How To Improve Health Care In West Seussex

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1 Specification for a Locally Enhanced Service (LES) Predictive Analytics ( Helping you to stay Healthy Initiative) Introduction As part of the Helping you to stay Healthy initiative, the PCT has contracted to provide a risk-stratification model to assist primary care in identifying those patients at risk of hospital admission within the next year. The model will draw on data extracted initially from primary and secondary care sources although it is anticipated that, in time, other data sources can be included within this. By way of applying weighted scores to a minimum data set (based on the Combined Predictive Model initially, but ultimately moving to a bespoke West Sussex model) practices will receive details of their patients ranked in order of risk. It is recognised that for the top ½% of patients identified the work is likely to be limited to printing off and passing on of lists to established teams, such as Unique Care when they are available. The primary purpose of predictive analytics is to seek to identify and make interventions for the next 19.5% of the pyramid. The purpose of this LES is to ensure that GP practices are appropriately incentivised to participate in this initiative during the lifetime of the contract (2 years). Background The PBC Localities of West Sussex and the PCTs provider arm West Sussex Health have set at the heart of its services the objective of providing a 21 st Century model of care for those with specific or multiple chronic disease that is personalised, needs-led and integrated with all local services. Patients will become better at self-management of their conditions and service providers (GPs, Community staff within Virtual Wards etc) will become more proactive in promoting well-being and tackling inequalities.

2 The strategic framework A Breath of Fresh Air 1 ( makes several references to self-care and self-management and describes a bespoke virtual ward model (an iteration of the Croydon PCT model) which will provide advanced levels of care set around groups of GP practices within PBC localities. This model aims to fully integrate health and social care services into multi-professional teams. The self-care/self-management agenda has already received endorsement from the patients as recognised in Our Health, Our Care, Our Say ( review where patients clearly expressed a desire for: Help in making healthy choices For local surgeries to provide more support to help them manage their own health and well being To be able to maintain their own independence and feel part of society a theme that has been picked up by Lord Ara Darzi in his review of the NHS. The Long Term Conditions Clinical Pathway Group (LTC CPG), led by West Sussex PCT, identified patient education as a key driver to change in a patient s well being, habits and approach to their conditions. This has now been endorsed in the NHS South East Coast s vision Healthier People, Excellent Care. ( In addition to this, the PCT must achieve financial balance and integral to this is managing demand, particularly for those patients with long term conditions. This viewpoint was articulated in the Wanless Report where it stated that for sustainable reform and financial balance patients must become fully engaged in their own healthcare. Evidence available suggests that people with long term conditions are far more likely to access Emergency Care Services than other members of the population, thereby exacerbating health inequalities. The key element in preventing unplanned use of services is to identify those patients who are most likely to experience a deterioration in their condition. GPs can generally identify their cohort of patients who are reluctant to use services, find medicines concordance difficult and are frequent users of emergency or out-of-hours services. 1 This document was finalised by the PCT Board on 16 July 2007

3 However, to be proactive it is necessary to predict those at future risk and West Sussex PCT are seeking a contractor to use as a minimum - the NHS Combined Predictive Model available through the King s Fund ( ) to score patients at risk of next-year hospital admission. This model uses a combination of primary, secondary care and other data in order to produce the next-year risk of hospitalisation for each eligible patient, over the age of 18 years. Data Extraction Each practice will be visited by the Health Intelligence service delivery team in order to discuss the sign up document. Once the practice has signed up to the documentation Health Intelligence will then initiate the data export. There are three potential methods of supporting the export of patient data from Practice Clinical Systems in support of the CDRIntell service: MIQUEST (manual exports, with data transferred over N3) this method may be used in the last resort to support of the investigation of an individual practice s data export problems only) SQL (automated daily exports over N3) xml (automated daily exports over N3). The CDRIntell service may make use of any of these methods. The clear advantage of the SQL and xml approach is that it is more efficient, reliable and secure. Data is transferred in a secure and encrypted format over N3. No changes will be made to the GP Practice Clinical System, however software will be added to the server or a PC selected by the practice to initiate the data export process. The server or PC selected needs to be left on each night. The practice should log out but keep the PC switched on. The data is then exported at a time agreed by the Practice. It can be run at the same time as other programs, with the exception of the system backup. The data will be automatically exported and sent to the CDRIntell system which is located within Health Intelligence s secure offices which are connected to N3. Service Outline The following details the commitment required by the Practice in order for it to qualify for the payment made under this LES. Payable against the total practice population over 18 years of age excluding those who have opted-out

4 Commitment to sign up to providing patient data, as appropriate, securely in a manner to be determined and agreed with the LMC, to the company contracted to run the Predictive Analytics Model ( the provider ) and to work with the Provider as data extraction methodology is established. To work with the PCT and Provider to inform patients of the initiative, to respond to patient queries both face-to-face and using pre-printed material as supplied by the PCT and/or Provider. To record and READ-code as appropriate those patients that have expressed the wish to opt out of the initiative. To receive data from the Provider on a monthly basis. To check the data on arrival for deaths and changes of address. To extract the top risk patients (1/2%) and to pass this list on to the Community Matron team as appropriate. To have achieved IM&T paper-light accreditation by 30 th September Costs A one-off retainer payment of 500 per practice. An additional payment of 10p per patient on the practice register over the age of 18 that has not opted-out at the time of claim. Practices will be required to complete and submit the attached form in order to receive payment. Exclusions This LES excludes children under the age of 18 years old. Future Developments A further LES will be established for those practices that are actively intervening with the cohort of patients deemed to be in the top 19.5% at risk of hospital admission ie those requiring disease management. It is anticipated that practices will be in a position to sign up for both LES within the 2009/10 financial year. In 2010/11 practices would be expected to continue to work with data provided but to develop and subsequently offer an enhanced range of services and interventions for the identified cohort of patients..

5 Application GP Provider Application for Locally Enhanced Scheme 08/09 Predictive Analytics 2009/2010 Practice Name: How will you meet the aims of the scheme? Briefly describe the service to be provided and facilities available. Will providing this service adversely affect the practice s ability to provide essential or additional services? Who will be providing the service? Do you have evidence of appropriate staff qualifications, if appropriate? How will you monitor and audit service provision (refer to any requirements within the scheme). Please outline any other details relevant to your ability to provide this service Cost 500 retainer, plus 10p per patient over 18 years, minus those who have opted-out x 10p Practice declaration: The practice has understood the terms of the scheme and is seeking to provide a service on this basis. If commissioned the practice will adhere to the terms of the scheme and provide the monitoring/audit information within the timeframe given above. N.B This form must be completed in full for your application to be accepted and will be used as part of the monitoring information for the scheme. `

6 Breach Breach of conditions of this contract will be referred to the Enhanced Services Commissioning Group. Signed on behalf of Practice. Name of Practice GP Name (Print).. Date... GP Signature... Signed on behalf of PCT.. Pat Radley Head of Primary Care Contracting Date

7 Specification for a Locally Enhanced Service (LES) Predictive Analytics ( Helping you to stay Healthy Initiative) CLAIM FORM Total number of patients in practice over 18 years of age [Insert Number] Total number of patients in practice [Insert Number] that have opted-out at the time of claim submission Amount Claimed: [Insert ] (Practice Population over 18 years, minus those who have opted-out x 10p) Retainer Payment 500 TOTAL CLAIMED Declaration: The Practice has achieved paper-light accreditation as defined Practice Name: Name of Claimant: Signature of Claimant: BLOCK CAPITALS PLEASE Date: Please send completed claim forms to: Tina Wilmer, Acting Programme Director, Unscheduled Care & Long Term Conditions c/o Lorraine Burgess, Programme Administrator, West Sussex PCT, 1 The Causeway, Goring-by-Sea, Worthing, BN12 6BT