Roadmap Hounslow CCG 23 August 2019 Contents Item Slide 1 - - PowerPoint PPT Presentation
Hounslow Integrated Care Partnership Roadmap Hounslow CCG 23 August 2019 Contents Item Slide 1 Vision and ambition for the partnership 4 2 Scope, composition and partner commitment 10 3 Model of care 18 4 Approach to population
Hounslow CCG 23 August 2019
Item Slide 1 Vision and ambition for the partnership 4 2 Scope, composition and partner commitment 10 3 Model of care 18 4 Approach to population health management 20 5 Priority areas of focus 22 6 How this plan and areas of focus deliver NWL financial recovery 25 7 Key milestones in development 29 8 Governance arrangements 31 9 Key areas for development support 34 10 Appendix 1 36
A young and enterprising borough High employment rates Dedicated health and care staff who stay in the borough Staff who are invested in Hounslow More residents living with complex health and care needs A steady increase in unplanned hospital admissions Around 3,000 older people experience chronic loneliness High levels of smoking and
Source: Hounslow Joint Strategic Needs Assessment, 2017 and Loneliness and Social Isolation in the London Borough of Hounslow, 2017
Hounslow has a number of shared challenges across partners
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Hounslow Health and Care Partnership: Who are we?
Hounslow Health and Care Partnership has come together to build on what already works well in Hounslow to address our shared challenges. We are working to deliver a future, financially sustainable care and support system that improves patient and citizen outcomes by embedding the principles of integration, prevention, proactivity and localism.
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Joint vision Shared challenges Framework to work within Capacity
We want to set out that we work together because… Our shared challenges that we can only resolve by working together are…. We release the capacity to deliver integration though new ways of working and behaviours that support that
We build on what we do well, release our staff to adopt integrated ways of working and support our residents to co-produce the changes
Our framework that enable us to work flexibly to realise our ambitions is…
We agreed that relationship building across the system is critical to successfully build an
depth OD programme that will support us in strengthening system relationships and integrated vision for joint working from September We are actively developing a joint approach to population health
system BI and analyst group has launched its work to support working groups in shaping of the care models. The group will support the ICP development by providing a system view and evidence for future care models We have agreed our joint working governance arrangements and the roadmap will set the key milestones for further development of our joint working framework including risk and share arrangements, partnership agreements/MoUs etc. We have also started work on jointly developing commissioning
Our emerging joint approach to resources needed to build an ICP has already changed the way we approach performance meetings with our provider partners. Through this we have been able to release staff from both CCG and partner organisations to be involved in ICP work.
Our Vision, Values and Aims
“To be a place that provides continuity of care and support, leading to empowerment for all. This will mean better health and wellbeing for the people of Hounslow.” Our Vision The Triple Aim
Responding to our Population: Communicating and Engaging
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Hounslow has strong foundations of developing the vision for Hounslow health and care system across partners and the public: Principles of Integrated Care are well embedded in the Hounslow Joint Health and Wellbeing Strategy
Futureproofing Health and Social Care in Hounslow co-produced and co-designed
for integrated care
Hounslow Outline Business Case for Integrated Care shared with CCG Governing Body and all partners
home, preventing deterioration Primary Care Network Development
supporting the establishment of primary care networks (PCNs) and primary care at scale.
recruitment of pharmacists and first contact physiotherapists (FCPs) roles as part of the network delivery teams to increase provision of allied care professionals in primary care, as indicated in the NHS long term plan. Public Event in March 2019
In the long term we will seek to develop our knowledge of the population's needs and behaviours to co-develop Self Care, align Preventative Care with wider health and wellbeing and seek to address the social determinants of health.
Strengths
2022 Hounslow Health System: Futureproofing Health in Hounslow
Changing our Mindset, Culture and Behaviours
9 We recognise that we have more to do to further develop, refine and socialise our shared vision and demonstrate progress on a regular basis to staff and stakeholders. Our vision is underpinned by the work required to change our mindsets, culture and behaviours.
Theme Actions for 2019/20
Strengthen our relationships We agreed that relationship building across the system is critical to successfully build an ICP. Our CEOs have stressed this as our primary focus and have endorsed a in-depth 6 month OD programme that will support us in strengthening system relationships and integrated vision for joint working from September. Refine our shared vision and purpose and understand our shared challenges The OD work will further develop and deepen the collaboration, relationships and practice in order to build and strengthen the foundations for an integrated place based approach to agree
health and care system in Hounslow. Engage and communicate We will build on our communications strategy and work to date with the community and staff to demonstrate our progress.
all partnering organisations) will shape the strategy for engaging and communicating about the ICP and the work we do to both staff and the public.
can co-design and co-produce the care that ICP will be providing to our local population. Our approach is to a joint leadership and engagement programme targeted at all levels of staff; executive, middle management and frontline.
emerging models of care jointly.
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Scope, composition and partner commitment
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Programme is to develop and deliver an integrated model of health and social care for patients and citizens who are current users of our local health and care system.
and it is critical that the partnership operates across the key building blocks of Neighbourhood (as defined by the Primary Care Networks); Place (defined as the Borough) and the System (defined as the North West London sector). Our key building block and primary area of focus is at the Place level.
based public service integration in Hounslow with blended leadership and redefining the service user relationship with our population.
SCOPE:
approaches embedded within some of our partners we will empower staff and clinicians to develop solutions that allow them to work to the ‘top of their licence.’
scope, there will be opportunity to incorporate these (subject to agreed sign-off arrangements).
with NWL or London-wide rather than within Hounslow ICP (e.g. forensic mental health etc). Scope of Current Integrated Care Programme
12 If workstreams can demonstrate system benefits by including services outside scope, or that don’t obviously align with the scope, there will be opportunity to incorporate these (subject to agreed sign-off arrangements). This may lead to additions to scope as the work progresses. The waves below are provided over a three year period, incorporated in time for the Alliance contract let in April 2023.
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Unwell (Complex/High Risk) Mostly Well (Stable, with potentially 1 LTC) Well Type of Integration Formal Integration through Health and Care focussed on improving outcomes for patients Alliance/Health Provider Integration Population Health Management Approach across health and social care Place based public service Integration across Council and CCG with Joint Posts Thriving and resilient communities Scope £150m of identified services. £420m CCG budget, bringing in social care and Public Health elements £420m CCG spend and associated/relevant level of social care and other council spend. Programme Phase Phase 1: 3 Year programme Broken into Waves 1, 2, 3 April 2023 Phase 2: Year 4 April 2023 Beyond April 2023 Contractual Form By April 2020 – Alliance Agreement By April 2023 – Alliance Contract Alliance Contract Alliance Contract with Blended Leadership Model
In Hounslow we see three opportunities to build on our work to date and further strengthen our collaboration and
Composition
Memorandum of Understanding signed off at Board level by all partners to: a) Work together to develop a full business case for integrated care b) Develop joint working arrangements to deliver and ICP within Hounslow. This is underpinned by CEO level sign off of a Programme Governance Framework. Alliance Agreement Our initial focus is on the design and shaping of the new care models. The Alliance Agreement will enable service delivery to be aligned to the new models of care, supplementing, rather than replacing existing service contracts. The Agreement is a contractual framework which unifies providers towards a shared set out
involvement of the commissioners. This arrangement provides a mechanism to alter contracts and unify budgets as needed to ensure effective alignment with the new models of care and the associated improvement measures and agreed collective outcomes. Alliance Contract An alliance contract is a single contract whereby the provider partners will enter into a single arrangement with the CCG to deliver services. This will require contract integration and all
partners. We will need to develop sufficient internal governance arrangements and determine the mechanisms by which we will hold each other to account as well as an integrator function to manage the delivery of care within a single contract. Today April 2023
Building resilient communities Sharing knowledge Leaders empowering staff to work to common values and behaviours Establishing trust and transparency
Relationship building underpinning the agreements and contractual framework
As the ICP progresses from Alliance to Contract the partners will: 1) Move from delegated unified budget within existing contracts to 2) A single contract across the partnership April 2020
Partner commitment: What we have in place
Board level sign-off of Memorandum of Understanding with the purpose of working together to develop a full business case for integrated care, and to develop joint working arrangements to deliver and ICP within Hounslow Well established Health and Care Partnership Board attended by all partners Five clinical workstreams with clinician and managerial representation across all partners. In the Local Authority this also extends beyond social care and includes housing
Staff resource input across partners to progress the work
ICP Programme Manager shared across all partners Project support from a range of partners, including joint commissioning team SROs for projects across a range of partners Clinically Lead Groups Analyst Group, chaired by HRCH and includes the council’s Business Hub Primary Care Network Clinical Directors covering each of the clinical workstreams All partners attending the TCSL course. This is an intensive NHS ACT Academy 6 day course. Hounslow has 11 representatives ranging from directors, to senior clinicians, PCN Clinical Director, and VCS representation. Local Authority has committed to funding a 6 month OD programme to strengthen relationships. Programme Governance framework signed off at CEO level. This includes monthly CEO strategy setting meetings and weekly Executive Director calls to drive forward the programme. We continue to build on the strong partnership working already in place in Hounslow. Our integrated care programme is building and expanding on the success of our many partnership models/initiatives. Partners are committed to achieving the vision of the ICP in a collaborative way. Enabler work groups established, including CFOs, BI and Analyst group and Comms and Engagement groups to support the programme and the development of care models through the clinical workstreams VCS are an integral part of the programme governance and delivery and active partners in working groups to co-design the emerging models
Partner commitment: Building on what works well
Locality Working with GP Consortium, PCNs and Community Services (HRCH) In forming the PCNs in Hounslow, there has been a collaboration between community and primary care partners. Formal Memorandum
to improve healthcare for local people, join up and coordinate health care services in better ways and break down organisational barriers by creating multi-disciplinary teams who focus on patients’ specific needs in various localities. New recruitment is done together, with the employer being the
although they are based within the enhance primary care team and accountable to the GPs. The Hounslow community service, GP consortium and PCN staff work as a single team to deliver the long term plan’s vision of a neighbourhood. This is overseen through a monthly working together meeting where collective approaches are agreed and refined.
Stems Growth Reduces Transactional Costs Clinical Transformation
Diabetes Services
with the GPs, Community Trust and Acute Trust to deliver an intermediate diabetes services as a three way partnership.
develop and provide the whole diabetes pathway.
PCN leadership:
transformational)
potential for job share) PCN delivery teams:
with Vol Sec)
Stems Growth Clinical Transformation
Relationship between Health Services and the Local Authority
part of the Community Recovery Service, which is
Stems Growth Clinical Transformation
Primary Care Patient Coordination Service
approach, efficient processes and share best practice.
agreed that the service would support Consortium and network leaders and support the delivery of consortium and network priorities. This has strengthened the close working between HRCH and Hounslow GPs and supported them to identify and focus on joint priorities
Clinical Transformation
Building on what works well: Relationship between Health Services and the Local Authority
JOINT COMMISSIONING TEAM
the CCG and LA in LD, OP, and MH. This provides a structure that focuses on joint working to deliver both organisations responsibilities while meeting the needs of the patient / resident.
delivering the right care, in the right place at the right cost. Joint working removes duplication and disputes and releases resources to ensure we deliver high quality affordable care.
Reduces Transactional Costs Reduces Transactional Costs
Health and Social Care Interface
levels of the programme. Adult Social Care have a dedicated resource to act as the interface between the programme and its
changes are communicated/implemented within the department, that ICP is kept high on the agenda, and that the workforce is well informed at every step.
team meetings, team manager meetings, regular blog updates and will soon offer comprehensive briefing sessions and lunch time drop by Q&A sessions.
ensure that resource is balanced, business as usual continues and that Adult Social Care are able to maximise its contribution towards the ICP. This also gives the senior and departmental leadership the opportunity to ensure that its overall priorities and pipeline initiatives are aligned to the ICP.
Clinical Transformation
Integrated Services
has an integrated multidisciplinary teams from both health and social care. There is an increased social work presence in the CRS as part of the borough’s reablement function.
facilitate quicker discharge.
Mental Health Unit. This is a virtual team that incorporates health and social care staff, housing department and mental health trust, all the necessary skills to facilitate effective discharge
Stems Growth
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Model of care
The Hounslow Model of Care proposes a range of integrated approaches for the local population who are most at risk of hospital intervention or long term care. We are also building integrated approaches to support the health and wellbeing of the local population without a long term condition. These solutions will be around the Primary Care Networks and established localities we have in place. Partners have agreed to prioritise the Model
address the urgent care deterioriation and allow us to stem that growth, including how the population accesses services Partners will use our evaluatory approach to test effectiveness and lay a platform for continuous improvement.
most appropriate place for care This neighbourhood and place level Model of Care will also work to the common sector level principles set out by NWL ICS.
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21 Our Business Intelligence and Analyst Group is driving our approach to population health management. It is driven by the senior intelligence and insight managers across all provider partners, CCG and the local authority including social care, and public health. The group is gathering data and insights about population health and wellbeing across multiple care and service settings, with a view to identifying the main health care needs of the community. The data is crucial in enabling the clinical workstreams to identify the target populations and design solutions accordingly. A key principle of the group is to build a Heat Map at locality level and then identify primary care networks for service redesign as appropriate. Key activity underway: a) tracking of historical activity data for a specific patient cohort associated with significant growth in urgent care presentations. b) Map the data at Lower Super Output Area. This will provide the necessary granularity for monitoring trends and identifying hotspots. The next phase is to match the activity data with cost data to enable the system to understand a ‘do nothing’ scenario at locality level based on annual growth assumptions. By April 2020: Work with Information Governance Leads to develop a tool with patient level data that will segmentation of people with distinctive characteristics and needs into target groups.
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Partners have agreed to prioritise the Model of Care to focus on the components that will reverse the growth in Urgent Care. This has resulted in four priority areas of focus for the initial phase of the programme.
care for Hounslow residents.
which will underpin a number of the changed models of care.
Hounslow, both form a public health and community asset perspective.
Hounslow Locality Partnership Group Developing IC working in Primary Care Networks
Model of Care Design Deterioration Rising Risk Falls Atrial Fibrillation Home High Intensity Users Urgent Care
Hounslow Locality Partnership Group Developing IC working in Primary Care Networks
The Hounslow Falls SRO is also the NWL Falls SRO. The ICRS/LAS pathway is being developed and will be shared as a blueprint across NWL
Priority areas of focus
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How this plan and areas of focus deliver NWL recovery plan
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NHS providers, the CCG and the Local Authority. The purpose of the group is to agree how the Alliance will manage the budget across organisational boundaries, recommend the most appropriate contractual enablers to establish the Alliance. It is the sign off group for ensuring new models of care are sustainable and affordable.
the level of savings expected from providing care in the most economical setting, where clinically appropriate, via the new integrated care model.
the income providers are receiving. The CFO Group is working on the principle that by stemming growth and redesigning clinical pathways this will contribute to wider system recovery. 1. Stemming Growth 2. Reducing Transactional Costs 3. Clinical Transformation Stemming growth
doing this through the lens of managing demand and non-elective growth.
prevention and demand management. These is in line with NWL Recovery plans and we have working group tasked with reducing admissions, focussing on appropriateness of attendances, high intensity users, and work with social care colleagues to improve ‘discharge to assess’.
model of care provision to reduce the cost to the system of these admissions and mitigating further growth in non-elective admissions.
How this plan and areas of focus deliver NWL recovery plan
27 Reducing Transactional Costs In July, Hounslow CEOs endorsed a proposal to work towards implementation of unified budgets, by April 2021. This is based on the integrated budget payment approach set out by NHS England as it supported Vanguards and early adopters for New Models of Care and is characterised by the following features:
vired across from multiple contracts into a unified budget. This could be undertaken on a ‘real time’ or ‘shadow’ basis as determined by the ICP. The flexibility offered within the workstreams to respond to the emerging priorities of partners, such as the PCNs will be beneficial to wider system recovery.
clarity on financial benefits and recurring costs.
transactional costs and focusing on service improvement rather than contract negotiations.
make more efficient use of space.
How this plan and areas of focus deliver NWL recovery plan
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effective (and de facto cost effective) setting. By stopping activity where it adds little value, we are seeking to reduce costs while improving outcomes for patients.
This includes:
risk’ users,
care Timescales Each workstream has a go live date of April 2020. The CFO Group will support and test each of their proposals against value for money principle and ensuring that repurposing the money has an overall gain for the system, that is beneficial to system wide recovery. The proposals will be required to demonstrate cost reduction/impact by Q4 2020/21, with a quarterly review of progress to achieve this against milestones. Alongside this the CFO Group will develop and agree a mechanism for risk and gain share to underpin the implementation of integrated care.
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A Summary of our Journey to an ICP 2019/20 – 2022/23
Phase 1: 2019/20 1. Develop joint approach to population health Management. 2. Implement OD programme focusing on relationship building and leadership at all levels of
Hounslow residents and staff and define our common challenges. 3. Alliance Agreement in place with Alliance Board formally established and Agreement signed off by all partners sovereign boards. This will financial principle agreement and gain share etc 4. Jointly develop outcomes, measurements and processes. 5. New models of care agreed for Urgent Care and High Intensity Users priority areas. This will include unified budgets for the care models approved by CFO, ED and CEO levels. 6. Embed Communications and Engagement Strategy through a process of co-design and co- production with staff and local
aligning Quality Improvement processes across partner
Phase 2: 2020/21 1. Alliance Agreement live and Urgent Care and High Intensity User models of care mobilised at PCN level with a Q4 evidence of return on investment. 2. Home, Falls, Rising Risk and AF new models of care implemented (Q2). 3. Identify shared workforce problems and develop a workforce strategy. 4. Information Governance Agreement and Framework approved and implemented. 5. Clinical workstreams bringing online models
scope’ services: (see slide 12) In-scope value: Up to 150m Phase 4: 2022/23 1. Wave 3 ‘in-scope’ services (slide 12) developed through clinical workstreams and
(Q4) In-scope value: £200m to £340m Phase 5: 2023/24 1. Develop and let Alliance Contract (let by April 2023). 2. Wave 4 in-scope’ services as developed during 2021 3. Fully Integrated, all services, aligned social care, population health management approach In-scope value by 2023: £420m (total CCG budget) and relevant social care/public health budgets as per agreed models of care and cross NWL London with other CCGs. Phase 3: 2021/22 1. Wave 2 ‘in-scope’ services (slide 12) developed through clinical workstreams and
(Q4) 2. Place/borough level ICP working within NWL ICS and delivering key components at sector level (as defined in 20/21. 3. Active Case Management Embedded In-scope value: £150m-£200m
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ED Management Group Chair: Rotating Attendees: Exec Directors
4 Clinical Working Groups Deterioration Rising Risk Falls AF Home High Intensity Users Urgent Care
Health and Care Partnership Board Chair: Mary Clegg/Provider Exec? Attendees: ED Group, VCS Rep, CFO Rep, GPs, PCN GP, Consortium COO CEO Group Chair: TBC Attendees: CEOs CFO Group Chair: David Hawkins Attendees: CFOs W L, CW FT, HRCH, GP Consortium LA, CCG
Hounslow Locality Partnership Group Dev eloping IC working in Primary Care Networks Purpose of the ED Group is to:
any barriers to the working groups
through dev eloping PCNs
the progress of the working groups and enabling workstreams
suggested by working groups; are they real or tangible
f rom the CFO Group.;
the perf ormance f ramework to ef f ectively manage emerging Partnership Alliance Purpose of Health and Care Partnership Board:
programme to account
decisions
Purpose of CEO Group
f or IC Strategy
about the Alliance including f inal decision about organisational commitment Purpose of the CFO Group is to:
boundaries;
care
f ewer interv entions v ia the new IC care model
Delegated Decision Making Assurance Decision Making and Direction/Strategy
Enabling Workstreams in line with NWL features of integration Comms and Engagement Group IG Group Clinical Reference Group Collaborative Leadership & OD
Advisory
IT & Digital Infrastructure Estates
Hounslow Health and Wellbeing Board Provider Boards NWL ICS
Governance arrangements
Relationship with Sovereign Boards
HRCH Chelsea and Westminster
Overtime the specific programmes would expect to be aligned with service line and Divisions Operating Plans with project
West London NHS Trust
Services Senior Management Team and then Executive Team.
required
ensure the sharing of work on ICP work streams for all geographical areas covered by the Trust
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The ICP would be looking to take forward its ‘agile model’ and integrate with emerging NWL ICS through key support in: Governance & Inter-Operability
architecture and governance for ICS, that our local ICP/borough level arrangements will align with
to help local areas/analyst group define Hounslow population needs at borough and neighbourhood level.
Digital
communications and ‘test and scale’ approach with NWL Digital Transformation Group
enablers to underpin service transformation.
Workforce Development
site for NWL Workforce Development e.g. new roles
Health & Care academy (apprenticeship schemes) being developed and extend single model across NWL
workstreams where Hounslow ICP is testing/early adopting
Finance
borough level system control total.
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Vision and purpose Developing plans Bringing teams together Trying new things
To develop a model of practice for reducing the impact of High Intensity Users as part of the Integrated Care Programme. The purpose is to improve the experience of users who are in regular contact with multiple services without resolution of issues to their satisfaction. This is an adult only cohort.
The HIU Workstream oversees the Frequent Attenders Operational
cohort of high cost frequent attenders and w ork w ith MDTs to develop care plans of identified
being tracked and costed and fed into the w orkstream group to inform a potential service level solution. The HIU w orkstream is currently w orking to:
high intensity users that moves beyond frequent attenders
various service areas to identify heaviest utilisers of multiple services
services utilised
local area coordination models
There is representation from multiple services and partners
group and service level groups. Red Cross is now represented at the work stream level meeting. The MDT approach to the Operational Group has been particularly successful which is solution focused and demonstrates a real range of patient journey; the solution will not be a one size fits all.
The group intends to link in w ith the new primary care link w orkers to establish a model of care for this group and build on the w ork. The group has also started exploring the Local Area Coordination models as potential solutions and build on existing successful models elsew here. By triangulating the data across all partners, the group is especially keen to identify the needs of that cohort and build the solution around them. For instance, West Mid data indicates that nearly 70% of HIU at A&E have been diagnosed w ith underlying MH condition w hich w ill inform the joint approach to addressing their needs and reducing impact on services across Hounslow .