Chapter 11 - What do providers need?

How will providers deliver care?

The new models of care will require professionals delivering care to behave in different ways. This includes working with service users and carers so they are more empowered to set their own care goals and manage their own well-being, being part of a multi-disciplinary team and delivering more responsive and proactive care. They will need information systems to achieve this to help communicate with service users, carers and colleagues in their team, coordinate with colleagues about the care individuals are receiving and understand how individuals and their team are performing.

The expectation is that there will be different care models for different population groups. However, the working group has identified the core principles of care delivery that will apply regardless of care model choices and analysed the information needs, data and tools they imply.

What tools are needed for care delivery?

Care delivery will require the following tools that analyse and then display information collected in the data warehouse and provider systems:

Service user registry. To support an effective and truly integrated delivery of care, providers will need to have access to an accurate summary of information for each individual in their care, with input from all providers, the care coordinator and the service user.

Population analytics. Similar to commissioners and to the provider network organisation, individual providers and care teams should have the ability to define and measure indicators on their population’s needs, activity, outcomes and costs.

Service user identification capability. Care teams will have to care for a specific population group and therefore the segmentation capability is not necessary. However, providers will need to employ a more granular approach (e.g., risk stratification) to identify specific service users that they will need to focus more attention on.

Care planning capability. The care coordinator will need to have the ability to create a care plan and review progress and results. The care plan will be the road map for the integrated care that the individual will receive, ensuring its appropriateness and timeliness. As part of the care planning process, access to a library of care protocols should also be available, to support decision-making and ensure that the care plan being created is in line with relevant guidelines and best practices.

Intervention management capability. To ensure that they can respond to the specific needs of individuals in a timely fashion, care teams should be alerted to relevant events. This could include alerts issued when an individual requires an intervention (e.g., vaccination reminders), based on recent events (e.g., discharge from hospital) or on a "care gap analysis”.

Delivery analytics. A core principle of care delivery in Whole Systems Integrated Care is that the progress and impact of the care delivered to specific individuals and groups will have to be carefully monitored. Care teams should review the care they are delivering multiple times a week. Similarly, the individual and the care coordinator should have a review interaction at least annually to discuss the impact of the care the individual has received. These types of reviews will need to be informed by adhoc analytics that track metrics tied to specific care plans and models and are therefore different from the higher level outcome and service standard indicators determined by commissioners or the provider organisation.

Remote monitoring capability. Whole Systems Integrated Care has the objective of supporting user empowerment and the ability of individuals to receive appropriate care in their home and, where appropriate, to self-manage. To enable this, providers should have the ability to monitor certain service users remotely.

What will providers have to do and what information will they need?

In order to support new models of care and multi-disciplinary teams, providers as organisations will need to work more closely together and behave in new ways. First, providers need to agree on how they will cooperate, the population they will be supporting and the model of care they will use to achieve desired outcomes. They will need to set service standards and allocate resources to support and manage the performance of the multidisciplinary teams delivering the model of care. Information will support this closer working by helping providers make decisions about performance management, ongoing refinement of the model of care and using resources effectively.

Care provision is the core activity that providers will have to perform and has already been discussed in this chapter.

This section considers the behaviours and activities and the supporting information provider organisations will need to support improvements in care delivery. The flow diagram below sets out the most important actions provider organisations will need to take in planning, delivering and improving care.

What tools will provider organisations need?

Once again, many of the information needs for providers will have to be supported by a comprehensive data set and data warehouse with inputs from all providers and care settings. This is being developed for use across North West London.

Other tools include:

Population analytics and segmentation capability. Just like commissioners, providers should have a thorough understanding of their population. At a minimum, providers should try to have a parallel approach to population analytics and segmentation to the one that commissioners employ, to ensure that their understanding is aligned. However, a more sophisticated understanding of the population could enable better definition of care models and support improved outcomes for the population.

Performance analytics. Again, providers should be able to track, at a network level, the same indicators that commissioners are monitoring, to ensure compliance with expectations. They should also be able to track costs accurately to ensure care is delivered within the assigned budget. To ensure that the contribution of each provider in the network can be clearly measured, network-specific service standards are also expected to be put in place. Performance analytics should also track these at an individual provider (if not professional/clinician) level.

Payment calculation capability. Provider networks will receive payment from the commissioners and will need to have the ability to calculate the payment for each individual provider and to adjust it based on performance of the individual provider or of the network (upside/downside sharing).

Care model resourcing/costing capability. Providers will need to have the ability to quickly estimate the resources required and resulting costs of various care models, adjusting them continuously until they have defined an approach that delivers the desired outcomes well within budget. This could probably be done leveraging a commercial software solution (potentially even Microsoft Excel or equivalent).

Project management tracking. Providers will have to track very specific operational metrics as part of their performance monitoring. This need could likely be addressed through an existing project management software solution.

• What information needs will your provider organisations have in order to work together effectively under a new model of care?
• What data and tools do you need to provide this information?