Unbundling recovery: Recovery, rehabilitation and reablement national audit report

Transcription

1 NHS Improving Quality Unbundling recovery: Recovery, rehabilitation and reablement national audit report Implementing capitated budgets within long term conditions for people with complex needs

2 LTC Year of Care Commissioning Programme The Long Term Conditions (LTC) Year of Care Commissioning programme aims to transform the quality of care for people with complex care needs. People with multiple long term conditions need personalised care that enables them to live as well as possible for as long as possible. They need all their health and care services to be joined-up. Personalised, integrated services can achieve better outcomes, a better quality of life, and a more efficient use of health and care resources. However, NHS funding systems have traditionally focused on isolated episodes of activity, rather than longer-term packages of care planned proactively around the needs of the individual. This internationally groundbreaking programme is supporting commissioners and providers to develop and implement funding models so that an annual budget for individuals with complex care needs can be used to commission tailored, joined-up packages of care. Implementing capitated budgets The programme, which began in 2012, has been working with early implementer sites to develop, test and refine tools and techniques for identifying groups of patients with complex care needs and calculating the costs of their care. Early implementers are also modelling the effects of different tariffs and patient cohorts, trialling new pathways of care and new datasets, and exploring workforce implications. A number of fast followers are implementing the shared learning as it develops. About this document This report describes how an audit methodology used previously for surgical conditions can be used to assess whether the rehabilitation aspects of a patient s acute hospital stay could be better provided. It shows how, with some further evidence, a locally derived tariff for recovery, rehabilitation and reablement could be developed to support service improvements. This document should be seen alongside Unbundling recovery: A step-by-step guide to audit and modelling which describes how providers can carry out the audit and model scenarios in their own organisation. Other documents and learning materials This document is part of a suite of learning materials being produced by the LTC Year of Care Commissioning Programme to support the spread and adoption of capitated budgets for people with complex care needs. For all the latest available documents, please visit:

3 CONTENTS Executive summary 4 Background and key definitions 6 Introduction 9 Main conclusions from the analysis 10 Relevance of results to original national aims for the recovery, rehabilitation and reablement audit pilot 17 Step-by-step guide to local audit and modelling 21 References 22 3

4 EXECUTIVE SUMMARY The recovery, rehabilitation and reablement (RRR) clinical audit is a component of the LTC Year of Care Commissioning Programme. The audit was carried out by four early implementer sites who are part of the programme. The aim of a RRR clinical audit is to improve the quality of patient care and outcomes by delivering a seamless RRR service for acute admitted patients based on their clinical and biopsycho-social needs, rather than just their diagnosis or where the care is currently delivered. The clinical audits were conducted with a view to answering four main questions: Could an audit methodology developed for surgical conditions be used for non-surgical chronic conditions? Could the methodology be applied consistently by different clinical staff at different acute providers? Was there consistency in the results such that a national statistical X-point approach could be developed, or did variation between audits suggest a local approach to unbundling tariffs was more realistic? Was there clinical support for the theoretical principles in the expert clinical reference group RRR paper 1? The pilot audits found that the RRR theoretical principles were generally sound and that the audit methodology (in modified form) could be applied to non-surgical conditions. Due to the experimental nature of the audit there were significant differences in results between the pilot audits. There were differences in the selection of patients for the audit, and differences in interpretation of the key audit definitions. An overall assessment of the audit methodology suggests that it could be improved by: Altering the selection of patients to incentivise a prospective rather than retrospective audit, where the clinical decision-making could link directly into the existing discharge planning process at the acute hospital Improving the definitions and guidance for the audit to ensure greater consistency of results from different health economies. 4

5 The audit results from four early implementer sites were well accepted locally as they were able to demonstrate that: In all health economies, some RRR services were being delivered in acute hospitals. Some of the reasons for this are listed in the figure on page 8 and Figures 4 and 5 There was scope for improving the efficiency of discharge planning by: 1. Perhaps starting this planning process earlier 2. Focussing on unblocking hold-ups in the discharge process (particularly awaiting a bed in another organisation and awaiting community/social care assessments ). Consistently across three health economies, 30% of patients diagnosed with a chronic condition who were assessed as needing an RRR service, spent time in hospital after they were medically fit for discharge With further evidence, some health economies could see how a locally derived unbundled RRR tariff could be developed to support service improvements. A step-by-step guide to RRR audit and modelling 4 has been produced to accompany this report. It describes the methodology for any health economy to carry out a local audit. It also sets out how to use an associated RRR modelling tool to explore the impact of varying lengths of stay on tariff and bed utilisation. 5

6 BACKGROUND AND KEY DEFINITIONS The RRR clinical audit is a component of the LTC Year of Care Commissioning Programme, commissioned by NHS England and delivered by NHS Improving Quality. It is a clinical programme of work within Domain 2 of NHS England, overseen by Dr. Martin McShane, clinically led by Professor Keith Willett and supported by the RRR expert clinical reference group. RRR is a concept to support the redesign of patient pathways through early discharge from an acute phase of care. The RRR concept explores whether funds can be liberated (unbundled) from within national acute care PbR tariffs to incentivise rehabilitation and reablement services in a range of settings. The aim of the RRR programme is to improve the quality of patient care and outcomes by delivering a seamless RRR service for acute admitted patients based on their clinical and bio-psycho-social needs, rather than just their diagnosis or where the care is currently delivered. RRR pathway redesign should change the responsibility for care (and associated tariff) at the point when the patients needs change, not at the point when they change institutions. 6

7 Two key time points in the RRR pathway have been defined by the RRR expert clinical reference group the R-point and the L-point 1 : The R-point the point at which an accurate assessment of a patient s RRR need can be made i.e. the point at which decisions about both where and when to send a patient for RRR services can be finalised 3. Assigning an R-point for a patient is a purely clinical decision. The L-point (liberation point) the point in the pathway where a patient could be safely discharged from the acute phase of care (if alternative support services existed). Some clinicians describe this as medically fit for discharge. Under our definition, this is the beginning of the RRR phase of treatment. Assigning an L-point for a patient is a purely clinical decision. However, there is a financial aspect to the L-point as it is the point in the patient pathway at which funds could be liberated from the acute tariff to support services being delivered in a setting that is most appropriate to the patient (i.e. the start point for the unbundled RRR tariff). As a rough guide, the L-point is proposed to be R-point + 2 days 1. In the above definition, we state that the L-point describes the point at which a patient could be discharged from an acute phase of care. There are some medical services that may normally be delivered by acute hospital clinicians but which could be considered part of a RRR service. In this paper, the only medical services that we include within the RRR phase are: Medical tests, assessment and pharmacological advice and training that are part of the normal acute hospital discharge process Medical services that need not be delivered in an acute hospital setting, such as: Simple diagnostic and radiology services Acute treatments delivered by community clinicians or GPs Acute clinicians delivering services in community settings (including clinicians who are part of integrated care teams or similar). 7

8 Illustration of key dates during a patient stay in an acute hospital R-point Decision criteria Acute phase RRR phase R-point. Date at wich the patient s RRR need can be accurately assessed. Decision made purely on clinical criteria. L-point Acute phase RRR phase Discharge date L-point. Date at which patient is medically fit for discharge. Date at which unbundling of tariff could occur. ( Liberation point.) Decision made purely on clinical criteria, but could have financial implications. Beginning of RRR phase. Acute phase RRR phase Discharge date from acute hospital. The length of the current RRR phase in acute hospital is likely to depend mainly on: Medical deterioration of the patient s condition (i.e. extension of the acute phase) Lack of appropriate alternative services outside of the acute hospital Delays in the acute hospital discharge pathway for patients. From the LTC Year of Care RRR audit pilots, reasons for delays in the discharge pathway were found to include: Traditional delayed transfer of care to social care (DToC) Waiting for additional medical tests Waiting for assessment(s) (medical, therapists, intermediate/community, mental health, social care) Waiting for a bed in intermediate care, residential care, nursing home, etc. Waiting for a new or changed care package (i.e. referral and management by Integrated Care Team (ICT)) Patient reasons (patient refused discharge, home not suitable for discharge, patient refused care package, etc.) 8

9 INTRODUCTION Early implementer sites from the LTC Year of Care Commissioning Programme were asked to contribute to the RRR work being carried out by the RRR expert clinical reference 1 and to link with: Work by the Health and Social Care Information Centre (HSCIC) that aimed to identify an Xpoint or statistical R-point (or trim point) for admissions for four high volume specific long term conditions stroke, heart failure, diabetes and chronic obstructive pulmonary disease (COPD) 2 A RRR audit for patients following hip fracture conducted by Claire Pulford, Consultant Trauma/Geratology, Oxford University Hospitals 3. The original audit methodology provided to the early implementer sites was developed to match the audit method used for the Oxford University Hospitals RRR clinical audit but limited to the four long term conditions included in the HSCIC X-point analysis. The methods are described in the accompanying paper Unbundling recovery: A step-by-step guide to audit and modeling 4. The scope for the RRR audit conducted by early implementer sites was mainly determined by two factors: A minimum of 100 patients were required for the audit The audit should, as a minimum, include patients where their admission was related to four long term conditions (COPD, diabetes, heart failure and stroke). Data from the four early implementer sites contributed to the analysis. These were: North Staffordshire and Stoke East Kent Leeds Barking and Dagenham, Havering and Redbridge. Due to the experimental nature of the audit, the patients selected by the teams varied widely (particularly in age profile and overall health of patients), making comparison between the early implementer sites at a national level difficult. Patients who died in hospital, or for whom there was no L-point date, admission date or discharge date were excluded from the analysis. 9

10 MAIN CONCLUSIONS FROM THE ANALYSIS 1. There is opportunity for shifting recovery, rehabilitation and reablement services out of an acute setting. The percentage of patients assessed as having a need for RRR services varied between the early implementer audits (Figure 1). For three of the four clinical audits, the length of stay for patients assessed as having some level of RRR need was longer than patients with no assessed RRR need (Figure 2): East Kent RRR need 20.5 days, no RRR need 1.5 days Leeds RRR need 7.8 days, no RRR need 5.4 days Stoke high or medium RRR need 7.1 days, low RRR need 4.0 days. However, there was not a consistent relationship between the assessed level of RRR need and the length of the hospital RRR phase (Figure 2). This latter conclusion is perhaps expected. Those patients assessed as having a need for the services are also likely to be patients who already have some level of support outside of hospital (i.e. already have a community or social care support package, or already in residential care). For example, Figure 3 illustrates that a smaller percentage of patients with higher levels of assessed RRR needs were discharged home (40% to 60% of patients with some level of assessed RRR need were not discharged home) more often, these patients were discharged to nursing or other residential homes or to other hospitals (including intermediate care). Figure 1: Percentage of patients assessed as having an RRR need. Legend is level of assessed RRR need; value in brackets is the number of patients. 10

11 Figure 2: Length of acute and RRR phases for patients assessed as having an RRR need. Value in brackets is the number of patients. Figure 3: Percentage of patients discharged home for patients assessed as having an RRR need. Value in brackets is the number of patients. 11

12 Figure 2 illustrates that patients are spending some RRR phase in acute hospital, and thus there is opportunity to discharge some patients earlier into RRR support if alternative services existed. In Figures 4, 5 and 6 we investigate the reason why the RRR phase was spent in acute care. Data from the North Staffordshire and Stoke clinical audit illustrates that approximately 30% of patients spend any RRR phase in hospital (Figure 4; in this clinical audit, patients were diagnosed with one of six chronic conditions). Figure 5 illustrates that the reason for the RRR phase may include medical or patient reasons, or a delay waiting for assessment (community or social care), or waiting for a bed in residential care or another hospital, including intermediate care. Patients who were waiting for assessment or waiting for a bed spend on average 30% of their length of stay in hospital for these reasons. Figure 6 illustrates consistency across the early implementer audits. Approximately 30% of patients with chronic conditions assessed as having some level of RRR need spend some of that phase in hospital unnecessarily while they wait for assessment or a bed. These data suggest that a major reason why patients in the RRR clinical audits could not be discharged earlier was that either: Patients were not identified as requiring assessment or a bed early enough during their stay to ensure that these services were available when the patient was ready for discharge; and/or Services outside of hospital were not available on the day that they were required. Figure 4: Percentage of patients by reason for RRR phase. North Staffordshire and Stoke data only. Value in brackets is the number of patients. 12

13 Figure 5: Length of stay and length of the RRR phase by reason RRR was required. Medical RRR required for medical reasons; Patient RRR required for patient reasons (patient or relative refused discharge or no carer support at home); Awaiting assess Awaiting assessment for community or social care; Awaiting bed Awaiting a bed in community hospital or care home. North Staffordshire and Stoke data only. Figure 6: Percentage of patients by reason for RRR phase. Patients assessed as having some need only. Value in brackets is the number of patients. 13

14 2. Some features of patients with longer hospital RRR phases Older patients that were part of the Leeds and North Staffordshire and Stoke clinical audits tended to have longer lengths of stay, but this was not true for the East Kent audit (Figure 7). However, consistent across all three RRR clinical audits, the length of the RRR phase increased as patient age increased (Figure 7). Larger percentages of patients diagnosed with COPD and diabetes were moved during their stay in hospital than patients diagnosed with stroke and syncope and collapse (Figure 8; data from the North Staffordshire and Stoke RRR clinical audit only). Patients who experienced more moves between wards tended to have longer overall lengths of stay and longer RRR phases (Figure 9; data from the North Staffordshire and Stoke RRR clinical audit only). Figure 7: Length of acute phase and RRR phase by patient age. Value in brackets is the number of patients. 14

15 Figure 8: Percentage of patients split by the number of times the patient was moved between wards, by long term condition. North Staffordshire and Stoke RRR data only. Value in brackets is the number of patients. Figure 9: Length of acute phase and RRR phase by the number of times the patient was moved between wards. North Staffordshire and Stoke data only. Value in brackets is the number of patients. 15

16 The audits conducted by the early implementer sites yielded results that varied strongly between the sites. Even when selecting patients with the same diagnosed condition (e.g. COPD or diabetes) the recorded data varied substantially between the RRR clinical audits run by the early implementer sites. We believe the main reasons for these inconsistencies were: The patient groups selected for the clinical audits were very different mainly in age profile, and in the severity of the chronic condition with which they were diagnosed The interpretation of the R-point and the L-point by clinicians varied. 16

17 RELEVANCE OF RESULTS TO ORIGINAL NATIONAL AIMS FOR THE RECOVERY, REHABILITATION AND REABLEMENT AUDIT PILOT The RRR clinical audits were set up to, in part, answer four main questions: Could the audit methodology developed for fragility hip fracture (Oxford University study) be used for non-surgical conditions? Could the methodology be applied consistently by different clinical staff at different acute providers? Was there consistency in the results such that a national statistical X-point approach could be developed, or did variation between audits suggest a local approach to unbundling tariffs was more realistic? Was there clinical support for the theoretical principles in the Expert Clinical Reference Group s RRR paper 1? 1. could the audit methodology developed for fragility hip fracture be used for non-surgical conditions? The results indicate that the basic methodology can be used for patients with non-surgical conditions. However, there was general consensus among the early implementer sites that future RRR audits should not focus on specific conditions, but be targeted towards a more general group of patients. For example, Leeds audited all patients admitted to a geriatric ward rather than restricting the audit to patients with one of the four specified chronic conditions. This enabled the team to conduct a prospective audit rather than a retrospective audit clinicians could assess the L-point during ward rounds rather than using clinical notes because there was not a need to identify the diagnosis for the patient before the audit was conducted. The other three early implementer sites conducted retrospective audits. They identified patients suitable for the RRR audit from diagnosis codes assigned to patients by clinical coders once the patient had been discharged, and then recorded information for the audit using clinical notes. 17

18 2. could the methodology be applied consistently by different clinical staff at different acute providers? There was substantial variation between the audit data from the early implementer sites (Table 1). The early implementer sites suggest that there were two main reasons for this variation: The selection of patients varied substantially between the RRR clinical audits, particularly in age profile and overall health of the selected patients. This had a significant knock-on impact on the length of stay, length of the RRR phase and on the assessed need (and thus on the requirement for community or social care assessment and on the discharge destination) Clinicians interpreted the L-point differently. In particular, we believe clinicians found it difficult to make a decision purely on clinical grounds, without regard to whether alternative services were or were not present. Table 1 Length of stay and length of the RRR phase for all patients who were part of the clinical audits run by early implementer sites. BHR Barking and Dagenham, Havering and Redbridge Kent BHR Leeds Stoke All conditions Excluding stroke Average length of stay (days) Average length RRR phase (days) Feedback from the early implementer sites described a wide range of factors that contributed to differences in the interpretation of the national guidance for the audit. Improvements in definitions and guidance should improve consistency between RRR clinical audits by different clinicians. 18

19 3. Was there consistency in the results such that a national X-point approach could be developed, or did variation between audits suggest a local approach to unbundling tariffs was more realistic? There was not enough consistency in the results from the RRR clinical audits reported in this paper to assess whether a national statistical X-point approach could be developed. With current data, we can only suggest that local approaches to unbundling tariffs should be developed. Furthermore, we believe that the International Classification of Disease version 10 (ICD10) diagnosis code and HRG approach that the HSCIC use 2 is not appropriate for this purpose for three main reasons: The use of ICD diagnosis and HRG codes for the selection of patients incentivises retrospective audits, rather than prospective audits that could link with acute providers current discharge planning pathways The early implementer teams currently believe that patients with multi-morbidity for chronic conditions are more likely to be assessed with higher RRR need than patients with singlemorbidity. If this is proved, then selecting patients and defining X-points using specific HRG or ICD10 codes is unlikely to target the most relevant group of patients Results from the audits reported in this paper suggest that patients with a chronic condition are assigned a wide range of HRGs. Our results suggest that an HRG level is not appropriate for assigning an X-point and perhaps a sub-hrg level based on IDC10 codes would be required (i.e. similar to some of the PbR best practice tariffs). 4. Was there clinical support for the theoretical principles in the expert clinical reference group s Recovery, Rehabilitation and Reablement paper 1? In general, the theoretical principles in the expert clinical reference group paper were not disputed by results from the early implementer audit teams. Although, as described above, this audit methodology would benefit from an update focussed on improving definitions and guidance. 19

20 5.How are early implementer sites taking this work forward? Several of the early implementer sites have indicated that the audit has been useful and that they wish to build upon it by: Conducting further audits, for different geographic locations or different groups of patients Using the evidence from the audit to re-assess the effectiveness of the current early discharge process, and to contribute to a gap analysis of the community services that perhaps could be put in place Using the evidence to start discussions about whether a locally developed RRR budget, using funds released from unbundled acute tariffs, is appropriate and possible. 20

21 STEP-BY-STEP GUIDE TO LOCAL AUDIT AND MODELLING A step-by-step guide to RRR audit and modelling 4 has been produced to accompany this report. It describes the methodology for any health economy to carry out a local audit. It also sets out how to use an associated RRR modelling tool to explore the impact of varying lengths of stay on tariff and bed utilisation. For more information, please visit 21

22 REFERENCES 1. Recovery, Rehabilitation and Reablement. Unpublished strategy paper, Expert Clincal Reference Group QIPP LTC X point analysis paper for the RRR element of the funding model. Unpublished research paper, Health and Social Care Information Centre Potential R point for fragility hip fracture: clinical considerations. Unpublished research paper. Claire Pulford, Consultant Trauma/Geratology, Oxford University Hosptials Unbundling recovery: A step-by-step guide to audit and modelling 22

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24 NHS Improving Quality To find out more about NHS Improving Quality: Improving health outcomes across England by providing improvement and change expertise Published by: NHS Improving Quality - Publication date: May Review date: May 2016 NHS Improving Quality (2015). All rights reserved. Please note that this product or material must not be used for the purposes of financial or commercial gain, including, without limitation, sale of the products or materials to any person.