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

2. 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

3. 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

4. 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

6. 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

7. 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

8. 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.

9. 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

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

11. 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

12. 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

13. …….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

14. Film – summarises phase 1 of Integration work
Play video attached

15. 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 %
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

16. 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

17. 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

18. Identifying Integrated Care needs - ArtemusICS™

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

20. 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

21. Your feedback please………

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