Leeds West CCG Business Case for Recurrent or Non Recurrent Funding request.

Transcription

1 Leeds West CCG Business Case for Recurrent or Non Recurrent Funding request. Proposal Title: Proposal to commission enhanced clinical services for people in care homes Transformation Workstream: NHS Leeds West CCG Local Scheme Accountable Lead Officer/ Lead Director: Simon Stockill / Susan Robins Lead Clinician: Keith Miller Lead Finance officer: Sam Mason Theme: Developing primary care, improving quality of care, avoiding admissions to hospital, improving choice and care at end of life, integrating services Responsible Transformation workstream or CCG programme as applicable: Primary Care Steering Group Approval Group: CCC Business case Author: Keith Miller / Sue Wilkinson / Becky Barwick Recurrent or Non Recurrent funding required?: Non-recurrent as pilot scheme for two years to allow time for robust evaluation Description of Proposal Statement of current position and why investment is required-what exactly are you proposing to do/change? In order to respond to feedback from members and increasing evidence of the need to improve care of vulnerable older people including care homes, a task and finish group including member practices have co-designed a proposal that NHS LWCCG implement an enhanced clinical service for people residing in care homes. The service to be provided to those on the registered list of NHS LWCCG member practices who live in care homes, previously known as residential and nursing homes 1. Consensus (see rationale section below) suggests that a form of enhanced primary care supported by focused community nursing and therapeutic provision, along with access to specialist input from geriatricians and other specialists when required, provides the highest level of quality care. This can be highlighted by schemes (such as examples implemented in Manchester and Sheffield) where such provision can lead to improved outcomes for people and for reduced activity in secondary care. 1 N.B The term care home will be used throughout this document to denote both residential and nursing homes. Care Home definition includes self funders as well as those who are LA/NHS funded Page 1 of 17

2 Although this proposal is for a specific care home population it will free up resource to broaden the remit of practice case management registers. The co-designed recommended option (option C) is made up of 3 integral elements: Enhancing GP led primary care above core contractual provision Expanding Integrated Neighbourhood Team specialist support working with the GP led team Expert pharmacy support to provide medication reviews and prescribing advice Principles of enhanced care home scheme for Leeds West 1. List-based approach to care of care home residents, supported by an Expanded Integrated Neighbourhood Team (EINT) of nursing and therapy professionals, sharing responsibility for care and patient outcomes. 2. Universal standard of proactive care for all people living in care homes will be provided. No discrimination between types of care home provision to be made, although it is recognised that some cohorts of people within this population will have particular healthcare needs, which may require different levels of input e.g. patients with dementia; patients with end-of-life needs. 3. If the scheme proves successful against agreed quality outcome measures, will be used as a basis for expansion for other vulnerable groups in the community, such as older people living in assisted living complexes and in their own homes. 4. Proactive care planning by a GP led team, including pharmacists, and nursing and therapy professionals from an expanded integrated neighbourhood team; obviating need for traditional referral patterns in the community, each resident being proactively reviewed on a scheduled basis with a view to minimising symptoms and optimising function. 5. Early identification and review of patients with end-of-life needs. 6. Encourage collaborative working between practices, with proactive visits carried out by GP led team. 7. Develop workforce of health and care professionals with specific skills, experience and training in caring for older people. This would include development of a GP with a particular clinical interest in the care of older people, supported by timely access to specialist support e.g. geriatrician, care home CMHT. 8. Explore opportunities for assistive technologies in supporting professionals to enhance proactive care of people in care homes, and improve their experience of care. 9. The service will operate over 7 days as routine general practice develops the enhanced access model. Model of Delivery 1. Named and accountable GP with a clinical interest to have the clinical responsibility for the outcomes of patients; leading a team (drawn from the expanded neighbourhood team) of an extended range of skills to deliver the specified outcomes. 2. Regular, scheduled visiting by the GP led team, anticipating care needs and changes in condition, and responding to reactive health concerns. This will include proactive scheduled reviews and care planning, discussions with families and carers, Page 2 of 17

3 contributing to MDT and reviewing the data relating to patient outcomes. Proactive plans shared with OOH medical and nursing teams and aligned to the Leeds Care Record implementation. 3. The Expanded Integrated Neighbourhood Teams will work closely with the hospital team where care home patients are admitted to support early discharge. 4. Assessments will include medication review in partnership with pharmacists, including a medication review following discharge from all acute hospital admissions. 5. It is recognised that reactive care will continue to be needed and covered as now by the GP contract. The enhanced model will support a reduction in unscheduled visit requests over time. 6. Member practices encouraged to work together in hubs based around GP networks led by a GP lead with a particular clinical interest in the care of older people. This will be facilitated through the enhanced access service and developing peer review sessions. Lead GP s for the care home scheme, neighbourhood team members and community geriatricians becoming part of the professional network on frailty. This will include peer review of care plans, assuring compliance and review of expected outcomes. Outcomes will be discussed with patient reference groups (PRG), and increasingly PRG s will help to agree priorities and outcomes. 7. Expanded Integrated Neighbourhood Teams to provide proactive input, with an expectation of reactive input as needed. *It should be noted that one practice within Leeds West CCG is to pilot the Year of Care Commissioning pilot which will provide early testing and evaluation of a number of the characteristics of the new models of care identified within the Five Year Forward View. This will include use of different forms of capitated budgets to drive integration, strengthen case management, improve patient satisfaction and outcomes and deliver cost savings. At the time of writing this business case it is not clear what the financial impact will be on being part of the commissioning pilot and therefore all practices will be included in the scheme unless alternative funding is identified for the Year of Care pilot. *Appendix 1 details GP core contractual requirements, existing arrangements that support access to services, and those additional activities required as part of the care home scheme proposal. Threshold/Eligibility for the scheme 1. Lead GP for the scheme to be a member of a managed clinical network in the care of older people; the lead GP will provide medical leadership as part of the clinical network and develop a programme of competencies and training. 2. No minimum number of care home patients to be part of the scheme. 3. Member practices who choose to be part of the scheme will exclude care home patients from their Case Management Registers (the 2%); Member practices who choose not to be part of the scheme will be required to include care home patients in their Case Management Registers. Scheme Numbers in NHS Leeds West CCG There are approximately 1500 people registered with GP practices in Leeds West who currently live in care homes. Proactive care planning- multidisciplinary review led by a GP at least every six months a. This would mean 3000 CP reviews per year / 60 reviews per week across Page 3 of 17

4 CCG b. 1 hour/week/20 patients, which would mean 75 hours of clinical time per week across CCG, if all practices participated (2 hours per practice per week). *Numbers based on schemes elsewhere and that seemed financially achievable Rationale for Proposal How will it achieve the aims of the theme, transform services & reduce whole system activity &costs? include any benchmarking information, evidence or data here Feedback from members Member practices who have many care homes patients registered have consistently fed back that these patients have increasing levels of need and are becoming harder to manage within the parameters of core contracts. Two LWCCG practices have received enhancements to manage care home patients over a number of years as part of a historical pilot scheme. The cost of funding the 2 practices is 70k per annum, and the evidence around these local schemes is included in the literature review at appendix 2. In line with the principles of the equitable funding review, which aims to address the wide variation in core funding per patient, any scheme would need to be available to all member practices, and to be widened to include a range of multi-disciplinary clinicians to offer the holistic care that care home patients need to enhance their quality of life. British Geriatric Society Evidence from the British Geriatric Society, as well as from local and national schemes, shows that traditional models of primary care provision are not sufficient to provide highquality care for people with complex care needs living in care homes. No formal delineations have been attempted in the evidence synthesis between different types of care home, though it is recognised that care needs vary in range and complexity across this population. The care home scheme should be seen as the initial project for a longer-term and broader proposal to improve care and medical leadership for all older people with complex care needs in the community. Patients in care homes have ongoing nursing and often associated medical needs. These patients require a home based service from GPs that is not the most efficient use of unallocated time. This patient cohort is also increasingly complex with multiple morbidities and requiring greater time input. Much of the current GP input to care homes will be unplanned. The BGS defines high quality care to those in nursing homes as: 1. Regular proactive and responsive input from Primary Care 2. Holistic care planning with regular reviews Locally commissioned literature review In order to help develop the model the task and finish group commissioned an independent literature review of all the available local and national evidence on such schemes. This review can be found at appendix 2. The review highlighted the key elements of a care homes scheme that should be included Page 4 of 17

5 as best practice and to increase quality of care and these have been included within this proposal (noting that Leeds West are already delivering some of these elements, particularly through the medicines optimisation scheme). However the evidence nationally and locally is inconclusive around cost effectiveness, sometimes due to the limitations of local evaluations. The Five Year Forward View There are also emerging opportunities emphasised in the NHS planning guidance for 2015/16. The publication outlines the development of new models of care including further integration of primary and community care and enhanced clinical support for care homes. This supports the broader vision for developing new models of care emerging for LWCCG and technological solutions for care homes have also been developed as part of the Challenge Fund 2 bid which has progressed to the second stage of consideration. NHS Leeds West CCG Primary Care Strategy This proposal is underpinned by the emerging LWCCG primary care improvement strategy which describes how our network of practices will move towards the new models of care described in the Five Year Forward View. It would be able to be delivered by hubs of practices, should those practices choose to manage the scheme in that way and it would also mean increasing partnership multi-disciplinary working with community services. Additionally the technological element of enabling effective care for care homes patients would be implemented by the innovation workstream of the strategy which would increasingly develop video consultation and conferencing. Local CQUIN development NHS Leeds South and East CCG, in their role as lead commissioners for community services, are developing a CQUIN to improve quality in nursing homes out of hours. This is in line with a new national CQUIN requirement around reducing admissions. The LWCCG care home scheme will help to shape the developing CQUIN which will also be aligned with the developing clinical network on frailty. Intended Benefits: analysis of benefits highlighting relevant aspects from list below. Patient Benefits Increased quality of care Greater continuity of care from GP practice Joined up package of care More proactive and less reactive care through care planning approach Reduced need for emergency admissions Patients feeling supported and able to identify what matters to me System Benefits Fewer attendance to A&E Fewer unplanned admissions to hospital Achieve greater integration of services Page 5 of 17

6 Reduced prescribing spend General Practice benefits Enhancement to enable proactive, quality care to be delivered Additional specialist support available from the expanded integrated neighbourhood team Opportunity to integrate with other providers and to work in partnership Key Functions/Stakeholders affected and how they will need to operate differently to succeed. Detail how patients/ members will be engaged Members Views: This model has been co-produced by a task and finish group to which all member practices were invited to be involved with. Those who were unable to attend meetings have fed in their views. Practices with a large number of care home patients registered (but not part of the current/previous enhanced scheme) articulated the pressure they were under to provide a good level of service to these patients within existing resources. There were a wide range of views expressed by members during the process of developing this proposal about what the solution should be. The role of the task and finish group was to listen to the views of all stakeholders, review the evidence and achieve consensus around the model. Patient Experience and Public Views: An initial engagement exercise was completed in late A survey was used to gather the thoughts and experiences of patients, carers, family and staff on the input to care homes from GP surgery teams and how the service they offer to care homes could be improved. The report made a series of recommendations to support the development of a business case for an enhanced GP care home scheme. The report recommended that the project looked at ways to standardise the primary care received in care homes and free up primary care staff to spend more time with residents and their families. A further engagement exercise was carried out during summer 2014 by Brainbox Research to ascertain patient, carer, family and staff views on community provision to nursing homes. They conducted 48 separate interviews and 4 focus groups with stakeholders associated with ten different types of care homes in our area. The report highlighted that continuity of care from GP practices and community teams was very important to those who gave their views, as was access to specialist care for those with complex needs. Proactive and coordinated care was highlighted as an important way to deliver care for patients with complex needs, as was access to training and mentorship for staff. This proposal has incorporated all the recommendations made in the engagement exercises. NHS LWCCG Patient Assurance Group: The PAG discussed the care homes work in November 2013 and reviewed the report from the initial engagement in February The PAG supported the fact that the engagement included carers and families and care homes staff and were concerned to find that these groups felt the care received by primary care could have been more coordinated and Page 6 of 17

7 proactive. They acknowledged that the direction of travel locally was supported by national recommendations. An update on progress and next steps will be provided to the PAG at the April 2015 meeting. Existing providers: Leeds Community Healthcare, LTHT and LYPFT have been kept up to date around the development of the process through the System Change Group of the Integrated Health and Social Care Transformation Programme. Representatives from LCH and LYPFT have also attended project group meetings. A community geriatrician and representative from adult social care are members of the task group. Depending on which recommendation is approved for development further detailed discussions will need to take place with LCH around varying their contract. Leeds North and Leeds South and East CCGs: Commissioners from the other Leeds CCGs have been kept up to date through the System Change Group and individual updates and meetings. Equality and Diversity analysis / impact considered in relation to communities protected by Equality Act 2010 Currently services are not equitable as they are not universally available to all patients. An equality impact assessment (EIA) has been completed in advance of the development of this proposal. No adverse actions have been identified in relation to the development of this work. No equality and diversity issues associated with protected groups have been highlighted as part of the engagement process so far. The EIA will be updated and reviewed as part of the project implementation and providers will be required to capture demographic data to provide ongoing monitoring to this work. Sustainability Impact assessment Detail the environmental impact of the service, * Improvements for social value a service adds * Innovation and new technologies * Planning and adapting to the effects of climate change A key principle of this proposal is integration of services that may currently be delivered separately, placing medical leadership at the heart of community based care. An outcome of integrating services is that economies of scale can be identified reducing duplication. This also increases the quality of care received by the patient. Additionally a key development associated with this proposal will be the technology detailed within the innovation workstream of the LWCCG primary care improvement strategy. More joined up and shared information and records will mean that care will be streamlined and the fact that patients will receive most of their care from one organisation will mean that resources are used more efficiently. It is also proposed to implement technology to enable e-consultation between primary care and care homes and acute providers. There is also a desire to develop telemedicine in our care homes. This is in operation elsewhere with successful outcomes. This would contribute to the sustainability of this proposal by decreasing the number of journeys needed to be made to provide care to this cohort of patients. Page 7 of 17

8 Finance Key investment requirements where and what type of investment/extra cost is required to deliver the changes required Financial modelling Option A Do nothing. This would require the re-apportionment of 500k nonrecurrent funding and 70k recurrent funding. Option B Enhanced GP led primary care (333k) + Pharmacy Support (103.4k) = 436.4k Option C Enhanced GP led primary care (333k) + Pharmacy Support (103.4k) + Expanded Integrated Neighbourhood Team (510k) = 946.4k Workings for costing Primary Care Enhancement Salaried GP cost per weekly session per year, factoring in complexity of care is 12,000. This would equate to 230 per GP session, or per hour. The clinical hours required per week to cover 1,500 patients, needing 3,000 reviews is 75 clinical hour per week. So 75 clinical hours per week would mean costs of; Week Year GP costs 4.2k 216k Supporting team costs 2.3k 117k Total Primary Care Enhancement 6.4k 333k For illustration purposes the GP led team would receive 220 per occupied bed per year Expert Pharmacy support The Medicine s Management team has suggested the Pharmacy staff required to support this scheme would be 1.8 WTE Band 8a Pharmacists. This would mean costs of; B8a Pharmacist on top of band + on costs is 57k. So 1.8 WTE s is 103.4k. (*Non-recurrent budget currently covering care home pharmacist contracts ends on 31 st July 2015). Page 8 of 17

9 Expanded Integrated Neighbourhood Team This would consist of the professionals below (costs including on costs and based on top of salary scale); 0.5 WTE Geriatrician 73k 1.0 WTE Occupational Therapist 49.5k 3.0 WTE Physiotherapist 148.5k 0.5 WTE Speech & Language Therapist 25k 3.0 WTE Community Matron 168k 1.0 WTE Dietician 34k 0.5 WTE Clerical 12k Total Cost Expanded Integrated Neighbourhood Team 510k Procurement Detail any procurement plans or considerations. What procurement options may apply? Advice has been sought from the procurement team at Yorkshire and Humber Commissioning Support Unit, the CCG Legal advisors and the cooperation and competition section of Monitor regarding the procurement of Services from Primary care providers. It is important to note that for the purposes of procurement a pilot must abide by the same laws and rules as a recurrent service. Criteria for not requiring full procurement includes: Provision of a GP registered list based service. In effect this means that the service can only be provided by the GP with whom the patient or service user is registered. It must be apparent that several options have been considered. The structure or location of a service is an important consideration- in this case within a Care home setting. Be clear on the rationale for why this needs to be a list based service-this is clear in this business case. The primary care enhancement element of the preferred option (option C) could be secured by asking for expressions of interest from member practices. The model is based around the principle of the GP registered list so therefore there are no procurement implications. The Expanded Integrated Neighbourhood Teams element of the preferred option (option C) could be secured by a contract variation to the existing contract of Leeds Community Healthcare, as it represents an extension to the services they already provide to the CCG. The additional financial value falls below 10% of the total NHS Leeds West contract with Leeds Community Healthcare Trust and is therefore not considered to be a material change to the remit and scope of the existing contract. An enhancement of the existing contract is therefore a reasonable and cost effective approach. This approach also supports the integration of services locally which is allowed for in the competition and procurement guidance and this is our preferred option. There could be an option to link this element of investment to the registered lists to enable Page 9 of 17

10 practices or localities of practices to purchase care appropriate for their populations. This would be pro rata according to care home population need identified in each locality. This would be in line with the direction of travel in the Leeds West Primary Care Strategy. The detail around this option would need to be further explored. There could be an option to consider a full procurement exercise. There are two reasons why this is not our preferred option;- 1. Time involved in full procurement would delay implementation 2. Increased complexity of integration by increasing numbers of providers making up the integrated neighbourhood teams The pharmacist element of the preferred model is already provided by the LWCCG Medicines Optimisation team and there are no procurement issues. Outcomes and Outputs Impact of Proposal Activity/ Service/ Quality benefits What reductions in relevant activity will the proposal have expressed as numbers of people / % of current activity levels?, what impacts on quality are expected? The primary outcomes in terms of reducing system cost will be reductions in emergency activity, in particular A&E attendances and unplanned admissions. For Leeds West care home patients CCG in there were: Approximately* 1820 A&E attendances = approx. 2% of LWCCG total (all ages) and approx.10% of LWCCG aged 65+ Approximately* 1111 non elective admissions = approx.4% of LWCCG total (all ages) and approx. 9% of LWCCG aged 65+ *This data has been provided by LTHT using validated postcode proxy data. The figures will include patients registered with GP practices outside of LWCCG but residing in a care home (both nursing and residential homes) within our geographical area. This data will also include people living in their own homes who have attended A&E or been admitted nonelectively and who happen to share the same postcode as a care home. Primary outcomes: Reduction in A&E attendances Reduction in number of unplanned admissions to hospital - Reduction in admissions for common infections e.g. chest/uti - Reduction in incidence of falls/fracture neck of femur - Reduction in admissions related to delirium/better understanding, recognition, treatment Secondary outcomes: Reduction in ADRs (adverse drug reactions) and regular reviews to reduce Page 10 of 17

11 medication side effects and interactions associated with polypharmacy Reduction in weight loss, improved nutrition, hydration proactive care Patients and families reporting improved experience of care Evaluation measures (please see evaluation section below for more detailed evaluation plans) Process measures 1. Proactive care planning multidisciplinary review led by a GP every 6 months, or more frequently if needed 2. Comprehensive assessment to establish care plan upon admission to care home overseen and agreed by the GP Lead started within 3 working days and completed within 6 weeks, including establishment of an advance care plan, and end of life care plan where appropriate 3. Same/next day review (or next working day) of those with immediate end of life careplanning needs, prescribing anticipatory medications when needed and palliative care input as appropriate 4. Scheduled visits by the GP led team, to include medication review in partnership with pharmacists, and development of patient-centred care goals in line with individual care plans 5. Care and medication review following discharge from all acute hospital admissions within 3 days 6. Regular collection of patient and family experience information explore alignment with the Friends and Family work, and to include an annual report Clinical outcome and patient safety measures CCG wide 1. Reduced number/rate of falls and fractures 2. Reduced number/rate of pressure sores 3. Increased uptake of immunisations 4. Reduced numbers/rate of ADRs 5. Increased numbers of people dying in preferred place of death, and improved recording of this 6. Reduced rate of occurrence of infections such as UTIs 7. Improvement in patient reported health and wellbeing measures 8. Improved nutritional status - diet / reduced supplement prescribing 9. Mobility assessment and outcomes System measures 1. Reduction in hospital admissions 2. Reduction in emergency ambulance use 3. Reduction in A/E attendances 4. Reduction in unscheduled GP home visits 5. Reduction in usage of GP out of hours services Metrics for modelling impact of proposals on reductions of relevant activity / cost This proposal will measure the following indicators which are associated with impact / reductions in activity and cost for other providers: Page 11 of 17

12 Reduction in avoidable emergency admissions Reduction in rate of hospital admissions for care that could have been provided in the community Reduction in delayed transfers of care Reduction in length of stay on medical and elderly wards The evidence around cost savings and impact on activity on other providers is not definitive from other local and national schemes and therefore cannot be assumed. However this scheme represents a comprehensive implementation of all the recommendations from the literature review and therefore a high level cost saving model has been included below for illustration. For Leeds West care home patients CCG in there were: Approximately* 1820 A&E attendances Approximately* 1111 non-elective admissions Assuming an average A&E attendance costs 100, total cost of these attendances is 182,000 If the scheme were to save 20% of A&E attendances as per evidence associated with some schemes this would translate into system savings of 36,400 Assuming an average non-elective costs 1000 total cost of these admissions is 1,111,000 If the scheme were to save 11% of admissions as per evidence associated with some schemes this would translate into system savings of 222,200 Based on a best case scenario it is possible that this scheme could save 250,000 of secondary care activity, however this may not be cash releasing. *This data has been provided by LTHT using validated postcode proxy data. The figures will include patients registered with GP practices outside of LWCCG but residing in a care home (both nursing and residential homes) within our geographical area. This data will also include people living in their own homes who have attended A&E or been admitted nonelectively and who happen to share the same postcode as a care home. ** The 20% A/E savings and 11% non-elective savings are taken from the Leeds South and East CCG care home scheme evaluation indicators (not yet validated)- see evidence document at appendix 2 Impact of Proposal Cost Benefits Where and how much cost would you expect to save from this proposal. eg based upon the reductions in activity levels assumed? Page 12 of 17

13 The local schemes were evaluated in using the best data available (see literature review at appendix 2). The data is unreliable, but appears to show little evidence that either of the schemes had any significant impact on emergency admissions or A&E attendances 2. Nationally, there is a mixed picture with some schemes reporting significant reductions in non-elective care and A&E admissions, others have inconclusive data or a failure to evidence reduced secondary care activity Cost saving through this scheme cannot be assumed through the evidence. Declarations of interest Please detail any declarations of interest in the development of this case The preferred option (option C) has been co-produced in the task and finish group with members who will ultimately be the providers of a key element of the model. However GPs will not be involved in the decision making around this business case in order to appropriately manage any conflicts of interest. Key Risks to success of the proposal include risks to other parts of the health and social care system Risk There is a risk that implementing this scheme will not realise reductions in system cost. This will result in the scheme not being able to be self-sustaining financially. Additionally the enhanced access scheme also aims to have an overall impact on system cost. There is a risk that it will not be possible to implement this service extension with existing providers as it may be contractually difficult to secure. This may lead to a full procurement for a new service being necessary. There is a risk that implementing this service will lead to health inequalities in Leeds as it will only be available to patients in nursing homes in Leeds West. Mitigation The scheme will be implemented on a non recurrent basis and staff recruited temporarily. Early evaluation will be carried out to assess impact and allow a decision to be made around future funding. We need to link the evaluation of both schemes to ensure we can identify which area is making the greatest impact. The contracting and commissioning route to securing this service extension which promotes integration is to be determined initially through conversations with partners, lead contractors, commissioners and stakeholders. Discuss plans with stakeholders including commissioners in other CCGs in Leeds to reduce the impact of health inequalities. Explore options around commissioning the scheme to the whole city. 2 Please note postcode proxy SUS data used Page 13 of 17

14 There is a risk that there is not the additional workforce available to extend this service to people in care homes. This could lead to a delay in implementation. There is a risk that existing providers may not wish to or may not be able to extend their services to include care home patients. This could lead to a delay in implementation. There are risks around some practices choosing not to engage with the scheme (particularly if they have low numbers of people in care homes), leading to inequitable provision within the CCG. There are risks around how the project is implemented with 7 day working The care home resident population are not a static population, with high numbers of new residents every year. There is a financial risk around providing non-recurrent funding if the service is not then implemented. Extending LCH contract to provide the service will offer resilience around workforce issues. 2 year funding supporting recruitment and full benefits realisation LCH have provided a high level workforce plan and planned approach to workforce planning for the scheme. This has been highlighted as a key area to address in the implementation plan see appendix 3 If it is not possible to implement this scheme through contractual routes a procurement will need to take place to secure a provider. Member practices choosing not to be part of a scheme will be required to include care home patients in their Case Management Registers. The scheme will operate over 7 days as routine general practice develops the enhanced access model. The model to be included in the investment workstream of the primary care development strategy to ensure that implications are monitored and that providers are supported to overcome any issues that arise. The business case has taken into account a potential rise in the care home population with a minimum/maximum of residents incorporated into the resource modelling Non-recurrent funding is regularly monitored throughout the year to ensure funding is appropriately used and if necessary re-apportioned. There is a financial risk of providers requiring more funding than initially given to maintain service. A contract will be in place to ensure financial stability and requests will have to follow necessary process and require approval. Page 14 of 17

15 Primary care has already received significant investment to improve access to services which for some practices has focused on the needs of care home patients and therefore there is the potential for duplication This service would represent an enhancement to the access scheme and requires practices to deliver a comprehensive service to care home patients. Each practice would need to review their requirements to ensure they meet the criteria for both schemes. If a practice is signed up to the care home scheme they would be required to release patients from other schemes that support proactive case management. This has been highlighted as a key area to address in the implementation plan see appendix 3 Mitigation against Risks What actions will be taken to reduce or mitigate those risks? Mitigation detailed in the risk table above. Options appraisal detail alternate options- impact of do nothing / alternative schemes considered Each element has been described and detailed above on pages 2 and 3. The options have been costed up separately in the finance section on page 8 and 9. Option A: Do nothing. This would require ceasing current care home services and reapportioning non-recurrent funding. Option B: Enhanced GP led primary care and pharmacy scheme Option C: Enhanced GP led primary care, pharmacy and expanded integrated neighbourhood team (recommended option) Benefits analysis table: Criteria Option A Option B Option C Equitable solution for all practices X Equitable solution for all care homes residents X More frequent proactive care planning for all care homes residents Medication reviews for all care homes residents Access to holistic multi-disciplinary specialist care X X X X Page 15 of 17

16 Workforce workforce requirements to deliver the proposal- highlight recruitment that would be requiredand consider in risk section, also role changes The preferred option (option C) requires some adaptability of the GP workforce, particularly if some GPs take on a clinical interest role in the care of older people. In addition, there will be an expansion of the Integrated Neighbourhood Teams workforce however this will tend to be an expansion of existing skills. It is proposed that this model is included in the investment workstream of the primary care development strategy to ensure that implications on workforce are monitored and that providers are supported to overcome any issues that arise. Evaluation plans evaluation of outcomes, outputs and risks- detail the criteria you will use A separate project work stream will be established to lead on evaluation of the scheme. Evaluation support has been built into the SLA with Yorkshire and Humber Commissioning Support Unit. Design and implementation will use robust methodology, using recognised validated measures to evaluate the impact of the scheme in meeting its objectives, by evidencing the locally defined scheme outcomes. The evaluation framework is based on a matrix approach of four themes including:- Clinical outcomes and process measures Economic outcomes Patient and carer experience Staff feasibility and acceptability Suitable sources of data collection for monitoring and evaluation purposes will be identified as part of the evaluation design, utilising routine data collection where possible, this will include:- GP practice monthly returns a template could be developed for this purpose Analysis of information in GP practice clinical systems (supported by the use of a suitable template) Secondary care information / impact on other services and providers from SUS and other sources of commissioning information Patient and/or carer reported outcomes and experiences Staff experiences As part of the evaluation design process, suitable measures will be defined and agreed by the evaluation group to evidence the service objectives. Data collection in primary care may need to be standardised through the use of an electronic template. It is advised that the following measures should be prioritised by the evaluation group: Process measures 1. Proactive care planning multidisciplinary review led by a GP every 6 months, or Page 16 of 17

17 more frequently if needed 2. Comprehensive assessment to establish care plan upon admission to care home overseen and agreed by the GP Lead started within 3 working days and completed within 6 weeks, including establishment of an advance care plan, and end of life care plan where appropriate 3. Same/next day review (or next working day) of those with immediate end of life care-planning needs, prescribing anticipatory medications when needed and palliative care input as appropriate 4. Scheduled visits by the GP led team, to include medication review in partnership with pharmacists, and development of patient-centred care goals in line with individual care plans 5. Care and medication review following discharge from all acute hospital admissions within 3 days 6. Regular collection of patient and family experience information explore alignment with the Friends and Family work, and to include an annual report Clinical outcome and patient safety measures CCG wide 1. Number/rate of falls and fractures 2. Number/rate of pressure sores 3. Uptake of immunisations 4. Numbers/rate of ADRs 5. Numbers of people dying in preferred place of death, and improved recording of this 6. Numbers/rate of infections such as UTIs 7. Mental health scores (using appropriate validated tools) 8. Improved nutritional status - diet / reduced supplement prescribing 9. Mobility assessment and outcomes 10. Patient reported health and wellbeing scores (using appropriate validated tools) System measures 1. Numbers of hospital admissions 2. Numbers of emergency ambulance use 3. Numbers of A/E attendances 4. Number of unscheduled GP home visits 5. Numbers of usage of GP out of hours services Exit Strategy For non-recurrent cases, give clear details of how and when the work will be completed, In line with the funding requested Non-recurrent funding is requested for a period of 2 years. Whilst the impact of the service will be assessed throughout the period the evaluation will be ongoing. Should it be required, an exit strategy will be developed for each practice / provider individually, as their needs may differ. This will be based upon their workforce profile and performance against required outcomes. Transitional support as part of an exit strategy will be considered. Page 17 of 17