Development of the Nottingham NUH OPAT service – a Study

analyzing the Figures behind the Funding

Dr Susan Snape

Consultant in Infectious Diseases and Microbiology

The Quest for the Holy Grail

• A recurrently funded officially commissioned OPAT service

• To help others achieve commissioned OPAT services

• OPAT - What is it?

- What are the benefits?

Patient perspective – ‘No brainer’

Hospital perspective – ‘No brainer’

Commissioners perspective – we can see the patient and hospital benefits BUT is it in our financial interests?

Evidence Gathering • Evidence in the literature • Feasibility Study • Help with writing an business case

– http://e-opat.com/toolkit/ • The Dragons Den - Backing from senior management • Serendipity - Temporary non-recurrent funding

– £44,330 for 6 months – 2 Nurses

• Presentations of progress - including to commissioners - Again the same issue - we can see the patient and hospital benefits BUT is it in our financial interests?

• Temporary year-long funding – QIPP (Quality, Innovation, Productivity and Prevention) project – £214,00 – 3 Nurses, 1 Support worker, 0.2WTE Band 5

Pharmacy Technician, 0.15WTE Band 8b Pharmacist 2PAs Consultant time

QIPP

What population does the current NUH OPAT service serve?

• Majority cohorts - Early discharge: – Orthopaedics and trauma – bone and joint infections – Diabetes - Diabetic foot infections – Respiratory - Infective exacerbations in bronchiectatic patients

• Minority cohorts - Admission avoidance: – Infectious diseases – recurrent abscess (mycobacterial infection) – Recurrent Infective exacerbation of bronchiectatic patients

• Predominantly patients taught to administer their own iv antibiotics – when study performed patients had to compound their own antibiotics or a few attended hospital daily for administration of iv Abx - limited numbers of slots available. ( ie no pre-filled devices/ no home healthcare worker delivered service)

How Patient Episodes of Care are Funded

• Commissioners are happy to pay for the HRG (Healthcare Resource Group) coded tariff (nationally agreed).

• Commissioners will pay the Post Trim bed days (nationally agreed) but feel that the episode of care should have been covered already.

HRG code applied

Set number of days of care paid for as a set lump sum

Trim point

Bed days over Trim paid for on a daily basis – the amount is dependent on the HRG code

INPATIENT

Patient length of stay in hospital

EG DZ12A – Infected exacerbation of Bronchiectasis; Number of days covered by HRG 31; Excess Bed Day cost £190

What impact can OPAT have on payments?

• A OPAT allows discharge pre Trim point – Trust ‘wins’ financially – commissioners do not want to pay more

• B OPAT allows discharge post Trim point commissioners have had to pay more for the same episode of care and if OPAT achieves this then the commissioners ‘win’ financially

• C If OPAT allows discharge pre Trim for care that goes over the Trim point and beyond – both Trust and commissioners win.

• D OPAT allows admission avoidance NO HRG code is applied and hence the commissioners do not pay for the care BUT the hospital loses out on income – commissioners win/Trust loses

Trim point HRG code applied

A

B

C

Inpatient stay

OPAT care

D

Study performed whilst receiving Non-Recurrent Funding - Savings (1)

• Consecutive data collected from Dec 2011 to Dec 2012

• Early discharge - 176 patient episodes were analysed for individual HRG codes, Trim points and excess costs beyond Trim points

• Admission avoidance – 10 patient episodes were analysed for the HRG code, Trim point and excess costs beyond Trim point that would have been applied if the patient had been admitted was calculated

• Individual Commissioning Groups wanted CCG level data

Study performed whilst receiving Non-Recurrent Funding - Savings (2)

• 176 episodes of patient care resulted in a saving of 4489 bed days of hospital admission

• 2146 bed days (48%) were pre Trim point (A and part of C) – viewed as Trust savings

• 2343 bed days (52%) were post Trim point (B and part of C) - £528,786 savings for the commissioners

Trim point HRG code applied

A

B

C

Inpatient stay

OPAT care

Early Discharge

2146 OPAT bed days saved

2343 OPAT bed days saved

Totals Trust benefits

Commissioners benefit

Study performed whilst receiving Non-Recurrent Funding - Savings (3)

• 10 episodes of patient care resulted in a saving of 392 bed days of hospital admission resulting in a saving to the commissioners of £79,708

Admission Avoidance

Trim point NO HRG code applied OPAT care

D

Commissioners benefit

Totals

Study performed whilst receiving Non-Recurrent Funding - Costs

PAY

Consultant PAs (4.5 total – 3 funded from OPAT budget) £30,000

Band 7 Nurse (1 WTE) £44,500

Band 6 Nurses (2 WTE) £74,000

Band 3 Support Nurse (1 WTE) £21,886

Band 5 Pharmacy technician (0.2 WTE) £6,100

Band 8b Pharmacist (0.15 WTE) £9,350

NON-PAY

Drugs and Consumables £73,723

Miscellaneous £6,000

Overheads (20%) £53,111

TOTAL £318,670

Conclusions on Savings and Costs…

• Total savings to the Commissioners £608,494.

• Total cost of the OPAT service £318,670.

• Commissioners have funded the NUH OPAT service in full on a recurrent basis as they are still realised savings of £289,824.

• Mechanism of funding through recording Outpatient, Ward Attendance and Nurse Home Visit activity.

• Trust and Clinical Commissioning Groups have agreed to spilt the QIPP benefit 50:50 because the benefits were so evenly.

• The Trust and Commissioners have agreed a bed day price of £250 having analysed the HRG codes.

QIPP

Acknowledgements

• OPAT Team

– Nurses: Amanda Bort, Collen Jackson, Sarah Williams, Sandra Orme

– Pharmacist: Tim Hills

– Fellow Drs: Liz Hart, Roshina Gnanaduria, Ivo Elliott

• Business manager

– Sally Forster

• Corporate analyst/ liaison with commissioners

– Juliette Looker

Proposal to the Commissioners as to how the NUH OPAT service can be commissioned on a

Recurrent Basis

• Payment of ID tariff for outpatient clinic attendance - £271 for New patients £208 for Follow ups

• Payment of ID follow up tariff (£208) for ward attendance for iv antibiotic administration

• Payment of £180 for nurse home visit at start of iv antibiotic administration at home

OUTPATIENT

New patient tariff

Follow up tariff

Follow up tariff

Follow up tariff

Follow up tariff

One-off Nurse Home Visit

ID ward attendance visit