Integrated Care in Somerset
Linking Big Data with a Right Care
Approach
Kevin Hudson
Head of Business Solutions & Innovation
SaWCS LPF Bid Director
Kevin.hudson@swcsu.nhs.uk
07717 530 220
Context in Somerset
 Somerset’s imperatives for integrated care
o Understanding those patients who would benefit
o A person-centred approach
o A radical ambition for commissioning change
 Our understanding of national Right Care principles
(particularly in relation to data)
o Where to look? (understanding what matters?)
o What to change? (undertaking a deep-dive)
o How to change? (equipping the commissioning tool-kit)
 Through this work we have discovered that local priorities
and national initiatives can be one and the same
2
Telling the story
through data – BIG DATA
 Most data analysis (and commissioning) is ‘episodic’ - Episodes of care,
amalgamated over time and categorised by provider
 We built a Holistic data model – where the patient is the ‘base unit’, not
the episode
 577,000 Somerset patients – activity mapped and costed
-
All their encounters with all aspects of Health & Social Care - £676M of health and
social care spending
Cross-cut against all their diagnostic conditions (mapped from 400 Episode
Treatment Groups recorded through Primary and Secondary Care Coding)
 Purpose of the model is to:
–
–
–
Help set the scope of Outcomes Based Commissioning
Help set the focus within any agreed scope
Help develop an evaluation methodology to measure change
 Biggest Challenge: Not how to build it but how to understand it
Where to look? Cost by age….?
Where to look? …or by condition?
Morbidity (number of ETGs) by age band
100%
90%
80%
Number of
conditions
70%
0
Patients (%)
60%
1
2
50%
3
4
40%
5
6
30%
7+
20%
10%
0%
0-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
Age band (Years)
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85+
What drives cost – age or conditions?
Regression
variables
Age
Number of
conditions
Age, Number
of conditions
Variation
explained
3.36%
18.76%
19.30%
What matters?
The Symphony Project wanted to get
ideas and thoughts from people with
lived experience and from current
frontline staff. April Strategy were
engaged to help do this and they
undertook a series of activities in
Autumn 2013. They:
• Reviewed national and local
publications (often based on patient
and staff engagement)
• Held one-to-one interviews with
people with long term conditions
• Facilitated a large event with
people, carers and frontline staff.
(it’s not all about data)
People and carers’ shared hopes:
Staff’s shared hopes:
Insights were gathered about what
works well now, what people hope to
see more of and what they want to see
less of in the future.
7
Deep-Dive
What might you change?
• Patients on Pathways?
• Patient with Condition?
• If so, which conditions?
Starting point: Different conditions / characteristics
Starting point: Multi-morbidity and Cost
But not all follow this pattern…
For multi-morbidity, number ≈ type
For multi-morbidity, number ≈ type
For multi-morbidity, number ≈ type
For multi-morbidity, number ≈ type
What to change?
Multi-morbidity,
not disease type
How to change?
(Equipping the Commissioning Tool-kit)
•
•
•
•
Year of Care Budgets
Patient Mapping / Social Factors
Person-Centred Outcomes
Personalised Care Planning
And for the LIG’s (Local Implementation
Groups) we map where the patient’s are…
Number of Patients
…their cost…
Cost of Patients
…and the setting of care (‘at home’ or
‘in a home’)
Cost of Patients
Mosaic Social Indicators can help inform scope and engagement:
Type M56 – Older people living on social housing estates with limited budgets
Key Features:
• State pensioners
• Low use of credit
• Enjoy reading
• Small housing
• Basic education
• Shop locally
• Traditional
• Lifelong council tenants
• Face to face contact
Communication Preferences:
Access Information
• Local Papers and Face to Face
• Not Internet, Telephone, Magazines, SMS Text
Service Channels
• Face to Face
• Not Internet, Mobile Phone or Telephone
2% Population, 8% of full cohort, 12% of high cost patients
What matters – designing a outcome set
The insights were used to create a mandate to guide the design work and formulate the outcome set
Focus
Outcome
Features
Enablers
Me and my carer (s), taking account of all my conditions and our physical, mental, social and
emotional needs
I am helped to manage my conditions and live in the way I want to the best of my ability
ACTIVE
INVOLVEMENT
POSITIVE
RELATIONSHIPS
EASY
ACCESS
I am listened to and
involved in planning
and making choices
about my care in a
way that suits me.
I have one key person
who takes ownership for
coordinating all aspects
of my care. They make
me aware of all the
options and keep me
informed about what’s
happening. They
understand me and I
trust them.
I can contact my care
coordinator when I need to.
I am given access to
information, education,
advice and expertise to help
manage my condition.
Support and services are
available as close to my
home as possible and I know
there is a 24/ 7 response
available if I need it.
SEAMLESS COORDINATION
I receive seamless timely,
coordinated care with easy,
efficient transitions from
one service to another.
Professionals across all
services have access to an
up-to-date shared record of
my condition, needs history
and services and treatments
I am receiving.
• Caring, compassionate, competent and knowledgeable staff work in multi-disciplinary teams across
organisational boundaries with up-to-date, shared records, facilitated and supported by organisations and
systems.
• Patients and carers are asked for feedback on services and see improvements happen as a result.
23
Outcomes
Hierarchy
Personalised Care Planning Training
“It has been really interesting to see how
the medical model is driven by tests, tasks
and numbers, rather than by the individual. I
am really positive about the opportunities
Care Planning presents for partnership
working and to get the voluntary sector and
other services involved in healthcare.”
Personalised Care Planning and
Support Training Courses 2014/15:
Venue / Location
Frome Medical Practice (delivered by
National Training Team)
Irnham Lodge Surgery, Minehead
Woolavington Surgery
North Sedgemoor Federation
The Thatch Cottage, Shepton Mallet
The Meadows Surgery, Ilminster
North Sedgemoor Federation
Wells Health Centre
Williton Hospital, West Somerset
Springmead Surgery, Chard
Yeovil District Hospital
Taunton Deane Federation
Frome Medical Practice
Taunton Deane Federation
Available to book
Available to book
Yeovil District Hospital
Bridgwater Hospital
Available to book
Taunton Deane Federation
Date of 1 day
‘Making it
Happen’
10/0714
21/10/14
09/01/15
21/01/15
26/01/15
03/02/15
11/02/15
25/02/15
12/03/15
16/03/15
24/03/15
30/03/15
01/04/15
16/04/15
07/05/15
19/05/15
03/06/15
16/06/15
29/06/15
07/07/15
22/07/15
No. of
attendees
Regional Lead, Age UK
11/09/14
25
11/11/14
20/02/15
10
7
09/03/15
17/03/15
25/03/15
08/04/15
23/04/15
27/04/15
05/05/15
11/05/15
13/05/15
28/05/15
18/06/15
30/06/15
15/07/15
28/07/15
03/08/15
18/08/15
02/09/15
10
9
7
“The Care and Support Planning training
gave me a ‘light bulb’ moment about
preparing patients for their annual
reviews. It acted as a useful reminder in
these busy times, that putting a bit of
time into empowering the patient can
have positive rewards in terms of
subsequent use of services as well as
clinical outcomes”
Date of 1/2 day
follow-up
GP
“Self-reflection of my consultation skills. I
have realised that patients may not
always hear what I think I am saying. I
will also try to dig deeper to find their real
story and agenda, rather than just doing
what I think it is.”
Practice Nurse
25
National Coverage
• Symphony data analysis
was covered on the front
page of HSJ – April 2014
• Professor Andrew Street
also recorded a video:
http://www.youtube.com/
watch?v=Cr7aevRGBqM
(or search Youtube for ‘integrated
care in Somerset’)
• Published in International
Journal of Integrated Care –
January 2015 (after
academic peer review)