1. Commissioning Integrated Care for Older People London 1 February 2005 Paul Forte, Richard Poxton Chris Foote, Tom Bowen, The Balance of Care Group

2. Workshop objectives Integration of health, social care and other services for older people: a high priority - but not easy to achieve Commissioning is a potentially powerful tool to support this, but how does it work in the current environment? What were aiming for today is: –strategic and practical insights into commissioning integrated care –opportunities to consider potential local implications –ideas for further action

3. Workshop agenda Commissioning environment –What do we mean by integration? –Current issues in commissioning integrated care –Group work: whats happening locally at the moment? Whats the evidence? Whole System modelling of Older Peoples services –Aligning demand and supply –Telemedicine and telecare –Group work: developing local whole system perspectives So what will you do about it…?

4. First thoughts… Take a few moments to introduce yourself to your neighbours and discuss: –your take on whats affecting integrated care commissioning – whats getting in the way? –your magic bullet solutions – and whats looking promising? –your expectations of todays workshop

5. Typical demands… We want to reduce emergency/ unnecessary admissions We want to improve the flow of patients through acute beds We want to reprovide our care home stock We want to provide high quality care We want to provide a seamless service We want to be at home!

6. …begging the following questions –What alternative care processes are there? –Where are they/ should they be located? –Which types of users and patients are these suitable for and how do we identify them? –What are implications for the types and volumes of resources required such as staff, beds and places? –When might we achieve this by? –Who pays? –Why arent we doing it already?

7. Commissioning Monitoring & evaluation - service delivery - client satisfaction Planning - identify need/ demand - priorities Purchasing -settings/ providers -contracts Strategy/ vision - stakeholders - sense of purpose

8. Commissioning implications Tension and complexity is the working currency A need for both long and short-term views and a capacity to respond at both these levels To be effective a key focus of the commissioning process should be to incorporate the patient/ user experience and engage the clinicians Data and information – who owns it and who has access to it?

9. Stakeholders in commissioning OLDER PERSON/PEOPLE MULTIDISCIPLINARY PROFESSIONALS CROSS AGENCY COMMISSIONERS COMMUNITIES

10. What is Integrated Care -I? For the older person, it is their involvement in their care such that they feel in control of a seamless and easily accessed service as it affects them. That permits them to act responsibly both to themselves and their communities so that they feel valued and part of their community.

11. What is Integrated Care – II? For the professional, it is working in a context of positive and supportive relationships, within and across boundaries, such that they can more easily provide an appropriate and timely service to their patients and colleagues.

12. What is Integrated Care - III? For the commissioners integrating commissioning results in robust partnerships across agencies and communities that provide innovative, high quality care which is cost effective. Central to this is balancing the needs of the individual to the needs of the population, supported by the commissioning of shared information, shared training and development and shared governance.

13. Pre admission AdmissionDiagnosisTreatmentDischargeRe-admission Social details alone, carers, accommodation Risk factors: age, drugs, co- morbidities, psychiatric/ dementia, falls Preventative care Disease management Managed populations Source of referral Time Waiting time Route Decision maker Reason for admission Alternatives to admission to acute setting Admission diagnosis Inpatient diagnosis Delays in diagnosis Chronic disease Alternative access for diagnosis Delays in therapy Alternative settings for therapy (especially rehab) Discharge planning Delays in planning Delays in execution Alternative locations for discharge Revolving door Avoidable eg. through chronic disease management Alternative locations for readmission Integrated care

14. Future care trends More active rehabilitation in the community: hospitals, care homes, clients own homes Blurring of boundary between health and social care environments More flexibility and devolution of tasks within and between care professions More active upstream management –long-term conditions management –risk management of frail elderly in the community –health promotion

15. Older people Define by age, condition? Older people as individuals Older people as part of a population How do we identify and target particular types or groups of older people? Role of carers

17. Intermediate Care - a cautionary tale of initiatives? Many definitions and models; poor evaluation; little scientific evidence (Melis, 2004) Have tended to focus attention on patients who can be rehabilitated quickly – doesnt take much account of slow-stream rehab However, community-based services could broaden their scope in this direction More creativity both in locations for care and in the care processes themselves comes with better knowledge about patients

18. PCT reorganisation Support for commissioning –critical mass of appropriate skills Overview of Practice-based Commissioning –strategic function –equity Keeping the focus on integrated care –potential wide range of service providers –continuing alignment with social care services

19. Practice-based commissioning Commissioning is its raison dêtre –strategic overview –support for Practices Predicated on: –strong clinical leadership - essential for effective service development –clear strategic focus –case finding and service co-ordination –appropriate skills, information –mature partnerships

20. Payment by results Currently focused on event-based care in hospital Since money follows the patient, healthcare outside hospitals can release funding for development of integrated care But need to adopt whole systems approaches if, for example, hospital admissions are to be reduced

21. Direct payments Money for assessed support, instead of services Emphasis on individual choice, control, flexibility Users at the centre; pulling together individualised patterns of support Challenges for integrated care: –not available for health support –important to move away from notion of services as standardised and aggregate –in-house services and block contract issues –commissioners, clinicians and providers must work closely together

22. What does the evidence tell us? Analysis of the local system is about transforming: –suspicion into data –data into information –information into action To support the commissioning basis: –developing the local vision –identifying and prioritising needs –resource implications and purchasing –alternatives to existing service delivery

23. Typical aims of a bed usage survey To assess the potential for alternative approaches to care delivery across the local health and social care economy through: –identification of the number and types of inpatients currently receiving hospital care who might have: been treated elsewhere instead of admitted, required admission, but could now be treated elsewhere –including: patients in acute wards patients in community settings elderly mental health placements

24. Patient profile: age group (n = 444) Average Age 73

25. Risk factors by location (n = 444)

26. Who are the patients? (n = 341)

27. % Within AEP admission criteria by specialty group (n = 316, acute beds only )

28. 1st Preference alternatives to admission by care location (n = 115: acute = 61, non-acute = 54)

29. % Within AEP day of care criteria by specialty group (n = 316, acute only) Average 46%

30. 1st Preference alternatives on survey day by location of care (n = 293)

34. Key directions Integrated home care is a priority –need to link intermediate care, rapid response, intensive nursing, management of long term conditions –involve the doctors eg comprehensive geriatric assessment Rehabilitation in beds: acute or community-based? Community hospital roles –fewer beds –resource centre role –north end of patch EMH: care home provision to free up services

35. Priorities in developing frailty management Importance of shared criteria which identify those at risk Knowing when an individuals condition changes significantly Obtaining and sharing information

36. Admissions outside clinical protocols by risk factor (N=977)

37. Indicators of avoidable admissions Readmissions concentrated in last 2 years of life Need to avoid the first admission outside criteria Admissions outside AEP are not related to number of previous admissions Based on sample of 300 –40% of admissions outside AEP result from exacerbation of chronic conditions –on average each has 2 identifiable chronic diseases The more risk factors, the more likely to admit outside AEP

38. Bringing the data together

39. Whole system modelling of older peoples services Key issues to address: –clinical engagement –modelling approaches –partnerships - in broadest sense –telehealth (...med...care) –importance of data and information for evaluation and planning

40. Commissioning needs to pull initiatives together National Service Frameworks Payment by Results Practice-based Commissioning Healthcare outside Hospitals Its crucial that there is common ground for care professionals and commissioners to drive these agendas

42. Alternatives to MAU/SAU

43. The Balance of Care model Older People high dependency low dependency medium dependency

44. The Balance of Care model Older People high dependency low dependency medium dependency long -term care bed community nurse Voluntary & Private sector NHS Local Authority nursing home physiotherapist care assistant day care centre respite care

45. The Balance of Care model Older People high dependency low dependency medium dependency long -term care bed community nurse Voluntary & Private sector NHS Local Authority nursing home physiotherapist care assistant day care centre respite care option1 option 2 option 3

46. Tensions in the system Care ProfessionalsNon-Clinical Managers Health ServicesSocial Services High DependencyLow Dependency

47. Community care workforce implications – by dependency

48. By staff grade and location

49. DH Telecare project Support to develop cases for funding from the Preventative Technology Grant Development of a cost-benefit decision support tool to enable identification of potential cost savings through: –reduced admission to residential care –reduced cost of home care packages –potential cost savings to the NHS (eg through reduced admissions to hospital)

50. So…. what next? Personal action points arising from todays workshop –how are you going to behave differently as a result of todays workshop? –what will you do: tomorrow, in the next month, six months? What might be potential local work streams –specific to your locality? –generic to the NHS? Feedback to and from the Integrated Care Network: www.csipconsultation.org.uk www.balanceofcare.com