PROJECT INITIATION DOCUMENT - NHS Croydon CCG body/Governing Boday...Page 1 of 30 Attachment C2...

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Attachment C2

DRAFT PROJECT INITIATION DOCUMENT

Management of Care for People with Long Term Conditions Based on a Platform of

Tranformational Integrated Care

Working draft :

Document Version: V5 : Working Draft

Date: 20th November 2012

Review:

Author: Philippa Robinson

Approval:

Croydon CCG Risk Stratification Roll Out Project v 0.1

DOCUMENT CONTROL Draft Version Control

Version Date Detail Author Approval

0.1 12th June 2012 Initial working draft Monica Duncan

0.2 18th June 2012 Working draft Monica Duncan

0.3 28th June 2012 Working Draft Monica Duncan

0.4 07th November 2012 Working Draft Philippa Robinson

0.5 20th November 2012 Working Draft Philippa Robinson

Distribution

Name Role Organisation

Approval This document has been approved by: -------------------------------------------------- Designation Date:_____________

Croydon CCG Risk Stratification Roll Out Project v 0.1

Table of Contents

1. Purpose ............................................................................................................ 1 2. Background ..................................................................................................... 3 3. Project Definition ........................................................................................... 18

3.1 Objectives ................................................................................................ 18 3.2 Scope and Exclusions .............................................................................. 19 3.3 Deliverables ............................................................................................. 19 3.4 Constraints .............................................................................................. 19 3.5 Assumptions ............................................................................................ 20 3.6 Dependencies .......................................................................................... 20 3.8 Critical Success Factors........................................................................... 21

Stakeholder Success Criteria ....................................................................... 21 Project Success Criteria ............................................................................... 22

4 Resource Requirements and Project Plan ................................................... 24 4.2 Tolerance ................................................................................................. 25

5 Project Controls ............................................................................................. 26 5.1 Meetings and Reviews................................................................................... 26 5.2 Escalations .............................................................................................. 27

6 Risk and Issue Management ......................................................................... 27

1. Purpose

This purpose of this document is to set out the strategy for Croydon Clinical Commissioning Group (CCG) and its partners to implement the recommendations set out in the South West London Better Services Better Value Long Term Conditions and Out of Hospital Care (Including Mental Health) Clinical Working Group Final Clinical Report (March 2012)1. The analysis in the SW London report drew on a wide range of experience and evidence of best practice both locally and nationally and included views from patients and members of the public about what is important to them about how services are developed to meet the needs of people with Long-Term Conditions, their families and carers. These views have been reflected in the recommendations of the SW London report which are as follows:-.

Recommendation 1: The group recommends that the generic long-term conditions model is adopted and implemented across south west London. This would require CCG to develop a care programme approach for Chronic Obstructive Pulmonary Disease (COPD), diabetes and heart failure that encapsulates the key principles of prevention and self-management, early diagnosis, patient education, risk stratification and management. It is essential that a systematic programme to identify people with diabetes, heart failure and COPD is in place by 2012/13 in order to improve the care of people with long-term conditions and reduce unscheduled hospital admissions. This would help ensure SW London achieved the outcomes set out in the National QIPP programme locally by 2013/14. Recommendation 2: The characteristics of an effective integrated long-term conditions care pathway are endorsed and recommended by the clinical working group. CCG should develop a work programme that works with colleagues in hospitals, social care, primary care (including Community Pharmacy), and the voluntary sector that focuses on better management of the frail elderly. Recommendation3: The clinical working group recommends that improved access to psychological therapies (IAPT) and Liaison Psychiatry services for the treatment of long-term conditions and medically unexplained symptoms should be part of an integrated care pathway across physical and mental health care Recommendation 4: The clinical working group recommends self-care models are commissioned and developed as part of any long-term conditions care pathway. Therefore the group recommends each CCG commissions a comprehensive evidence based patient education programme for COPD, diabetes and heart failure. Recommendation 5: As evidence becomes available, the group would recommend Telecare and Telehealth is used, where appropriate, in the management of people with long-term conditions. This document is the Project Initiation Document for the CCG Management of Care for People with Long Term Conditions Based on a Platform of Transformational Integrated Care. This document will state:-

1

http://www.southwestlondon.nhs.uk/Haveyoursay/BSBV/Final%20Clincal%20Reports/Long%20Term%20Conditions%20and%20Out%20of%20Hospital%20Care%20(including%20Mental%20Health)%20Clinical%20Working%20Group%20Report.pdf




i. What the CCG Management of Care for People with Long Term Conditions Based on a Platform of Transformational Integrated Care Project aims to achieve;

ii. Why it is important to achieve the stated aims

iii. How we plan to implement the recommendations of the SW London BSBV Long Term Conditions and Out of Hospital Care (Including Mental Health) Clinical Working Group Final Clinical Report

iv. Who will be involved in managing the project and what their roles and responsibilities are;

v. How and when the arrangements discussed in this document will be put into effect;

vi. A clear and unambiguous view of how the project will be managed and controlled.

vii. When approved, this document will provide the “baseline” for the project. It will be referred to whenever a major decision is taken about the project and used at the conclusion of the project to measure whether the project was managed successfully and whether it delivered an acceptable outcome for CCCG.

The strategy set out in this document is based on a common approach for prevention, treatment and care in both health and local authority settings for people who have long term conditions and the frail elderly in Croydon and forms a major plank of the service transformation strategy for Croydon. The strategy is underpinned by a more detailed business case that sets out the case for change, costs of change (investment and disinvestment) and the links with the QIPP target savings going forward. The business case also identifies the assumptions and the modelling to support the case for change and inform the proposals set out within this strategy. Best and worst case scenario savings associated with specific impacts are factored into the business case in order to take into account data sensitivity. The Croydon CCG strategy recognises the need for these transformational plans to be informed by and monitored against where appropriate, the business case assumptions based on Croydon need, acute unscheduled care activity and up to date data.

2. Background What the CCG Management of Care for People with Long Term Conditions Based on a Platform of Transformational integrated Care Project aims to achieve.

The CCG Management of Care for People with Long Term Conditions Based on

a Platform of Transformational integrated Care Project aims to implement the recommendations set out in the South West London Better Services Better Value Long Term Conditions and Out of Hospital Care (Including Mental Health) Clinical

Working Group Final Clinical Report. This will enable CCCG to achieve better outcomes of care (including prevention and self-care) of people with Long Term Conditions by providing services which are more responsive and accessible, resulting in identifying potential complications earlier, fewer planned and unplanned acute episodes and shorter lengths of stay in hospital when the admission is unavoidable. In short, implementing the recommendations will help us to improve health outcomes for people with long term conditions in Croydon. The critical success factor to report the outcome of this project will be an improvement of our current position on the Croydon key dataset indicator from 73.1% of patients being supported with long term conditions to the England average of 78.5%.

We will implement a whole systems transformational integrated care model for physical and mental health services, with linked social and voluntary sector services providing co-ordinated services for individual people closer to home to reduce unnecessary and distressing hospital admissions. QIPP initiatives will also form part of the workstreams to maintain a strong focus on clinically-driven transformational change, improving outcomes of care and quality of service for people while making more efficient use of resources. The financial deficit in Croydon is one of the drivers for transformational change. We intend to use two cross cutting key enablers of:-

Reablement projects and outcome measures with social care and

Integrated emergency urgent care underpinned by NHS 111 as a single point of access and directory of services to support generic pathways of care to support people with multiple morbidities and high risk of frequent hospital admissions. NHS 111 also connects to the “golden number” which signposts service users to local authority support.

Why it is important to achieve the stated aims.

CCCG Management of Care for People with Long Term Conditions Based on a Platform of Transformational integrated Care Project is necessary because of the following contextual issues:-

Rising demand for healthcare: more people needing more care in the future. Many people with long-term conditions are undiagnosed; they do not benefit from preventative care and become intensive users of health services. Changes to the make-up of the Croydon population and lifestyle trends are likely to lead to more people needing care in the future. The number of people with long-term conditions is predicted to go up rapidly over the next ten years, particularly people with respiratory problems, asthma and diabetes. This is expected to put additional pressure on the health service. People are also living longer. Increasing prevalence of long term conditions.

Source: Croydon Public Health Intelligence Team (C-PHIT)

Best estimates of the 2011 baseline in Croydon are as follows (taking comorbidities into account): o Cardiovascular disease (including strokes) 25,159 o Dementia 1,540 o Diabetes 18,350 o Serious mental illness 3,922 o Asthma 18,754 o COPD 3,765

LTC total 46,331

It is also reasonable to assume that people with long term conditions will suffer from aggravating conditions such as obesity, intractable pain, anxiety or depression at least in line with the general population if not to a greater extent. A current estimate for the prevalence of obesity in Croydon is 24% and low level mental illness such as anxiety or depression is 15%. Uplifting the total to account for aggravating conditions gives a total of around 137,000. This is almost 40% of the population of Croydon although many of these people will have relatively low levels of illness.

Source: Croydon Public Health Intelligence Team (C-PHIT)

The need to do more with less to mitigate the impact of financial pressures. There are financial constraints and demands being placed on the local health and social care economy in Croydon, as well as opportunities for creating more efficient processes that also benefit patients and their carers. Many older people who also have long-term conditions need better organised care closer to home, to help them to live as independently as possible. Patients with long-term conditions find it hard to navigate the health system. The main challenge is connecting parts of the health and social care system so people are supported to manage their own health problem better. At the moment, there is often poor coordination between GPs, practice nurses, Community Pharmacists, social services and hospital staff. There is evidence to suggest there is not enough urgent support available in the community (e.g. through out-of-hours GP services, community nursing, etc), especially at evenings and weekends. This may explain why so many people end up going to A&E seeking emergency treatment and staying in hospital. The South West London Clinical Working Groups estimate people with long term conditions are the most intensive users of health services. A relatively small cohort of people account for 36.5 per cent of bed days. Current information suggests that if care provision remains the same, the biggest proportionate growth in hospital activity in London will be in dealing with long term conditions

We need to achieve the highest possible standards of care and meet patients’ expectations. Improving the quality of healthcare on offer to patients must be at the heart of any future changes to provide local people with safe, effective, easily accessible and patient-centred services. People with long-term conditions can often benefit from other kinds of support, for example, counselling, to help them cope with living with a long-term condition. They may not know how to access these services or how to be referred to them by a health professional. At the moment, patients who want to manage their own condition better are not always supported. Medicines play an important role in the management of long-term conditions and patients need to be involved in

understanding why these medicines are crucial to their well being and accept the need for compliance with their treatment as part of their personal management of self care.

How we plan to implement the recommendations of the SW London BSBV Long Term Conditions and Out of Hospital Care (Including Mental Health) Clinical Working Group Final Clinical Report

CROYDON CCG is committed to our integrated service for people with LTC covering the five elements of assessment, pro-active and preventative management, acute management, post discharge support and rehabilitation and reablement. There will be a two stage approach to implementing the recommendations of the SW London BSBV Long Term Conditions and Out of Hospital Care (Including Mental Health) Clinical Working Group Final Clinical Report. Croydon CCG has successfully recruited two Darzi Fellows who are linking the integrated care work by contributing to related workstreams and integrated care plans for adults and children. Stage One The first stage is to map existing services, finding where there are gaps and overlaps in service provision and then linking the services up in a virtual framework so patients and clients can access the services they need quickly.

Key features of the virtual framework include:-

Early recognition of disease to minimise late diagnosis through systematic case finding and better recognition of signs and symptoms by healthcare professionals especially those in primary care and by the population itself.

Personalised care and support for self management, with people with Long Term Conditions and their carers receiving disease specific education and training to become active partners in care.

Proactive management by health and social care professionals starting with an accurate diagnosis and assessment of needs, impact of disease and implications for lifestyle, regular reviews with specialist input depending on severity of condition, and early and specialist rehabilitation to support independent living in their own homes

Effective prevention and management of acute episodes with prompt identification and treatment (where possible in the community) in a care model which facilitates admission avoidance, or, where admission is unavoidable, early supported discharge, proactive follow up for treatment review.

Community provision of specialist interventions/devices to support treatment and monitoring of signs and symptoms, and provision of proven psychological support treatment including Cognitive Behavioural Therapy for depression and anxiety within Long term Conditions Management.

Effective and equitable end of life care to enable the patient to die in a setting of their own choice.

The six key structures of the virtual framework are:-

Risk profiling We anticipate full roll out of our new risk profiling IT platform to all of our GP practices by March 2013 to drive case management across the CCG although a significant number of practices will be operational before that date. We will use risk profiling for people with long term conditions who are at highest risk or readmission to hospital in the first instance and admit, where possible, to the virtual ward. The population segmentation will underpin future targeted pro-active case management for people with Long Term Conditions, and Co-morbidities at a lesser risk of acute unscheduled hospital admission to facilitate cost effective early impact intervention. It is anticipated the risk stratification tool will have the capacity to identify those within the cohort population with social risk factors, and those who will not have had prior hospital admissions, in order to address some of the shortcomings associated with the Patient at Risk of Readmission (PARR) models. The N3 Connectivity of London Borough of Croydon Council should act as a further conduit for joint risk identification (for example top risk clients on 4 x care packages per day)and an underpinning feature of the Year of Care Model pathway of care / tariff

Virtual Ward. We will re-invigorate our virtual ward to include more people who are at high risk of hospital admission and rigorously case-manage patients while they are in the virtual ward. The virtual ward is critical to the success of providing care for PwLTC in community settings and will be subject to review to assess the capacity and capability of the current structure and working arrangements to deliver the kind of care we need.

Integrated Neighbourhood Care teams We are developing integrated care plans to redesign core processes. Community health services are integrated with our major secondary care provider and, with social services colleagues in Croydon, we are using our multi-disciplinary care delivery system to drive up the quality and cost benefit of the care we all provide. There is strong strategic commitment at senior levels to make information sharing a reality and further develop shared professional values in front line staff. We are implementing a joint governance model with aligned incentives and shared or compatible information systems. The integrated neighbourhood care teams have forums for case and act as platforms for peer and performance review to support learning and development, thereby shifting the focus of care from uni-professional process mapping to shared working and improvements in outcomes of care.

Integrated reablement service We have a successful integrated reablement service which is currently run by the London Borough of Croydon and links hospital discharge to active reablement in a variety of care settings, including the patient’s home. Assistive Technology - Telehealth We see risk profiling to drive vigorous case management, the virtual ward and integrated neighbourhood care teams to supply necessary care and telehealth and telecare to support self care as three parts of a triangle which supports high quality, patient focussed support to enable people with moderate and severe long term conditions to live in their own homes for as long as possible, enjoy an improved quality of life and avoid unnecessary and distressing admissions to secondary care..

NHS 111 The 111 service aims to make it easier for public to access urgent healthcare services and we intend to use this service as the main portal for people to access the services they need in community settings. National pilots (which include Croydon) have reported reduced A&E and UCC attendances and Croydon will monitor the impact of its pilot using a national Minimum Data Set (MDS) and an agreed daily situation report on an electronic dashboard to assess the impact on local ED and UC services, including GP OOH services, and to inform future commissioning intentions.

Stage Two The second stage will build on stage one, developing, training and utilising integrated community teams who may be drawn from health, local authority or other organisations such as the voluntary sector to deliver services both pan Croydon where necessary, but more commonly within one of the six Croydon localities which will be their “home” locality. Staff will work as single teams to common protocols and have access to resources outside their traditional organisational boundaries. This will involve structural and organisational change to the infrastructure and delivery system as set out in the diagram below.

.

The principles of care will be based on the following: - .

Case management - dedicated one to one support for people from a highly skilled professional (e.g. GP, community matron or social worker) with regular face to face contact.

Personalised care planning - placing the person at the centre of decision making about their care and agreeing a plan of how that care will be delivered.

Support people to self care - providing people with information and skills to make day to day decisions about the way they manage their health.

Assistive technology - using the emerging telecare and telehealth technology and telephone coaching arrangements to support people to remain independent and self care for as long as possible.

A diagram showing how we expect information to flow is set out below. Telehealth, telecare integrated reablement service and integrated care teams are included in the type of intervention. The patient or carer can also contact 111 directly.

Infrastructure

Su

pp

ort

ing

Delivery System

Cre

atin

g

Better Outcomes

Community resources (health, local authority and voluntary sector)

Case Management

Empowered and informed patients

Decision support tools and clinical information systems

Disease management

Health and Social care system environment

Supported self care

Prepared and proactive health and social care teams Promoting

better health

Case manager for clients identified in a primary/community setting, accessing a multi-professional case management conference discussion, enabled through the whole system LES for LTC

The recommendations of the SW London BSBV Long Term Conditions and Out of Hospital Care (Including Mental Health) Clinical Working Group Final Clinical Report, CCG actions to date and projects arising from each recommendation for CCCG

Recommendation 1: The group recommends that the generic long-term conditions model is adopted and implemented across south west London. This would require each primary care trust to develop a care programme approach for Chronic Obstructive Pulmonary Disease (COPD), diabetes and heart failure that encapsulates the key principles of prevention, early diagnosis, patient education, risk stratification and management. It is essential that a systematic programme to identify people with diabetes, heart failure and COPD is in place by 2012/13 in order to improve the care of people with long-term conditions and reduce unscheduled hospital admissions. This would help ensure SW London achieved the outcomes set out in the National QIPP programme locally by 2013/14.

CCCG actions to date.

LTC Model. CCCG has adopted the generic long term conditions model set out by the Department of Health in 20102 to provide a structured and consistent approach to the management of long term conditions – matching care to need. CCCG will use a risk prediction approach to identify those people who are the most regular users of hospital services (and are at risk of re-admissions), then stratify them according to complexity of need and commission services to meet those needs. We estimate approximately 5% of people with long term conditions will have complex needs, approximately 25% of people with long term conditions will have a medium level of need and approximately 70% of people with long term conditions will have a low level of need with conditions relatively under control. There is strong clinical engagement and support for risk profiling in Croydon. Risk Profiling A new risk profiling platform has been agreed and has started a scheduled roll out in the summer of 2012. The algorithm is based on an adjusted clinical group methodology which assigns all diagnostic codes a given aggregated diagnosis groups (ADG.) based on five clinical dimensions: duration, severity, diagnostic certainty, aetiology and specialty care and includes reference to age and gender. The risk profiling tool will capture both clinical information and a more generic assessment of patient need in terms of physical, mental and social support services they may require. Risk profiling scores will be

2

http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Healthcare/Longtermconditions/DH_120915

captured electronically at CCG level in the form of a dashboard to performance manage use of urgent and secondary care. In the meantime we are using patient registries and risk profiling scores based on existing information to refocus our services on case management to meet needs of patients rather than disease pathways. Service costs The London Borough of Croydon is progressing integrating its commissioning service with health partners to support the CCG as a commissioning support provider. Almost all commissioning activity has joint involvement across the CCG and local authority and we are keen to develop local tariffs for community services while establishing a risk profiling tool for primary, community and secondary care data with social care and ambulance data to be included at some time in the near future. We have already started to develop good costing information at a patient level using patient level costing and information systems. (PLICS). We already have a good understanding of the costs of services we commission (financial assumptions are currently being reviewed) but would like to develop a better understanding of the relationship of costs of services to outcomes of care. We would therefore like to progress work in developing outcome measures, the impact of level of need on service provision and baseline costs

Sub-projects to implement Recommendation 1.

Project Workstream

Project Start Time

Project End Time

Project Outcome(s) Project Lead

Agreed information sharing protocols across partner agencies

Oct 2012

Jan 2013 Common datasets agreed, platforms understood and legal use of shared data

Philippa Robinson Ivor Evans Glyn Jones

Using historical data as a proxy in the first instance and refine this as more “live” data becomes available. - for example the 2010 SPRU

3 research

which included Croydon data

Nov 2012

Part of 2013/14 contract negotiations

Informing the development of costs of pathways for each level of need.

PH/finance CHS/SLaM

Identify specific cohorts of patients on a multi specialty basis. Aggregate of all OP, diagnostic, separate acute IP and RRR spells and other tariff/local costs for designated

Dec 2012

Establish the baseline for cost and activity of care for people with LTC, attach resource use / costs to each levels of need in the classification system and understanding the impact of separating

PH/Finance/CHS Commissioning SLaM

3 Glendinning et al. 2010. Home Care Re-ablement Services: Investigating the longer-term

impacts (prospective longitudinal study) SPRU. University of York

cohorts and align associated costs for community, mental health, primary care and social care costs. Create an average year of care baseline cost.

LTC HRGs using the RRR model

Manage Darzi Fellows work programmes

Oct 2012

TBC Review LTC pathways-Diabetes, HF, COPD & older frail people against key principles

Agnelo Fernandes/Philippa Robinson

Roll out risk stratification tool to GP practices

April 2012

March 2013 All Croydon GPs have and are using risk stratification tool

Ivor Evans/Wendy Gault

Case management training

Jan 2013

Trained case managers in place with agreed shared protocols

LBC/CHS/CCG SLaM

IT Platform to support risk management, case management and virtual services linkages

Nov 2012

June 2013 IT requirements scoped, costed and implemented

Ivor Evans

Review of capacity and capability of community services provision. This includes the virtual wards) and is critical to the success of this project.

Nov 2012

Feb 2013 Match supply to demand

PH/CHS/LBC Philippa Robinson

Review of capacity and capability of virtual ward

Nov 2012

Feb 2013 Match supply to demand

PH/CHS

Alignment of budgets with local authority colleagues

TBC Aligned budgets for virtual teams in place

Finance

NHS III directory of services with link to local authority and voluntary sector services

8 Nov 2012

14 Dec 2012

Enable NHS 111 to access appropriate patient/client history and direct to appropriate service. Access to full patient records currently subject to national objections. Issue for discussion in national 111 operational meetings

Margaret McHugh

Combine Net Promoter Score (NPS) with the emerging DH and Commissioning Outcomes Framework

TBC The development and refinement of costs of outcome measures

Agnelo Fernandes

End of Life Strategy Nov 2012

Jan 2013 Coral Alexander

Clinical Reference Group for LTC to be established

Dec 2012

Feb 2013

Use of high-level data and information to provide a series of dashboards across 10 distinct areas of health and social care.

June 2012

.Jan/Mar 2013

The information provided will be used to drive and inform management decisions with a view to providing faster and more appropriate Patient outcomes resulting from re-aligned pathways based on a comparison of data from (often disparate) areas. In addition, the project will facilitate and ignite data sharing across the Social-Health boundary and lead to greater cooperation and closer links between the local authority and the NHS in line with the Health & Social Care Act and, in time, for the CCG installation.

Simon Carlino

Recommendation 2: The characteristics of an effective integrated long-term conditions care pathway are endorsed and recommended by the clinical working group Each PCT should develop a work programme that works with colleagues in hospitals, social care, primary care (including Community Pharmacy), and the voluntary sector that focuses on better management of the frail elderly. CCCG actions to date.

Integrated Care Teams Health and social care services are working together to provide joined up and personalised services to provide care and support to people with long term conditions, including psychological support, in their homes for as long as possible. There is a key worker within each team who co-ordinates the individual’s care and acts as the point of contact for them.

Falls Prevention The London Borough of Croydon has committed to the Department of Health’s Dignity and Care campaign demonstrating the commitment and shared values it has with colleagues across the health economy. It also hosts the multidisciplinary care support team which focuses on people who are resident in both nursing and residential homes to embed best practice in falls prevention. Croydon is focusing on early identification of patients with LTC through development of enhanced services that impact on LTC and KPIs in PMS contracts (i.e. Proactive review LTC and other LES) and continue to work in partnership with local authority and other stakeholders to develop proactive support for people in supported accommodation.

Fast Access Review Croydon has and will continue to develop appropriate fast access review capacity, including pharmaceutical review of prescribed drugs in community

settings, to ensure that all patients with established LTCs are seen rapidly to prevent deterioration and potential emergency admission.(e.g. COPD Hot Clinic) and establish more community based outpatient clinics for LTCs. Intensive Assessment Service (IAS),

There are two beds plus specialist staff available on a call off basis in the Greenvale Residential Nursing Home. The Service provides assessment for those people who are thought possibly to need NHS continuing care and who need a level of nursing care in a bed whilst a comprehensive assessment can be carried out. The service is particularly designed to cater for people being discharged from CHS (and potentially other acute hospitals) where the completion of a full assessment might otherwise lead to a delayed discharge on the acute ward.

Staying Healthy Staying Healthy initiatives are an integral part our integrated care strategy and feature in all care pathways below. Examples include:

Proactive review for all people with LTCs.

Improving access to psychological therapies to reduce the burden of long term mental ill-health (Mental Health)

Increasing the range of options for accessing urgent care to facilitate appropriate level support.

Urgent Care initiatives Croydon led the work of the SW London UC project, a ‘task and finish’ group, which developed UC action plans to reduce the impact of winter pressures on A&E, as measured by national A&E indicators, including the 4 hour wait target (95%). The actions plans were innovative in that they were based on an UC whole system map, including an analysis of service demand and capacity across the whole system, including primary, community, acute, LAS and social care services. The actions aimed to improve the whole UC system to achieve:

reduced A&E attendances/NEL admissions;

improved A&E/ward effectiveness; and

reduced A&E re-attendance and ward readmission, underpinned by UC KPIs at all levels of the system.

Further to the development of the Croydon UC Action Plan, Croydon established its own UC Network, supported by the new UC Data Repository, another product of the SWL UC project. Croydon contracted with CHS in 2011/12 for the deployment of the RCGP’s Urgent and Emergency Care Toolkit to ensure best practice in the clinical audit of urgent and emergency care services delivered by CHS. Practice in Croydon around delayed discharges has been used by DH in the development of a best practice tool kit.

This initiative is closely linked with the Staying Healthy pathway and the integrated model of care initiative. A 24 hour primary care-led urgent care centre is co-located with A&E to make the best use of primary care skills and provide timely access to diagnostic services. 12 hour urgent care access through Urgent Care Centre or GP-led Health Centre is available across Croydon to provide the capacity and capability to treat patients in locations which are closer to their homes. Our actions to date and the priority service changes commissioned are

contributing to improving the patient experience and the rebalancing of our healthcare system. The main focus of this initiative is on increasing productivity and achieving South West London Clinical Working Group pathways. The new service at Croydon University Hospital (CUC) UCC is delivered at a reduced basic UC tariff of £40.00 compared to the A&E basic tariff of £65. It also delivers GP OOH ‘face to face’ services for the first time to ensure that patients are receiving ‘the right service, first time’. The UCC service operates through integrated governance arrangements with the CUH ED service to ensure a quality integrated service for patients, measured by national and local KPIs, including patient satisfaction. Alternative Care Pathways Alternative Care Pathways (ACPs) protocols have been agreed between commissioners, providers and LAS to support LAS in conveying patients to UC services other than A&E, including UCCs at CUH and Purley and the Parkway MIU. Sub-Projects to implement Recommendation 2

Project Workstream Project Start Time

Project End Time


Silver Book recommendations

Nov 2012 Part of 2013/14 contract negotiations

Commissioners will work with CHS to implement the Silver Book recommendations on outcomes of care

CCG/CHS

Virtual integration of services building on IT platform developed for Recommendation 1

Nov 2012 May 2013 Appropriate patient/client data able to be shared in real time by front line practitioners

Ivor Evans

Organisational development

Oct 2012 Feb 2013 Staff from health, local authority and social services trained to work across traditional organisational boundaries

Brenda Scanlon & Steve Morton

Aligned budgets Oct 2012 Mar 2013 Budgets are clearly aligned between health and social care to support the patient pathway

Finance

Recommendation 3: The clinical working group recommends that improved access to psychological therapies (IAPT) and Liaison Psychiatry services for the treatment of long-term conditions and medically unexplained symptoms should be part of an integrated care pathway across physical and mental health care

CCCG Actions to date.

Mental Health Continuing Care Pathways Local mental health continuing care pathways have been re-designed to ensure that every assessment considered by the Croydon Continuing Care Panel for people with serious mental health problems has been led by a mental health professional. This work has been completed and the new pathway agreements implemented in late September 2011. Monitoring indicates that all pathways and appropriate routes have been observed since September. Self Directed Support for Adult Mental Health Service Users. Croydon has made notable progress in extending self directed support to adult mental health service users of working age and The South London and the Maudsley NHS Foundation Trust (SLaM) has been particularly instrumental in facilitating progress made to date. We therefore propose to establish and pilot mental health reablement services for mental health service users in Croydon which may be expanded to meet the needs of people with LTCs who have low level mental health needs. Croydon council and Croydon CCG are also collaborating to provide personal health budgets for people recovering from substance misuse. Dementia The prevalence of dementia in people 65+ in Croydon is predicted to rise by 9 -10 percent over the next 7 years and we will increase the capacity of the Memory Service to cope with increased demand. A programme has been introduced to reduce NHS Croydon Borough Team expenditure in NHS continuing care where the primary need is dementia (by reducing the numbers of people who are awarded NHS Continuing Care inappropriately).

Sub-Projects to implement Recommendation 3

Project Workstream

Project Start Time

Project End Time

Project Outcome(s)

Project Lead

Researching beyond the IAPT pilot

Dec 2012 TBC Dedcide on feasibility of future pilots

John Haseler

Recommendation 4: The clinical working group recommends self-care models are commissioned and developed as part of any long-term conditions care pathway. Therefore the group recommends each primary care trust commissions a comprehensive evidence based patient education programme for COPD, diabetes and heart failure.


Self Care Croydon is tackling LTC through prevention and services that enable people live independently in their own homes for as long as possible. Croydon is empowering patients by giving them information about their condition(s) and offering them choice about where and how they are treated. The local authority has created a local authority trading company which assists people with self-care particularly in relation to meeting their needs for equipment. A significant element of the promotion and enabling of self-care is reliant on introducing contractual enablers and performance metrics and is aligned to the contract negotiations round. In addition, further resources from Public Health and potential incentivisation for provider organisations will require indentification and or incentivisation.

Sub-Projects to implement Recommendation 4.

Project Workstream

Project Start Time

Project End Time


Prevention & Self care support

Nov 2012 TBC Prevention and self management strategy including:

Comprehensive evidence based patient education programme for people with long term conditions

Steve Morton

Recommendation 5: As evidence becomes available, the group would recommend Telecare and Telehealth is used, where appropriate, in the management of people with long-term conditions.


We have already successfully invested in Telehealth and Telecare projects. Our vision is to increase significantly the choices available to people with long term conditions in terms of planning and managing their own care requirements in ways they prefer and sustaining them to live in their own homes for as long as

possible. People with long term conditions will be able to engage in shared decision making in order to co-produce a care plan, that both they and their carers have access to the appropriate information about how to manage their condition. This will require a cultural shift for both people with long-term conditions and clinicians whereby the importance and value of self-care and education are truly understood and where shared decision-making and

supported self-care are seen as an integral elements of LTC management. Telecare and Telehealth in partnership with social care and the voluntary sector will be key enablers for self-care.

Sub-Projects to implement Recommendation 5.

Project Workstream

Project Start Time

Project End Time

Project Outcome(s)

Project Lead

Assistive Technology-Telehealth provision

April 2012 March 2014 Capacity of Telehealth and Telecare services meets demand and x no of patients/clients with LTCs are supported through telehealth and telecare arrangements.

Christine Griffiths & Andrew Maskell LBC

3. Project Definition

3.1 Objectives

Implement a whole systems transformational integrated care model for physical and mental health services with linked social and voluntary sector services providing co-ordinated services for individual people closer to home to reduce unnecessary and distressing hospital admissions.

Underpin the project by QIPP initiatives to maintain a strong focus on clinically-driven transformational change, improving outcomes of care and quality of service for people while making more efficient use of resources. The financial deficit in Croydon is a driver for transformational change.

Use the two cross cutting key enablers of:

o Reablement projects and outcome measures with social care

o Integrated emergency urgent care underpinned by NHS 111 as a single point of access and directory of services to support generic pathways of care to support people with multiple morbidities and high risk of frequent hospital admissions. NHS 111 also connects to the “golden number” which signposts service users to local authority support.

The critical success factor to report the outcome of this project will be an improvement of our current position on the Croydon key dataset indicator from 73.1% of patients being supported with long term conditions to the England average of 78.5%.

3.2 Scope and Exclusions

Scope.

The scope of this project is the development and implementation of a CCCG strategy for treating and caring for people with long term conditions based on transformational integrated care. A programme management approach will be used to manage the sub projects to deliver this strategy.

Exclusions

The transformational integrated care platform will be used as the platform for all care delivered in community settings in the near future, but the focus of this project is confined to people with long term conditions.

3.3 Deliverables

The following deliverables will be produced by this project:

Services designed around patients and focussed on bringing “islands” of health and social care together to exploit the synergy and improve patient experience.

A move from reactive care to preventative care so that there is:-

o Personalised prevention: targeting public health and education messages at individuals to make it personal in an attempt to prevent the behaviour that leads to illness)

o Delay of onset: some people will already have undertaken risky behaviours and will develop an illness, the aim here would be to change behaviour to delay the onset of that condition for as long as possible or to intervene early to prevent further deterioration)

o Better management post-diagnosis: involving people in their own care, using, where possible, generic long-term conditions pathways so that conditions are managed well, and incorporating assistive technology.

o In line with the BSBV agenda, we are reassessing the assumptions made in the supporting Business case for Transformational change.

3.4 Constraints

The project will be run under two major constraints, timescale and resources.

Timescale

The project is required to deliver results, in terms of progress towards the implementation of the integrated care platform by the end of March 2013.

Resources

The project will require input from four groups of staff in order to be successful. These groups are

NHS SWL CSU Informatics staff,

staff within CCCG

staff within the practices

staff from the local health and social care system. This includes Croydon borough, public health and local providers who by working with and responding to CCG/system requirements are key to delivering the required targeted care for the local population

It is recognised that all these groups are already under significant pressure of work: CCCG staff are focused on achieving authorisation and GP practice staff are preparing to take on a greater responsibility for commissioning. However, without the required input from these groups, the project will not be successful.

Two Darzi Fellows are engaged with the clinical aspects of this project and we are in receipt of funding from NHS SW London of c £1,000k to support the integrated care project which underpins the long terms conditions strategy.

3.5 Assumptions

In defining the approach to this project, the following assumptions have been made:

All Practices agree to use the risk stratification tool and associated networked arrangements the CCG puts in place to ensure the whole CCCG population is included in the strategy and use of the transformational integrated care platform.

The project commenced on 1st June 2012 although preparatory work has already taken place in advance of this date.

The roll out builds on the application of learning from the wider SW London integrated care project, and the significant work undertaken with infrastructure and information governance.

Staff from CCCG, Local Authority, GP practices and any other organisation involved in this strategy will provide the necessary time and resource to the project as set out in this PID.

3.6 Dependencies

Implementation of the risk stratification tool in GP practices and connectivity

Wider organizational development to effect the cultural change required in collaborating organisations to accept shared responsibilities for outcomes of care and risk.

Alignment of any new contracts let which impact on care for people with long term conditions to ensure that they are based on the principle of transformational integrated care. This will be particularly important for the community services contract provided by CUH and diabetes, both of which are currently under consideration.

3.7 Approach

The approach to this project is as follows:

Project set up and initiation:

Establish the project governance arrangements within CCCG and reporting arrangements to CCCG executive. The Strategic Sponsorship Board has the authority, breadth of membership and capability to act as overall Project Board for this project. The initial set up phase would be developed through the multi-agency project group including input from social workers, care managers, OTs, Community Nurses, Modern matrons and the lead GP from the Clinical Commissioning group.

All providers joining the Transformational integrated Care project will enter into a detailed Memorandum of Understanding, Establishment Agreement, Hosting Agreement; and IT Managed Service Agreement which together establishes the infrastructure, funding arrangements and requirements providers must sign up to.

There will be two phases:

Phase 1 o Map and cost current service provision for LTC o Virtual integration of these services at the patient level to improve the

patient experience and reduce overlaps in service provision by primary, community, secondary, social care, mental health and voluntary sector providers

Phase 2 o Map activity, outcome and costs of service provision for people with

long term conditions; o Base outcomes of care on Silver Book definitions where possible and

seek common outcomes with London Borough of Croydon to support better evaluation of care;

o Decommission services where there are overlaps and redesign some services where there are gaps;

o Underpin with a cost benefit evaluation. 3.8 Critical Success Factors

There are two categories of success criteria, those relating to stakeholders and those relating to the project.

Stakeholder Success Criteria

Patients

Success criteria/benefits from a patient’s perspective:

• Earlier interventions;

• Provision of the most appropriate care for the patient’s condition(s);

• Avoidance of admission to hospital;

• Provision of integrated packages of care across all care providers.

Clinicians

Success criteria/benefits from a clinician’s perspective:

• Increased information and intelligence about the patient population;

• Identification of patients at risk.

GP Practices

Success criteria/benefits from a practice’s perspective:

• Improved disease registers;

• Improved data quality;

• Opportunity for contribution to QOF;

• Easier and more complete identification of patients with long term conditions, which is part of the operational framework;

• Stimulus for increased intra-practice working and peer review.

Croydon CCG

Success criteria/benefits from CCCG perspective:

• Improved working relationships with community and other services;

• Better intelligence to allow negotiation of changed SLAs;

• Support for the development of integrated care pathways;

• Potential to disinvest in secondary care;

• Support for the sharing of best practice and improved peer review;

• Potential to redistribute budgets and reduce costs;

• Opportunity for more integrated commissioning of services.

• Potential to support the continually evolving operational model;

• Support for QIPP;

• Financial savings - assumptions currently under review

• Potential to benchmark “efficient” commissioning choices in each practice

Project Success Criteria

The critical success factors for the project are that the practices embrace transformational integrated care and use the tools and information to manage patients with long term more effectively. Success will be measured in terms of

• Quality

• Cost effectiveness

• Patient and carer experience

The metrics used must be outcome focussed and capture qualitative as well as

quantitative measures and will reflect the five domains in the NHS Outcomes Framework 2011/12 which are:

• Domain 1: Preventing people from dying prematurely • Domain 2 : Enhancing quality of life for people with long-term conditions • Domain 3: Helping people to recover from episodes of ill health or following

injury • Domain 4: Ensuring people have a positive experience of care, and • Domain 5: Treating and caring for people in a safe environment and

protecting them from avoidable harm

The initial metric used will be the avoidance of unnecessary hospital admissions.

4 Resource Requirements

The resource requirements for the project are summarised in the following table. Note – A full business case is being developed which identifies the assumptions and the modelling to support the case for transformational change in Croydon.

Workstream commencement and milestone achievement dates

Programme deliverables Resource requirements and indicative cost

Workstream commencement date May 2012 Milestone achievement date July 2012

Current and Projected Services Requirements for People with Long Term Conditions in Croydon.

Current service model

Current and projected service demand

Current and projected service outcomes

Current and projected service costs

Programme Director £100k 2 x Project Managers (Frail Elderly and Children’s) £120k External programme facilitation £40k

Workstream commencement date June 2012 Milestone achievement date October 2012

Proposed Transformational Integrated Care Model Structure

Capacity

Costs

Impacts on outcomes of care

IT links

Clinical and information governance arrangements for integrated working

Risk management

Workforce planning and organizational development needs to enable full implementation and benefit realisation of model. This will include shared training for professional integrated teams focusing on outcome delivery.

Communications and engagement, including equality impact assessment.

Activity/finance modelling £100k IT solutions including risk stratification software and establishing cross provider combined electronic patient records £100k Pump priming of primary care to facilitate transfer of activity £120k Pump priming of community services to facilitate transfer of activity £270k Communications and engagement

£50k Legal and commercial fees £50k

Workstream commencement date November 2012 Milestone achievement date December 2012

Cost Benefit Analysis

Current and projected benefits

Current and projected costs

Cost benefit sustainment strategy

Contingency £50k

4.1 Project Budget The budget for the long term conditions strategy based on a platform of integrated care project is circa £1,000,000

4.2 Tolerance

The Project Manager has zero tolerance on budget and resources; the impact of this is that the Project Manager must refer all decisions relating to budget or resources to the Project Board. This also means that all risks and issues will be escalated immediately to the Project Board.

5 Project Controls

The overall control of the project sits with the CCCG Executive and, in line with PRINCE2, it manages the project by exception. The Programme Manager carries out day-to-day management of the project within the delegations of authority. The controls that this project may or will employ are:

Controls Who Exercises Control Triggering Event

Project Initiation CCG Executive Approval for the project to go ahead by signing off the Project Initiation Document

Quality Control Programme Manager A product has been completed.

Risk Log Project Board Programme Manager

As risks are identified

Issue Control Project Board / Programme Manager

As issues are identified

Change Control Project Board / Programme Manager

As changes are identified

Project Closure Project Board / CCG Executive

All products have been delivered.

Tolerance Project Board The Project Manager has zero tolerance on budget and resources (see above)

Checkpoint Programme Manager Weekly or as determined by the CCG Executive

Update Reports Project Board Fortnightly updates sent to the CCG Executive.

5.1 Meetings and Reviews

The following meetings and reviews are required.

Deliverable Description Delivery Method

Frequency Owner Audience

Project Team Meeting

Meeting to review project status and risks and issues

Meeting Weekly Programme manager

Project Manager Project Team

Project Board Meeting to review progress of all project milestones, high level risks and issues and approvals

Meeting Monthly tbc Project Board members Project Manager

CCG Executive

Meeting to review programme progress

Meeting Monthly tbc CCG Executive members Project Manager

5.2 Escalations

The first point of contact for any project related issues is the programme manager Any issues that cannot be resolved by the programme manager will then be escalated to the Project Board.

6 Risk and Issue Management

A risk log will be maintained by the Programme Manager throughout the duration of the project, although individual risks may have specific owners as determined and assigned by the Project Board. These will be reviewed by the Project Board at their meetings.

Risk assessment will be an on-going process and will be managed as such. The Programme Manager will also maintain an issues log. A full risk assessment would underpin this project but an early issue which would need to be managed is capacity and engagement of front line, local authority and voluntary and community sector staff required to co-ordinate care and the reduction in activity in secondary care may affect financial viability of some local services. Mitigations for this risk include:-

Total support of chief executive level staff and associated strategic sponsorship boards from every key stakeholder.

Good clinical engagement of General Practice as a result of CCG development of clusters of GP practices which are already in place.

Joint working between health, social care and the voluntary sector. Key stakeholders are already developing a joint strategy on the Health and Wellbeing Board.

Good engagement with and support from Healthwatch to support user and carer involvement.

All of the key UC projects: NHS 111 service pilot, CUH UCC, Purley UCC (GP solution) are the subject of formal project governance arrangements, including risk registers which identify and manage the potential risks to the projects through mitigating actions.

We are also aware that measuring the impact of interventions on service use can be challenging, particularly if they are being targeted at people who have had recent encounters only with the health care system. In these cases, a reduction in hospital utilisation may occur simply as a result of regression to the mean. We therefore intend to include social care utilisation data we already have and embed a fairly straightforward analysis to help us compare expected and actual rates of service demand and outcomes.

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