Care Pathways & Payment-by-Results

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Care PathwaysPayment-by-Results

• David Kingdon
• University of Southampton
• NHS South Central/Hampshire Partnership FT

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Whats 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

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Whats 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

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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
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Care pathways
Persistent
Stable
Acute
Low
Memory difficulties
Psychosis
Moderate
Stable
High
Persistent
Anxiety/depression related conditions
High (PE)
Eating disorders
Acute
Emotional difficulties
Bipolar disorder
Acute
Rapid cycling Borderline Personality Disorder
Persistent
Stable
Payment-by-Results
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Costs












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

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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

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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