Appendix A Integrated Care Co-Ordination Model Healthier Together Project Initiation Document
Contents 1. Purpose... 2 1.1 Key Deliverable... 2 1.2 Approach... 2 2. Introduction... 3 3. Programme Vision... 4 3.1 Our Joint Vision... 4 3.2 New Financial Flows... 5 3.3 Guiding Principles... 5 4. Scope... 5 4.1 Options Considered... 6 4.2 Agreed Scope... 6 4.3 Rationale for Agreed Scope... 7 4.4 Exclusions... 8 4.5 Phasing... 9 5. Process and Patient Outcomes & Quality... 9 5.1 Outcomes... 9 5.2 Quality, Safety and Patient Experience... 10 6. High level timeline... 10 7. Governance Arrangements... 11 7.1 Roles and responsibilities... 12 7.2 Reporting... 13 7.3 Additional Programme Resource Requirements... 14 8. High level communication plan... 14 8.1 Public and patient engagement... 15 8.2 Engagement with our Partner & Provider Organisations... 15 9. Risk and Issue Management... 15 10. Interfaces and Dependencies... 17 11. Constraints and assumptions... 17 1
1. Purpose The purpose of this PID is to: Set out the proposed high level aims, deliverables, timescales and work streams required to successfully deliver the programme objective Act as a contract of delivery between the Programme Manager and Programme Sponsors (both from NHS Castle Point & Rochford Clinical Commissioning Group and Essex County Council) Act as a point of reference in evaluating the success of the programme on completion 1.1 Key Deliverable The key deliverable for the programme will be the production of a business case outlining the proposed service model to deliver co-ordinated, integrated care for the population of Castle Point and Rochford, by March 2016. This timeframe will allow for sponsors to secure project funding for the delivery phase of the project scheduled to commence on 1 April 2016.. 1.2 Approach The Project Initiation Document (PID) describes the creation of an integrated model of care in five phases of work. Phase One: Business Case and Formal Decisions (Sep 2015- Mar 2016) Phase Two: Evaluation and further development of Care Co-ordination pilot (Sep 2015 Mar 2017) Phase Three: Procurement (if required) of the new service model (Apr 2016 April 2017) Phase Four: First Stage Implementation (Frail & Older People) (April 2017) Phase Five: Second Stage Implementation (All adults) (TBC) Further developments: Consideration of whether an additional model may be required for children (TBC but planned to be progressed concurrently with the Adults model) Whilst it is proposed that integration principles and assumptions will be shared across CCGS, Castle Point and Rochford will be designing a model of care for the agreed population, taking a bottom up approach and building upon the existing care co-ordination pilot. 2
Phase one of the programme culminates in a Business Case for the approval of all partners. This is intended to describe the vision of a single system of governance for integrated health and social care in Castle Point and Rochford for a specified range of services and cohort of the population. It will include the care model, financial and commissioning arrangements and the supporting implementation strategy. It is proposed that a proportionate programme management approach is taken to ensure that the programme is monitored and governed effectively. This includes establishing a programme board and several work stream groups to oversee the delivery of programme objectives. Both Castle Point and Rochford Clinical Commissioning Group and Essex County Council will be represented at all levels of the programme, with representation from other partner organisations including providers as required. It is the intention to have maximum input from the incumbent providers, particularly the frontline staff, to test models of care being developed. However, it is essential to ensure that all conflicts of interest are managed particularly when the project enters the procurement phase. Patient, public, staff and stakeholder involvement is essential to ensure that services are designed around the needs of patients and service users, and will be a key feature of the programme throughout. 2. Introduction The Five Year Forward View calls for a more radical focus on integration and an expansion and strengthening of primary and out of hospital care models. Lessons from international experience shows us that the success of care models is dependent on a number of enabling factors including capitated budgets, long term contracts, flexible employment and workforce models as well as the ability to attract investment. Both the CCG and ECC manage multiple provider contracts which are process based and currently not driven enough by patient outcomes. In addition, there is little to no incentive for providers to focus on outcomes and no single payment mechanism to support consistent provision and performance. Additionally there is little commercial incentive for primary care and community providers to care for vulnerable and complex people in their own home avoiding both non elective and planned hospital based care. The Five Year Forward View sets a challenge to develop new service models that will offer integrated care across the whole patient pathway with a focus on caring for people outside of hospital. 3
This PID has been developed in partnership by executives from Castle Point and Rochford Clinical Commissioning Group and Essex County Council, in response to the Integration paper presented to the Governing Body in July 2015 which outlined the need to change the way we work and to consider different financial models that will support integrated working. 3. Programme Vision 3.1 Our Joint Vision Our joint vision is to create a healthier and more sustainable future for people in Castle Point and Rochford through commissioning high quality care in the most appropriate place at the optimal time. We hope that we will see a shift from many people being acutely unwell and requiring complex care in hospital settings, to more people taking responsibility for their own health and wellbeing, with more care being delivered in the community and closer to patients homes. Our Joint Vision The initial focus to develop integrated care models in our health economy is care for frail and older people as this is where integrated models will deliver the maximum benefit both in patient outcomes and in financial sustainability. We want to deliver integrated co-ordinated care for frail, older people, or those with complex needs. This could include a key worker, risk stratification, care co-ordination, care plan, case management, escalation processes and support for prevention and health/wellbeing. 4
3.2 New Financial Flows A move to integrated care delivery models will require radical changes to the way we fund care. We are already procuring a capitated model of care for diabetes, and developing a care-co-ordination service for frail and elderly people. Neighbouring CCGs are working on developing capitated models with Essex County Council for frail and older people, and in addition a range of different models are being tested by pilot Vanguard sites. All of these will contribute to our work on developing appropriate funding and contracting methods for the integrated, co-ordinated care model. 3.3 Guiding Principles Shared value and goals such that all participants are committed to delivering high quality, affordable care to patients Patient centred and population health focus that includes patients in healthcare decisionmaking and resources directed at improving healthcare in the population or community Coordination of care and sharing of information across providers Care provided at the right time and in the right place i.e. care being closer to home Financial incentives aligned with delivering high quality, affordable care and prevention among providers with a clear aim to keep people fit and healthy outside of hospital Deploying evidence-based best practices to minimise quality shortfalls and variations in care Accessible and shared electronic medical records among providers to enable tracking each patient through the provision of care, performance review, and status of health problems across provider panels Workforce fit for the future professional, flexible and integrated Continuous innovation and learning to improve value 4. Scope Our population can be split into 9 broad categories, shown below, considering age and complexity of care need. Whilst we recognise that not everybody will fit neatly into one of these categories it is helpful to consider our scope in this way. 5
Population Categories 4.1 Options Considered As part of the development of this PID the executive leads from CPR CCG and ECC have considered which of our population should be included in the new model of care with different funding arrangements. The following options were considered: 1. Older people, over 65 including those healthy, moderate and complex care needs 2. All adults everyone over 18, with all levels of care need 3. People with complex needs those who are frail, including children and young people 4. Adults with complex and moderate needs 5. All of the population, including children and young people 4.2 Agreed Scope After consideration of the above options and conversations with GP members over a period of time it was has been agreed that the ultimate scope of this work will be all adults including those who are healthy, have moderate needs and those who are frail with complex needs although it is recognised that there will need to be a phased approach to deliver this model. 6
Agreed Scope for the Business Case & Options Appraisal All Adults 4.3 Rationale for Agreed Scope In order to facilitate true integration and offer improved, joined up, services for our patients, we will need to radically change the way we fund commission care. The executive team felt that, in the longer term, a broad scope would offer greatest opportunities to pool budgets and benefit from economies of scale, incentivise health promotion and prevention, ensure our limited skilled workforce is used effectively across a wider pool of patients, as well as ensure that our most vulnerable people receive the care they need. Including healthy and those with moderate needs with a capitation funding model incentivises providers to promote health, wellbeing and independence Including all adults in this model offers a large budgetary pool to draw on when considering a capitated model of funding. It was felt that children and young people had very specific needs, whereas the range of care required by adults has similarities, whether they are of working age or over 65. Additionally both health and social care services are currently typically delivered differentiating between children and adults. 7
This avoids multiple providers delivering services to cohorts of patients where overlap and transfers between providers would add significant complication in the service modelling to ensure a seamless service to the patient. Skilled workforce is recognised as a key constraint, this model ensures that all workforce can be used across a wide pool of patients. The detailed work around service lines, to include Public Health, and their application to the model will be undertaken by clinical teams as part of development of the business case. 4.4 Exclusions The executive team have agreed that specialist inpatient care will be excluded from the scope of this work. For example: it has been suggested that major surgery, acute inpatient mental health services, acute learning disability services may not be included in this model, however the exact scope will be agreed by the clinical working group. It is essential that services that are included work seamlessly with the excluded service and interfaces are clearly defined as well as ensuring commercially gamin is mitigated. Scope of the Work CPR is part of an Essex-wide review of learning disability services that includes both health and social care commissioners. The decision has been made not to include specific learning disability services within this work to ensure that people with learning disabilities benefit from the improvements that will be proposed as part of the review. People with learning disabilities will continue to access health services within scope, and for those services LD will be included. 8
4.5 Phasing The current scope for the care co-ordination pilot is the frail and elderly people, (shown in the top right hand corner category), and this cohort will form the basis for the first phase of implementation, along with older people with moderate or few health and care needs. Additionally, there may be service specific cohorts of patients, such as mental health or all those with a respiratory condition, that may be singled out for separate phasing. A care co-ordination service is already operational and it is planned that this becomes the baseline service to build the new model of care. During 2016/17 services can be added to the scope of the specification and evaluated before a permanent contract is due to commence in April 2017. The decision on how the permanent contract is awarded will need to be made by the sponsor organisations by February 2016 to allow sufficient time if a contested procurement is deemed to be the most appropriate process to follow. Over time consideration will be given to whether a similar model may be established to focus on children and young people, and their individual health and care needs. 5. Process and Patient Outcomes & Quality 5.1 Outcomes It is proposed that the clinical teams working on developing the content of the business case formulate a clear outcomes framework for the programme that will include quality, patient experience, efficiency measures and incentives to keep patients out of hospital. We have been working in partnership to deliver the Better Care Fund (BCF) within which a range of process and patient objectives/outcomes have been agreed. The BCF outcomes along with a range of national targets and standards that we are committed to delivering, (such as the NHS Outcomes Framework and the Adult Social Care Outcomes Framework), will form a basis for consideration. The clinical work stream will support the development of detailed outcomes as part of their deliverables and these will seek to incentivise prevention and self-care agenda as well as support care for frail and elderly people. 9
5.2 Quality, Safety and Patient Experience Improving and protecting quality, safety and patient experience are fundamental to our vision, as set out in the CCG s Quality, Safety and Patient Experience Strategy, which will be a key document used by the Clinical Design work stream when assessing the viable integration models. This also sets out the required assurance processes around quality, patient safety and patient experience. 6. High level timeline A high level timeline has been prepared for the development of the business case, and associated patient, public, staff and stakeholder engagement processes. At this stage it is anticipated that there will not be a need for a formal public consultation process, but that ongoing thorough public engagement throughout the development of the service model will allow a high level of public and patient input to the work. This is described later in this PID. High Level Timeline Task Documentation Timeline Sign-off (TBC) 1 Agree joint working principles and PID 10 th Sept 2015 - CEC 24 th Sept 2015 - Partnership Board governance arrangement Partnership Board 24 th Sept 2015 CCG Governing Body Governing Body PCMG 2 Formal public and stakeholder engagement on case for change, vision & outline thoughts on scope 3 Clinical Model High level HNA Services required in the model Desired outcomes and metrics 4 Payment mechanisms (to include risk/gain share) Link to countywide capitation work stream/methodology (Sept-end of Oct) CPR modelling Costs and Benefits Engagement document Easy read Languages? Engagement report Clinical Model Paper Output from FTI / modelling work stream Start October 2015, run for 4 weeks in focussed way Ongoing patient, public, stakeholder and staff engagement throughout By mid- November Clinical working group CEC / TSC Start October 2015, complete by 31 st December Public and stakeholder meetings CEC / TSC Workshop 10
5 Present : Business Case for Approval 6. Formal Consultation: Material Preparation Consultation period Feedback Analysis 7. Initiation of change processes: Procurement? Contracting processes Market engagement Business Case By the end of March Governing Body Cabinet TBC Business Case Specification March Apr-May June July Procurement Group High Level Service Delivery Timeline Activity Timeline Care co-ordination pilot and evaluation Sep 2015-Mar 2016 Enhanced Care co-ordination pilot and evaluation Mainstream Service (5+2 year contract) Apr 2016-Mar 2017 Apr 2017 onwards Phasing of additional cohorts Apr 2017 Mar 2019 Full service operational Apr 2019 7. Governance Arrangements It is proposed that the following governance structure be put in place to manage the ongoing deliverables and oversee progress. It is likely that there will be sub-groups formed as part of the workstreams. 11
CCG Governance ECC Governance Partnership Board Part II Programme Board Transformation Director TBC CCG/Saba Gondal ECC Project Manager Amanda Swift ECC Clinical Design Workstream Tricia D Orsi/Mousumi Basu Population Needs Workstream Danny Showell Finance & Commercial Workstream Margaret Hathaway/Bev Winter Workforce & OD Workstream Ann Finn ECC/CCG? Communication & Engagement Clare Routh/ECC TBC Sami Ozturk Yvonne Campen Kevin McKenny Provider Reps GPs TBC PH Analyst Performance Analyst ECC/CCG Health Economist Andrew Nightingale ECC Viv Molulu CCG Kevin Edwards Attain Steve Ede ECCC CCG Rep Proivder Reps Harvey Panrucker ECC Band 6 Vacancy CCG Jessica Baldwin ECC Tina Starling ECC Enablers: IS/IG/Estates Will Gilmour/Paul Cook ECC -?CCG 7.1 Roles and responsibilities Name Role Responsibilities Key Deliverables Kevin McKenny CCG /Helen Taylor ECC Project Sponsors Setting the project vision, chairing the Programme Board TBC CCG/Saba Gondal ECC Programme Directors Responsible for providing strategic direction and ensuring the project aligns to the overarching integrated commissioning approach Amanda Swift Project Manager Responsible for managing the project and ensuring it is delivered on time and on budget 12
Work stream Lead Workforce & OD Work stream Lead Population Health Management Work stream Lead Finance & Commercial Work stream Lead Clinical Design Work stream Lead Communication & Engagement Responsible for delivery of the Workforce & OD work stream Responsible for delivery of the Population Health work stream Responsible for delivery of the Finance & Commercial work stream Responsible for delivery of the Clinical Design work stream Responsible for delivery of the Communication & Engagement work stream Workforce strategy Workforce plan Local health needs assessment Gap Analysis for identified cohort Capitation model risk/share mechanisms Contracting and commissioning models Costs and Benefits Research emerging best practice MCP/PACS, other Clinical model design Commissioning Outcomes Framework Communication Strategy Joint Engagement Campaign Joint Consultation (internal & external Regular communications to wider stakeholder group to include GP members/practices 7.2 Reporting Regular reporting will be via a monthly highlight report and will be produced by the Project Manager and show actual and projected progress against plan. The report will be submitted to the Programme Board. A project plan will be created which will form the basis of the monitoring process. This will be updated by the Project Manager as the project progresses and referenced by the highlight reports. 13
7.3 Additional Programme Resource Requirements Role Duration Costs Programme Director CCG 3 days per week until 31/03/16 Tbc Communications & Engagement Officer Band 6 CCG Business Intelligence Analyst/Health Economist Full time for 12-18 months (potential for shared post within CCG) Sept/Oct - Dec Tbc Tbc Clinical Time X Sessions Tbc 8. High level communication plan A communication strategy will be developed by the Communications & Engagement work stream lead. Below are the key stakeholders and an outline of the approach to be taken: Stakeholders Role/Interest Involvement/engagement approach CCG Committee and Board Members, LCG and member practices To develop model, approve business case. Discussions scheduled at relevant meetings during September, November, January and March ECC PCMG, Outcomes Board & Cabinet To develop model, approve business case Discussions at PCMGs, Outcomes and Cabinet April 2016 tbc Clinicians and other staff within existing commissioned providers Members of the public in Castle Point & Rochford The market for the provision of health and care services As providers of the service they will be able to contribute to service model and add ideas, they will also need to work in new ways as part of the implementation of the new service model Have a direct interest in any changes to current configuration of NHS services and what this may mean for them. Must be involved in development of proposal, full business case and end model. Any proposals should be commercially attractive to encourage innovation and a wide range of potential bidders to any potential procurement. System engagement event to be held in October to inform full business case. Ongoing engagement throughout. Engagement events in October and throughout the programme System engagement event in date tbc 14
Stakeholders Role/Interest Involvement/engagement approach NHS England NHS England would be interested in any final service reconfiguration proposals, and dependent on final solution may require further involvement (e.g. cocommissioning of primary or specialist care). Brief NHS England on approach through existing regular meetings. Media / Press Potential for any procurement to have a significant value which may attract press coverage. Media relations strategy to be developed. 8.1 Public and patient engagement Patient and public engagement will play a key role in the development of a new service models so we can ensure the new ideas will genuinely meet the needs of our population and enhance quality, safety and patient experience. We have started the public communications and engagement process, and are committed to working with patients, carers and service users to develop our plans. 8.2 Engagement with our Partner & Provider Organisations We have already worked with partner organisations in a range of service developments, and are committed to working with them for this new venture, however it is anticipated that the new service model will have a big impact on our current health and care landscape. We are keen to offer local providers the opportunity to work with us to transform care consider how we can deliver care in innovative and transformational ways to reduce pressure on acute services and offer more care in community settings. 9. Risk and Issue Management The CCG corporate risk register and process will be used to manage risks associated with the programme. However in the development of this PID the following high level risks and issues have been identified: 15
No. Issue Description Impact (1-5) Probability (1-5) Mitigation RAG 1 Lack of dedicated CCG resource to undertake a large change programme which could result in delays in meeting the key milestones 4 4 1. Existing staff - senior managers to ensure this is seen as priority work. 2. New Resources - funding to be confirmed and appointments made as a matter of urgency. 2 No ECC funding beyond March 2016 which will result in lack of any programme management to support delivery 5 4 Imperative that the timeline is achieved. Resources for implementation are requested within the full business case. Linked to Issue 1 availability of required resources 3 ECC agreed capitation cohort is 65+, CPR s cohort will include adults 18+ identified as at risk. 3 3 Countywide workstream aware of this issue and will be working with FTI to seek a solution. No. 1 2 Risk Description Providers not wanting to invest now for future benefits creating a high level of financial and commercial risk within contracts. Incumbent providers not willing to change behaviours/do not have the level of maturity needed to meet our ambition Impact (1-5) Probability (1-5) 4 4 4 4 Mitigation Commence market engagement with providers once the Business Case has been approved Build in sufficient market engagement into the programme timeline. Work with Attain to establish key dates RAG 3 No clear model for determining system benefits which will undermine the business case. 3 3 Potential to build upon the methodology used by BB in the absence of any other agreed model. 16
10. Interfaces and Dependencies There are a number of interfaces and interdependencies for us to manage: Our own care co-ordination project can be used as a fore-runner for the wider integrated coordinated care model, as can the capitation work on the diabetes model of care. We need West Essex CCG and Basildon & Brentwood CCG are also working on similar integration programmes, some of the financial modelling work will be interdependent with ours, and we may need to align timescales and outputs with that work to benefit from the economies of scale offered through joint working on the capitation modelling work The CCG transformation programme is developing new models of care including an integrated Care Co-ordination project. These will have bearing on the development of new models of care, and need to be aligned The ECC integration programme may have complimentary projects that will need to be aligned such as the learning disabilities and mental health countywide service reviews. 11. Constraints and assumptions There is an expectation that full business case will be submitted to the ECC Cabinet within the financial year, and this fits with our planned timescales. 17