Sunderland MCP Vanguard

Transcription

1 Sunderland MCP Vanguard Ian Holliday- Head of Service Reform and Joint Commissioning, Sunderland CCG Kerry McQuade- Head of Vanguard Delivery, Provider Board

2 Aim: Better health and care for Sunderland Key objective: To transform out of hospital care to achieve better outcomes for people and the whole system OBJECTIVES FOR PEOPLE Person-centred co-ordinated care Less people being admitted as an Emergency to hospital Less delayed transfers of care More people dying in preferred place Giving information once People with long term conditions living longer with better quality of life People supported to recover from episodes of ill-health and following injury Higher levels of patient and family satisfaction OBJECTIVES FOR WHOLE SYSTEM Integrated commissioning Integrated Provision Teams wrapped around practices with MDT decision making Moving investment from acute to community/primary care Sharing of patient information Better Value from reducing resources

3 Before Vanguard: GPs operating independently with little influence on community services and over discharge planning. Hospitals paid based on activity with little incentive to work with other providers across pathways to reduce demand. Mental health, social and community care were delivered independently of each other. Difficulty navigating around services, with confusion around points of access. Most at risk patients were not supported and bounced around the system. Imbalance of activity between acute admission avoidance and discharge facilitation in the Intermediate Care Services. Patients did not feel involved in their own health and social care needs.

4 Risk Stratification approach: Population cost pyramid: Top 3% of patients drive 50% of cost in Sunderland Population cost segmentation, secondary care, community and mental health spend,

5 Risk Stratification approach: Average Frail Elder without Cancer or Specialist Dementia care (2,000 patients in segment 73% of Frail Elders) Details Utilisation Spend Name Age 65+, 2+ comorbidities no Cancer or Specialist Dementia 79 (avg.) Primary 2 Appointments > Inpatient Spells 3 7,300 Outpatient Episodes A&E Attendances Mental Health Clusters Health Top Comorbidities COPD (49%) Myocardial Infarction (39%) Diabetes (38%) Community Visits 55 2,000 Social Visits Expected high user of social care Total 87 11,200 Top Risk Factors Hypertension (70%) Addictions (14%) Obesity (4%)

6 The Care Model

7 Where are we now: Formation of two GP Federations working collaboratively. New, city wide NHS contract between CCG and Sunderland GP Alliance, for input into model. Risk stratification of the population to target initially 1% of patients, and early signs of reduction in non-elective activity for this cohort. MDTs and person centered care across five co-located teams Rapid response Recovery at Home preventing emergency admissions and supporting effective discharge. OPAL model at front door of City Hospitals Sunderland. Early implementation of Enhanced Primary Care.

8 Number of Delayed Days Performance: Delayed Discharges 400 Sunderland Total Number of Days Delayed by Month - NHS and Social Care Attributable

9 Performance: Anticipated impact on non-elective Description 2016/ / / / /21 Saved Emergency Admissions from Transformation 1,250 2,869 4,519 4,519 4,519

10 Better Care Fund Learning Disability 39.41m Carers 2.97m Integrated Teams 51.42m m Intermediate care Reablement 6.82m Nursing/ Res.- CHC 33.16m Mental Health 24.62m CCG 80.66m LA 77.74m

11 Better Care Fund Single Commissioning Process s75 agreement between CCG/LA - lead commissioning; integrated management; integrated commissioning unit The rules of the pools accounting, audit, efficiencies, risk sharing, review Devising a commissioning strategy that incentivises change and continuous improvement in services Collaborative commissioning with providers - innovation Commissioning for Outcomes New contractual forms Lead Providers, Alliance

12 Things are improving!... In spite of many obstacles, effective community care is being promoted in a number of areas. Successful schemes often include the following : strong and committed local champions of change; a focus on action, not on bureaucratic machinery; locally integrated services, cutting across agency boundaries; a focus on the local neighbourhood; a multi disciplinary team approach; and a partnership between statutory and voluntary organisations.

13 Things are improving! The quote is from: Making a Reality of Community Care, Audit Commission, 1986

14 Find out more! Web: All Together Better Contact us: