Care Pathways & Payment-by-Results

1. Care Pathways&Payment-by-Results David Kingdon University of Southampton NHS South Central/Hampshire Partnership FT

2. What’s a care pathway? • An integrated care pathway (ICP) is a multidisciplinary/ multi-agency outline of anticipated care, placed in an appropriate timeframe, to help a patient* with a specific condition or set of symptoms move progressively through a clinical experience to positive outcomes * also for general population, carers, primary care, general medical services, non-statutory sector, mental health services and commissioners

3. What’s a care pathway? • Clinical care pathways are “both a tool and a concept that embed guidelines, protocols and locally agreed, evidence-based, patient-centred, best practice, into everyday use for the individual patient. In addition, and uniquely to ICPs [Integrated Care Pathways], they record deviations from planned care in the form of variances” [Defining and monitoring quality] • ‘Bandolier’ description [providing information for …] • Diagnosis: Treating the right patient ) Guidelines • Treatment: Treating the right patient right ) • Organisation: Treating the right patient right at the right time • Pathway: Treating the right patient right at the right time and in the right way

4. Care pathways, clusters and tariffs • Clusters define current need • Clusters span Disorder care pathways • Disorders define pathways (e.g. NICE) • Interventions and specific outcome measures relate to CPs. • How do we relate pathways to clusters? PbR

6. Acute Acute Persistent Persistent Stable Stable Care pathways Persistent Stable Acute Low Psychosis Memory difficulties Moderate Stable High Persistent Anxiety/depression & related conditions High (P&E) Eating disorders Acute Emotional difficulties Bipolar disorder Acute ‘Rapid cycling’ Borderline Personality Disorder Persistent Stable Payment-by-Results

9. +++ +++ +++ Costs ++ ++ + ++ + + +++ ++ ++ +++ +++ ++

10. LOS – length of stay * = x (multiply)

11. Weighting – measured or estimated (e.g. Persistent = 2 x Stable; actual costs for IAPT) LOS – length of stay * = x (multiply)

12. Weighting – measured or estimated (e.g. Persistent = 2 x Stable; actual costs for IAPT) LOS – length of stay * = x (multiply)

13. Weighting – measured or estimated (e.g. Persistent = 2 x Stable; actual costs for IAPT) LOS – length of stay * = x (multiply)

15. Deriving Cluster TariffsWorked Example! £14. Psychotic crisis (tariff) = [(No. of 14. Psychotic crisis with Psychosis x £P-A) + (No. of 14. Psychotic crisis with Bipolar x £BP-A)] / No. of Patients in Cluster 14.

16. Developing a tariff • Cost each CP category (A, P, S) • Use clusters to assess need; Cluster * CP for tariff • Base weighted costs on current or estimated usage • Commence with using annual census (initially then increase frequency to 6 to eventually monthly) • Account for new entrants and exits from pathways PbR

17. Questions: • Can diagnostic care pathway, LOS & cluster info be gathered on all patients? How will we do it? • Are clusters allocated appropriately to pathways? • How do we deal with dual diagnosis; • use primary diagnosis only or e.g. psychosis [drugs or not?] • How do we cost pathways? • Acute: HTT + Acute + PICU (combine or split) • What about ‘delayed discharges’? • Community: • What is a community reference cost? • Persistent – care coordinator & psych (2x cost) + psychology - i.e. = CPA (?) • Do we separate EIT, AOT & high-cost CMHT? Liaison & Perinatal services? • Stable – care coordinator or psychiatrist, i.e. = non-CPA? • Allow for supervision & training costs; accounting for overheads • How do we link to outcomes? [HoNOS, DIALOG, & specific measures eg IAPT] • Exceptions – e,g. very high-cost & possibly forensic patients