Whole Systems Integrated Care
Governing Body:
20th January 2015
“I want my care to be coordinated
and not to feel afraid”
COMPREHENSIVE & COMPASSIONATE CARE
1
Objectives for today
 Agree the high-level co-designed
West London Older Adult Whole
Systems Model of Care
 Agree approach to phasing and
implementation
 Agree high-level cost
assumptions, upon which to build
a more detailed cost model
2
Co-designed model of care – who and how have we worked together
Two major c-design events
West London Health &
Wellbeing Board
West London CCG Governing
Board
West London Out of Hospital
Committee
West London Whole Systems
Patients Panel
West London Whole Systems
Steering Group
Putting Patients First & Model
of Care Working Group
West London Primary Care
Design Group
West London Social Care
Working Group
NWL Collaborative design
groups
3
Based on the service user & staff feedback the working groups have
identified 6 core elements of a proposed Whole Systems Model of care
1
Centred around the holistic needs of the service users and their carers, involving
them in all decisions while providing with simpler access and a shared care plan
2
Personalised and tailored to changing health as well as social needs, covering
planned as well as reactive needs and one that empowers self-care
3
Has a clear point of accountability (both for clinical & nonclinical outcomes ) with
a core team that reflects user’s needs and helps coordinate their care
4
Is supported by a number of local operational whole systems bases where joint
teams work on a day to day basis coordinating the care and tracking outcomes
5
Helps coordinate the services (via the base) as needed from different
organisations, on behalf of the service users and their carers
6
Is brought together by shared cultural values & ethos, organisations working as
an Accountable Care Partnership that is commissioned to single set of outcomes
and is enabled by shared systems & incentives
4
Co-designed model of care – West London Whole systems Model of Care
Shared care plan for health & social
needs
Single point of
access
Equally involved Carers & family
Involved in making decisions for care
1
Service
users
2
Tier 1: Over 65s with well managed
LTCs
Tier 0: Mostly healthy over 65s
Tier 3: Complex and / or with intense
needs
Tier 2: At risk, under
monitoring
Increasing health and social care needs
Users & carers empowered for
self-care
CIS teams
Tailored increase in resources for self-care, carer involvement and primary care for over 75s e.g., longer appointments, 24x7 GP cover
Operational base
Home
5
6
Whole systems
case managers
Named GP
3
4
Prim. care navigators / Int.
care workers
Dist. Nurses
Soc. care
workers
Learning
disabilities
Groups of practices
Physios
Pool of case
managers & service
leads
Mental
Health
Voluntary
services
▪
▪
▪
GP practice
Housing &
Benefits
HCAs
Advanced
diagnostics
SPA admins
North / South Hub
PCNs
Pharmacy
Relevant CIS team
members, RR, In-reach
etc.
OTs
GP-on call
cover
Pharmacy
Major hospital
Base coordinator
&
Clinical lead
Supports a
fixed number
of practices
Older adult
Support teams
Continuing
care
North &
South Hubs
Acute Elective
Specialist
999, CIS,
LAS,
OOH,UCC
Acute NEL
Cultural and people integration: of local base staff moving towards a single organisation
Financial integration: Capitated budgets, aligned financial incentives in the long terms
Systems and operational integration: Shared IT and systems supported with robust legal and governance arrangements
5
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•
4
Mental health
Dementia, depression/anxiety
•
5
Community development
Community champions, links to other services
(e.g. Housing, CAB)
6
Carers
Befriending, support
GP referral
PCN or Case
Manager
referral
Self-referral
On-line
3
Self-care – condition specific
services
Expert patient
Community outreach
2
Self-management – lifestyle services
– to support changes in behaviour
Health Trainers, Weight
management, smoking cessation
Professional ‘trainers’
1
Befriending services
Community champions, links across and
between communities
Peer-to-peer, group and self-support
Co-designed model of care – high-level self-care model
Co-designed model of care – self-care, the baseline and next
steps
•
•
•
•
•
Voluntary sector are committed and excited to be a part of this
Recent data suggests that there are around 1,172 registered VCOs in K&C (further data
required on QPP)
KCSC are aware of around 500 active organisations with 2009/10 estimates of income of
approximately £127m in total, £7m of which came from NHS, Social Care and Public
health (which we expect to have staid the same in real terms)
While that funding (from NHS, Social Care & Public health) provides for services for all
age groups we believe about half of it is utilised towards specific services for adults
Over the next 2-3 months we want to continue our work with this group to
• Create an in depth baseline of what exists and how it is used
• Identify which services fit with our high-level model and how they could be better
integrated in the whole systems pathways
• Develop internal capability and a more integrated relationship with the joint
health and social care commissioners to enhance / monitor any of these services
for supporting the whole systems proposals
• Work with the teams on the ground to think through the operational implications
of making joint working with the VCOs and various health & social care services
easier e.g., sharing information, communication etc.
Increasing degree of operational and
financial integration
Phased implementation – broad approach
Real capitation
with risk & benefit
sharing, single
operational staff
management
3a
3b
Possible options to
consider for April 2016
3c
Shadow financial
arrangements,
staff colocation
common SOPs,
outcomes, perf.
management etc.
2a
2b
2c
1b
1c
Plan for April
2015 or soon
thereafter
1a
Information
sharing only,
common goals and
outcome targets
etc.
… with colleagues from across
health, social care and the
voluntary sector to
implement some elements of
our model of care and provide
integrated services to our
population
Few practices only,
different local models of
care
Group of practices – largely
similar model of care with
some variations
All practices with a single
consistent approach and one
model of care
Increasing scale of participation and
uniformity of model of care
8
Phased implementation – broad approach
By April-June 2015
 Pilot in 40-60% of the
practices in WL (in waves
depending on sign up)
 Implement shared health &
social care plans with
stronger case management
better links to rapid
response & reactive care,
and greater number of
primary care appointments
 Setup 2-3 of the
operational hubs with
colocation of staff,
common outcomes, daily
operational huddles etc.
By April 2016
Throughout 2015
• Lessons from the
pilots
• Refinement of the
operating
procedures
• Investment in
frontline training,
organisational
development and
culture change
 Roll out refined model to
all willing practices and
establish remaining
operational hubs
 Implement single number
for access to all needs
 Establish an Accountable
care partnership with
integrated organisation
structure , common
systems, and responsibility
for shared outcomes and
pooled and capitated
budgets for the population
covered
9
Phased implementation – operational rollout
Q4
GP and
provider signup (see over)
Q2 15/16
Q1 15/16
General
practice
Recruitment of
two Network
Development
Managers
•
•
•
One focused on
the North, the
other on the South
(will phase
recruitment to
reflect this)
Clinical and
managerial
background
To be employed by
the WS provider
from April/June
2015 onwards
Lead operational
design
Q4 15/16
Operationalised North Hub, based around St Charles
Operationalised South Hub, location TBC
Voluntary
sector
CNWL
•
Q3 15/16
Service
users
CLCH
General
practice
Social
care
Further operationalised hubs?
Voluntary
sector
CNWL
Service
users
CLCH
General
practice
Social
care
Voluntary
sector
CNWL
Service
users
CLCH
•
•
•
•
•
•
•
Risk stratification
Care planning
Case management and multi-disciplinary working
Integration with CIS/OAST
Continued primary care navigation
Enhanced primary care
Self-care and self-management
Social
care
Phased implementation – the balancing act – dependencies and
enablers will need to be managed to ensure they come together at
the right time
Service user engagement
Contracting,
commissioning
and provider
development
GP
engagement
and sign-up
Estate
Recruitment
and workforce
development
Provider
engagement
(CLCH, RBKC,
WCC, Age
Concern,
CNWL…)
Dependencies
People and
organisational
development
Governance
Business case –
signing off the
investment
Operational
design
Data and
analytics
Phased implementation – timescales and workstreams
February
March
April
May
Phasing and operational design
Data and analytics
People
Service user engagement
Estate
Business case
Contracting, commissioning and provider development
Governance
June
July onwards…
January CLS to brief and outline
process to register interest
Partner liaison
Consolidation of sign-up and
liaison with parties to agree
phasing and rollout plan
General practice network
design – two four hour
sessions
Wider provider design (inc.
general practice) two days
Session 1 and Day 1
Outcomes and
performance
measures
Operational
planning (two
or three)
Session 2 and Day 2
Clinical
governance
and quality
workshop
Organisational
development –
creating an
integrated team
Ongoing June-July April-May
One-to-ones as required
Operating plan, service specification and MOU
Recruitment of development managers
Feb-Mar
Jan
Phased implementation – phasing and operational design and people
• Data and
analytics
• Business case
• Governance
• Service user
engagement
• Estate
• Contracting and
commissioning
Mobilisation (including organisational development)
Go live
Alignment with these activities will also be critical …
CLSs (ongoing) and joint CLS (24th
February)
ISA Workshop (19th February)
GP Federation project
Costings - sharing our high-level modelling
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•
•
•
•
We have developed some high level modelling for the high-level model
of care, they are currently in draft and will change. These are theoretical
and based on an ideal model as suggested by the Model of Care
Working Group and the Primary Care Design Group
They assume that all the costs identified are extra at this stage and only
for a pilot year. Extra staff may in reality be new or re-focussed existing
community staff
A Finance & Analytics Workstream is being established to support more
detailed working
A fuller business case will be developed and tested in Q4 (Jan-March
2015) and will be brought to the Governing Body for review and
approval
CCG Financial Plan for 15/16 is still to be developed and would
determine what is the available investment
We need to consider the governance process both internally and with
other providers
Costings – practices and providers participating in the 2015 pilot
would be...
Practices1
Existing
performance
Additional
commitments





CQC registered
Good QOF scores
Patient Ref Group,
Achievement of 14/15 care planning targets
Actively involved in PPF
1. Share information (ISAs etc.)
2. Participate in daily operational huddles
3. Additional practice level 2 sessions per
week dedicated for the above 65s (with
longer appointments)
4. One session per week (attended by all
practice GPs) for performance management
& planning
5. Up to 2 hours daily of dedicated practice
level on-call GP level input for a 2 way
dialogue with operational base
6. Strong operational connection with the
base (e.g., a practice member spends up to
50% of their time at the operational base)
Other providers2
 Actively involved in supporting PPF
 Participation in the co-design process
1. Greater sharing of information (ISAs) and
access to IT systems
2. Collocation of staff (with other providers)
into 1 to 5 operational bases and closer
joint working e.g., daily and weekly
huddles (at the base), care planning
meetings etc.
3. Using referrals as only a means for tracking
the activity but working together with
other members of the operational base to
take holistic responsibility of outcomes
4. Developing a day to day operational
reporting responsibility with the base
coordinator / manager
1: A typical practice assumed to be ~6200 size with ~700 over 65s for planning purposes, smaller practices could be grouped with their peers
for purposes of whole systems planning and resource allocation
2: Mainly consists of social care, community care, mental health, OOH and some voluntary sector providers. Impact on acute staff expected to 15
be more limited for 2015
Costings - for 2015 this incremental investment may need to be
considered as pump priming cost and yielding the following benefits
Description and Rational
Improve user
experience &
outcomes
 The service users and their care experience and outcomes
have been kept at the centre of all the co-design work
and specific care outcomes that have been agreed will be
tracked throughout the implementation in 2015
Support the CCG
in achieving CIS &
QIPP targets
 The whole systems proposals would play an important
part in ensuring that the proposed CCG targets from CIS
and other QIPP schemes are met in 2015 and also ensure
that CIS is not over-used, by providing the step-up / step
down capability
Improve joint
working and real
culture change
Lay the ground for
a fuller whole
systems adoption
 Lack of investment in frontline OD and culture change has
always been cited as blockers to real culture change. The
Whole system proposals recommend specific investments
in those areas as well as make colocation of staff a
fundamental operational principle
 Providing an empowering environment with limited risks
to all providers through 2015 is a necessary pre-requisite
to prove the benefits of whole systems working, and for
setting the stage as well as overcoming the resistance and
fear to more ambitious proposals for capitation,
Accountable care partnerships etc.
Therefore in 2015
while all the
outcomes as well as
additional activities
/ provider
commitments will
be tracked at a
programme level no
single additional
financial benefit
number is
associated with
these proposals,
over and above
what has already
been budgeted for
by the CCG in its
existing QIPP, CIS
and other business
cases etc.
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