Working with the changes to QoF 08/09

Who are Insight Solutions? Working with the changes to QoF 08/09 Training Consultant Independent Primary Care IT Training Consultancy Unique in that we can provide clinical system training across all main systems Flexible approach to the restrictions you face with training Budgets Time Staff availability Who are Insight Solutions? Experts in Primary Care QoF, IM&T DES, Enhanced Services & other NHS initiatives Accredited training provider for: Welsh Assembly Government Many 3 rd party software providers Ensure that you get the best possible investment out of your training Ethical Disclaimer Most of the information provided in this presentation is fact, however, is open to interpretation & opinion. It is a practice decision as to whether you choose to implement any of the changes. If you have any queries, check with your PCO/LHB. Agenda Summary of changes Points removed General updates QoF business rule sets, QoF software & Read Code updates Changes to disease areas Asthma, AF, CKD, COPD, Depression, Diabetes, MH, Palliative Care, Smoking, Stoke, PE General House-keeping Data Quality, Exception Codes & Statistics, Recalls Quiz Summary of the changes No new disease areas have been introduced as part of QoF Indicators within six existing domains have been changed: Smoking, AF, CKD, Palliative Care, COPD and Stroke and TIA 58.5 QoF points have been reallocated to reward Patient satisfaction with Access 1

Summary of the changes Guidance in some disease areas has been updated based on new clinical evidence National Prevalence Day will be 31 st March each year from now on Data will still be extracted automatically as previous years Aspiration payments rise from 60% to 70% Disease areas with no changes Some slight updating of references in the guidance but no indicator changes for: CHD, Hypertension, Epilepsy, Thyroid, Cancer, Dementia, Obesity, Learning Disabilities or organisational indicators No changes to thresholds Points removed Points removed Holistic Care Information 3 arrangements for pts to speak to clinicians throughout the day Information 7 Pts are able to access a receptionist for at least 45 hrs over 5 days 20 points 1 point 1.5 points Management 8 policy to ensure the prevention of fraud Medicine 7 System to identify & follow-up pts who do not attend for regular injectable neuroleptic med COPD 9 reduced by 5 points from 10 to 5 1 point 4 points 5 points Education 4 All new staff receive induction training Management 4 Arrangements for instrument sterilisation comply with national guidelines Management 6 Person specs & job descriptions are produced for all advertised vacancies 3 points 1 point 2 pts PE5 Patient Survey TOTAL 20 points 58.5 points QoF Business Rule Sets V12 have now been released Detail the rules, dates & codes applicable to every indicator Pivotal to way in which the QoF software is written Software updates Clinical system software Suppliers can only make appropriate changes when the business rule sets have been released Some suppliers will release an interim update that will assist with management of QoF but not upload to QMAS Once accredited, can then update QMAS Unlikely to be until October 2

Software updates (2) Read Codes April 2008 has been released, next release is due October 2008 QMAS / CM Web / PCAS Cannot collect data until supplier software is accredited Asthma Common condition which responds well to appropriate management Principally managed within Primary Care Diagnosis & medication issued within the last 12 mths are inclusions for the register Difficult to manage Register can constantly change Intermittent symptoms result in patients not attending for reviews Asthma - changes No changes to indicators Guidance updated & expanded in relation to the annual review & what should be included (ASTHMA6) Summary of review: Assess symptoms (using RCP 3 questions) Measure peak flow Assess inhaler technique Consider personalised asthma plan Asthma - changes RCP 3 questions In the last month: 1. Have you had difficulty sleeping due to your asthma symptoms (incl cough)? 2. Have you had your usual asthma symptoms throughout the day (cough, wheeze, chest tightness or breathlessness)? 3. Has your asthma interfered with your usual activities (housework, work/ school)? Asthma - changes If asthma appears uncontrolled Check smoking behaviour Poor inhaler technique Inadequate adherence with regular preventative asthma therapy Rhinitis Asthma - actions Update data entry tools to include all areas of the asthma health check Identify all patients who have had a review since 1 st January 2008 (15 mth rule applies) For those who have components of the review missing, may wish to invite them back for further check-up 3

Asthma - actions It is recognised that significant numbers of pts with asthma do not attend for review Upper threshold remains at 70% Assessors are recognising that many pts with asthma have never been reviewed since QoF but have had med reviews Need to do all you can to encourage them to attend for review Atrial Fibrillation (AF) Often inaccurately coded Pts with an irregular pulse may have been diagnosed with AF although the accuracy of this is only approx 30% AF is associated with a five fold increase in risk of stroke AF - changes AF2 AF4: % of patients with AF, diagnosed after 1 st April 2008, with ECG or specialist confirmed diagnosis Only affects those newly diagnosed since 1 st April 2008 The confirmed diagnosis must be within 3 months (before or after) of the diagnosis recorded (previously 12 months) Referral for a specialist opinion (e.g. cardiology /ECG) is insufficient to achieve this indicator AF - actions Update data entry tools as appropriate Identify patients diagnosed with AF since 1 st April 2008 Ensure diagnosis has been confirmed by ECG or specialist confirmed diagnosis within 3 months of initial diagnosis If initial diagnosis is incorrect, edit as appropriate CKD Present in approx 10% of the population Applies to patients with stages 3-5 only People with stages 3-5 have less than 60% of their kidney function CKD is a risk factor for CVD Early detection is vital & can prevent the progression CKD - changes CKD4 CKD5: % of pts on CKD register with hypertension & proteinuria who are treated with ACE-I or ARB (unless contraindicated or side-effects recorded) 4

CKD - changes New codes introduced in April 08 included codes for CKD with/without proteinuria Rulesets include existing read codes and new combined codes To qualify for inclusion in CKD5 pts must have CKD stages 3-5 recorded as well as diagnoses for hypertension AND proteinuria CKD - changes V2 Codes 1Z17. CKD Stage 1 1Z18. CKD Stage 1 without XaLHI% with Proteinuria Proteinuria XaLHJ% XaLHK% 1Z19. 1Z1A. 1Z1B. 1Z1H. 1Z1K. CKD Stage 2 with Proteinuria CKD Stage 3 with Proteinuria CKD Stage 4 with Proteinuria CKD Stage 5 with Proteinuria 1Z1C. 1Z1J. 1Z1L. CKD Stage 2 without Proteinuria CKD Stage 3 without Proteinuria CKD Stage 4 without Proteinuria CKD Stage 5 without Proteinuria CTV3 Codes CKD - actions CKD Proteinuria codes Change data entry tools to include appropriate tests & diagnosis for proteinuria Identify patients already reviewed For those who require tests for proteinuria, call them back in for review V2 4674. 4677. R110. R1100 R1103 R110z CTV3 4674. - 4677 R110. R1100 XaE6q R110z COPD COPD is a common disabling disease with a high mortality Some patients with COPD may also have Asthma Should appear on both register & be treated for both conditions Approx figures for COPD pts with Asthma is 15% If your figures are higher than this, may be worth checking as assessors are likely to COPD - changes COPD 9 COPD12: % of all patients diagnosed after 1 st April 2008 in whom the diagnosis has been confirmed by post bronchodilator spirometry Post bronchodilator spirometry suggests more accurate diagnosis May reduce the prevalence of COPD by 25% 5

COPD changes COPD 9 COPD12: Only applies to diagnoses after 1 st April 08 Timescales - must be recorded up to 3 mths before or 12 months after confirmation of diagnosis Indicator reduced from 10 points to 5 points COPD - actions Identify any patients diagnosed since 1 st April 2008 Exclude those confirmed already by post bronchdilator spirometry Arrange to review those not already confirmed by post bronchdilator spirometry Update data entry tools to include new Read Code for all future diagnoses Update appropriate staff COPD - Spirometry codes V2 CTV3 33H..% XaIUY% 33I..% XaIUa% 33J..% XaIUc% 66Ya. 66Yb. XaJuz 8HRC. XaJv0 XaK02 Depression By 2020, depression looks set to be 2 nd after CVD in terms of the World s disabling diseases NICE guidelines recommend screening for depression be carried out in primary care for high-risk groups Depression is more common in pts with CHD & Diabetes 33% of pts develop depression following MI Depression - changes DEP1 remains the same, guidance updated Screening for pts with CHD or Diabetes using the 2 standard screening questions 1. During the past month, have you often been bothered by feeling down, depressed or hopeless? 2. During the past month, have you often been bothered by having little interest or pleasure doing things? Depression - changes New guidance states that these questions should be asked as part of a consultation and should not be posted to patients Assessors will randomly select records to ensure that these questions are being used appropriately Will expect to see the recording of this within the CHD or Diabetic review consultation 6

Depression - actions Ensure that your CHD & Diabetes data entry tools include the appropriate code for depression screening If you use postal questionnaires Stop & review practice protocol Identify those patients who have been screened by postal questionnaire since January 2008 Further review may be appropriate Diabetes Over 1 million people in the UK are diagnosed with diabetes Includes patients with Type 1 or Type 2 Excludes pts <17 yrs & gestational diabetes Although patients care may be shared (particularly for Type 1), it is the responsibility of the practice to ensure that appropriate annual checks are carried out Diabetes - changes No changes to register or indicator set Changes to the rationale for DM13 (% pts who have a record of micro-albuminuria testing in the previous 15 mths) Identified as a risk factor for cardiovascular complications Suggests that all pts should have their urinary albumin concentration & serum creatinine measured at regular intervals Diabetes - actions CVD Risk was one area for inclusion in QoF Many PCOs/LHBs may well introduce a CVD Risk LES In terms of QoF, as this is only a suggestion, it is up to the practice to decide how to manage this As this is a current hot topic, we would suggest that this is added to data entry tools Mental Health Pts with serious mental health problems are at increased risk of physical ill-health More likely to smoke, increased risk of respiratory disorders Poorer living conditions Increased risk of diabetes (Schizophrenia & bipolar disorder) Mental Health - changes No changes to indicators Guidance updated & expanded in relation to the MH annual review & what should be included (MH9) As this is a physical review, unlikely to be done by secondary care, therefore, more than likely to be carried out by practice 7

Mental Health - changes Physical health check will normally include: Issues relating to alcohol or drug use Smoking & blood pressure (inc history of arrythmias) Cholesterol checks where appropriate All pts over 40 yrs even if no indication of risk BMI Risk of diabetes from Olanzapine and Risperidone (diagnoses of schizophrenia & bipolar disorder) Cervical screening where appropriate Medication review Mental Health care plan To include: Pts current health status & social care needs How met, by whom, pts expectations How socially supported Summary of services rec d Mental Health team/secondary care Occupational status Known early warning signs of relapse Pts wishes in the event of a relapse Contacts Medication Mental Health - actions Update data entry tools to include all areas of the physical health check Identify all patients who have had a MH review since 1 st January 2008 (15 mth rule applies) For those who have components of the review missing, may wish to invite them back for further check-up Assessors are likely to randomly check all components undertaken & recorded Palliative Care Definition Active total care of patients with a life-limiting disease, and their families, by a multi-professional team Introduced to ensure that the wider practice team provide more appropriate patient focussed care Reception staff aware of the need to prioritise communications from relatives for patients on this register Palliative Care - changes PC1 PC3: Practice has a complete register of all pts in need of palliative care/support irrespective of age Patients should be included if Death in the next 12 mths can be reasonably predicted They have clinical indicators of need for palliative care in accordance with the gold standard framework They are the subject of a DS1500 form Palliative Care - actions Ensure ALL appropriate patients are coded for inclusion on the register Read Codes for inclusion remain the same Numbers on the register may well rise due to age change In the case of nil register at year end, practices eligible for payment if proof of register can be demonstrated 8

Palliative Care actions PC2 No change, regular (at least 3 mthly) multidisciplinary case review meetings Aims of these meetings are to: Improve flow of information (out-of-hours, etc) Ensure each patient has a management plan Decisions in the plan are acted upon Includes preference for place of care Ensure support needs of carer are discussed & addressed Smoking - changes Smoking 1 Smoking 3: % of pts with any or combination of the following; CHD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder or other pychoses whose notes record smoking status in the previous 15 months Smoking - changes Smoking 2 Smoking 4: % of pts with any or any combination of the following; CHD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder or other psychoses whose notes record smoking cessation advice or referral to a specialist service within the previous 15 months Smoking - changes Non-smokers life long non-smokers unlikely to start, get irritated when constantly asked Record every 15 months up until the age of 26 Ex-smokers Smoking status should be updated for 3 consecutive QoF years and then only if there is any change Both the above apply to clinical & organisational domains Smoking - actions Ensure you make changes to data entry templates for CKD & MH (diagnoses added to SMOKING3 & SMOKING4) Ensure everyone is aware of the new timescales around ex-smokers & nonsmokers Ensure all data entry tools reflect smoking data entry for all pts 15 yrs + Stroke 3 rd most common cause of death ¼ of stroke deaths occur under the age of 65 Appropriate diagnosis & management can improve outcomes 9

Stroke - changes STROKE 11 STROKE 13 % of new patients with a stroke or TIA who have been referred for further investigation Refers to pts with a stroke or TIA from 1 st April 2008 Referral should be up to 3 mths before or within one month of diagnosis of presumptive stroke or TIA Previously 12 months Stroke - actions Identify all patients diagnosed with stroke or TIA since 1 st April 2008 Ensure all have been referred Within one month of the diagnosis Up to 3 months before the diagnosis was entered Patient Experience Two new indicators (PE7 & PE8) are required to Support the reward of 48 hr appointments Advance bookings 58.5 points released from QoF will support these indicators Routine GP appts remain at 10 mins (PE1) Practice undertake routine survey & reflect on the results (PE2) Patient Experience PE7 % of pts who, in the appropriate national survey, indicate that they were able to consult with a GP (Eng) or appropriate health care professional (Scotland, Wales, NI) within 2 working days (Wales 24 hours) 23.5 points Thresholds 70-90% Dependant on results of survey Patient Experience PE8 % of patients who, in the appropriate national survey, indicate they were able to book an appt with a GP more than 2 days ahead 35 points Thresholds 60-90% Dependant on results of survey Patient Experience PE7 & PE8 designed to encourage & incentivise practices to continue to improve quick & convenient access for patients Arrangements for the survey are likely to differ in each of the 4 UK countries Guidance for Scotland, Wales & NI will be available in due course 10

Patient Experience Survey Guidance for England - National survey conducted by 3 rd party on behalf of the DoH 3 rd party will send surveys to patients & collate results for all practices Practices should encourage patients to respond Communicating appropriate materials General house-keeping Data Quality Check accuracy of disease registers They should always be as accurate as possible Check for multiple diagnoses of the same condition Date of diagnoses Does it tie-in with diagnosis date? Is it a full date? Partial dates/unknowns may not be picked up by QMAS/CM Web/PCAS General house-keeping Data Quality Regularly run your data tidy-up searches As well as pts not on relevant register s, check those pts on register s where they shouldn t be Condition resolved codes Diabetes, hypertension, epilepsy, AF, asthma, depression Review pts on these registers where they may not be taking any medication Add to relevant pts where appropriate to remove them from the registers Resolved codes Disease V2 Atrial Fibrillation 212R. Asthma 21262, 212G. Depression 212S. Diabetes 21263, 212H. Epilepsy 21260, 212J. Hypertension 21261, 212K. CTV3 XaLFz 21262 XaLG0 XaFsp 21260 21261 General house-keeping Data Quality Medication reviews Identify all pts on repeat meds who have not been issued over 12 months and move them to past drugs will help significantly with annual med reviews Patients on Palliative Care Register Check if they are on any other registers and if applicable add patient unsuitable codes Exception figures Based on 2006/07 data from 8331 practices Overall exception rate for England was 5.83% 460 practices had overall exception rates higher than 10% 48 practices had overall exception rates higher than 15% 3270 practices had overall exception rates lower than 5% 4 practices had overall exception rates lower than 1% 11

10 indicators with the highest exceptions CKD03 (29.68%) Pts on register whose last BP reading measured 140/85 or less in previous 15m CHD10 (27.84%) treated with a beta blocker AF2 (20.92%) - The percentage of patients with atrial fibrillation diagnosed from 1st April 2006 with ECG or specialist confirmed diagnosis ASTHMA8 (20.38%) Pts diagnosed since April 06 with measure of variability or reversibility HF2 (20.21%) Diagnosis confirmed by echo or specialist assessment STROKE11 (18.18%) The percentage of new patients with a stroke who have been referred for further investigation DEP02 (17.46%) - % pts diagnosed between 1 April & 31 March who have had an assessment of severity using an accredited tool MH06 (17.38%) - % of pts on the register with a comprehensive care plan EPIL8 (16.69%) - % of pts on the register who have been seizure free for the last 12m, recorded in the previous 15m MH09 (14.75%) Pts on register with a review recorded in the previous 15m 10 indicators with the lowest exceptions DM16 (2.70%) Pts with diabetes with total cholesterol in the previous 15m DM22 (2.26%) Pts with diabetes with a record of egfr or serum creatinine in previous 15m STROKE5 (2.03%) - The percentage of patients with TIA or stroke, who have a record of blood pressure in the notes in the preceding 15 months DM11 (1.47%) Pts with diabetes with BP recorded in previous 15m CHD5 (1.17%) Pts with CHD with BP recorded in previous 15m BP4 (0.99%) Pts with hypertension with BP recorded in the previous 9m SMOKE2 (0.90%) - % of pts with any or combination of the following conditions: CHD, stroke or TIA, hypertension, diabetes, COPD or asthma who smoke whose notes contain a record that smoking cessation advice or referral to a specialist service, where available, has been offered within the previous 15 months 10 indicators with the lowest exceptions (cont d) CKD2 (0.78%) - The percentage of patients with newly diagnosed angina (diagnosed after 1 April 2003) who are referred for exercise testing and/or specialist assessment THY2 (0.59%) Pts with hypothyroidism with TFT recorded previous 15m SMOKE1 (0.48%) - % of pts with any or combination of the following conditions: CHD, stroke or TIA, hypertension, diabetes, COPD or asthma whose notes record smoking status in the previous 15 mths (except those who have never smoked where smoking status need only be recorded once since diagnosis) Exception Codes No changes to the way in which exception codes work or what they can be used for Designed to prevent a practice being penalised for factors outside of its control Never use inappropriately Alternative to data quality Where a single indicator code is not available Compensate for bad practice Exception codes Patient unsuitable exception codes Identify all pts who had unsuitable codes added last year, review and re-add if still applicable Use free text to support Other exception codes Identify pts who had single indicator codes which expire annually, review & re-add if applicable E.g. max tolerated, not tolerated, refused Recall Systems Still contractually obliged to extend 3 invitations to every patient registers Can change from area to area Check content of the letters Does it give the pt enough information for them to make an informed choice? Invites can be letter, face-to-face, telephone, texts? Ensure you record all invites using practice approved codes 12

Summary There are some changes which could catch us out this year No doubt it is difficult to manage without the appropriate software You ve done it before and you have little choice Many of the changes are based on new clinical evidence Ensure your clinical staff are up-tospeed Summary If you need any changes to data entry tools Changes can be made once and rolled out to local practices speak to your PCT Talk to Insight we d be happy to help! Make sure you are signed up to our newsletter Guaranteed way to keep yourselves ahead of the game Training Support Helpdesk only 120 per annum (Unlimited training support by email) Register for our free newsletter www.insightsol.co.uk Request a prospectus - visit www.insightsol.co.uk Contact Details: www.insightsol.co.uk Telephone: 0870 460 5960 Email: info@insightsol.co.uk Copyright 2007 Insight Solutions Copyright 2007 Insight Solutions Quiz What date has Prevalence Day been changed to? A. 1 st January B. 14 th February C. 31 st March 13

Which will include patients on the COPD Register? A. History of COPD B. Mild COPD C. COPD NOS How many points have been removed from QoF 2008/09? A. 58.5 points B. 68.5 points C. 78.5 points What is the correct range of codes for ethnicity monitoring? A.9i B.9s Patients newly diagnosed with AF should have ECG or Specialist confirmation within? A. 1 month B. 3 months C. 12 months How long do you need to record someone is an ex-smoker? A. Up to one year B. For 3 consecutive years C. Up until they are 26 years+ What is the timeframe for a referral to be recorded following a stroke or TIA? A. Up to one month B. Up to three months C. Up to 12 months 14

What is the timeframe for including cancer diagnoses for review? A. Diagnosed within the last 12 months B. Diagnosed within the last 6 months C. Diagnosed within the last 18 months 15