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 Pi Ltd
Purposes for Information Sharing B. Care coordination and planning: C. Risk Stratification for F. Understanding Population Supporting coordination of care Case Finding: Identifying Needs: Strategic and across providers those at risk of an adverse Commissioning Needs Analysis event Sharing for Sharing for direct care commissioning A. Using Patient Medical D. Tracking Outcomes across E. Developing a Capitated Records, Care History Inc. a Pathway of Care: Tracking Budget and New Care Model: Prescriptions Electronically: particular cohort groups Profiling and segmenting the Integrated Digital Care irrespective of care setting population & developing a Records to improve care capitated budget Pi Ltd
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 Pi Ltd
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 Pi Ltd
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 our 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 Pi Ltd
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 outpatient attendances Pi Ltd
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 Pi Ltd
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 Pi Ltd
Pi Care and Health Offers Requires • Service use data (activity and costings) • Strategic and operational implementation integrated at an individual level plan • Pseudonymised (using NHS Number as • Senior level buy in and SRP leadership identifier in line with sharing rules) • Work on data dictionary and understanding • Ability to take in historical data set (up to 3 of data fields for sharing years) with data flows updated monthly for • Information Governance agreements and a variety of systems SLA with CSU/DSCRO • Integrated database which can be • A trained local resource of licence holders presented on standard and bespoke (Super users and users) skilled in analysing dashboards, tailored to local priorities integrated data • Routine reporting capability • A set of business intelligence priorities for • An integrated view of journeys taken across the creation of meaningful dashboards and the health and social care system, that is reports that can essentially become the not possible to achieve from existing first local workplan for applying the tool systems Pi Ltd
What worked for us • Commitment at Chief Officer level and buy-in of key specialists within organisations (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 Pi Ltd
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• Placeholder for screen shot - contingency Pi Ltd
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 Pi Ltd
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