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The North Kirklees Clinical Commissioning Group (CCG) and Curo Health GP Federation Clinical Care Coordination Project


David Anthony Cochrane


The project: The North Kirklees Clinical Commissioning Group (CCG) and Curo Health GP Federation joint-project has been designed to scale up effective case management and demonstrate replicability informed by the developing international research evidence on best practice . Effectiveness is defined using the triple-aims framework of patient experience, clinical quality and cost control. This project has the following antecedents.

• A series of UK-based pilots between 1999 and 2008 in community and primary-care-based case management of patients with multiple morbidity, and other complex needs who are in the 5% of patients who typically consume 35-40% of local NHS resources.

• Feasibility work undertaken between 2005 and 2010 with Johns Hopkins and Imperial College to explore the applicability of ACGs to support a number of informatics needs in UK health care .

The project has developed 5 practitioners who entered practice in April 2015 serving 15 GP practices with combined resident population of 100k or half the CCG total. The staff development programme (training and mentorship) was designed in part with Imperial College but has since been updated to reflect best practice and the requirements for professional development for British nurses. Only one recruit had any prior case management experience. Following a two-week training module, each nurse entered a 4-month mentorship programme working to a ‘competence framework’ which allowed them to learn the major case management skill-set in a structured and supported way working with actual local cases .

Data from the Johns Hopkins ACG system is employed to identify the cohort of patients who could most benefit from the service and who were not in receipt of other case-management service. Mean per capita health care cost in the previous 12 months was 4.5 times the population overall mean of which 25% was pharmacy; predicted cost (ACG system) rises by 15% in year 2.

ACGs is also being used to support quantitative outcomes reporting and comparative analysis between patients in receipt of the service, and those from practices not participating but who have similar morbidity, risk and utilization and cost profiles. Medium-term high resource users (2 year or more) are identified so that changes to entrenched patterns of reactive service can be measured. Qualitative outcomes are being captured via a patient questionnaire which measures patient experience, changes to health literacy, self-management and care- navigation skills: improvements in these parameters are correlated with lower utilization and costs .

Findings: The project will have 12 months data to report by May 2016. The findings to-date from the first 6 months are:

(1) Before entering the programme (i) all patients did not understand why they experienced episodic illness, (ii) report declining health status life over the previous 12 months and (iii) 90% are confused by their medications; factors correlated with likely hospitalization in the next year ;

(2) The programme can address these by improving self-care skills and individualized heath intelligence alongside provision of social care support often at quite low cost. This is provided clinical care coordinators establish effective working arrangements with social care and the voluntary sector so that care packages can be put in place quickly;

(3) Patients with entrenched patterns of unscheduled hospital and primary care utilization have been stabilized;

(4) Patients on multiple medications have had their pharmacy simplified reducing costs ;

(5) Positive outcomes have proved replicable in 3 English regions over ‘4 generations of practitioner’ subject to adaptation and development based on research and evidence;

(6) Systematic outcomes measurement faces both operational and cultural challenges in the British NHS which can be successfully addressed at GP practice-level by resourcing and accessing data via current, readily accessible system;

(7) Transition from the ‘ hands-on, reactive’ care giving roles to which staff were accustomed, to the holistic, pro-active approach employing motivational interventions proved challenging at the outset. However as new skills are embedded and the benefits to patients emerge, job satisfaction can improve.

How to Cite: Cochrane DA. The North Kirklees Clinical Commissioning Group (CCG) and Curo Health GP Federation Clinical Care Coordination Project. International Journal of Integrated Care. 2016;16(6):A180. DOI:
Published on 16 Dec 2016.


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