1. Dr Laura Hill (Clinical Director, Crawley CCG) Adrian Flowerday (Managing Director, Docobo Ltd) Bharti Mistry (Project Manager, Crawley, Horsham and Mid Sussex CCG)

2. Outline of the Presentation Context (collective challenges) Data Enabled Planning Evolution of benefits and learning Next Generation Delivering the Forward View Sustainable Transformation A look under the hood of the technology

3. 21 st Century Challenges Nationally 2 million attendances at A&E monthly Crawley, Horsham and Mid Sussex CCGs >75,000 attendances at A&E annually

4. 21 st Century Challenges Complexities and fragmented care Multiple chronic conditions, complications, longevity combined with frailty and resilience, multiple medications, intensive care needs ( health [physical and mental] and social care), social isolation

6. Start of the journey late 2012 Stage 1: Segment population by risk of admission to provide Early Intervention Enabled …….. by Risk profiling, its application & further development

7. Crawley and Horsham Mid Sussex CCG Application of Risk Profiling Very high risk of admission High Risk of admission Moderate risk of admission Low risk of admission 1. Proactive Care via Multidisciplinary teams ( Integrated care) 2. Tailored Health Coaching 3. Intensive support, High cost low volume Diabetics Self Support

8. Multidisciplinary model of care Structural Integration and co-ordinated care

9. Benefits Sought and achieved Empowered Patient, Age well stay well, Promote Independence : patients reported improvements with respect to motivation and confidence to self care, their social network, emotional and physical well being Person Centred, co –ordinated care, whole patient, Integrated Partnership working: Multidisciplinary infrastructure in place serving a population of up to 50,000 Family centric: Considers the carer and associated family members Prevention and rehabilitation : >600 conveyances avoided, >200 admissions avoided, reduction in 2 unplanned bed days fro about 400 risk of admission patients

10. Development of Partnership Interdependencies and contributions recognised & Valued Clinical Directorship Commissioning Insight Digital Innovation and Technical experience

11. Evolution of Risk Profiling Models PARR Patients at risk of readmission (Hospital Episode Statistics only) CPM Combined Predictive Model ( risk of admission) ACG Adjusted Clinical Groups H&SC Combined Health and Social Care Data Multiple risk model 2006 2015 Combined Data Correlational approach Integrated Intelligence & Relationships

12. Catalysts for evolving risk profiling beyond risk of admission Integrated care needs Fragmented Health and Social care Understanding value of combined data Lessons learnt Risk profiling applications Integrated care needs (Multidisciplinary working) Highlighted Need for 1. Intelligence driven strategies for integrating care 2. Outcomes that optimise care not just risk of admission 3. Data led correlational approach to mitigating risk of deterioration in patients

13. …….a bold step.... Developing a New generation of risk profiling model Stage 1 Segment population by risk of admission to provide Early Intervention Stage 2 Develop prototype to address complex patient and social isolation

14. Film – summarises phase 1 of Integration work

15. Early Segmentation of complex patients and facilitating a support network 25% of high risk patients (~ 1450) (High risk patients comprise about 1% of the population) have at least 4 factors contributing to complexities Identified key factors and include co morbidities, depression, immobility, being housebound, memory impairment, multiple medications, bereavement Demand and Impact of complexities and social isolation better understood Increase support using existing community assets with improved connectivity

16. Community Based Integrated Teams Stage 1 Segment population by risk of admission to provide Early Intervention Stage 2 Develop prototype to address complex patient and social isolation Stage 3 Multi Risk Model with Integrated Intelligence from different care sectors

17. CCGS are working towards Seamless care by creating capabilities to Triangulate intelligence between care sectors Understand timelines, gaps, demand and capacity between sectors Manage transitions between care sectors …… Enable shift from service improvement to system wide transformation

18. Identifying Integrated Care needs - ArtemusICS™

19. ArtemusICS™ Enabling Cross Continuum Collaboration Health Sector Social care Mental Health Community Care

20. Success factors Driven by Clinical Insight Starting small and incremental change Innovative concept continually developed Patient at heart Information driven Technology supports the service Learning from trial and error on small scale before scale up

21. Your feedback please………

22. Dr Laura Hill Clinical Executive Director, Crawley CCG Adrian Flowerday Managing Director, Docobo Ltd Bharti Mistry Project Manager, Crawley Horsham & Mid Sussex CCGs