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Complex, long-term health and social needs

This progress report delves into the complexities of managing long-term health and social needs, emphasizing the shift from single-condition focus to a multi-condition approach. The Cumberland Initiative Grand Challenge aims to address co-morbidities and improve care delivery through innovative research pillars. The report highlights market trends, integrated care models, and the importance of prevention and risk stratification in tailoring services. Industry engagement, workforce development, and simulation tools offer promising solutions. The next steps involve collaboration with Pathfinder CCGs and Local Authorities, expanding team capabilities, industry engagement, and funding initiatives.

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Complex, long-term health and social needs

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  1. Complex, long-term health and social needs ‘Grand Challenge’ Progress report and Next steps

  2. Grand Challenge - reprise • 70% of all health and social care activities. Enough said…. • ‘Standard’ approach focuses on single conditions • Extensive experience of dementia, E of L, frailty etcbut for eg • Eg 60% over 65 have at least one long term condition Hence… • Complexities/co-morbidities dictate a multi condition solution • In May, this begat the Cumberland Initiative Grand Challenge

  3. Extending the single condition view Significant co-morbidities Predominance of single conditions LTC 1 LTC 2 LTC 3 Frailty End of Life Care LTC 4 LTC 5 LTC etc…….

  4. Progress to date… • Research proposal - ‘people not pathways’/population health focus • Four clearly identified research ‘pillars’ - Clinically driven • Cohort analytics • Co developed solutions • Alternative service model bank • Patient-Professional relationships • Dedicated Ethos team plus a technology partner • ‘Seminal’ 8/9000 word paper in outline specification • Encouraging initial market traction in England and Wales

  5. Initial market traction • Future localised cost trends - the scary ‘blue line’ • Increasing focus on integrated care • Greater emphasis on prevention • Risk stratification to tailor service responses • Hospital admission • Admission to a care home • Frailty likelihood that end of life is approaching; • Cost/service impacts of strategic redesign initiatives • …particularly savings accrue to health plus social care

  6. Emerging industry engagement • Clinical - Primary care, geriatricians, palliative, psychiatry • Commissioners - CCGs, LAs and CSUs • Industry - Data-mining, aggregation, visualisation • Academic/AHSNs - Service evaluation, epidemiology • Social care-Integration agenda & stat responsibilities • Workforce development - 70% of all services are people

  7. Emerging simulation ‘offers’ • ‘Extended’ individual condition pathways • Data mining and risk stratification • Geographic mapping & health inequalities assessment • Population/cohort modelling for strategic redesign • Local stakeholder engagement/integ’ed responses • Demand-side modelling workforce training & devm

  8. Next steps - Collaboration • Pathfinder CCGs and Local Authorities • AHSN, CSU and of course Cumberland relationships • (Exciting) on line visual technology development • Further scale up of the (extended) team and capabilities • Progressive and/or selective industry engagement • Major collaborative grant and funding bids….

  9. Next steps - Collaboration

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