Population Health Planning and Forecasting in Acute and Chronic Disease

Global healthcare challenges

Claire Cordeaux

So I think we all recognise, as Brittany said, these global challenges that we have. As people live longer, they’re living more with multiple long-term conditions, multi-morbidity, both physical and mental which puts a pressure on our health systems. We need to make sure that there’s proper access for people that the treatment’s in place. And also, our current system tends to look at curing people, not necessarily caring for them, and looks at potentially body parts rather than looking at the whole person. So, we’ve got a challenge really in the way in which we manage our health services to meet the needs of that group. And within our healthcare system, we have models that aren’t necessarily reflecting the new demands that we’re seeing. But also, we have issues around recruitment and retention of our workforce and our workforce is ageing as well. And we need to be able to make sure that our workforce fits the needs and the support needs of the patients, the people that we’re looking after.

In many cases, we have a fragmented system in health and in social care. And of course, if you’re in need of support for living with multiple chronic diseases, multiple long-term conditions, then you need probably both parts of that system. And where it’s fragmented, it’s not easy to access. Many people in this situation also suffer from exacerbation. So, being able to get behind the crisis curve will help us to support them in the long-term and enable them to maintain their independence for as long as possible. So, we’ll talk around these sorts of challenges as we go through the presentation. But I think we all recognise that regardless of where we live, actually, these issues are very similar the world over. And Jacquie’s going to talk about the particular solution that the NHS has been developing to this particular challenge but before we get into that, I’m going to hand over to Eileen who’s going to talk a little bit about the Canadian and the UK healthcare systems just to give us a bit of context and orientation.

Canadian and UK Healthcare Systems

Eileen Pepler

Thank you, Claire. Thank you Claire and thank you everybody for coming on. It’s such an important topic and we can all learn from others who are actually on the ground implementing. And the lessons learned, I think you’re going to learn today, are really fascinating especially the way the UK has embraced technology-enabled care and looking after workforce and looking at different funding models. So I think you’ll enjoy this session. And the reason I was really interested in this is Canada and the UK are so similar. And Canada usually turned to the UK or Australia or the US to look at what’s new and what kind of models of care are they starting to explore. But on this particular screen, what really struck me was that Canada has 33 million people and the UK has 66 million. But if you look at the per capita spend on health, the UK spends 29.92 and we spend 38.95. And although we’re all cognizant of the expenditure, it’s not really about the expenditure. It’s about patients and whether or not the outcomes are achieved.

The other is as we move forward and the real reason for looking at this is if you look at the nurses, again, nurses per 1,000, you’ll see a difference between the UK and Canada. And as we look out into 2035 and we’re looking at new models of care, how can we use nurses and other professionals differently? And as we move forward with new models of care, what does the workforce implications look like? So on the next screen you’ll see that Brittany is going to be speaking a little bit at the end about the US. But then if you look at the spend on this diagram… you can see if you move from the left to the right, we have the US, we have Canada, and we have the UK. So there are definitely lessons that we could learn from other jurisdictions.

And as we move forward, you’ll recognise and see – and I’m sure all of you know this – it’s really the similar challenges that we’re facing. And the big one for us was of course the Health Accord, which expires in 2014 and the federal government’s readjusting and resetting the funding going from 6% in the first three years and a minimum of 3% in the remaining 7%. So now, we’re looking at going from 7% to 6% or from 6% to 3%. And the other is in 2015 this year of course. A number of us had had a new government and we’ve got new thinking, new demands, and of course, new governments bringing their own perspective. But I guess the piece that is really important for all of us as we look forward to the 2035 and trying to achieve more services that are patient-centred is how can we move away from a non-physician-centred model? And that’s not to say that physicians aren’t going to be involved but how can we begin to get people to practice and use our scopes more effectively so that people can in fact have access and get outcomes and begin to have their wishes heard? From my perspective and from my learning and from what I’m hearing across the country is we need to reset our delivery system.

And reset, if you look at the dollars on this screen, it really does say that we need to reset, we need to rethink the models, we need to rethink our workforce, and rethink the tools that we’re using to look at planning strategically and then begin to link our strategic choices and our strategic models to our operation. So what does that mean, resetting? Well, resetting really means shifting to a population health from episodic or from looking at new models of care and using the new models of care as a strategic methodology which then drives you’re what ifs and your workforce. And then you’re allowed to test whether or not those outcomes can be achieved. It needs resetting the way we look at our population shift.

So, looking at over the next 10, 15, 20 years, how does our population age? How well do they age? And what are the impacts of chronic disease, ageing, and the social determinants of health on the wellness of our population? What are our workforce implications today and in the future? What’s that look like if you change and shift to a new model of care because our workforce of course is also ageing. We’re shifting the dynamics between patients and clinicians. And patients are really beginning to take hold. Each of the jurisdictions across Canada are involved in patient engagement at looking at pulling patients at the centre of our models which then can lead to better and improved self-care management. The impact of technology is not just the electronic record but also more the impact of technology-enabled care. And of course, the impact of technology as we join up the connections across the continuum. We’re looking at the workforce arrangements, the demand, and cooperation between very different workforce groups. What does that look like? The coordinator or navigator roles will become more crucial and complex than a fragmented landscape.

So with new models of care involved, community, justice, health, and education, how do we begin to coordinate or navigate across that jurisdictional health system? Is it thinking outside the box and keeping the welfare of the patient at the front and learning from other jurisdictions? And how can we reset or shift the population health and test without actually looking at implementing projects or pilots? How can we begin to test in a different environment and use our technology to help us? And this is where Jacquie is going to talk about and look at the long-term conditions programme, the simulation and the funding, and how they view technology to help them get more in front of the cost curve.

Long-Term Conditions Programme

Jacquie White

Thanks Eileen. And again, it’s a great privilege to be here talking to everybody. The first thing I’d like to say is that actually we’ve seen that there’s still lots more that we definitely need to do. We have, as Eileen pointed out, a lower overall spend. We have some good outcomes but we don’t have all good outcomes. So this is important for us and we’re equally keen to hear and learn from all of you about things that we can replicate. So, the main thing I wanted to talk to you about then was about – as Eileen said – how we carry on using modelling and the importance that you think that has to ensure that we look at the right thing to do and the right thing to less of and the right thing to do better. It’s really easy to look into an individual approach and individual organisation, make changes that have bigger impact on everybody without necessarily understanding that at that time. So, it’s really important we found a huge scale approach that enables you to model based on a system level and individual…so system level and strategic level as well as individual operational level. And so, change as you go through and to plan for and agree that they are the right things to do.

So for NHS England, I’m going to start and talk to you about where we are now and then get back to how we managed to get where we are now through the programme that Claire and Eileen mentioned which has been a four-year process of learning for us. And bring back then how we’ve used modelling to help reach this goal. So, some of the people will know the really unfortunate places we are now that we weren’t four years ago. But again, learning from it, we have a specific way now of talking about things, so the definitions and the language that we use that we think is important to get the changes that we want to happen. So we started talking about the person rather than the patient. So we start to move away from a physician based approach of care to more of a partnership. We started talking about long-term conditions rather than chronic disease so that we don’t focus on the individual condition, the individual body parts, but think about the person and what they are living with through the course of a year in their life. We’ve started to really focus across the whole person and then not separating out a physical bit of care and mental bit of care and then a completely separate look at what their social and emotional needs may be because we recognise that the whole thing is completely interdependent. When one bit goes wrong, the rest of it goes wrong for that person. And we started focusing more on coordinated care and how we deliver that than talking about integrated care per se because there is a – definitely in the NHS – quite an extension around integrated care structure than organisational approach. So, rather than how we just shift the care to focus and coordinate around the person.

But just some language points first that we’ve learned had helped to move some of these things forward. And some of the things that were now happening that four years ago when we started looking at them and they weren’t particularly well-thought through. And some of you know the Five Year Forward View in detail. I’m sure for the NHS and other system partners you know about how we really transform our system of care to focus very much on the person and their life and their quality of life through lots of changes around care. But also, have some of the system enablers and workforce and data will be there at the same time. So, just a few of these things that we’re looking at, and I won’t go in some detail. We’ve only got a certain amount of time here but there’s more information available on all of these. We’re doing a lot of work on empowering people and carers to be full partners in their own care. I’m sure that some of you will be very familiar with the patient activation works that’s originated from the US through their studies. They were looking at how we can properly embed that and approach the self-management and an approach to partnership, goal setting, and care and support planning. With supporting, you think about the whole person as I said earlier and linking together the health care and the social providers around a local neighbourhood care-type team.

We’re strengthening the role of primary and community care to really take on that critical role about being the home for people with long-term condition and being the place to go to rather than waiting until crisis hits and people ending up in hospital. We’re having a big focus on all the people who have increasingly complex needs including now frailty, other long-term condition and the impact of that for older people. We’re looking at lots of different new care models that are looking at that wider approach to care, population-based. And we have lots of what I’ve called vanguard testing out different models in different areas. We are focusing on what IT can do better including having a patient online access to their own record, the ability to share that with the health provider, and including non-traditional NHS. We’re looking at workforce planning and how that could be done jointly across providing commissioners and how workforce could be moved to support the need rather than working in a traditional organisational boundary approach. And we’re looking at what the new and emerging roles bring around different people with skills and competencies to be able to support a population and locality-based community care model for people with long-term conditions.

Population Healthcare- House of Care Model

Jacquie White

The main thing though that we wanted to talk to you today about is the approach that we’ve been using to look at what actually can we do to support purchase of care and provide that care through a different way of understanding known population needs, understanding current utilisation and cost of their services, and how that could be delivered differently but also funded differently to really enable coordinated care to become a reality rather than being a current block in the system as it had been for a while. Quick one here where the various things that are happening in the NHS concerning long-term condition. And I think your representation that we use is the House of Care, which is on the screen essentially puts into four components. Those are really important things that need to be happening in the system to make all of this work. And the outcomes and benefits that we’re starting to see that are getting people on board with a different approach to delivering care, so the next slide around the outcomes and benefit are starting to show us that if we can really focus on the person and how to support them and get them the right care then we could be lowering utilisation of services and lower costs.

We’re starting to see that health coaching and particular interventions can reduce the need for emergency care and coaching for much more in control and seeking the support at a much earlier point. We’re starting to see that medication adherence, when we actually look at the person’s needs rather than just purely what the medication is there for. We’re starting to see that really improve. So, medication adherence but also outcomes for what the medication may be prescribed for. And with that, we can see that we can also reduce the need for urgent care and can reduce the impact on special care. It’s starting to help the finance people get excited about change and about viewing that with the whole system approach. And staff would be able to see some of the benefit too. So just now the long-term conditions, the Year of Care programme that’s been mentioned is I guess where we were four years ago. So, lots of changes in the NHS! We’ve survived one political organisation or one organisation with the NHS and two elections whilst progressing in the programme. And what’s been really impressive from our perspective is the commitment from the people who started this work but also the increasing interest in engagement from others who are absolutely walking to the need to think differently about it and the way that it can help them to do that locally.

So we started with this programme with a bit of a discussion about how this was. Some challenges that people told us that it was too complicated to think about how we can pull together and approach funding 12 months worth of care for someone with long-term conditions who needed multiple providers involved in that. So we took that challenge we accepted it and we set about pretty much with the six areas that we have worked on. I have to say that they’re not perfect. There have been an awful lot of learning and going back here and where people are at, the part of the process, because it looks like this is an experiment. But now we have an awful lot of knowledge about what they are and going forward and what others might be interested in thinking about for their own population. But the engagement commitment across the system is fairly evident but it has been an on-going important step to keep people on-board with this throughout the whole process. It’s about how you increase outcomes for everybody as the result of working differently. And then the next four stages, we’ve had modelling input from SIMUL8 throughout the whole of those four stages to really help the team understand what exactly it was that we were trying to do and what it was that could be done. So, some of the learning, I’ll go into it in those four stages and Claire’s going to talk about it in more detail, the tools that we used and how we gained that learning.

NHS England: Population Analysis

Jacquie White

What we’ve been able to distil as the results of this work happening and meeting with other data sources is a move from what we thought were 15 million people with long-term conditions in the UK and that number that has been around for about the last six or seven years. We now think there are more like 27 million and that’s probably still under-recorded. We think mental health is definitely one area that’s still under-recorded. We know that 10 million of those have two or more long-term conditions. The multi-morbidity agenda is almost starting to become as big as people with long-term conditions. And that would really push forward the agenda around supporting people rather than knowing individual conditions because that just wouldn’t make sense in terms of efficiency of utilisation of services. But it doesn’t make sense, the burden we place on people. We now know that at least a million people in England have frailty, as I said, that’s now a diagnosable long-term condition. And over half a million, we’re able to see approaching end of life. We recognise that the number of co-morbidities impact on quality of life, lower the quality of life. And then we’re starting to see evidence of overtreatment, and in some instances harm, because we have quite an individual approach to guidelines, new guidelines for specific conditions that for some people can be contraindicated. And we now also know social isolation is a risk factors for mortality. But it’s also a burden along the same lines as having multiple long-term conditions for the person himself but also for the system. So we recognise that recording and understanding social isolation is that important for health and it is the social care.

On the next slide, we’ve got some of the impacts we understand on the health system. Any by default, people are self-managing but without any particular support. As Eileen said about primary care conditions and complications are for people with multi-morbidity. But certainly in the UK, we have again an individual approach where you go with one symptom because there’s a timing that generally allows for an appointment. So the ability to help primary care a bit differently about how to support people at that point, we can see and we have examples of how that impacts on the whole system as well as that. We know that for older people is significantly increased, 7 million versus 1 million for the under 40. We know that frailty has a three-fold increase in costs and we know that 25% of all hospital beds are occupied by someone who’s dying and probably doesn’t want to be there. So those are just some of the high-level headlines that we’ve been able to gather as a result of this working with other data as we have gone along. And that helps us really think about some of the key changes that we need to help nationally as well as the local teams understand their own population better.

The multi-morbidity, just going back to that, look at published articles about three or four years ago about scale of multi- morbidity that they were actually able to record. And we looked at how we replicated that in the UK. And this is an example from one of the teams using exactly the same approach. And what’s been incredibly helpful is not only reinforcing about how few people has only one thing wrong with them but also it helps people who are in the specific clinics like our cardiac consultants or our special family nurses. Think about the fact that even though their heart, there are a lot of other things going on that might be impacting on their heart and the management of their heart condition but it helps in other conditions. We don’t necessarily see that broader picture. Think about how that healthcare needs to be approached and what other things can be linked in. We’ve often looked at the approach around multi-morbidity and the driver and how that drives costs in the system. So what we’ve been able to identify, the number of long-term conditions is the strongest driver and it’s the most stable predictor of cost than any other weighted segment of population. It helps with understanding utilisation, current utilisation, and really thinks about how to redesign that utilisation to get better outcomes, We have been using that and the teams that we’ve been working with have been using that to elect the cohorts that they are looking to support differently and track the last three to four years to see how that impact over time.

NHS England: Crisis Curve

Jacquie White

And here’s what we’ve also been able to demonstrate is their crisis curve. So, what we recognise is most of the risk-predicting tools have focused very much on people who within the next 12 months of the hospital admission in the UK in the NHS. And actually, what we know is that that we need to be able to get the people before they hit that prediction tool so that we can put the right support in to enable that crisis to not happen to those people. So the crisis curve has been able to show where we’ve tracked danger over time. Also, there is a way of comparing, look at the risks tool and the number of long-term conditions, the multi-morbidity tool, to just see what difference there is. And whilst basically analysing the curve, again, what we found previously is that the number of long-term condition is the most stable predictor of who the people are that need support. So that’s one of the reasons why we’re focusing on how we can use the number of long-term condition to drive changes.

So, next slide touches on, as a result of that and understanding the data, what the services are – service bundle if you like – that have been pulled together as a result of all of this. And again, through the modelling work that Claire will talk about, we’ve looked at the current and the future potential delivery of these types of services. So within the approach to this different way of working, the different way of buying and providing care, we’ve got a red bundle which we’re already able to – within our current legislation and our current legal framework – pull together into one approach to being able to care and one approach to being able to pool money and fund it. We also want to move to the green bundle. So that’s happen within the time but we can’t do everywhere yet because of the different legislation and frameworks, etc.

But ultimately, what the data have told us that you can put all of the red and all of the green together and have a firmly stable approach to be able to predict and plan the care that’s needed and be able to fund it with some risk and reward arrangement built into that. The purple, that’s the very high-volume, need much bigger population to be able to buy and provide that care. And there’s a last slide that I want to touch on is that, so what is that telling us in terms of what difference this is making? Well, the data, the understanding of the services, the providers working together, how that’s working differently, has basically led to different delivery models but with some key similarities.

So some of the similarities are around the real need for single point of access; the key enabler around care planning; supported self-management as an intervention; coordination of care for people rather than expecting them to do all of that themselves; having that multi-disciplinary team based around GPs, primary care physicians, and the community in the neighbourhood they live in; the recovery, enablement, and the rehabilitation service which we’ll touch on in next bit; and then bringing in also the voluntary sector and the use of care navigators to support some of that social element in bringing people into their own community to engage much more around the social isolation agenda. They look different depending on local population whether people have different active organisation, and what else is going on that business needed to be brought into and part of. So, differences are obviously there and this isn’t a one size fits all that some of the similarities have been quite key and reflect a lot of the evidence around what great long-term condition care should include.

Using Simulation to Remodel Healthcare Systems

Claire Cordeaux

Jacquie, thank you so much for that really helpful overview of the programme! And what I want to talk about is how we’ve been using simulations to support that programme in a number of different ways. And the first thing I want to talk about, Jacquie mentioned using simulation for all sorts of different points of decisions. And this particular type of decision is really at the strategic level. For people not so familiar with simulation, what we’re doing here is able to model the system in a virtual environment on a computer. And the benefit of that is that it allows you to ask some of the questions around these complex changes in system that you need to bring about in order to provide really good care for people living with multiple long-term conditions. And so, it’s a useful system to do that because obviously, it takes the risk away from putting that change in place in the real system before you work out that it’s actually going to work or not. So, in this particular case, I’m going to talk about this as a strategic decision where we are looking at wanted to look at the impact of changing demographics on their patient journey and looking particularly at the group that would need additional support that Jacquie’s been talking about. And they wanted to look at that whole system view. So they wanted to go right across health and social care right from the first point of contact.

Scenario Generator Tool

Claire Cordeaux

So they use our tool scenario generator to do that. And what that enables them to do is to take their age-banded population and multiply it by age-banded disease prevalence – and that’s an HIV example there – to get a sense of the demand from that particular population. So it’s an easy way of associating your population health and the likely trajectory, the likely demand with what you’re expecting to come into your system and the services that you need to provide. And what they did was to put that calculation into the scenario generator which allows them to model multiple pathways of care and look at the costs and resource required and ask a number of the what if scenario questions that will help them test out whether changes and improvements are really going to have the desired outcomes. So, this example comes from North Staffordshire and Stoke on Trent. And their question was what does current unscheduled care flow actually look like? They wish to understand that better. And they only took into account the ageing population, what’s it likely to look like in five years with the increasing complexity and if they increase to referrals to home care direct from hospital.

In the current situation, they had a number of people that went into community hospitals or who were staying in hospital. What would that mean? What would the cost be? What would be the resource requirement in order to manage that? So that was their question. They built a lovely complex model. We’re talking about a really complicated system here. So I don’t think any of you would be surprised to see that level of complexity. And you can see the numbers on the screen there. But essentially, what thing is the first point of contact with the system right through all the different ways in which you might access emergency care.

This is the hospital part here and this is the part where they either go at a community hospital or to a variety of different social care providers. And the first thing to do was to make sure that the simulation was representing what was happening in real life. So, they validated the simulation, needed the numbers on the scenario generator with the actual NHS data to make sure that they were getting a reasonable result and they felt competent that actually, it was producing a reasonable replication of their current system. And they also put in the cost and length of stay function. So you can see the cost for hospital and community beds and they had a number of different social care interventions in there. And also, the length of stay within beds because they wanted to look at the bed capacity that would be used if they made that change. So you can see the results are showing here that with the population increase over the next five years, you can start to see how demand’s going to increase in emergency care and what that means to the emergency department and emergency admissions over the next nine years, which are around about 5% increase. And also, we look on impact on home care.

So the scenario, the what if scenario that they wanted to test was what happens if we put in increasing home care at the moment? A lot of referrals are going straight out to the community hospital, which, actually, people were staying quite a long period of time. They’re on 21 days when in fact, they perhaps could have been moved out with a supported packaged and also enable them to stay home a bit longer. So, they looked at the sort of packages of social care that people who were being referred directly were getting. And then what would happen if 30% of those people who are now going to the community hospital actually go to a home care arrangement? Let’s say, and erring on the side of caution, let’s say that that group are going to spend an additional two days in hospital because it’ll take us a while to set up that package and we’ll need to put the assessments in place. So, there might be a knock-on impact on the inpatient beds in the hospital. And let’s say that about 10% of those referrals are complex cases, 38% are sort of maintenance, and 51% are reablement services. And so, here are the results.

Results of the Scenario Generator Tool

Claire Cordeaux

What they thought was that there would be a 2.6 million savings overall which was a good result for all the things that they wanted to put in place. But big surprise, £4 million was going to have to be found via social care in order to provide that service. And in fact, the savings would be accrued by the healthcare system because the utilisation of the community hospitals would be reduced. And they could see what that would mean for their maximum bed occupancy. They could also see that, actually, they would have an additional 1.3 million cost because of additional length of stay in the hospital and how that would impact on the maximum bed occupancy. But with some of the savings they were going to accrue within the system, of course, that could be managed.

Now, you can imagine when those results come out and you take them to a set of stakeholders, how different parties might feel about where the savings are going to be made. But as Jacquie was outlining, the whole point of having a capitated budget with a service bundle which is based around the individual is to enable some of those savings to be shared and to be associated with the person so that individual organisations providing that care are recompensed for what they’re doing. They’re able to build their capacity, reduce the capacity where they need in order to ensure that the care is in the right place for the individual person. So, in this particular case, the simulation was used in order to build a strategic case for what this might look like to get the engagement of the different partners in that change and to get buy-in for moving forward with that and to make sure that the financial flows reflected the patient pathway. So that’s the first example I wanted to show you.

Using Simulation to Inform Decision Making

Claire Cordeaux

The second one is the simulation which is actually available online through NHS England for the Year of Care. Now, this has very much been following the evolution of the Year of Care programme. And it was produced both to help inform decisions over those four years but also to disseminate how people have been managing the implementation of the Year of Care approach. And the way that the model is set up reflects the programme. So, it’s looking at the typical person, let’s say, with one to two long-term conditions. They’re reasonably independent but they’re accessing a whole range of different services from hospital services to care services to mental health services and support within the community. Now, one of the things that the programme was able to indicate was the proportion of people who were likely to access those services in a year which then enables us to plan what services need to be in place and what capacity needs to be in place. So this is the kind of pathway for somebody who’s not at the most acute stage but is still going to need those services. And when we looked at the data, what we could see that obviously, over time, people did start to develop more long-term conditions that Jacquie showed in that multi-morbidity graph. And therefore, they’re going to need the same services but they’re going to need them in different proportions.

So you can now see that of this group, 56% of this group that are high-level of acuity are likely to access the emergency department. Forty per cent are likely to access a hospital bed of an admission. So, because this is the way that we understood the cohorts of patients and the way in which they were using services through the national programme, we were able to replicate this in a simulation so that a number of different local sites all over the country could use those same different assumptions and could put in their own data to see what the impact would be if they implemented this kind of system. So this is the simulation and you can see that we grouped patients in a number of different types of groups based on their acuity. And at a local level, people can decide what that is.

But of course, we’re accounting the fact that they transitioned between those different dates. And as the previous images show, if you transition from state to state, you’re likely to have a different package of service with a different level of frequency. And that of course has a knock-on impact on the cost, but the group or that particular person or those same groups of patients. And also, give an indication to the healthcare system what capacity they need to put in place in order to make sure that those services are available. Now, the real purpose of the simulation is to help systems understand what would be the likely capitated budget, the likely sum that you would need to assign to each patient in those different groups and show coherent between those individual patients. So you could say, ‘Yes. Well, typically, somebody in that median group would probably need about £10,000 in order to be able for us to meet their care needs over that particular year.’ And it allows you then to simulate types of services that you would need in order to produce those kinds of results for planning purposes.

And the results that you can see is that this is the number of patients across the simulation over a number of years, the cost per patient. So you can set that capitated budget and have that compared with the cost within your system. And you can drill down into the emergency department. So you can see the resources that you would need, for example, the level of activity and the cost. Then you can go across the model and look at any service that you’d like in order to get that kind of resource in order to help you plan.

And then lastly, I wanted to very quickly show the rehabilitation model which is looking at how patient moves from the acute phase of their care in hospital to the rehabilitation phase so that, we can see the bed utilisation. But also, if we were to move people into rehabilitation phase when they would no longer needed to be looked after by a physician, what sort of capacity we will need in order to do that. Now, there was a lot of work that went on in this area but I’m just going to very quickly click to the simulation so you can see what this looks like. I’m just running the simulation through here. And what this is showing is the number of beds available and it’s allowing people to see if they were to change the length of stay in a hospital and have a proportion of that length of stay in a recovery facility or at home with support. What’s the likely impact on cost, what’s the impact on capacity, and how would that work? Most hospitals were not collecting the data, the point in which a patient no longer needs their physician and the point at which a rehabilitation nurse could look them after. And so, they use the simulation – they still do – to look at some of the results in order to help with the planning where the data has not been available. So I hope that’s given you a brief view of how we’ve been using simulations to support a programme. And I’m just going to move over now to Eileen, who can talk about how she’s been applying some of it, learning and thinking in Canada.

The Value of Simulation in Risk Free Testing

Eileen Pepler

And before we giddy into the lessons and applicability to Canada, can I ask you, Claire, to go back to your diagram of the RRR model? That one. This one really has stuck with me and it’s such an important simulation as we begin to look at ALC beds and we look at people transitioning between the facilities, long-term care, residential home, supported care, and the acute care. And this diagram is really important as we look at people who have falls or people that need to go into acute care because of UDIs or whatever. And as you see on the left where it says the pre-admission community stage, what if – and this is where we start to giddy into what if – what if…the person leaving the facility being transported into the acute care, what if we hadn’t agreed, common agreement between the baseline going in and we understood where that person needed to be in order to get them in? And what if we knew prior to the person going in whether or not it was going to be a rehab bed or whether they were going to be transitioned to a different type of facility? So this model is really, really important as we start to look at new models of care for people going in and out of rehab or recovery and staying in their own home and what does that allow us to start to test. Thank you, Claire.

Lessons and Applicability to Canada

Eileen Pepler

So, in Canada, we have – as Claire said – next slide is over, we’ve been working for the last seven years trying to introduce a new concept called scenario planning and starting to get people to test their what if and to shift the focus from operations really to strategy and looking at strategy, driving the care delivery of the patient to the other way around. And so, scenario planning, we’ve had very good luck and have been very successful in introducing it into a number of provinces. And it certainly allows us to take what if and to test our new models of care without investing in projects and without harming patients. But you can see that on the right-hand side, it really truly does allow you to take a long view over time. And it also helps you to identify the triggers and it helps you to gain consensus collaboratively with the group. And I’ve used this with using simulation with a group of physicians and tested their view and what their view would look like on the system.

So again, as Claire said, really looking at what is the impact of whole system change and what is the workforce implication? And if we talked about mental health, what does that look like? What can new models of care look like? What if we brought in peer coaching? What if we brought in technology-enabled so that young people could actually begin to have their counselling sessions from their iPhone? So, what if..? So, we started to look at – as Claire talked about – the demand from the age. And you can see here that we’ve used it also with the group out of Alberta who were interested. And this is a really interesting one. It’s for people who are overweight or obese. And everyday, we see in here about the obesity or overweight problem. And they’re starting to look at what can we do to get in front of the cost curve or get in front of prevention. So my suggestion in working with the group on obesity and overweight and diabetes is what if we were to actually simulate over the next 5 to 10 years the status quo? So let’s say we don’t do anything. And in 2015, we have 1,732,000 people in Alberta out of 4 million who are considered overweight or obese. So we don’t do anything as of today until 2025.

What does our population look like and what does it do to downstream bone and joint? What does it do to depression? What resources are going to be consumed from pain? What resources are going to be consumed from unemployment insurance or disability? Because people are going to have to stop working for a while if they’re a truck driver so again, what if….And using this population analytics to really begin to say, ‘What do we really need to focus on and what are some of the new models?’

So, you can see that the questions that we started the dialogue with this group was how many children aged 1 to 15 with complex needs may need access to primary and paediatric services? What impact do different care stage duration have on cost? And how do people who now have one actually get to three because they say that if you are overweight or obese, there are 22 conditions, chronic conditions linked to obesity. So, what will that look like in 2020 and 2025? And more importantly, what is the impact on our workforce and our services in x amount of time? So what percentage of the population with type II has access? You can choose a different what if question. But number four was really the important one if you want to put your business case together to create awareness of what obesity does downstream.

So just very quickly, in 2010 or 2011, we worked with an organisation in Ontario to test non-funded maternity cares to immigrant and refugee women. And so, we started to look here at the long-term vision of partnerships between the different groups downtown for delivering immigrant and refugee care services. We wanted to look at creating a critical decision path for choosing, what are some of our strategic options in order to ensure that immigrant and refugee women receive the right care in a timely way? And it also allowed us to look at a path that accounted for and adjust it for changing federal government regulations. So very quickly, it was a very successful project. It highlighted the need to look at addressing funding issues and encourage the physician collaboration across the system.

Next, it was the project that we looked at which was very exciting for me, was linking food banks to chronic disease. And this was another Ontario project where we had a food bank across the street from a major hospital. We had it next door to a community centre. And also, folks from the food bank were using three or four of the major emergency departments for their services. So bringing together the city, bringing together two major hospitals, a community centre, and a couple of food banks, we wanted to look at what would a new model of care look like and how can we begin to implement prevention services as opposed to waiting for people who have to go to the food bank to become increasingly at risk of diabetes and overweight as a result of the food they were eating. So again, this one here was a demonstration. We used scenario generator. We took the population projections. We looked at the age-related. We looked at the immigration and ethnic factors. We included the income - so the whole social determinants of health. We looked at the moving out, the increased people that would be accessing food banks. Took into consideration what the Canada Conference Board said about food security and access to food. And the next picture will show you exactly that when you think about linking food banks to chronic disease.

Next picture, next slide. You can see here that when we were looking at linking the food banks, we really were interested in what are the modifiable factors? So that was the focus of this project. The one solution and one scenario that we did come up with was we’ve tested a nurse practitioner-led clinic. And you can see here that this particular scenario, I actually highlighted people coming from the food bank going into the nurse practitioner clinic and eliminating the need for the emergency department. Next. This is a high-level concept picture and it shows the food bank. So we had the family health team from the major hospital across the road from the food bank. And we had the Mt Sinai academic health team look at co-locating in the community sports centre, the community centre. And people from the food bank, the clients of the food bank, if they were detected of having a mental…some of the health issues, they would be given a referral over to the nurse practitioner-led clinic. They would see the nurse who would then manage.

So, it’s really a truly primary care service hub. And in this particular case, some of the referrals were for physical activity and recreational access to the community centre versus a medication prescription. So again, very quickly, this was one for children and youth mental health, again, across South-western Ontario. We’re interested in taking a region, a very strategic look, a helicopter view of how children and their families access mental health and social care service across South-western Ontario. And looked…we were interested in looking at the fragmentation, the duplication of resources and services, and looking to see whether or not there were new ways of delivering services to improve access. Reduce the fragmentation, the bottlenecks, the handoffs, and look at information sharing cross-sector between health, justice, education, and social services.

This is just a particular diagram, a scenario for a simulation of a referral. And you can see here the total cost of just one referral for the number of referrals in this one agency. And if they did nothing, each referral would continue to cost $14,000. And you can see here that referral was seen in the way in which we operated and we worked and functioned. The referral was seen as a true bottleneck to getting access to the service.

Just a screenshot of the simulation result here and you can begin to see that the intake process timing and you can see the individual steps of trying to get just right into the service. So, just the intake process, the initial assessment timing. And what we found fascinating was the assessment meeting, 67.5 minutes so an hour and a half for every…. So you can begin to see with these results that we really needed to look at simulating and working differently. And if you look at the bottom right-hand side, you’ll see discharge transition and follow-up. If you add up all those minutes, it really truly does show that there is an opportunity to reset and rethink the way we work. Okay. So some of the potential opportunities that came out of this particular work, this work is available on www.kidsjourney.ca, the entire findings and the methodology and the tools and the different collaborative approaches we use to get at what are some of the possible solutions and the buy-in from across the system which led to five distinct opportunities which too have been implemented. So you can begin to see the individual steps in your process and some of the possible solutions and the benefit. Next. I don’t call them cost savings. I call them cost reinvestments back into the system to enable us to be able to improve the service, change the way we work, and also improve access. So it’s really cost avoidance.

Key areas of learning

Brittany Hagedorn

Yes. Thank you, Eileen. This has been a really fantastic discussion. I am so glad that we’ve been able to have this panel together today. I want to just reflect very briefly about how…this is very, actually, similar to the US, the challenges that we face as well and the applicability of this. For those of you who are coming at this from a US perspective, you saw very early on Eileen pointed out there was a chart that had all of the expenditures per capita. And the US was almost double of the Canadian and the UK dollars. So while Canada certainly has opportunities as Eileen has talked about and the UK is continuing to improve, we have a much larger gap to close. And there are a lot of different reasons that maybe part of it is our public, private system and how that impacts how we manage things. But actually, the largest expenditures are hospitalisations where the inpatient stays. And those are some of the things that we’re talking about avoiding in both the UK and the Canadian examples that we’ve just heard about. And the challenges are the same, right? How do we transform our system? How do we make this non-physician-centric? How do we think about the payments and the incentives and the workforce and inputting all of these solutions in the practice? There’s a ton of opportunity. I think the one thing I do want to point out as well is the great results that we heard about from Jacquie, 8%, 12%, 30% savings that they’ve been able to achieve in readmissions and cost and hospitalisations and a variety of other key metrics. This is just a fantastic set of results and I really think it’s important that we start thinking about how we learn from some of these lessons. And as we are setting up our ACOs and our patient-centred medical homes and we’re starting to change the way we contract, these are all going to be important lessons for us because we’re starting to work in a very similar kind of environment. And maybe we can speed that innovation process along. There are a couple of questions that have come in. But before we get to those, I just want to ask everybody. Jacquie, can you start us off? One sentence, what is the some of the key learning’s and what is your key takeaway from today?

Jacquie White

So, a lot of international brains are better than one national brain. We’re all grasping with the same problems and we’re all different and doing different things and in a more advanced way. We could all find time to do it together rather than individually.

Brittany Hagedorn

Thanks. Claire, do you have a thought?

Claire Cordeaux

Just how, despite the differences between our jurisdictions, how very similar the questions are. And I think what’s been interesting in Canada has been the focus on the workforce and workforce planning. And also, the application of the sorts of things that Jacquie and that team are doing to paediatrics, children, young people, and mental health.

Brittany Hagedorn

Great thinking. Eileen, do you have a thought?

Eileen Pepler

Yeah, I do. I was going to say thank you very much for facilitating. Thank you for putting this together. The learning for me has been we’re working with Alberta and with a great team in Alberta who have embraced the learning’s that we’ve heard today and are starting to look at the what if and the workforce implications using the model of care approach. So, it is exciting and I think that the lesson is that there is no better tipping point than today because we really do need to bring and look at new tools and look at strategy and how we’re going to move forward especially in today’s economy. Thank you for doing this today.