Dr Laura Hill (Clinical Director, Crawley CCG) Adrian Flowerday (Managing Director, Docobo Ltd) Bharti Mistry (Project Manager, Crawley, Horsham and Mid Sussex CCG)

Outline of the Presentation Context (collective challenges) Data Enabled Planning Evolution of benefits and learning Next Generation Delivering the Forward View Sustainable Transformation A look under the hood of the technology

2 million attendances at A&E monthly 21st Century Challenges Nationally 2 million attendances at A&E monthly Crawley, Horsham and Mid Sussex CCGs >75,000 attendances at A&E annually Rising Longevity Long term conditions and co morbidities

Complexities and fragmented care Multiple chronic conditions, complications, longevity combined with frailty and resilience, multiple medications, intensive care needs ( health [physical and mental] and social care), social isolation 21st Century Challenges Complexities and fragmented care

Start of the journey late 2012 Enabled …….. by Risk profiling, its application & further development Start of the journey late 2012 Stage 1: Segment population by risk of admission to provide Early Intervention

Crawley and Horsham Mid Sussex CCG Application of Risk Profiling Very high risk of admission High Risk of admission Moderate risk of admission Low risk of admission 1. Proactive Care via Multidisciplinary teams ( Integrated care) 2. Tailored Health Coaching 3. Intensive support, High cost low volume Diabetics Self Support Slide 5 and 6 go on to describe the current initiatives at the CCG and the approach to care

Multidisciplinary model of care Structural Integration and co-ordinated care Model of delivery ….. Flexible/adaptable as see later in video. How we are integrating care post referral. Person centred etc. Hollie and probably Jane can provide quick overview of case study on page, emphasising the complexities, the plethora of interventions that encompass physical health, mental health and social care.

Benefits Sought and achieved Empowered Patient, Age well stay well, Promote Independence : patients reported improvements with respect to motivation and confidence to self care, their social network, emotional and physical well being Person Centred, co –ordinated care, whole patient, Integrated Partnership working: Multidisciplinary infrastructure in place serving a population of up to 50,000 Family centric: Considers the carer and associated family members Prevention and rehabilitation: >600 conveyances avoided, >200 admissions avoided, reduction in 2 unplanned bed days fro about 400 risk of admission patients Benefits Sought and achieved from 2600 referrals….whilst service embedding. Potential for better gains with maturation Implies improving quality of care and positive patient outcomes

Clinical Directorship Commissioning Insight Digital Innovation and Technical experience Development of Partnership Interdependencies and contributions recognised & Valued

Evolution of Risk Profiling Models 2006 PARR Patients at risk of readmission (Hospital Episode Statistics only) CPM Combined Predictive Model ( risk of admission) ACG Adjusted Clinical Groups H&SC Combined Health and Social Care Data Multiple risk model Combined Data Correlation of the burden of illness (morbidity and demographics) Correlational approach Integrated Intelligence & Relationships 2015

Catalysts for evolving risk profiling beyond risk of admission 1. Intelligence driven strategies for integrating care Highlighted Need for Integrated care needs Fragmented Health and Social care Understanding value of combined data Lessons learnt Risk profiling applications Integrated care needs (Multidisciplinary working) 2. Outcomes that optimise care not just risk of admission Demand and Capacity Ageing population Scarce economics 3. Data led correlational approach to mitigating risk of deterioration in patients

…….a bold step.... Developing a New generation of risk profiling model Stage 2 Develop prototype to address complex patient and social isolation Stage 1 Segment population by risk of admission to provide Early Intervention

Film – summarises phase 1 of Integration work Play video attached

Early Segmentation of complex patients and facilitating a support network 25% of high risk patients (~ 1450) (High risk patients comprise about 1% of the population) have at least 4 factors contributing to complexities Identified key factors and include co morbidities, depression, immobility, being housebound, memory impairment, multiple medications, bereavement Demand and Impact of complexities and social isolation better understood Increase support using existing community assets with improved connectivity Risk of admission 50-100% 4137 patients 1% Co morbidities, oncology, depression, housebound, memory impairment, Self referrals, poisoning epileptc drugs, falls, limb ulcers. Work with data and knowldege to build further 1450 patients > 5000 A&E episodes annually (range 5 -15, ave 3.5 per patient) nearly 11,000 unplanned bed days (ave 7 per patient) GP contacts range 26 to > 50 per patient >18,000 medications in total for group Targeted Support network and social prescribing in planning phase: Patient education, co-ordinating the social connectivity, shift from GP

Community Based Integrated Teams Stage 3 Multi Risk Model with Integrated Intelligence from different care sectors Community Based Integrated Teams Stage 2 Develop prototype to address complex patient and social isolation Stage 1 Segment population by risk of admission to provide Early Intervention

CCGS are working towards Seamless care by creating capabilities to Triangulate intelligence between care sectors Understand timelines, gaps, demand and capacity between sectors Manage transitions between care sectors triangulate intelligence on health ( physical/mental) and social care  add connectivity to patient care and management  understand complexities  Understand timelines, gaps ,demand and capacity in health and social care  design new integrated pathways  manage transitions between care sectors ……Enable shift from service improvement to system wide transformation

Identifying Integrated Care needs - ArtemusICS™

ArtemusICS™ Enabling Cross Continuum Collaboration Health Sector Social care Mental Health ArtemusICS™ Enabling Cross Continuum Collaboration Community Care

Success factors Driven by Clinical Insight Starting small and incremental change Innovative concept continually developed Patient at heart Information driven Technology supports the service Learning from trial and error on small scale before scale up

Your feedback please………

Dr Laura Hill Clinical Executive Director, Crawley CCG Adrian Flowerday Managing Director, Docobo Ltd Bharti Mistry Project Manager, Crawley Horsham & Mid Sussex CCGs