The Leicestershire Experience: Delivering Better Care Together with - - PowerPoint PPT Presentation

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The Leicestershire Experience:

Delivering Better Care Together with Pi Care & Health

Cath Roff – Chair, Director of Adult Social Care, Leeds Cheryl Davenport, Director of Integrated Care, Better Care Together Brenda Howard, Programme Manager, Better Care Together

Pi Ltd

‘For the first time, NHS and local authority partners across Leicester, Leicestershire and Rutland can analyse the journeys taken by local people across the whole health and care system. Our interactive launch involved over 50 champions from partner organisations. The tool will help us plan and measure the impact of all the service improvements we are making jointly within our Better Care Together programme.’ Cheryl Davenport

Purposes for Information Sharing

• A. Using Patient Medical

Records, Care History Inc. Prescriptions Electronically: Integrated Digital Care Records to improve care

• C. Risk Stratification for

Case Finding: Identifying those at risk of an adverse event

• E. Developing a Capitated

Budget and New Care Model: Profiling and segmenting the population & developing a capitated budget

• B. Care coordination and planning:

Supporting coordination of care across providers

• F. Understanding Population

Needs: Strategic and Commissioning Needs Analysis

• D. Tracking Outcomes across

a Pathway of Care: Tracking particular cohort groups irrespective of care setting Sharing for direct care Sharing for commissioning

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The challenges facing Adult Social Care

• Ongoing austerity measures - an even higher bar to achieve savings
• Social Care and new models of working - what is the new offer to the public
• Implementation of the Care Act – Phase 1, postponement of Phase 2
• Implementation of the living wage
• Personalisation/personal budgets
• Perceptions about the status of social care as a profession
• Demand management
• Recruiting/retaining the workforce
• Statutory – how to play non-statutory

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The challenges facing Adult Social Care working with Health

• NHS reorganisation - how to maintain relationships/momentum
• Engagement with health is too complex, so many elements and organisations

– unmanageable

• Local Government funding is not protected and has delivered efficiencies. Do

Health have the same incentive to transform?

• Fears that left shift = cost shift, without recognition of social care pressures
• Traditional focus for LA relationship has been core delivery of Adult Social

Care – need to move to broader level on wider determinants and prevention agenda

• Keeping strategic cohesion at a National, Regional and Local level
• Track record of joint working?
• Democratic deficit – NHS understanding of working with council members

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What we have achieved

• We now know how people flow through health and social care – where they

touch the system

• Collaborative leadership is now supported by shared information – ‘one

version of the truth’

• 26 skilled practitioners working as a ‘community of interest’ across 10 council

and NHS provider/commissioner organisations

• Customisable dashboards revealing otherwise unachievable insights into how
• ur services impact upon each other
• Using these insights to plan, commission, and audit services better by re-

shaping care, intervening earlier and working as a whole system to achieve Left Shift

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Better Care Together

• Integrated dashboards for each of 8 workstreams
• Data matched at Citizen level across Leicestershire, Leicester and Rutland
• Acute Care (inpatient, outpatient, A&E)
• Social Care packages
• Mental Health
• Learning Disability
• Community Care and therapies
• Ambulance
• 111
• Urgent Care Workstream
• Patients with high numbers of emergency admissions have already had outpatient

attendances and are known to hospitals

• Patients who are high users of emergency services have Opthalmology and MH
• utpatient attendances

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The impact we’re starting to have

• The work stream dashboards have significantly helped with
• the services accessed by people known to have had a fall, their demographics and the

services accessed before and after having a falls assessment; similar work is also underway on dementia services

• comparisons of service usage before and after a period of reablement

This allows service leaders and commissioners to identify areas for potential improvement in care pathways and to assess whether developments are leading to anticipated shifts in use of services

• Defining the social care impact following an emergency UHL and LPT

admission

• impact on social care after defined periods – and before and after costs and activity

for defined periods

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The impact we’re starting to have

• Analysis to support BCF refresh and Urgent Care Vanguard
• 10% of patients are reported to take up 55% of total bed days, dashboards show

cohorts defined by age, LTC, primary diagnosis to relive the pressures the 10% create

• Dashboard now being created to track the impact of intensive community

support beds (at home nursing support)

• Comparison to other services, impact and overall benefit

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Pi Care and Health

Offers

• Service use data (activity and costings)

integrated at an individual level

• Pseudonymised (using NHS Number as

identifier in line with sharing rules)

• Ability to take in historical data set (up to 3

years) with data flows updated monthly for a variety of systems

• Integrated database which can be

presented on standard and bespoke dashboards, tailored to local priorities

• Routine reporting capability
• An integrated view of journeys taken across

the health and social care system, that is not possible to achieve from existing systems

Requires

• Strategic and operational implementation

plan

• Senior level buy in and SRP leadership
• Work on data dictionary and understanding
• f data fields for sharing
• Information Governance agreements and

SLA with CSU/DSCRO

• A trained local resource of licence holders

(Super users and users) skilled in analysing integrated data

• A set of business intelligence priorities for

the creation of meaningful dashboards and reports that can essentially become the first local workplan for applying the tool

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What worked for us

• Commitment at Chief Officer level and buy-in of key specialists within
• rganisations (particularly Information Governance, Business Intelligence and

Analysts/Data Specialists

• Regular communications
• Internal trouble-shooters to keep things moving in individual organisations
• Neutral Project Management/facilitation as the agent for building the

community of interest – and this can be part-time!

• Partnership approach to problem solving with the key partners in the chain,

CSU and Pi

• Underpinned by good Governance and focus on solutions
• Well planned and well timed launch event to showcase the capability of the

tool

• Clinical champions willing to engage in the project

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• Placeholder for screen shot - contingency

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The Leicestershire Experience: Any questions?

Cath Roff – Chair, Director of Adult Social Care, Leeds Cheryl Davenport, Director of Integrated Care, Better Care Together Brenda Howard, Programme Manager, Better Care Together Also visit the Pi Stand or contact Gill.Smith@p-i.net