1. Leeds LTC Year of Care Commissioning Early Implementer Site Visit 7 th May 2015

2. Leeds Year of Care EI Pilot Journey to Date Tricia Cable

3. Overview 2012 to 14 Leeds PCT selected as an Early Implementer Project structure established within citywide Integration Programme Initial steps in establishment of Integrated Community Health and Social Care Teams, Risk Stratification & Leeds Care Record Selection of 550 sample and analysis of 2012/13 data 2014/15 Analysis of 2013/14 data for 550 sample RRR Audit Established NT, further developments of model Leeds Care Record Review of Transformation programme & YOC EI Pilot in light of context and policy & planning developments. Redefine project

4. Improve health outcomes and cost effectiveness for a specific population by: Using an approach of population health with a clearly defined cohort with- delivery based on integrated multidisciplinary community based care, with robust care planning and co-ordination with- care planned, delivered and managed by a new provider to provider partnership arrangements with joint accountability for outcomes and - new financial arrangements based on forms of a capitated budget/pooled budget and - new payment mechanisms and financial flows, if required. Leeds YoC EI Commissioning pilot

5. Year 1 and 2 Initially based on risk stratification Cohort of 550 patients 180 managed within NTs others from risk stratification Single Leeds cohort Cohort for building of capitated budget Small number of ‘case study’ approach RRR Audit. Patient Cohort

6. Year 3 and 4 Locally agreed by CCG based on: Analysis of whole population dataset by age, risk, frailty, LTCs Detailed review of multimorbidity and co-morbidity Service utilisation Cost Disease prevalence Outcomes – ability to manage own condition, quality of life, PYLL Clinical views Published evidence Size of cohort required for pilot Practice lists NT configuration. Patient Cohort

7. Years 1 and 2 For YoC long term conditions cohort To include Health & Social care spend Activity and spend 2012/13 & 2013/14, 550 patients Currency categories by risk category In depth analysis on small sample of patients Recovery, Reablement, Rehabilitation, (RRR) audit linked to tariff flexibilities Data availability and data sharing issues. Capitated Budget

8. Years 3 and 4 Activity & spend analysis 2014/15 – all patients with 1 or more LTCs Estimated capitated budget and currency categories Sense check against contract values Shadow tracking throughout 2015/16 Improved information & data development Refinement of budgets Modelling of Transformation workstream impacts Development of Risk and Reward Agreement Provider Impact modelling Agreement of Payment mechanisms and financial flows. Capitated Budget

9. Years 1 and 2 Development of Neighbourhood Teams (national visit) Risk Stratification Leeds Care Record Data sharing Transformation Portfolio Programme- Integrated Care & Prevention Integration Pioneer. Integration

10. Year 3 – Local Local Developments 2014/15: Next stage development of NTs CCGs Primary Care at scale development Integration between NTs and Primary Care BCF Whole population pseudonymised data set Review of YoC EI approach Integration

11. Year 3 – National Year 3 National YoC EI programme – Shadow year Information Governance issues Integration Pioneer support programme – new provider organisational forms – ACOs, lead provider etc. Flexibilities – tariff Personalisation & personal budgets Financial future 5 year Forward View Models of Care - Vanguard Integration

12. Leeds LTC Year of Care Commissioning Early Implementer Site Visit 7 th May 2015

13. Information Presentation Tom Mason

17. Multimorbidity/Comorbidity analysis for cohort identification

18. Leeds citywide prevalence of individual long term conditions

20. This chart shows the number of patients with long term conditions categories (based on the Scottish List … with some additions) The most common conditions in these groups are hypertension, depression, respiratory and coronary heart disease

21. This chart shows the age breakdown by CCG of patients with one of more LTCs (excluding Asthma as a single condition where there are high figures for younger adults Asthma is included where it is in conjunction with another i.e. COPD) Number of people with LTC’s (one or more), by age group, split by individual CCG

22. Prevalence of individual long term conditions Leeds North CCG

23. Prevalence of individual long term conditions Leeds West CCG

24. Prevalence of individual long term conditions Leeds South & East CCG

25. Number of Long Term Conditions with costs

26. Average number of LTC’s, by age group, split by individual CCG

27. For each CCG: Investigate combinations of LTC’s within agreed categories i.e. 2/3/4/5 LTC’s based on data and published evidence Investigate links between multimorbidity/comorbidity with age, frailty and cost Each analysis by practice and Neighbourhood Team (NT) Further analysis

29. Capitated Budgets

30. This chart shows average costs for Leeds patients with one or more long term condition. Community and Mental Health figures are indicative as they do not include all services. Adult social care costs are not included Leeds Citywide average costs for patients with one or more LTC, by service

31. Adult Social Care (ASC) Cohort Long Term Conditions by Age Group This chart shows the Leeds patients (split by age range and number of conditions) with one or more LTC by CCG in receipt of an ASC service

32. Total cost and average cost per patient, by CCG

33. Adult Social Care costs will be added Agreement of inclusions and exclusions Reconciliation of costs by service in the data with the payments that commissioners actually make Evaluate the difference between tariff and provider costs Shadow monitoring from 1 st April 2015 data for full cohort (each CCG pilot shadow monitoring to be introduced) Next steps

34. Leeds LTC Year of Care Commissioning Early Implementer Site Visit 7 th May 2015

35. Data Sharing and Data Linkage Leeds Care Record & CareTrak Alastair Cartwright

36. Data Sharing and Data Linkage Contribute Consume GPs 98/108 LYPFT NTs 2/13 LTHT LCH ASC GPs 98/108 LTHT LYPFT LTHT Leeds Care Record Data Processing Agreements Data Sharing Agreements Primary UseSecondary use

37. Data Sharing and Data Linkage Secondary use DSCRO DMIC Contribute Consume GPs LYPFT SUSLCH ASC Data Processing /Deposit Agreements LTHT YAS CCGsASC Pseudonymise + Link Integrated Dashboard + CareTrak ‘Transformation’ portfolios and providers Inform ASH / CCG

38. Data Sharing and Data LinkageChallenges

39. Contribute Consume GPs 98/108 LYPFT NTs 2/13 LTHT LCH ASC GPs 98/108 LTHT LYPFT LTHT Leeds Care Record Data Processing Agreements Data Sharing Agreements Primary UseSecondary use DSCRO DMIC Contribute Consume GPs LYPFT SUSLCH ASC Data Processing /Deposit Agreements LTHT YAS CCGsASC Pseudonymise + Link Integrated Dashboard + CareTrak ‘Transformation’ portfolios and providers Inform ASH / CCG Cohort Re- identification for direct care purposes

40. Data Sharing and Data Linkage Contribute Consume GPs 98/108 LYPFT NTs 2/13 LTHT LCH ASC GPs 98/108 LTHT LYPFT LTHT Leeds Care Record Data Processing Agreements Data Sharing Agreements Primary UseSecondary use DSCRO DMIC Contribute Consume GPs LYPFT SUSLCH ASC Data Processing /Deposit Agreements LTHT YAS CCGsASC Pseudonymise + Link Integrated Dashboard + CareTrak ‘Transformation’ portfolios and providers Inform ASH / CCG Cohort Re- identification for direct care purposes Patient opt-out via care.data

41. Data Sharing and Data LinkageEnd!

42. Leeds LTC Year of Care Commissioning Early Implementer Site Visit 7 th May 2015

43. Leeds YoC CCG Pilots Tricia Cable

44. The characteristics of the YoC pilot are completely consistent with the 5 year Forward View and MCP characteristics Local primary care development & primary care relationships with NTs are fundamental to development of MCPs YoC pilots will enable each CCG to test some of the characteristics, assumptions, questions, to inform the full development of primary care at scale and MCPs YoC pilots can test at local CCG level whilst models of care for city are discussed with providers By delivering 3 pilots different characteristics may be tested An overall Leeds YoC EI project will bring together the learning from each pilot site for the benefit of the Leeds Health and Social Care economy. Review of YoC EI approach

45. Primary care strategy Models of care development YoC pilot

46. Cohorts for NHS Leeds North CCG and NHS Leeds South & East CCG selected on basis of whole population dataset analysis - size? Cohort for NHS Leeds West CCG currently based on potentially identified pilot practice – all registered over 75 and care home residents, 700 – 800 patients Footprint to be selected based on cohort size, local practice joint working relationships, NT footprint, other CCG specific criteria e.g. PYLL – North Locality, South and East group of practices as subset of Federation, West – large single practice Agreement of pilot delivery model with partners in each pilot to be based on principles and characteristics of an MCP Agreement of pilot funding and timescale. Draft Pilot Framework proposal

47. Agreement of providers in partnership- 1) West single GP practice, Leeds Community Health, Leeds City Council Adult Social Care, LW CCG, 2)? S&E Federation, LCH, ASC, LYPFT, LTHT, LS&E CCG Development of Partnership Agreement e.g. devolved decision making Multilateral gain/loss share Agreement of use of a capitated budget, pooled budget or other financial arrangements. Shadow monitor capitated budget from 1 April 2015 Specific pilot Evaluation. Draft Pilot Framework proposal

48. Leeds based Central co-ordination Links with national team Responsible for ensuring maximum impact and value of 3 pilot approach Integration with ICP programme Overall project management, reporting etc. Engagement and communication across pilots Support to local pilot leads and project teams Evaluation. National YoC EI Arrangements

49. Leeds LTC Year of Care Commissioning Early Implementer Site Visit 7 th May 2015