1. Oxfordshire Clinical Commissioning Group Using an outcomes based contracting approach to improve the care of older people Oxfordshire CCG’s approach to contracting for outcomes

2. Oxfordshire Clinical Commissioning Group This presentation  Why an outcomes based contract?  Outcomes  Approach to procurement  Outcomes and Indicators  Service Scope  Service Model  Incentivization

3. Oxfordshire Clinical Commissioning Group The case for outcomes based contracting  Current commissioning converts money into activity, not outcomes  Incentives are not aligned to maximise benefit across the patient pathway  Current approach is financially unsustainable  If we are serious about integration we need a different approach to commissioning

4. Oxfordshire Clinical Commissioning Group How is an OBC contract different?  It aligns commercial arrangements to deliver outcomes for patients  It can deliver the optimum VFM service for patients and tax payers as commissioners will seek to pay out incentives to reward excellence  It supports integration through the inclusion of all relevant providers that jointly will need to achieve outcomes  It supports collaborative approaches through gain share arrangements to share financial savings between providers and commissioners  It provides a change mechanism for improvement and refinement  It creates stability for providers (and patients) and sets the pace of change over a longer-term contract It remains an NHS standard contract!

5. Oxfordshire Clinical Commissioning Group Approach to procurement  Integration central to approach  Services in scope provided by two main NHS providers  Providers had begun to work more closely together  Asked the two providers to work together and provide a single response  Achieved “most capable provider” designation  Contract negotiation to commence

6. Oxfordshire Clinical Commissioning Group So-what outcomes will drive individual and system change?

7. Oxfordshire Clinical Commissioning Group Outcomes and indicators OutcomeExample Indicators I want to be helped to be healthy and active % with fragility fracture who recover to previous level of functioning; % with no on-going care after reablement I want to be helped to be as independent as possible in the best place for me Proportion still at home 90 days after discharge; avoidable sight loss; DTOC; admissions for ASC conditions When I am in need of care it is safe and effective Effectiveness of community services; incidence of pressure ulcers I want to have a good experience and be treated with respect and dignity % who die in place of their wishes; experience of overall care

8. Oxfordshire Clinical Commissioning Group Service Scope  Non-elective admissions  Community hospitals  Community assessment and admission prevention services  Reablement services  Intermediate care beds

9. Oxfordshire Clinical Commissioning Group Provider Service Model proposals 1. Unified care network 2. Ambulatory care by default 3. ‘Specialist Generalist’ care 4. Universal Best Practice 5. Working with others Transforming care for Older People in Oxfordshire 9 Making our health and care systems fit for an ageing population. Oliver et al. Kings Fund 2013.

10. 1. Unified Care Network Therefore care must be: Individualised Comprehensive Coordinated Consistent Capable 7 day Right place ‘Close to home’ We propose: A seamless network of complex care: Community Care Hubs – Economy of scale – Resilience of scale – Quality & capability of scale eg coprovision of physical & psychological Health ‘Acute site 1’ ‘Community Care Hub Plus’ Integration across multiple axes Virtual presence of 2 ○ & 3 ○ capability Information sharing Telemedicine Transforming care for Older People in Oxfordshire 10 The Patient Frail, comorbid, vulnerable An individual in a network A partner in care Evaluating integrated and community-based care. How do we know what works? Nuffield Trust 2013

11. 2. Ambulatory Care by Default Patients Need: Prompt, effective, co- ordinated assessment and treatment Right place, right time Advanced decision-making with the patient Care to be safe and compassionate We Propose: The best care, closer to home. Infrastructure and teams adapted to outreaching care Re-balancing of the ‘care footprint’ Universal ‘active interface’ – EMU, EAU, SEU, ED Distributed advanced care: – diagnostics (PoCT & Radiology) – complex treatment and monitoring: true ‘Hospital at Home’ 11 Transforming care for Older People in Oxfordshire Directory of Ambulatory Emergency Care for Adults, 3 rd edition. NHS Institute for Innovation. 2012

12. 3. Specialist Generalist Care Model of Care Acute medicine In acute hospitals For adult patients with the most severe illness - General Medicine - Geriatric Medicine - Stroke - General Surgery - (non-MTC) Trauma Generalists  integrated platform of holistic care. Embedded Geriatric & Psychological Medicine Specialists  more focused (specialised) input in some settings. Complex and Interface medicine In both - acute hospitals - Community Care Hubs Longer LoS Complex needs Usually (very) elderly Dementia prevalent Risk of Harm Geriatricians Generalists Psychological Medicine + ‘the network’ ‘Active Interface’ capability Embedded in all assessment units Outreaching support to primary care delivered from Community Hubs Advanced relationships with clinical colleagues in the acute hospitals Cohort drawn and developed from - 1 ○ & 2 ○ care - medical & non- medical Transforming care for Older People in Oxfordshire 12 Future hospital: Caring for medical patients. Future Hospital Commission 2013.

13. 4. Universal Best Practice to deliver the best Patient-Centred Outcomes Patients need care that is: Effective Harm-free Joined-up Delivered in partnership Delivered by familiar people We Propose: Promotion of self-care Enabling care Tailored multi-disciplinary care – ‘CPA’ Zero delays Enhanced Recovery approach Capable care 24-7 ‘Care to the patient, not patient to the care’ Care environments that are universally frail-appropriate and dementia-appropriate 13 Tr ansforming care for Older People in Oxfordshire Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database of Systematic Reviews 2011.

14. Universal Best Practice to deliver the best Patient-Centred Outcomes Current Dis-integrated, isolated Provider-determined location Dated accommodation Weak clinical capability Brittle staffing Maximum 40 hour clinical care Minimal governance Opaque outcomes Proposed: Integrated Close to home Purpose-built Scaled to optimise care – Resilience, quality and value! – Co-location of complementary services Strong clinical team – medical, nursing, therapy, mental health 24-7 clinical capability Strong governance Transparent outcomes – Benchmarked – Quantitative and Patient-reported (PREM) National audit of Intermediate Care 2013. NHS Benchmarking Network. 14 Transforming care for Older People in Oxfordshire An exemplar: Intermediate Care beds

15. 5. Working with Others Primary Care needs: Immediate high quality advice Responsive outreaching home care Highest quality patient information Development of clinical capability We propose: Direct ‘phone access to senior clinicians CPA and ambulatory care Transformational improvement in IT Professional development opportunities 15 Transforming care for Older People in Oxfordshire Social Care providers need: Third sector providers need: The best functional outcomes An accurate client prognosis Excellent clinical information Effective response to medical crises CPA delivered by expert teams Advanced clinical network capability delivered 24-7 into the home Integrated Health & Social assessment A meaningful role in patient care Support during client crisis Valuing the opportunity of their offer Integration into the Network of Care Open access to CPA and ambulatory care Lessons from experience. Making Integrated care happen at scale and pace. Kings Fund 2013.

16. Oxfordshire Clinical Commissioning Group Incentivization-1  It is the commissioners intention to spend the money. Budget c£90m  Quantum to be at risk: TBC but 15-20%  At (e.g.) 20% that equates to £18m per annum  That £18m is shared across the outcomes and specific indicators. Each point (out of 100) is worth £180,000

17. Oxfordshire Clinical Commissioning Group Incentivization-2  So-if we allocate 30% of the incentive pot to “healthy and active”-that is worth £5.4m…  Is that enough money to drive a more proactive and preventative service model?  Phasing of incentives: what can be achieved in year 1, what needs 5+ years?  Improvements on baseline, and then for review  “bonus payment” for consistency across outcomes

18. Oxfordshire Clinical Commissioning Group Contacts  OBC Programme Lead:  Catherine Mountford catherine.mountford@oxfordshireccg.nhs.uk catherine.mountford@oxfordshireccg.nhs.uk  Clinical Lead  Dr Barbara Batty  Barbara.batty@oxfordshireccg.nhs.uk Barbara.batty@oxfordshireccg.nhs.uk