Slough CCG. February Developing a Complex Care Case Management Service within Primary Care. Sangeeta Saran Head of Operations, Slough CCG

Transcription

1 Slugh CCG Develping a Cmplex Care Case Management Service within Primary Care Sangeeta Saran Head f Operatins, Slugh CCG Alan Thmpsn Senir Cnsultant, Jhns Hpkins Healthcare Ricky Chana Prject Manager Slugh CCG February 2016 Right Care Casebk Series

2 The setting NHS Slugh CCG is respnsible fr cmmissining health services fr its ppulatin f apprximately 150,000 acrss its 16 GP practices. The CCG has had access t the Jhns Hpkins Adjusted Clinical Grups (ACG ) System 1 fr 3 years and had been using it mainly t identify the tp 2% f individuals mst at risk f an unscheduled admissin. The situatin r prblem The CCG and lcal GPs wanted t imprve their understanding f what factrs are the key drivers f cst and hspital activity. Analysis f the Slugh CCG patient ppulatin demnstrated that 5% (7,500) f peple cnsume 43% f healthcare resurces. In an attempt t realise cst savings and imprve quality f service, effrts were made t target thse at higher risk f an emergency admissin r A&E attendance. What actin was taken? Where t Lk Utilisatin f the ACG System within the ppulatin f Slugh CCG demnstrated that there was a clear relatinship between multi-mrbidity and cst. Peple assciated with the highest csts were thse with 7 r mre chrnic cnditins, with csts cnsistently high in pharmacy, unscheduled attendances and admissins (Figure 1). Althugh there is a relatinship between number f c-mrbidities and age, nt all ld peple have multiple chrnic cnditins. Multi-mrbidity als ccurs acrss the whle f the adult ppulatin, particularly in the year lds. Figure 1. 1 Starfield B, Kinder K. (2011) Multi-mrbidity and its measurement. Health Plicy 103:3-8. Right Care Casebk Series 1

3 What t Change Clinicians analysed the prbability f emergency admissin assciated with single chrnic cnditins and als with 2 c-mrbidities (cngestive heart failure (CHF) with chrnic renal failure (CRF) and CHF with chrnic bstructive pulmnary disease (COPD)t understand what cnditins have the mst significant impact n future risk,. Patients with either f these cmrbidities had a much higher risk f emergency admissin than thse with any single chrnic cnditin. Analysis t assess cmmnality in different risk grups shwed that thse at high risk f emergency admissin were nt always the same ppulatin as thse at risk f high cst: 40% f high-cst patients did nt have an emergency admissin There was nly a small verlap between thse at high risk f emergency admissin, thse at risk f high csts and thse flagged as frail elderly These analyses suggested significant pprtunities fr delivering clinically effective and value fr mney services when the patient ppulatin is stratified accrding t c-mrbidities. The stratificatin further illustrated and quantified that sme GP practices have a sicker ppulatin than thers. Hw t Change Lcal GPs discvered that multi-mrbidity is the nrm and that chrnic cnditins rarely exist in islatin. The GPs agreed they culd make a difference within the primary care setting fr a chrt f peple; multi-mrbid patients with a base disease that was unstable in nature and prne t exacerbatin. Each member f this chrt had ne f fur cmbinatins f disease: CHF and CRF CHF and COPD Diabetes, CHF and CRF Diabetes, Ischaemic heart disease and CRF Clinicians in Slugh GP practices reviewed the case ntes f 750 individuals within this chrt. Baseline data was gathered prir t the implementatin f the changes (fr a 12 mnth perid), including primary care, secndary care and pharmacy csts. 172 individuals were receiving acute secndary care interventins at the start f the service change and were therefre excluded frm the study until their cnditin had stabilised. What happened as a result? The remaining 578 patients were selected t receive a primary care based Cmplex Care Case Management Service (CCCMS). Each patient had an initial GP review fllwed by a series f appintments every 3 weeks. These are aimed at designing, with the patients, individual care plans and practively managing patients needs in a hlistic way, including educatin f the Right Care Casebk Series 2

4 patient and their carer(s), imprving the crdinatin f care prvided by health and scial care prfessinals, and by the invlvement f the 3rd sectr. The CCMS was launched in Octber 2015, and all 16 GP practices within Slugh CCG are engaged in its delivery. Prgress is mnitred t ensure that the service is being delivered as cmmissined, and data relating t perfrmance and utcmes, including patient feedback, are gathered t identify and share best practice. One mnth after launching the service, initial utcmes demnstrated that there was: 24% reductin in A&E activity in Nvember 2015 cmpared with the same mnth in 2014 (47 attendances cmpared with 62) (Figure 2). 17% reductin in nn-elective admissins (38 cmpared with 46) (Figure 3) Figure 2. Right Care Casebk Series 3

5 Figure 3. Next Steps Cases will be referred t, and reviewed by, the multidisciplinary Primary Care Integrated Care Teams (PCICTs) which were set up 2 years ag and which will be redesigned t accmmdate the CCCMS Further analysis will be undertaken by clinicians t identify additinal chrts that will benefit frm this apprach Additinal chrts may be identified frm thse at mderate risk f emergency admissins in rder t develp a mre practive apprach t the delivery f a quality and value fr mney service Qualitative data will be gathered frm the patients ver a 12 mnth perid t determine the benefits derived frm the CCMS in terms f self-management f the medical and psychlgical aspects f their cnditins and their satisfactin with the CCMS Right Care Casebk Series 4

6 Quantitative data will be gathered t measure the ttal financial benefits f this apprach t caring fr this chrt f patients What was the learning as a result f this experience? Risk stratificatin within the tp 2% f peple mst at risk f an emergency admissin is a useful tl t understand likely care needs and ptential interventins t prevent avidable emergency admissins but this shuld nly be a starting pint. Further analysis f the tp 5% f the ppulatin needs t be carried ut and a further stratificatin f this ppulatin needs t take place t identify clinically similar chrts f peple wh require different types f interventin t reduce csts and imprve the quality f their lives Clinical engagement and leadership was essential t identify new mdels f care within the primary care setting CCG leadership ensured that the benefits aligned t the CCG Cmmissining Intentins and that capacity and resurces were made available within primary care Right care methdlgy wrks and is transferable Significant resurces can be released Using the Right care tls, Atlas & Cmmissining fr Value packs helps t create the narrative fr all stakehlders t imprve the health f the ppulatin, nt nly thse patients knwn t the service The Atlas f variatin has highlighted anther pprtunity within the CCG ppulatin t undertake a similar risk assessment and thus transfer the learning frm this case study t ther patient chrts Right Care Resurce Centre Right Care has a resurce centre where CCGs can find supprting materials describing the Cmmissining fr Value apprach: Online learning vides Atlases, Spend and Outcme Tls Cmmissining fr Value tls Casebks shwing learning frm early adpters Essential reading lists and glssary Right Care Casebk Series 5