PAS 150 The Clinical Viewpoint - Diane Playford - VRSIG Chair, British Society of Rehabilitation...

PAS 150: The clinical viewpoint

Diane Playford

VRSIG Chair, British Society of Rehabilitation Medicine

Buy PAS 150 at www.bsigroup.com/pas150 www.bsrm.co.uk

Background

• PAS 150 sets unified standards for all rehabilitation services.

• Tool for – Service planning and development– Staff and service user induction– Development and programme evaluation– Benchmarking by purchasers– Reference to reduce risk and defend decisions


Other sources of standards


British Society of Rehabilitation Medicine

• BSRM is a learned society representing doctors who practise in Rehabilitation Medicine.

• formed in 1984 in the name of the Medical Disability Society

• BSRM encourages doctors in all clinical specialties to be involved in education and research into the management of disability.

• VRSIG established 2005


Government standards

• The National Service Framework (NSF) for Long-term Neurological Conditions requires rehabilitation resources to be available at all stages in a neurological condition, in both community and hospital settings.

• Relevant national clinical guidelines require specialist rehabilitation services, for example recent guidelines on brain injury and NICE Guidelines on multiple sclerosis


BSRM standards

• Standards for specialist inpatient and community rehabilitation services 2002

• Clinical governance in rehabilitation medicine – state of the art 2002

• Measurement in rehabilitation medicine 2005• BSRM Standards for Rehabilitation Services,

Mapped on to the National Service Framework for Long-Term Conditions 2009


Key publications

• Vocational rehabilitation: The way forward 2000 (2nd edition 2003)

• Vocational assessment and rehabilitation after acquired brain injury -2004

• Vocational assessment and rehabilitation for long term neurological conditions - 2010


Specialist rehabilitation

Specialist rehabilitation services consist of multidisciplinary teams including RM physicians, who provide and co-ordinate the comprehensive management of people with complex disability utilising pharmacological, surgical, and therapy approaches, while incorporating psychological and social dimensions, alongside the provision of assistive technology. Most specialist rehabilitation services are based in specialist inpatient neurological rehabilitation units, with strong community commitments including home visiting.


Rehabilitation services

Within each locality (Level 3):Local general rehabilitation teams includes

stroke units, intermediate care orthogeriatrics.

Local specialist rehabilitation services (Level 2)Population of 250-500K, Consultant in Rehabilitation Medicine (RM), Hospital and community settingsSpecialist multidisciplinary rehabilitation team

Tertiary ‘specialised’ rehabilitation services (Level 1) Population of 1 – 3 millionhigh cost / low volume service beyond level 2 & 3 services Collaborative (specialised) commissioning arrangements.


Complex Specialised Rehabilitation (CSR) - Tertiary services (Level 1)

District Specialist RehabilitationDistrict Specialist Rehabilitation(DSR) (Level 2)(DSR) (Level 2)

Local General RehabilitationLocal General Rehabilitation(LGR) (Level 3)(LGR) (Level 3)

Different levels of service

Complexity of need

Pts needing rehabilitation

Av. costAv. cost


Major areas of need – Primary care

• Progressive neurological disorders

• Long-term sequelae of trauma .

• Cognitive and behavioural disturbances

• Congenital disorders and disorders acquired in childhood


Major areas of need – Secondary care

• Trauma/orthopaedics – – brain injury. Incidence 75 to 175 per 100,000. – ~ 1% require admission to a neurological rehabilitation unit but a

larger number require support in view of physical, cognitive and behavioural sequelae.

– Spinal cord injury Incidence of around 2 per 100,000. • Acute medicine

– stroke is the largest source of acute onset neurological disability; some 15% of incident cases are of working age.

– subarachnoid haemorrhage and – anoxic encephalopathy – progressive disorders, frequently require hospital admission due

to either deterioration in their condition or intercurrent illnesses such as infections.


Major areas of need – tertiary care

• Clinical Neurosciences Centres – refer inpatients to neurological rehabilitation beds

following acute management of conditions – acquired brain injuries including subarachnoid

haemorrhage to severe peripheral neurological problems such as Guillain-Barré syndrome.


Efficacy of rehabilitation - stroke

• Trial-based studies provide – 'strong evidence' that more intensive programmes are

associated with earlier functional gains, – 'moderate evidence' that continued outpatient therapy

can help to sustain gains made in early post-acute rehabilitation.

• Non-trial-based studies provided – strong evidence for the benefits of early or late

rehabilitation, the effect of specialist programmes (e.g. vocational or neuro‑behavioural rehabilitation),

– evidence for the cost-benefits of rehabilitation.


Efficacy of rehabilitation

• Multiple sclerosis– Trial based evidence provide benefit for in-patient and

out-patient rehabilitation

• Community‑based specialist services


Cost-effectiveness

• Preventing costly complications and avoidable hospital admissions

• Reducing the duration of hospital admissions • Reducing costs of long-term care• Helping disabled people return to the workforce


Northwick Park Hospital

Regional Rehabilitation Unit– Catchment population 5 million

• Tertiary specialist service– Younger adults– Complex rehabilitation needs– Beyond scope of local services

• Mean age: 43 (SD 14) years• Average LOS: 3 - 4 months


Banding for dependency• Northwick Park Dependency Scale (NPDS)

– Ordinal measure of nursing dependency• High: Score >25

– Two people for most tasks• Medium: Score 10-25

– One person for most tasks• Low: Score <10

– Largely independent for self care

• Translates into:– NP Care Needs Assessment (NPCNA)

• Estimated care hours in the community• Approximate weekly cost of care


5 year Cohort data: 297 consecutive admissions

Dependency on admission

High (NPDS > 25)

Medium (NPDS >10-24)

Low (NPDS <10)

Initial cost of rehabilitation

Mean LOS

£41,782

155 days

£27,774

104 days

£17,226

71 days

Mean weekly savings in care

costs

£673 per week

£290 per week

£83 per week

Time to offset cost of rehabilitation

12 months 17 months 41 months

Turner-Stokes et al JNNP 2006; 77: 634-639Turner-Stokes et al JNNP 2006; 77: 634-639


Factors affecting delivery of specialist services

1. Commissioning processes2. Bed availability3. Discharge pathways4. Access to level 1 rehabilitation5. Consultant shortages6. Measuring outcomes7. Costing8. Accounting for working across agency boundaries


PAS 150

Designing the services• Services should be designed taking into account

the need to protect the user• The provider should ensure that all biological,

functional, social, psychological, vocational and financial factors affecting any service user are taken into account during assessment, planning and service delviery factors


Factors affecting specialist rehabilitation services – commissioning processes

• The pathways for commissioning low volume high-cost interventions for both in and out patient services are relatively complex and often slow. Commissioning difficulties have been reported in specialist out-patient services, vocational rehabilitation, and complex specialist in-patient services such as referral to specialist units.

• Commissioning discussions, particularly at primary care level, are hampered by lack of clarity about distinctions between general and specialist rehabilitation (also between long‑term neurological conditions and long-term conditions in general). In line with the recommendations of the NHS Next Stage Review, there is a need for consultants in RM to be linked more closely with their commissioning colleagues in order to clarify specialised clinical issues.


Factors affecting specialist rehabilitation services II – bed availability• The Royal College of Physicians recommends 60 RM beds per million

population with a minimum size of 20 beds per unit.• Currently the average provision is about 40 RM beds per million

population. • A survey of the BSRM membership showed that units satisfied with

their bed establishment had, on average, about 7 beds/100,000 population.

• Spinal injury units perceived a need for about 1 bed/100,000 population.

• Increasing bed numbers would – shorten the waiting lists. – Prevent repatriation– Decrease length of stay– Decrease patient risk of hospital acquired complications.


PAS 150

Service delivery

3.2.12 Services should be designed to be of high quality and efficiency with consideration for speed, timeliness and cohesive connections to the local community resources.


Factors affecting specialist rehabilitation services III – discharge pathways

• Discharge arrangements are only considered to be ‘good’ for 42% of units

• Problems arise – poor collaboration from social services – poor collaboration with community rehab teams– rehab units are exempt from Community Care (Delayed

Discharges) Act 2003 (section 2 and section 5 forms)


PAS 150

Service delivery

3.3.4 Financial and human resources should eb available for continuous service delivery and sustainability


Factors affecting specialist rehabilitation services– Access to level 1 ‘complex specialised rehabilitation’• 2/3 units will accept patients with some behavioural problems though

usually with limitations such as requirement for onward referral for severe cases (76%).

• <1/2 units are able to manage mobile cognitively impaired patients. Many specialist units lack resources to deal with challenging behaviour and complex cognitive difficulties, where mental-health trained nurses and high levels of psychology input are required.

• 1/2 have inadequate psychology input. • 1/3 units accept patients in vegetative/minimally conscious states. • The waits for many complex specialised services, e.g. specialist

cognitive rehabilitation, specialist behavioural rehabilitation, rehabilitation for low awareness states and specialist vocational rehabilitation are long.


Factors affecting specialist rehabilitation services – shortage of consultants

• The Royal College of Physicians recommends – 6 RM Consultants (WTE) per million population, – 2.7 WTE for inpatient and standard outpatient services, – 1.8 WTE for community provision.

– 1.4 WTE per 10 level 1 beds– 1.1 WTE per 10 level 2 beds

• The present consultant level is about – 2 RM consultants per million population. – Two-thirds of consultants in rehabilitation units are in single-handed practice

• Development of community services is currently hampered by the shortage of consultants.


Factors affecting specialist rehabilitation services– shortage of consultants

France Germany Sweden Italy UK

Number of RM specialists 1760 1571 160 2200 152 Number of RM trainees 125 65 20 350 57

Specialists (all types) per 100k 155 327 207 271 36 Specialists (RM) per 100k 2.9 2.0 1.9 3.7 0.2

RM as % of all specialists 1.87 0.61 0.92 1.36 0.55


Factors affecting specialist rehabilitation services - Outcomes

• Outcome measures are required as commissioning benchmarks

• Australian Rehabilitation Outcomes Centre collects routine data such as diagnosis, disability scores, length of stay


PAS 150

Designing services3.2.10 Services should be designed to be outcome

driven. Performance should be demonstrated against key performance indicators (outcomes, duration, average cost, etc.) …

3.2.11Services should be designed to be proactive. Programme targets should be identified and built into delivery mechanisms


Complex Specialised Rehabilitation (CSR)

District Specialist RehabilitationDistrict Specialist Rehabilitation(DSR)(DSR)

Local General RehabilitationLocal General Rehabilitation(LGR)(LGR)

Banding for different levels of complexity in rehabilitation

Complexity of need

AreasAreas

covered covered by by proposed proposed HRGSHRGS

InputsInputs

FIM±FAM

BIBIGASGAS

OutcomeOutcome


Factors affecting specialist rehabilitation services - Costing• Payment by Results

– Additional costs of complex rehabilitation (as opposed to ‘general’ rehabilitation

• The DoH is moving towards using HRGs v 4 for payment for core HRGs in 2009/10

• Rehabilitation HRGs are ‘unbundled’ HRGs. The DoH currently lacks sufficient costing information to price these. They are not expected to go to tariff until 2011/12.

• HRGs v 4 specifically exclude ‘complex specialised rehabilitation’ which will be subject to specialised commissioning, defined as ‘Brain Injury and Complex Rehabilitation’.

• DoH R&D project to develop case mix in neurological rehabilitation, supported by the BSRM and the Information Centre. A national database will collect case episodes from complex specialised and specialist services. Data on needs, inputs and outcomes for rehabilitation services in England will be collated.

• Future costing frameworks for long term conditions, must recognise the complexities of outpatient and community neurological rehabilitation.


Factors affecting specialist rehabilitation services - Accounting for work across agency boundaries

• The effectiveness of neurological rehabilitation depends crucially on co-working with other agencies such as social services; conversely, cost-effectiveness of rehabilitation interventions is often registered outside the NHS, so that PCTs may lack the financial incentives for appropriate investment in services. The NHS Next Stage Review initiates a whole-systems approach through the establishment of Integrated Care Organisations (ICOs)28. This development should bring large benefits to neurological rehabilitation services.


PAS 150

• Sets standards• Allows services to audit, and identify areas for

improvement• Factors that may prevent delivery of good quality

services will result in non-adherence to PAS 150• PAS 150 will work to drive up standards


What next?

• Co-ordinated, integrated and fit for purpose: A Delivery Framework for Adult Rehabilitation in Scotland

PAS 150 The Clinical Viewpoint - Diane Playford - VRSIG Chair, British Society of Rehabilitation...

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