Casemix: The New Zealand Journey

1. Casemix: The New Zealand Journey Dr Barry Welsh Principal Advisor Ministry of Health New Zealand

2. The presentation covers • Context • Defining casemix and its research basis • What is case class and purpose of casemix • Health of the Nation Outcome Scales (HoNOS) • Programme for the Integration of Mental Health Data (PRIMHD) • Implementation of the casemix grouper • The types of reports • Current issues • Conclusion

3. Policy and Strategic Context 2005

4. Context – some annual statistics - 146,000 people (over 3% of population) access specialist mental health and addiction services • - 19,000 access once • - 15,000 people are seen for more than 2 years (KPP group) • - 7,000 people admitted acutely • - 1,000 people are secluded • - 5,800 people compulsory assessed under the Mental Health Act • Significant variation in rates between boards

5. Casemix defined • Casemix is simply defined as a “mix of cases” • In New Zealand mental health casemix is defined by the CAOS study that covered clinical community and inpatient services – it did not include NGOs. • Only evidenced based study of its kind in NZ

6. What is a case class • Case classes apply to community and inpatient clinical services across Child and Youth and Adult • A community case class is premised on episodes of 91 days (+- 14 days) bounded by HoNOS collections and uses the following variables to determine what class the episode is allocated to: - a persons age, ethnicity, legal status, HoNOS score, focus of care • 56 year old, in the community, with HoNOS collections 91days (+- 14) apart, not under Mental Health Act and of European ethnicity having a functional gain focus of care is assigned to a particular class (AC05). • NZ case mix has 42 different classes (including assessment) that can be rolled up into 7 branches

7. Purpose of casemix • Quality improvement • Outputs measurement • Funding

8. HoNOS – Health of the Nation Outcome Scales • Five scales (HoNOSCA,HoNOS, HONOS65+,HoNOS-secure, HoNOS-LD) • HoNOS 12 items - ranging from problems with hallucinations and delusions through to problems with occupation and activities, on a scale of 0-4 with 4 being severe problems • Measures clinically rated health wellbeing changes over time • HoNOS changes useful for clinicians and clients to monitor progress

9. HoNOS – Health of the Nation Outcome Scales • Mandated by the Ministry of Health for national collection in 2006 • HoNOS data collected according to a protocol underpinned by 91 days +-14days in the community • Te Pou plays a huge role in training , inter-rater reliability and improving collection rates • Change in HoNOS scores used by the KPI project in New Zealand for inpatient admissions and discharges • Ministry also publishes change in HoNOS scores for community and inpatient services publically

10. PRIMHD the national mental health data collection system • Programme for the Integration of Mental Health Data (PRIMHD) superseded MHINC (Mental Health National Collection). • Established in 2008 to collected activity and outcomes data from 20 DHB clinical mental health services and activity data from 250 NGOs. • It collects HoNOS data according to the outcomes collection protocol (derived from CAOS study) from inpatient and clinical community services (91days +- 14 days)

11. Example PRIMHD HoNOS Report

12. Example PRIMHD HoNOS Report

13. Implementation of casemix • A complex algorithm has been applied to the PRIMHD data over 2011- 2013 (10 years since the CAOS study) • Selects only valid episodes. • Distributes valid episode into 42 different classes split by age, ethnicity, focus of care, mental health act, community or inpatient (can be grouped into 7 branches) • A difficult process to implement - significant support from Te Pou • PRIMHD casemix will provide 12 number of standard reports and adhoc queries. Case class reports can be drilled down to NHI (individual person) level.

14. Casemix reports available from PRIMHD • 12 standard reports plus adhoc query capability • The reports can be grouped – • Percentage of Outcome Episodes by Casemix Branch and District Health Board (DHB) • Mean Improvement in HoNOS, HoNOS65+ & HoNOSCA Total Scores • Reports that look at the relative mean improvement (CARMI) in HoNOS scores by DHB, DHB teams, by branch and class • Reports that look at PRIMHD reported activity (beds and community activity and activity duration) relative to the CARMI score by DHB, branch and class • The Percentage of Inpatient and Community Activities Used in Episodes of Care

15. Example Casemix reports available from PRIMHD

16. Example Casemix reports available from PRIMHD

17. Casemix issues • We’ve done it! • Offers an opportunity delve into the detail of HoNOS outcomes • Casemix complex and not well understood by the sector • A top down process - don’t see a case class walk through the door • Low matched pair rates (32,882 community and assessment branch episodes for 91,000 adults seen in 2011) • Risk that there will be little variation in change in outcome scores

18. Mean Class - Improvements

19. Conclusion • Its been a long journey (over 10 years) to develop and implement casemix. • Casemix is potentially a useful tool for quality improvement but still many hurdles to get over. • barry_welsh@moh.govt.nz • www.tepou.co.nz