Care Pathways & Payment-by-Results David Kingdon University of Southampton NHS South...

Care PathwaysCare Pathways&&

Payment-by-ResultsPayment-by-ResultsDavid Kingdon

University of SouthamptonNHS South Central/Hampshire

Partnership FT

What’s a care pathway?

• An integrated care pathway (ICP) is a multidisciplinary/ multi-agency outline of anticipated care, placed in an appropriate timeframe, to help a patient* with a specific condition or set of symptoms move progressively through a clinical experience to positive outcomes

* also for general population, carers, primary care, general medical services, non-statutory sector, mental health services and commissioners

What’s a care pathway?• Clinical care pathways are “both a tool and a concept

that embed guidelines, protocols and locally agreed, evidence-based, patient-centred, best practice, into everyday use for the individual patient. In addition, and uniquely to ICPs [Integrated Care Pathways], they record deviations from planned care in the form of variances” [Defining and monitoring quality]

• ‘Bandolier’ description [providing information for …]– Diagnosis: Treating the right patient ) Guidelines– Treatment: Treating the right patient right )– Organisation: Treating the right patient right at the right

time– Pathway: Treating the right patient right at the right time and

in the right way

Care pathways, clusters and tariffs

• Clusters define current need

• Clusters span Disorder care pathways

• Disorders define pathways (e.g. NICE)

• Interventions and specific outcome measures relate to CPs.

• How do we relate pathways to clusters?

PbR

CARE PATHWAYS AND CLUSTERS Trust A Trust B Trust C

Emotional difficulties:

1: Common Mental Health Problems (low severity) 102 1035 150

2: Common Mental Health Problems (low severity with greater need) 273 1368 462

3: Non-Psychotic (Moderate Severity) 1002 978 729

4: Non-Psychotic (Severe) 1701 2034 369

5: Non-Psychotic (very severe) 273 1368 735

7: Enduring Non-Psychotic Disorders (high disability) 927 942 1239

15. Severe Psychotic Depression 135 108 75

6: Non-Psychotic Disorders of overvalued ideas [Eating disorders & OCD] 234 435 300

8: Non-Psychotic Chaotic and Challenging Disorders [ ‘Borderline PD’] 777 1068 150

Psychosis: 0 0 0

10: First Episode in Psychosis 1350 963 1638

14: Psychotic Crisis 435 228 762

11: Ongoing Recurrent Psychosis (low symptoms) 702 750 1035

12: Ongoing or Recurrent Psychosis (high disability) 1161 702 1101

13: Ongoing or Recurrent Psychosis (high symptom and disability) 2670 1026 3030

16: Dual Diagnosis = ‘Psychosis with drug abuse’ 1377 396 1638

17: Psychosis and Affective Disorder Difficult to Engage 1128 294 1146

Memory difficulties: 0 0 0

18: Cognitive impairment (low need) 1026 1701 702

19: Cognitive impairment or Dementia Complicated (Moderate need) 1368 2010 1062

20: Cognitive impairment or Dementia Complicated (High need) 534 1035 207

21: Cognitive impairment or Dementia (High physical or engagement needs) 702 1638 402

Total patients 17877 20079 16932

Care pathways

Payment-by-Results

Emotional difficulties

Memory difficulties

Psychosis

Anxiety/depression& related conditions

‘Rapid cycling’ Borderline Personality

Disorder

Bipolar disorder

Eating

disorders

Acute

Persistent

Stable

Acute

Persistent

Stable

AcutePersistent

Stable

Acute

Persistent

Stable

Acute

Persistent

Stable

Low

Moderate

High

High (P&E)

http://eng.mapofmedicine.com/evidence/map/index.html

Care Pathway Acute (Acute care pathway - CRHT/Inpatient)

Persistent (Community pathway/AOT/EIP)

Stable(Community/recovery pathway/IAPT)

Psychosis 14: Psychotic Crisis 10: First Episode in Psychosis

13: Ongoing or Recurrent Psychosis (high symptom and disability)

16: Dual Diagnosis = ‘Psychosis with drug abuse’

17: Psychosis and Affective Disorder (Difficult to Engage)

11: Ongoing Recurrent Psychosis (low symptoms)

12: Ongoing or Recurrent Psychosis (high disability)

Bipolar disorder

5: Non-Psychotic (very severe)

14: Psychotic Crisis

15. Severe Psychotic Depression

3: Non-Psychotic (Moderate Severity)

4: Non-Psychotic (Severe)

7: Enduring Non-Psychotic Disorders (high disability)


1: Common Mental Health Problems (low severity)

2: Common Mental Health Problems (low severity with greater need)

Anxiety/

depression








‘Borderline PD’ 8: Non-Psychotic Chaotic and Challenging Disorders [ ‘Borderline PD’]






Eating disorders

6: Non-Psychotic Disorders of overvalued ideas [Eating disorders & OCD]







Care Pathway Acute Persistent Stable

Psychosis Often requires period of stabilisation, sometimes PICU, MSU or finding new community accommodation; risk & substance misuse issues. Home treatment not often accepted for engagement reasons/agitation/ accommodation instability.

Psychiatric & care coordinator; course of CBT psychosis (accepted by most); family work where agreed with family (relatively uncommon).

EIP & AOT for proportion.

Some NHS rehab accom

Meds – clozapine & depot

Psychiatrist &/or care coordinator (longer-term).

Social support.

CBT for psychosis if not previously received.

Bipolar disorder

Usually for mania and relatively brief admission; occasionally even briefer admn for depression. Rarely stabilisation & new accom. Some use of HT

Psychiatric management – sometimes care coordinator. Psychological input (often offered & accepted)

Psychiatrist or care coordinator (longer-term) .

Anxiety/

depression

Rarely admission needed for suicidal risk; should be brief. HT more commonly needed.

Step 1 & 2: Primary care & IAPT

Step 3 & 4: CMHT + CBT, day care/social support

Primary care/self-help

Psychiatrist or care coordinator (usually brief).

‘Borderline PD’ Admission generally contra-indicated but some brief for risk/rapid stabilisation. HT frequent in crisis periods.

Intensive CMHT involvement; family work; social support; DBT.

Brief NHS rehab accom.

Psychiatrist or care coordinator (brief/intermediate).

Social support.

Eating disorders

Where admission needed, specialist unit & can be intensive & lengthy. HT have role.

ED team + CMHT; psychologist.

Psychiatrist or care coordinator (longer-term).

Care Pathway Acute Persistent Stable

Psychosis Often requires period of stabilisation, sometimes PICU, MSU or finding new community accommodation; risk & substance misuse issues. Home treatment not often accepted for engagement reasons/ agitation/accommodation instablility.

Psychiatric & care coordinator; course of CBT psychosis (accepted by most); family work where agreed with family (relatively uncommon).

EIP & AOT for proportion.

Some NHS rehab accom

Psychiatrist &/or care coordinator (longer-term).

Social support.

CBT for psychosis if not previously received.

Bipolar disorder

Usually for mania and relatively brief admission; occasionally even briefer admn for depression. Rarely stabilisation & new accom. Some use of HT

Psychiatric management – sometimes care coordinator. Psychological input (often offered & accepted)

Psychiatrist or care coordinator (longer-term) .

Anxiety/

depression

Rarely admission needed for suicidal risk; should be brief. HT more commonly needed.

Step 1 & 2: Primary care & IAPT

Step 3 & 4: CMHT + CBT, day care/social support

Primary care/self-help

Psychiatrist or care coordinator (usually brief).

‘Borderline PD’ Admission generally contra-indicated but some brief for risk/rapid stabilisation. HT frequent in crisis periods.

Intensive CMHT involvement; family work; social support; DBT.

Brief NHS rehab accom.

Psychiatrist or care coordinator (brief/intermediate).

Social support.

Eating disorders

Where admission needed, specialist unit & can be intensive & lengthy. HT have role.

ED team + CMHT; psychologist.

Psychiatrist or care coordinator (longer-term).

Care Pathway

Acute (Acute pathway (AP): CRHT/ Inpatient/PICU)

Persistent (Community pathway (CP) /AOT/EIP)

Stable(Community pathway (CP) /IAPT)

Psychosis £ Acute bed day cost (AP) * av. LOS = £P-A

Bipolar disorder

Anxiety/

depression

‘Borderline PD’

Eating disorders

LOS – length of stay * = x (multiply)

Care Pathway




Psychosis £ Acute bed day cost (AP) * av. LOS = £P-A

£Community day cost (CP) * weighting * days = £P-P

Bipolar disorder

£ AP * av. LOS

= £BD- A

Anxiety/

depression

£ AP * av. LOS

= £AD-A

‘Borderline PD’

£ AP * av. LOS

= £BPDA

Eating disorders

£ AP * av. LOS = £ED-A

Weighting – measured or estimated (e.g. Persistent = 2 x Stable; actual costs for IAPT)LOS – length of stay* = x (multiply)

Care Pathway




Psychosis £ AP (acute bed day cost) * av. LOS = £P-A

£Community day cost (CP) * weighting * days = £P-P

£CP * weighting * days = £P-S

Bipolar disorder

£ AP * av. LOS

= £BD- A

£CP * weighting * days = £BP-P

Anxiety/

depression

£ AP * av. LOS

= £AD-A

£CP * weighting * days = £AD-P

‘Borderline PD’

£ AP * av. LOS

= £BPDA

£CP * weighting * days = £BPD-P

Eating disorders


£CP * weighting * days = £ED-P


Care Pathway




Psychosis £ AP (acute bed day cost) * av. LOS = £P-A

£CP * weighting * days = £P-P

£CP * weighting * days = £P-S

Bipolar disorder

£ AP * av. LOS

= £BD- A



Anxiety/

depression

£ AP * av. LOS

= £AD-A

£CP * weighting * days = £AD-P

[IAPT + £CP] * weighting * days = £AD-S

‘Borderline PD’

£ AP * av. LOS

= £BPDA

£CP * weighting * days = £BPD-P

£CP * weighting * days = £BPD-S

Eating disorders





Care Pathway Acute (CRHT/Inpatient)

Persistent (high need community pathway/AOT/EIP)

Stable(community/recovery pathway/IAPT)

Psychosis 14: Psychotic Crisis 10: First Episode in Psychosis

13: Ongoing or Recurrent Psychosis (high symptom and disability)

16: Dual Diagnosis = ‘Psychosis with drug abuse’


11: Ongoing Recurrent Psychosis (low symptoms)

12: Ongoing or Recurrent Psychosis (high disability)

Bipolar disorder


14: Psychotic Crisis







Anxiety/

depression








‘Borderline PD’ 8: Non-Psychotic Chaotic and Challenging Disorders [ ‘Borderline PD’]






Eating disorders








Deriving Cluster TariffsWorked Example!

£14. Psychotic crisis (tariff)

= [(No. of 14. Psychotic crisis with Psychosis x £P-A)

+

(No. of 14. Psychotic crisis with Bipolar x £BP-A)]

/

No. of Patients in Cluster 14.

Developing a tariff

• Cost each CP category (A, P, S) • Use clusters to assess need; Cluster * CP

for tariff • Base weighted costs on current or

estimated usage• Commence with using annual census

(initially then increase frequency to 6 to eventually monthly)

• Account for new entrants and exits from pathways

PbR

Questions:• Can diagnostic care pathway, LOS & cluster info be gathered on all

patients? How will we do it?• Are clusters allocated appropriately to pathways?• How do we deal with dual diagnosis;

– use primary diagnosis only or e.g. psychosis [drugs or not?]• How do we cost pathways?

– Acute: HTT + Acute + PICU (combine or split) • What about ‘delayed discharges’?

– Community: • What is a community reference cost? • Persistent – care coordinator & psych (2x cost) + psychology - i.e. = CPA

(?)– Do we separate EIT, AOT & high-cost CMHT? Liaison & Perinatal services?

• Stable – care coordinator or psychiatrist, i.e. = non-CPA?• Allow for supervision & training costs; accounting for overheads

• How do we link to outcomes? [HoNOS, DIALOG, & specific measures eg IAPT]

• Exceptions – e,g. very high-cost & possibly forensic patients

Care Pathways & Payment-by-Results David Kingdon University of Southampton NHS South...

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