Payment by Results in Learning Disability - LD Clustering Tool. Ashok Roy April 1 st 2011

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1 Payment by Results in Learning Disability - LD Clustering Tool Ashok Roy April 1 st 2011 Ashok.roy@covwarkpt.nhs.uk

2 POLICY CONTEXT Current policy supports commissioning and provision by care pathway Commissioning and provision of care to be organised around the clinical needs and outcomes from interventions delivered Similar clinical needs can be grouped into groupings called care clusters and will have similar resource requirements This will enable commissioners to purchase services at best cost and quality to meet the needs of the local population Development of a care clusters fundamentally changing the way we purchase, organise and deliver care linking interventions and outcomes to patient need. Care pathways can be illustrated by mapping teams delivering care, the interventions delivered and the referral routes within each care cluster

3 COMPONENTS OF PBR Activity based funding Healthcare resource groups (Clusters) Payment by volume of work done Groupings of individual cases which are clinically similar and require similar amounts of resource for their treatment Payment according to a national tariff Payment fixed based on average cost of treating that type of patient across the country

4 LESSONS FROM MENTAL HEALTH 1 Adjustments for treatment variables needed (e.g. setting, age, comorbidity etc) Diagnosis did not predict cost High cost variation for community based treatment Provider characteristics explained cost variation better than patient characteristics Demanding in terms of data requirements for collecting and coding information

5 LESSONS FROM MENTAL HEALTH 2 Condition assessed by HoNOS PbR (MHCT) Possible to develop and allocate clusters based on shared need which are the basis of care packages for the individual Interventions (care packages) for clusters can be standardised and costed Clusters and packages can help determine population need and skills required

6 POSSIBLE IMPACT OF PBR IN LD Negotiations focussed on access and quality and not on price Removal of link between price (tariff) and cost incurred promotes greater efficiency and activity Information systems will need to improve to record performance measures (appropriateness, effectiveness, outcomes) Increase choice of providers

7 CHALLENGES IN APPLYING PBR IN LD 1 People with same initial diagnosis (autism, affective disorder etc) have varying course of illness Comorbidity affects course and treatment and adds to cost Varying models of treatment and management

8 CHALLENGES IN APPLYING PBR IN LD 2 Treatment provided in many settings Conditions are often chronic and recurrent Services are usually provided by different agencies Informal care and support is an important factor for many service users No agreement on definitive list of need clusters No agreed intervention list No agreed outcomes framework

9 WHAT IS IN A CARE PATHWAY Needs Clusters Interventions Outcomes

10 HEALTH NEEDS IN LEARNING DISABILITY LD HEALTH NEEDS PSYCHOLOGICAL PHYSICAL GENERAL HEALTH AND WELLBEING MENTAL HEALTH PROBLEMS OBESITY PRIMARY CARE BEHAVIOUR PROBLEMS OFFENDING BEHAVIOUR EPILEPSY DSYPHAGIA GENERAL HOSPITAL CARE LIFESTYLE ISSUES DEMENTIA AND OTHER DEGENERATIVE CONDITIONS AUTISM SPECTRUM CONDITIONS/ ADHD END OF LIFE/ PALLIATIVE CARE SENSORY PROBLEMS MOVEMENT AND POSTURE

11 INTERVENTIONS The referral may be forwarded to more than one clinician for treatment Each clinician should select the intervention category from the tier 1 list: Assessment Therapeutic intervention Enabling activities Family/Carer/Liaison Monitoring Activities

12 OUTCOMES Quality (effectiveness) Safety (risk) User experience

13 COST AND CURRENCY

14 A CURRENCY MUST HAVE The ability to categorise service users (into clusters) Members of categories must be resource homogenous A time period The ability to weight the resources used by each cluster

15 CURRENCY REPRESENTATION Cluster Weighting Duration Period end Period start

16 CURRENCIES AND CARE TRANSITION POINTS Transition Points Unscheduled Review Periodic Review Mental illness cluster ASD cluster Period start Period end Period start Period end

17 CONTEXT AND AIMS Local initiatives appearing. Previous experience in MH where leaving projects to develop in a direction which will ultimately be incompatible with the central position has lead to wasted time, effort and loss of good will. Clusters providing maximum coverage to be finalised. LD formally adopted under the Mental Health PbR Programme. LD Sub-group formed reporting to Product Review Group and PbR Board.

18 MENTAL HEALTH NEEDS

19 HEALTH NEEDS IN LEARNING DISABILITY LD HEALTH NEEDS PSYCHOLOGICAL PHYSICAL GENERAL HEALTH AND WELLBEING MENTAL HEALTH PROBLEMS OBESITY PRIMARY CARE BEHAVIOUR PROBLEMS OFFENDING BEHAVIOUR EPILEPSY DSYPHAGIA GENERAL HOSPITAL CARE LIFESTYLE ISSUES DEMENTIA AND OTHER DEGENERATIVE CONDITIONS AUTISM SPECTRUM CONDITIONS/ ADHD END OF LIFE/ PALLIATIVE CARE SENSORY PROBLEMS MOVEMENT AND POSTURE

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21 PERFECT CLUSTERING

22 INSUFFICIENT COVERAGE

23 EXCESSIVE OVERLAP

24 AIMS Provide background/overview of the development of PbR in LD Provide background to Care Pathways Familiarise participants with needs through individual items on Clustering Tool Familiarise participants with draft lists of clusters (global description of health state) Provide background to existing Clusters in LD Offer specific instruction to complete the LD Clustering Tool

25 BACKGROUND AND OVERVIEW Original Clusters developed by groups of Clinicians in LD Trusts Intervention framework being developed Outcome Framework being developed DH agreement for LD Cluster Framework to be integrated with Mental Health Pilot to trial LDCT to finalise clusters

26 COMPLETING THE LDCT IT S NOT A NEW ASSESSMENT but summarises - in 2 parts - your holistic assessment

27 LD CLUSTERING TOOL PART 1 CURRENT RATINGS 1 Overactive, aggressive, disruptive or agitated behaviour 2 Non-accidental-self injury 3 Problem drinking or drug taking 4 Cognitive problems 5 Physical illness or disability problems 6 Problems associated with hallucinations and delusions 7 Problems with depressed mood 8 Other mental and behavioural problems 9 Problems with relationships 10 Problems with activities of daily living 11 Problems with living conditions 12 Problems with occupation and activities 13 Strong unreasonable beliefs occurring in non-psychotic disorders only 14 Mental Capacity 15 Carer needs 16 Cultural and communication needs 17 Non-accidental self injury (associated with cognitive impairment 18 Physical problems with eating and drinking 19 Seizures

28 LD CLUSTERING TOOL PART 2 HISTORICAL RATINGS A Agitated behaviour / expansive mood B Repeat self-harm C Safeguarding children & vulnerable dependant adults D Engagement E Vulnerability F Autism spectrum related G Communications and problems with understanding H Communications and problems with expression

29 LDCT SCORING GUIDANCE Rate every item (0-4 scale) Check Score Guide if necessary Consider Current and Historical ratings Score each item in turn (don t rate something twice) Item 8 choose and rate the most severe problem if relevant

30 LD CLUSTERS OVERLAPPING WITH MENTAL HEALTH (1-21) Non psychotic disorders Psychotic disorders Organic disorders producing cognitive impairment

31 EXAMPLES OF LD CLUSTERS NOT OVERLAPPING WITH MENTAL HEALTH Behaviour disorders Offending behaviour Developmental disorders (ASD, ADHD) Epilepsy Dysphagia and other problems with nutrition Problems with mobility and posture Sensory problems End of life

32 EXAMPLE: in Part 2 Section B : Repeated self harm (Rating period = Historical ) Item Description: Repeated acts of self cutting, biting, striking, burning, breaking bones or taking poisonous substances etc. Include: All of the above aimed at reacting to people, emotions, stressful situations or to produce mutilation for any reason. Do Not Include: Accidental self-injury (due e.g. to learning disability or cognitive impairment); the cognitive problem is rated at Item 4 and the injury at Item 5 in Part 1. Harm as a direct consequence of drug/alcohol use rated at Item 3 (e.g. cirrhosis of the liver or an injury resulting from drink-driving are rated at Item 5 ).

33 EXAMPLE: PART 2 SECTION B: REPEATED SELF HARM (CONTINUED) Item Scoring: 0 = None: No problem of this kind. 1 = Minor problem: Superficial scratching or non-hazardous doses of drugs. 2 = Mild problem: Superficial cutting, biting, bruising etc or small ingestions of hazardous substances unlikely to lead to significant harm even if hospital treatment not sought. 3 = Moderate problem: Repeat self-injury requiring hospital treatment. Possible dangers if hospital treatment not sought. However, unlikely to leave lasting severe damage even if behaviour continues providing hospital treatment sought. 4 = Severe to Very Severe problems: Repeat serious self-injury requiring hospital treatment and likely to leave lasting severe damage if behaviour continues (i.e. severe scarring, crippling or damage to internal organ) and possibly to death.

34 Item Score Item Score Part 1 (Current) 1 (0-4) 15 (0-4) 2 (0-4) 3 (0-4) 4 (0-4) 5 (0-4) 16 (0-4) 17 (0-4) 18 (0-4) 19 (0-4) 6 (0-4) 7 (0-4) 8i Please Circle A B C D E F G H I J 8ii (0-4) Part 2 (Historical) 8iii If J (other) please specify A (0-4) 9 (0-4) B (0-4) 10 (0-4) C (0-4) 11 (0-4) D (0-4) 12 (0-4) E (0-4) 13 (0-4) F (0-4) 14 (0-4) G (0-4) 15 (0-4) H (0-4)

35 Care clusters identify needs of service users at a particular moment in time Clusters allow for a certain amount of fluctuation in condition But a significant change in condition will always lead to a change in cluster allocation. So a service user s journey may involve them moving through a range of clusters as their condition changes over time???

36 CASE 1 Colin is a 55-year-old male who has been known to the psychiatric services previously with a diagnosis of Mild Learning Disability and Autism Spectrum Disorder. The GP has requested a reassessment. Colin has recently moved to a new home following closure of his previous residential placement. Since the move he has been increasingly unsettled with episodes of verbal and physical aggression towards the staff. On one occasion he threw a cup of hot tea on a staff member. More recently he has threatened staff with a knife on two occasions. It is difficult to identify clear triggers to his behaviour, however he has been noted to have high anxiety levels and has been pacing around a lot. There is no history of self harm. There is no evidence of pervasive lowering of mood or any psychotic symptoms. He reported feeling angry towards the mental health team and the social services whom he considers responsible for his move and repeatedly demanded to go back to his previous placement. In the past he has been treated with Citalopram for a Depressive Disorder. He has a history of Primary Generalize Epilepsy and has 1-2 tonic clonic seizures a month. He also has a history of problems with mobility with deformed joints.

37 CASE 2 Jenny is a 60 year old female with a Mild Learning Disability living in a small group home. She was referred to the Learning Disability Service for an assessment. Jenny started having problems with her mobility one year ago with weakness in her left leg. She now mobilizes only with the help of a Zimmer frame and has support brackets in her left leg. She has also developed problems with her swallowing. There has also been deterioration in her reading and writing skills and verbal communication. During the assessment it was highlighted that Jenny has been feeling low in mood with frequent crying spells for the last 08 months. She has a lack of interest and enjoyment in activities she previously liked and is isolating herself in her room on most days. Her sleep and appetite are fine but she has lost a stone in weight in the last few months due to problems with swallowing. There has been deterioration in her short-term memory over the last 06 months along with a decline in self-care. Jenny now needs help with most of her ADLs including washing, dressing and feeding, where before she was fairly independent with these. There has also been deterioration in her reading and writing skills and verbal communication. There is no history of self harm or harm to others. In addition to her mobility problems she has a history of hypercholesterolemia, anaemia, oesophagitis, and chronic constipation. She does not have a history of previous contact with the psychiatric services.

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