CRASH COURSE IN OUTCOMES

Transcription

1 CRASH COURSE IN OUTCOMES DR SUDIP SIKDAR FRCPSYCH, MD CONSULTANT OLD AGE PSYCHIATRIST ASSOCIATE MEDICAL DIRECTOR, OUTCOMES & PMH MERSEY CARE NHS FOUNDATION TRUST, LIVERPOOL

2 Understanding the outcomes that matter most to people in mental health and wellbeing. Outcomes are the changes, benefits or other effects that actually occur as a result of what is done Measuring outcomes the changes, benefits, learning or other effects that actually occur as a result of what is done is increasingly important to service users, taxpayers, commissioners and providers of health care. People want to understand not only the inputs and interventions provided by the NHS, but also the end result and improvements delivered through those interventions. Over recent years commissioning in health has rightly turned its attention and focus from commissioning for activity towards commissioning for outcomes. Outcomes are partly the basis of payment for care 2

3 PRINCIPLES Relevant to patients and clinicians Simple and easy to use in routine clinical practice Allow comparison between teams and services locally and nationally, Validated for the purpose for which they are used IT system for data analysis gathered from EPR Clinical Lead and Performance Lead working in conjunction Multi-professional outcome development team with SUC representative

4 TYPES OF OUTCOMES Clinician Reported Outcome Measures ( CROMs) Patient Reported Outcome Measures ( PROMs) Patient Reported Experience Measures ( PREMs) Social Outcomes Clinical Effectiveness/ Patient Safety outcomes Recovery-Focussed Outcomes Process Measures

5 Three mandatory measures Clinician Patient reported Reported Outcome Outcome Measures (CROM) Measures (PROM) HONOS SWEMWEBS/ReQ OL Patient reported Experience Measures (PREM) FFT QoL-AD 5

6 OTHER OUTCOME MEASURES Social Clinical effectiveness Recovery Safety Process measures Accommodation and living conditions Occupation and activities (including employment, volunteering, education and training) Relationships (reduction in problems with relationships) Physical health monitoring and interventions Audits of NICE compliance Reduction in premature mortality in under 75 year olds Length of stay Participation in the Recovery College Recovery / social inclusion focussed questions from the patient experience questionnaire Activities of daily living scores (HoNOS) Number of serious incidents and levels of harm Falls Self-harm Medication errors Number of suicides (Zero Suicide) Use of restraint (No Force First) Waiting times Cluster adherence (completion, review, red rules, rare transitions) CPA reviews 7 day follow up Speed and quality of communication with primary care Liaison and diversion KPIs (Street Car aim delivery) Carer involvement Triangle of Care selfassessments Delayed discharges

7 HONOS CALCULATION METHODS- APPROACH 1 HONOS 4 Factor (CROM) Analysis of HONOS can be completed based on Speke et al. s Four Factor Model (personal wellbeing, emotional wellbeing, social wellbeing and severe disturbance) using an effect size calculation. The HoNOS data will be captured at the start and end of each cluster episode and also at cluster reviews (both planned and unplanned).

8 APPROACH 2: to HoNOS Analysis Categorical Change Model Arbitary Cut-off Point 1. HoNOS scales rated 0 to 2 as LOW 3 to 4 as HIGH 2. From point 1 to 2 scores then classified as follows: - Low score to Low score [LL] - Low score to High score [LH] - High score to Low score [HL] - High score to High score [HH] 3. Minimum of 5 paired scores from a site for inclusion into analysis 4. Mock-up of data set to support reporting

9 APPROACH 3: to HoNOS Analysis A change of one MHCT point e.g. 3-2 may not be significant but the result of poor inter-rater reliability A change of two MCHT points e.g. 1 to 3 is a reliable improvement and 3 to 1 is a reliable deterioration

10 PROM - SWEMWBS Shortened version of the WEMWBS Rasch compatible. Has undergone a more rigorous testing for internal consistency 7 positively worded statements with 5 response categories Developed to measure wellbeing in the general population Six Mental health trusts took part in the SWEMWBS pilot. Tested in parts of Europe, Iceland, Middle & Far East. Available in a range of languages Sensitive to changes as a result of a range of wellbeing promotion initiatives e.g. physical activity, healthy eating, complementary, alternative medicine & parenting support Total score for each person converted via a conversion table.

11 ReQoL

12 QoL-AD

13 POST DIAGNOSTIC SUPPORT QUESTIONNAIRE 1. On the scale below please mark how much do you feel that you understand about the diagnosis of dementia Nothing A lot 2. On the scale below please mark how much stress you feel that the diagnosis of dementia is causing you No stress A lot of stress 3. On the scale below please mark how well you are coping at the current time Coping very well Not coping at all

14 ICHOM

15 ICHOM Includes anxiety, depression, behaviour, apathy, and psychosis. Tracked via the Neuropsychiatric Inventory (NPI). Includes memory, orientation, verbal fluency, and executive function. Tracked via the Montreal Cognitive Assessment (MoCA). Includes community affairs and relationships. Includes instrumental and basic activities of daily living. Tracked via the Bristol Activity Daily Living Scale (BADLS). Includes finance, enjoyment of activities, pain, and side effects of medication. Tracked via the Quality of Life-AD (QOL-AD) and Quality of Wellbeing Scale-Self Administered (QWB-SA). Tracked via the EuroQol-5D (EQ-5D). Tracked via the Clinical Dementia Rating (CDR).

16 OUTCOMES FOR OTHER SERVICES CROM PROM LIAISON CGI-S, CGI-I FROM-LP LIAISON CORE 10 FROM-LP PSYCHOTHERAPY CORE Therapy Assessment and End of Therapy PSYCHOTHERAPY CORE-OM AHP UK-TOMS

17 OTHER MEASURES 1 Do patients and carers report being treated with dignity and respect Receive well coordinated easily accessible care Feel safe and protected from avoidable harm Can we demonstrate reduction in avoidable, unscheduled care for people with dementia in A&E % referred to PDSG in 8wks % referred to CST in 12wks

18 OTHER MEASURES 2 Carers quality of life in dementia (EQ-5D; looks at mobility, self care, usual activities, pain and discomfort, anxiety and depression) Rate of progression from one cluster to other Median survival from first assessment per cluster There are many other measures routinely collected via MHSDS and Mental Health Benchmarking like LoS, bed numbers, numbers under MHA, numbers under CPA, premature mortality under 75, reference cost etc

19 OUTCOME BASED PAYMENT METHODS NATIONAL TARIFF PAYMENT SYSTEM GUIDANCE The guidance states that mental health providers and commissioners must link prices to locally agreed quality and outcome measures from 2017/18, and, to use one of the following three payment options: a) Episode of care/year of care, as appropriate to each mental healthcare cluster b) Capitation, informed by care cluster data and any other relevant data c) An alternative payment approach consistent with the rules for local pricing.

20 NATIONAL TARIFF PAYMENT SYSTEM GUIDANCE NHSE and NHSI suggest that in total a limited set of three to seven outcome measures with between six and fifteen indicators are used to link to payment for mental healthcare at the contract level. There are two options to consider on how the outcomes payment will be structured: a) A bonus on top of the total contract value. b) Withholding part of the total contract value until the required outcomes are met. The guidance suggests linking between 2% to 4% of the total financial contract value to incentives.

21 Oxford Capitated payment model

22 UNRESOLVED ISSUES How to proportionately allocate the quality based contract value to CROM, PROM and PREM?Gaming of CROM PREM data annonymised Are mental health trusts digitally equipped /ready to collect and analyse routine outcome data Are staff confident of reliably recording outcome data on a timely basis Are trusts ready to spend time and money on staff training on outcome rating scales