciplinary system – 7 core elements of the NWL model

MULTI-DISCIPLINARY SYSTEMS

Patient registry

1 List of covered population and associated data from all setting of care

Element Description

Risk stratification

2 Segmentation of individual patients by risk

Clinical3 Development of clinical protocols and care Clinical protocols and care packages

packages (including activity and resource requirements) for each risk group

Care plans4 Creation of individual care plans in one-to-one

meetings between clinicians and patients

Care delivery5 Delivery of care plans by multiple professional

groups

Case conference

6 Discussion of management of most complex cases

P f7

Review by MDS of patient experience, clinical

11SOURCE: Team analysis

Performance review

y p p ,outcomes, financial performance and team effectiveness

Post-Pilot

Following this phase of work; mechanisms will be in place to monitor and support the IC pilot within the first year

OVERVIEW OF IC PILOT

Pre-PilotPilot

Timeline▪ Start of Dec 2010 to end of

April 2011▪ End of April 2011 to end of

April 2012▪ End of April 2012 onwards

▪ Develop work-streams and enablers to IC pilot through various working groups

▪ Ensure milestones are reached, through

▪ Provide on-going support to MDTs across sector that have been formed

▪ Continue roll-out of more practices and MDTs across

▪ Agree ongoing resourcing and funding based on decision to continue pilot or not

▪ Monitor progress through

Focus of work

reached, through transitional IMB, and decisions made on-time for launch

▪ Support and coordinate ramp-up across NWL to

practices and MDTs across the sector (and/or sign-up more)

▪ Monitor progress through evaluation platform and performance management

Monitor progress through evaluation platform and performance management processes

▪ TBD (based on success of pilot): Introduce newramp-up across NWL to

form MDTsperformance management processes

pilot): Introduce new pathways and expand scope or partners of pilot

Enabler to ▪ Clinical Engagement▪ Rapid input and work from

▪ Clinical Engagement▪ Identification of early

▪ Clinical Engagement▪ Output from research group

12

success ▪ Rapid input and work from working groups

▪ Identification of early success metrics

▪ Output from research group on new opportunities

Questions for discussion

How can we learn from you?1

How should ‘organisational development’ be2 How should organisational development be handled during the IC pilot?

What financial arrangements need to work f ?3

How can we get clinicians to work together more collaboratively?

4

for success?3

y

13