“Help to Live at Home” Briefing: K Integrated commissioning for LLR Discharge Pathway 2 (Home with Support) WLCCG Board Meeting August 11, 2015 Leicestershire County Overview • Total Population = 650,489 • Population 65+ = 115,437 • JSNA predicted increase of 14.7% by 2037 • 2013/14 Home Care Expenditure • LCC Commissioned = £30.5m • NHS Commissioned = £10.9m • Total £41.4m • 149 providers • Existing Social Care contracts delivered approximately 1.7m care hours across Leicestershire Challenges: the current offer • Fragmented market and commissioning - over 100 agencies involved • Increase in demand and pace of demand with left shift - impact on await care list in early 2015 • Competing demands between Social Care, Continuing Health Care and self-funders in the market • Gaps in provision: • difficulties in securing right care at the right time • supply problems in some rural parts of the County • delays in hospital discharge • silting up of reablement throughput in HART Challenges- The skills market • Recruitment and retention issues for providers – Job satisfaction - time and task working practices – Limited career path – Difficulties attracting new people to the labour market – Low contract hours/zero hours contracts – Variable conditions of service (mileage, travel time etc.) • Difficulties for commissioners assuring provider employment practices due to numbers of providers • Not sustainable…. Current service model- does not maximise reablement/independence at home • Current payment model for domiciliary care services is based on Time and Task: – 15 mins (excl. personal care tasks) – 30 mins plus (incl. personal care) • Reablement is broadly limited to a single HART episode • Reablement not seen as part of the wider domiciliary care package • No incentives for providers to increase independence • No link with wider primary care/community/prevention services Joint working • Leicestershire County Council’s existing framework for domiciliary care was due to end in March 2015, extended to April 2017 • Extension allows for a new integrated model of care to be designed and commissioned with NHS partners • The LLR wide improvements for discharge and reablement pathways (per BCT) are being embedded • Joint commissioning between LA and CCGs • Joint procurement, joint service specification, joint outcomes • Tackle market risk, service quality, affordability • Address Care Act requirements Objectives • Reduce delayed transfers of care • Reduce permanent admissions to residential care • Drive up quality and innovation in the market • Seek improved outcomes for service users • Ensure best use of joint health and social care resources to meet growing demographic pressures • Achieve efficiencies in commissioning • Improve partnership working and joint commissioning capability Design Principles • Integrated service, built around the needs of the individual • Outcomes led care planning, maximising reablement • Consistent pathways into the service • Contractual terms to incentivise providers to meet outcomes • Better integration of domiciliary care providers within primary care, community services, prevention services in each locality • Smaller number of providers with whom more sustainable, strategic commissioning relationships can be developed • Resilient, sustainable market Clear Pathways Step Down- facilitating hospital discharge • HART will be an integrated service • All step down reablement will go through HART • Including Continuing Health Care Step Up- preventing avoidable admission • All community reablement to be done through Independent Sector providers • All ongoing support through Independent Sector providers • Health and Social Care domiciliary support commissioned through a joint service specification Contract payment mechanisms MECHANISM DESCRIPTION Stepped Cost Providers are paid at an agreed higher unit Approach cost for a fixed initial period, then at an agreed lower unit cost, to incentivise them to reable people as early as possible. This front- loads the incentive payment. Payment for Providers receive payment for an agreed achieving level of care, and once it is agreed that the outcomes (Pbr) outcomes have been achieved, payments continue at this level for a fixed period, before reducing to the ongoing new level of care (which may be nil). This back-loads the incentive payment. Provider delivery model MECHANISM DESCRIPTION Single provider Working with a single provider (including per geographical consortia) as the only point of contact within area a certain geographical area – this could be through a prime/sub-contractor arrangement Main provider There will be a lead provider within a with specialist geographical area: either a prime/sub- secondary contractor arrangement or LCC/CHC hold providers separate arrangements More than one Similar to current model but with a fixed provider per upper limit of providers in a geographical area, but with a area to aid contract monitoring and increase fixed upper limit competition within a zone Geographical market divisions MECHANISM DESCRIPTION Align to current LPT Community Health teams work in 7 LPT/CCG localities localities across the county, which would mean splitting the HTLAH contract into 7 areas which align with these Commercial Co-design with providers new areas to best differentiation support viable commercial operations based upon agreed parameters such as density or value Commissioning Approach • Lead commissioner model • Section 75 • One spec, one contract • Integrated performance management of providers • Single brokerage function • Simplified back office with view to integration • Savings and costs shared equitably Market Engagement 3 sets of market engagement events already held in Feb, May & July/Aug 2015 to build market readiness for: • Reablement- lessons from best practice, the national picture • Assistive Technology • Social Capital/Developing community resources • Outcomes commissioning & delivering to outcomes • Continuing Health Care • Service specification, lotting and procurement timeline • 18 lots proposed at OBC stage, covering 7 localities Service User Engagement • Specific HTLAH Focus group events held May & June 2015 with further engagement planned • Key themes and findings are informing the business case, service specification and Equality Impact Assessment and Section 75 Key Risks • Model not attractive or viable for CHC pathways/NHS commissioners • Council’s medium term savings plan not sufficiently aligned/modelled within the programme. • Market does not respond positively to new specification - not able to deliver outcomes approach, not able to procure across all lots/locations. • Risks to procurement timeline due to complexity and volume of work involved in delivering this jointly • Remodelling of core HART service not progressed at pace (dependency), which jeopardises delivery of HTLAH • Quality and availability of data (esp. CHC data) Chosen Provider Model: Limited number of providers per zone with fixed upper limit (of providers per area) • Proposal to divide each of the seven CCG Localities into 2-3 lots, depending on levels of care provision/anticipated demand • Fixed upper limit of 3 providers for larger CCG Localities • Lots based on 2014-15 levels of care provision (approximately 2,000 to 3,500 hours per week) • Lots will take into account urban and rural nature of area to produce more viable operating areas CCG Localities - Preferred Option Limited number of providers per Locality with defined Lots (operational areas) based on 2,000 to 3,500 hours per week Key benefits • 1 point of contact facilitates partnership working (quality & efficiency) • Regular minimum business for providers in designated areas • Allows for choice/market diversity via sub-contracting, alliance/consortia bids (including specialists) • Reduces volume & complexity of commissioning & contract monitoring (simpler referral & review processes, no “hand backs”) • Reduces risk of provider failure (compared to sole provider model) & easier for contingency planning in each area Table 1 – proposed Lots per CCG Locality Map CCG Draft Lot Number Locality in the Locality 1 North West Leicestershire Castle Donington & Coalville 2 North West Leicestershire Ibstock & Measham 3 North West Leicestershire Ashby de la Zouch 4 North Charnwood Loughborough East 5 North Charnwood Loughborough West & Shepshed 6 Melton Rutland & Harborough Melton Mowbray 7 Melton Rutland & Harborough Market Harborough 8 Melton Rutland & Harborough Thurnby & Syston 9 Oadby & Wigston Oadby 10 Oadby & Wigston Wigston & South Wigston 11 Blaby & Lutterworth Blaby & Countesthorpe 12 Hinckley & Bosworth Hinckley & Twycross 13 Hinckley & Bosworth Groby & Market Bosworth 14 Hinckley & Bosworth Broughton Astley & Burbage 15 Blaby & Lutterworth Glenfield & Braunstone Town 16 Blaby & Lutterworth Narborough & Lutterworth 17 South Charnwood Birstall & Anstey 18 South Charnwood Mountsorrel & Quorn Based on 2014/15 data for distribution of care packages Leicestershire Draft Localities and Lots 1 Castle Donington & Coalville 2 Ipstock & Measham 3 Ashby de la Zouche 4 Loughborough East 5 Loughborough West & Shepshed 6 Melton Mowbray 7 Market Harborough 8 Thurnby & Syston 9 Oadby 10 Wigston & South Wigston 11 Blaby & Countesthorpe 12 Hinckley & Twycross 13 Groby & Market Bosworth 14 Broughton Astley & Burbage 15 Glenfield & Braunstone Town 16 Narborough & Lutterworth 17 Birstall & Anstey 18 Mountsorrel & Quorn Next Steps • Outline business case developed and approved Now at Full Business Case Stage: Aug-Sept 2015 • Finalise analysis and financial model • Build in HART remodelling and back office assumptions • FBC to WLCCG Board and LCC Cabinet in October 2015, East CCG Board in November 2015 • Section 75 in progress • Procurement timeline from January 2016 • Transition period (with dedicated transition resources) planned during 2016 • Service to go live in mid 2016 – date TBC, dependent on FBC approval timescales .