An outline of the Cambridge Accountable Care Organisation (ACO) concept

James Morrow, GP, Sawston Medical Practice

Background

Our Vision

Partnership between primary and secondary care providers to deliver the best possible clinical outcomes within a fixed budget

Clinical teams moving seamlessly from home to community

centre to hospital

Shared electronic patient record with patient access

Financial alignment and risk sharing of a capitated budget

Transforming academic excellence and research into on-the-ground achievements for our population

Standard care model Expertise

Location

Home General Practice Local Hospital Tertiary Centre

Doing less of the same

“A man with a hammer

sees a lot of things

worth hammering” Attr. Mark Twain

“Insanity is doing the

same thing, over and

over again, but

expecting different

results" Attr. Albert Einstein

What can we learn from 1782?

Thomas Whitcombe 1763-1824

Comte de Grasse Admiral George Rodney

Accountable Care Model

A single provider organisation crossing

primary/secondary care boundaries

Commissioned by NHS; accountable for outcomes

Registered primary care population

Capitated whole population budget

Financial risk held on provider side

Breaking of the Line

Home Health Centre DGH Tertiary Hospital

Expertise

Location

Proposed ACO Structure

A Community Interest Company run for the benefit of the community, working in and with the community

Jointly owned by primary and secondary care

Board-level representation of patients, local authority & both primary and secondary care clinicians

Accountable to commissioners for outcomes, not processes

Pa

tie

nt E

du

ca

tio

n.

Prim

ary

Ca

re

Ed

uca

tio

n

Information Management

The person

with

diabetes/

self care

Other interval

visits

Annual Plan

Annual

Assessment Practice

Credentialing

Pharma-

ceuticals

Clinical data

sharing

Audit/

feedback

Population

Monitoring

Clinical

Governance:

Goals,

Targets,

Pathways

T1 Education

T2 Ongoing

Education

T2 Education

T1 Ongoing

Education

Carer

Education

P/N and GP

Structured

Education

Practice Visits

Clinic Visits

Practitioner

credentialing

The Integrated Care Model

Mx

D Simmons

ACO Advantages

Alignment of financial interests

Clinical integration across primary/secondary chasm

Allows flexible use of human and financial resources

Based around single shared electronic patient record

Reduced transactional costs and bureaucracy

ACO Priorities

Living within a finite budget

Relentless focus on quality of care, safety,

outcomes, patient experience and careful use of

resources

Flexibility around service provision

Local accountability and shared decision making

Commissioner Benefits

Simple commissioning structure

Top-level outcomes specified, not micromanagement

of individual service specifications

Capitated budget – transparent, fair and open

Financial risk sits with provider, not commissioner

System Benefits

Reduced waste, inefficiencies and transactional costs

Shared records

Better data for research, audit and outcome measures

Better patient outcomes

Setting the standard by which others are judged

Our Vision – Patient Services

Local easy access to quality-assured health care

Extended opening of primary care facilities. Full

range of diagnostics provided at local level.

Ability to manage most conditions on-site, using

specialist knowledge when needed

Rapid access to specialist opinion using shared

record

Competition

ACO will, as a provider, have the ability to build or buy services

ACO will purchase from other providers including NHS, independent and third sectors, where it is best use of resources and clinically appropriate

If ACO model delivers on quality and value then it sets benchmark for other providers

Growth/consolidation may occur but openness about system and structure will permit others to emulate design and compete

Scale

Need to start small and be fleet of foot

Risk sharing arrangements with phased adoption of

higher risk areas as size of organisation increases

Risk from additional activity and random events mitigated

by movement from PBR (price) to true marginal cost and

shared ownership between primary and secondary care

Growth by success

Risks

Death by committee

Regulatory, political and economic environments

Delay

Compromise of purpose

Financial Failure

Making it happen

Conceptual buy-in from primary and secondary care

Permission to innovate

Design of evaluation and reporting

Identify resources to get going

Agreement to commission (CCG)

Will it fly?

“... Must ensure that we keep our current focus on

practice engagement and referral management to

give us the best chance of breaking even at the end

of the year...”

“...We are not clear how your proposed model would

contribute in resolving this problem.”

Local Commissioning Group, August 2011

Our difficulty lies not so much in developing new ideas

as in escaping from the old ones

John Maynard Keynes 1883-1946

Thomas Whitcombe 1763-1824

Dare Commissioners

“Break the Line”?