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Commissioning Integrated Care for Older People London 1 February 2005 Paul Forte, Richard Poxton Chris Foote, Tom Bowen, The Balance of Care Group. Workshop objectives. Integration of health, social care and other services for older people: a high priority - but not easy to achieve

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Commissioning integrated care for older people london 1 february 2005 paul forte richard poxton chris foote tom bow

Commissioning Integrated Care for Older PeopleLondon1 February 2005Paul Forte, Richard PoxtonChris Foote, Tom Bowen,The Balance of Care Group

Workshop objectives
Workshop objectives

  • Integration of health, social care and other services for older people: a high priority - but not easy to achieve

  • Commissioning is a potentially powerful tool to support this, but how does it work in the current environment?

  • What we’re aiming for today is:

    • strategic and practical insights into commissioning integrated care

    • opportunities to consider potential local implications

    • ideas for further action

Workshop agenda
Workshop agenda

  • Commissioning environment

    • What do we mean by integration?

    • Current issues in commissioning integrated care

    • Group work: what’s happening locally at the moment?

  • What’s the evidence?

  • Whole System modelling of Older People’s services

    • Aligning demand and supply

    • Telemedicine and telecare

    • Group work: developing local ‘whole system’ perspectives

  • So what will you do about it…?

First thoughts
First thoughts…

  • Take a few moments to introduce yourself to your neighbours and discuss:

    • your take on what’s affecting integrated care commissioning – what’s getting in the way?

    • your ‘magic bullet’ solutions – and what’s looking promising?

    • your expectations of today’s workshop

Typical demands
Typical demands…

  • We want to reduce emergency/ unnecessary admissions

  • We want to improve the flow of patients through acute beds

  • We want to reprovide our care home stock

  • We want to provide high quality care

  • We want to provide a ‘seamless service’

  • We want to be at home!

Begging the following questions
…begging the following questions

  • What alternative care processes are there?

  • Where are they/ should they be located?

  • Which types of users and patients are these suitable for and how do we identify them?

  • What are implications for the types and volumes of resources required such as staff, beds and places?

  • When might we achieve this by?

  • Who pays?

  • Why aren’t we doing it already?


Strategy/ vision

- stakeholders

- sense of purpose


- identify need/ demand

- priorities

Monitoring & evaluation

- service delivery

- client satisfaction

  • Purchasing

  • settings/ providers

  • contracts

Commissioning implications
Commissioning implications

  • Tension and complexity is the working currency

  • A need for both long and short-term views and a capacity to respond at both these levels

  • To be effective a key focus of the commissioning process should be to incorporate the patient/ user experience and engage the clinicians

  • Data and information – who owns it and who has access to it?

Stakeholders in commissioning
Stakeholders in commissioning





What is integrated care i
What is Integrated Care -I?

For the older person, it is their involvement in their care such that they feel in control of a seamless and easily accessed service as it affects them.

That permits them to act responsibly both to themselves and their communities so that they feel valued and part of their community.

What is integrated care ii
What is Integrated Care – II?

For the professional, it is working in a context of positive and supportive relationships, within and across boundaries, such that they can more easily provide an appropriate and timely service to their patients and colleagues.

What is integrated care iii
What is Integrated Care - III?

For the commissioners integrating commissioning results in robust partnerships across agencies and communities that provide innovative, high quality care which is cost effective.

Central to this is balancing the needs of the individual to the needs of the population, supported by the commissioning of shared information, shared training and development and shared governance.

Integrated care
Integrated care

Pre admission

Pre admission






  • Social details

  • alone, carers, accommodation

  • Risk factors:

  • age, drugs, co-morbidities,

  • psychiatric/

  • dementia, falls

  • Preventative care

  • Disease management

  • Managed populations

Source of referral


Waiting time


Decision maker

Reason for admission

Alternatives to admission to acute setting

Discharge planning

Delays in planning

Delays in execution

Alternative locations for discharge

Admission diagnosis

Inpatient diagnosis

Delays in diagnosis

Chronic disease

Alternative access for diagnosis

Delays in therapy

Alternative settings for therapy (especially rehab)

‘Revolving door’

Avoidable eg. through chronic disease management

Alternative locations for readmission

Future care trends
Future care trends

  • More ‘active rehabilitation’ in the community: hospitals, care homes, clients’ own homes

  • Blurring of boundary between health and social care environments

  • More flexibility and devolution of tasks within and between care professions

  • More active ‘upstream’ management

    • long-term conditions management

    • risk management of frail elderly in the community

    • health promotion

Older people
Older people

  • Define by age, condition?

  • Older people as individuals

  • Older people as part of a population

  • How do we identify and target particular types or groups of older people?

  • Role of carers

Intermediate care a cautionary tale of initiatives
Intermediate Care - a cautionary tale of initiatives?

  • Many definitions and models; poor evaluation; little scientific evidence (Melis, 2004)

  • Have tended to focus attention on patients who can be rehabilitated quickly – doesn’t take much account of ‘slow-stream’ rehab

  • However, community-based services could broaden their scope in this direction

  • More creativity both in locations for care and in the care processes themselves comes with better knowledge about patients

Pct reorganisation
PCT reorganisation

  • ‘Support for commissioning’

    • critical mass of appropriate skills

  • Overview of Practice-based Commissioning

    • strategic function

    • equity

  • Keeping the focus on integrated care

    • potential wide range of service providers

    • continuing alignment with social care services

Practice based commissioning
Practice-based commissioning

  • Commissioning is its raison d’être

    • strategic overview

    • support for Practices

  • Predicated on:

    • strong clinical leadership - essential for effective service development

    • clear strategic focus

    • case finding and service co-ordination

    • appropriate skills, information

    • mature partnerships

Payment by results
Payment by results

  • Currently focused on event-based care in hospital

  • Since money follows the patient, ‘healthcare outside hospitals’ can release funding for development of integrated care

  • But need to adopt whole systems approaches if, for example, hospital admissions are to be reduced

Direct payments
Direct payments

  • Money for assessed support, instead of services

  • Emphasis on individual choice, control, flexibility

  • Users at the centre; pulling together individualised patterns of support

    Challenges for integrated care:

    • not available for health support

    • important to move away from notion of ‘services’ as standardised and aggregate

    • in-house services and block contract issues

    • commissioners, clinicians and providers must work closely together

What does the evidence tell us
What does the evidence tell us?

  • Analysis of the local system is about transforming:

    • ‘suspicion’ into data

    • data into information

    • information into action

  • To support the commissioning basis:

    • developing the local vision

    • identifying and prioritising needs

    • resource implications and purchasing

    • alternatives to existing service delivery

Typical aims of a bed usage survey
Typical aims of a bed usage survey

To assess the potential for alternative approaches to care delivery across the local health and social care economy through:

  • identification of the number and types of inpatients currently receiving hospital care who might have:

    • been treated elsewhere instead of admitted,

    • required admission, but could now be treated elsewhere

  • including:

    • patients in acute wards

    • patients in community settings

    • elderly mental health placements

Patient profile age group n 444
Patient profile: age group(n = 444)

Average Age


Within aep admission criteria by specialty group n 316 acute beds only
% Within AEP admission criteria by specialty group(n = 316, acute beds only)

1st preference alternatives to admission by care location n 115 acute 61 non acute 54
1st Preference alternatives to admission by care location(n = 115: acute = 61, non-acute = 54)

Within aep day of care criteria by specialty group n 316 acute only



% Within AEP day of care criteria by specialty group(n = 316, acute only)

1st preference alternatives on survey day by location of care n 293
1st Preference alternatives on survey day by location of care(n = 293)

Key directions
Key directions

  • ‘Integrated home care’ is a priority

    • need to link intermediate care, rapid response, intensive nursing, management of long term conditions

    • involve the doctors eg comprehensive geriatric assessment

  • Rehabilitation in beds: acute or community-based?

  • Community hospital roles

    • fewer beds

    • resource centre role

    • north end of patch

  • EMH: care home provision to free up services

Priorities in developing frailty management
Priorities in developing frailty management

  • Importance of shared criteria which identify those at risk

  • Knowing when an individual’s condition changes significantly

  • Obtaining and sharing information

Indicators of avoidable admissions
Indicators of avoidable admissions

  • Readmissions concentrated in last 2 years of life

  • Need to avoid the first admission outside criteria

  • Admissions outside AEP are not related to number of previous admissions

  • Based on sample of 300

    • 40% of admissions outside AEP result from exacerbation of chronic conditions

    • on average each has 2 identifiable chronic diseases

  • The more risk factors, the more likely to admit outside AEP

Whole system modelling of older people s services
Whole system modelling of older people’s services

  • Key issues to address:

    • clinical engagement

    • modelling approaches

    • partnerships - in broadest sense

    • telehealth (

    • importance of data and information for evaluation and planning

Commissioning needs to pull initiatives together
Commissioning needs to pull initiatives together

  • National Service Frameworks

  • Payment by Results

  • Practice-based Commissioning

  • Healthcare outside Hospitals

    It’s crucial that there is common ground for care professionals and commissioners to drive these agendas

Alternatives to mau sau
Alternativesto MAU/SAU

The balance of care model
The Balance of Care model









The balance of care model1
The Balance of Care model

long -term

care bed




community nurse






respite care

day care centre



care assistant



Voluntary &

Private sector

nursing home

The balance of care model2
The Balance of Care model

long -term

care bed





community nurse






option 2

respite care

day care centre



option 3

care assistant



Voluntary &

Private sector

nursing home

Tensions in the system
Tensionsinthe system

Care Professionals

Non-Clinical Managers

Health Services

Social Services

High Dependency

Low Dependency

Dh telecare project
DH Telecare project

  • Support to develop cases for funding from the Preventative Technology Grant

  • Development of a cost-benefit decision support tool to enable identification of potential cost savings through:

    • reduced admission to residential care

    • reduced cost of home care packages

    • potential cost savings to the NHS (eg through reduced admissions to hospital)

So what next
So…. what next?

  • Personal action points arising from today’s workshop

    • how are you going to behave differently as a result of today’s workshop?

    • what will you do: tomorrow, in the next month, six months?

  • What might be potential local ‘work streams’

    • specific to your locality?

    • generic to the NHS?

  • Feedback to and from the Integrated Care Network: