Hear the Hertfordshire story

Vanguard for enhanced health in care homes

Pioneering the practical use of linked data

A patient-centred approach

The Hertfordshire story • Vanguard for enhanced health in care homes

• Reviewing the practical steps of linking health and social care data

• Meeting the Information Governance requirements for linking data

• Discussing the practical steps of commissioning for outcomes

• Highlighting the patient and service-user views of the benefits that

joined up services can provide

Seamlessly

integrated health and

social care

system

Secure data shared across all partners

to support joined up delivery Front line staff

have a complete,

integrated care

record to optimise patient care

Commissioners access linked, patient-level, unidentifiable data to support

service quality and redesign

Extensive use of stratification to

identify different

cohorts of patients

Our Vision

Extensive joint commissioning

Early Supported Discharge

Vanguard

Intermediate Care

HomeFirst

A history of integrated working

HomeFirst

Supported Discharge

Rapid Response

Case Management

System-wide leadership

Strong system leadership

Common vision

Area data sharing protocol

Proactive, continuing public engagement

Care Home Vanguard • East & North Herts CCG Vanguard for enhanced health in care homes

• Hertfordshire partners are improving the health and wellbeing of care

home residents, through: – enhancing the skills of care home staff through education and training, so that

residents with complex needs can be looked after with confidence

– forming teams of GPs, district and practice nurses, mental health nurses, geriatricians and pharmacists, who will work closely with care home staff to support residents

– creating ‘rapid response’ teams of community nurses, matrons, therapists and home-carers who can get to care homes within 60 minutes, as an alternative to sending elderly patients to A&E

– committing to information sharing and investing in technology which will allow GPs to access comprehensive information about each care home resident when they visit them.

• Hospital

• Community physical health

• Community mental health

• Social care

• Primary Care (from the Autumn)

Since April 2015, we have been working with linked

person-level data, including:

The power of linked data

Information Governance?

S251

Explicit consent

Pseudo-at-source

(with public-private key encryption)

Work with de-identified data

Enable controlled re-identification by

authorised direct care professionals

-£500,000

£500,000

£1,500,000

£2,500,000

-12 -11 -10 -9 -8 -7 -6 -5 -4 -3 -2 -1 1 2 3 4 5 6 7 8 9 10 11 12

Before and after costs for HomeFirst patients seen 29/11/2012 - 31/12/2013

Community Secondary Care Social Care

Total Trend Before Trend After

HomeFirst’s financial impact

The operating model

Community physical

health

Community mental

health Hospital Social care

Link using public key encrypted NHS Number

Encrypt with shared public key

Person-level linked dataset

Secondary use Risk Stratification

Encrypt with shared public key

Encrypt with shared public key

Encrypt with shared public key

A sample dashboard

A sample report

Our next steps

• Develop a care home flag

• Incorporate primary care data

• Extend direct care opportunities

• Exploit predictive analytics

• Increase range and frequency of

local and direct data flows