Payment by Results in Mental
Health – An Update
Ashok Roy
Coventry & Warwickshire Partnership Trust
ashok.roy@covwarkpt.nh...
Structure
• General principles
• Clusters and care pathways
• Cost, price, tariff
• Service redesign
• Operational issues
...
General Principles
Components of PBR
• Activity based funding: Payment by volume of work
done
• Healthcare resource groups: Groupings of indi...
Justification of PBR
• Negotiations focussed on access and quality and
not on price
• Removal of link between price (tarif...
Lessons from Mental Health 1
• Adjustments for treatment variables needed (e.g.
setting, age, comorbidity etc)
• Condition...
Lessons from Mental Health 2
• Highly demanding in terms of data
requirements for collecting and coding
information
• Poss...
Clusters and Care Pathways
WHAT IS IN A
CARE PATHWAY
Needs ClustersNeeds Clusters
Interventions
Outcomes
Non psychotic (mild, moderate, severe)
1. Common mental health problems (low
severity)
2. Common mental health problems (l...
Non psychotic (very severe and
complex)
5. Non psychotic disorders (very severe)
6. Non psychotic disorder of over-valued
...
Psychosis (first episode)
10. First episode psychosis
Psychosis (ongoing or recurrent)
11. Ongoing recurrent psychosis (low
symptoms)
12. Ongoing or recurrent psychosis
(high d...
Psychotic Crisis
14. Psychotic crisis
15. Severe psychotic depression
Very Severe Engagement
16. Dual diagnosis
17. Psychosis and affective disorder –
difficult to engage
Cognitive Impairment
18. Cognitive impairment (low need)
19. Cognitive impairment or dementia complicated
(moderate need)
...
Patient Journey
Referral/Assess
ment
Cluster
2
Cluster
2
Patient Journey & System
Record
Assessment
Assessment
Review/Disc...
Local Area – Caseload Profile
124
75
173
566
213
114
155 158
26
100
314
219
112
56
90
128
107
5
19 10 10 0
0
100
200
300
4...
Cost, Price, Tariff
Currency Representation
,
Cluster
Period start
Weighting
Period
end
Duration
Currencies and Care Transition Points
Period
start
Period end
Unscheduled
Review
Periodic
Review
Period end
Period
start
C...
Service Redesign
Existing Service – Service User Distribution
CRHTT
ACUTE
WARD
PICU
2 -13
DAY SERVICES
13, 12, 11, 10, 9, 8, 7,6 ,5, 4,
3, ...
Reallocating Resources
CRHTT
ACUTE
WARD
PICU
Day Services
8a,8b,9,10,11,12,13 2a,2b,6 3,4,5
AOT (DD)
12,13
Psychological S...
Proposed Service
Recovery &
relapse
prevention
8a,8b,9,10,
11
Crisis and
Emergency
Ongoing and
Recurrent Psychosis
Common ...
Proposed Service– Workforce Planning based on
Integrated Packages
Ongoing and
Recurrent Psychosis
Common Mental
Health Pro...
Care Clusters
Operational Overview
Care Clusters
• To promote consistency in practice
• To collect needs-related data for clinical decision
making
• To aid c...
Priorities
• Integrate Care Clusters into existing business
processes of Trust
• Clarify transition from one care cluster ...
Care Clusters
Finance Overview
Department of Health Timescales for
Mental Health PbR
• 2010/11 – clusters available for use. Reference costs returned on ...
Payment by Results (PbR)
Analysis of activity for those patients allocated to Cluster 1
0
20
40
60
80
100
120
140
03/1887
...
Payment by Results (PbR) - Challenges
• 2010/11 reference cost submission
• Obtaining sufficient activity data
• Ensuring ...
Payment by Results (PbR) – Risks
• Centralised currency setting not reflect all service inputs
• Tariff not capture all pa...
Payment by Results (PbR) –
Priorities
• Reference Cost submission
• Increase activity capture
• Glossary of terminology
• ...
Take Home Message
• We are the front line
• We carry out the clinical activity
• We spend the money
• We provide quality
•...
Productive
Series
Reviews
CPA
PbR
Outcomes
DataQuality
LD – transforming
services
Adult MH
Service
Re-design Specialist
Se...
Test
Payment by Results in Mental Health
Payment by Results in Mental Health
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Payment by Results in Mental Health

  1. 1. Payment by Results in Mental Health – An Update Ashok Roy Coventry & Warwickshire Partnership Trust ashok.roy@covwarkpt.nhs.uk
  2. 2. Structure • General principles • Clusters and care pathways • Cost, price, tariff • Service redesign • Operational issues • Financial issues • Take home message • Test
  3. 3. General Principles
  4. 4. Components of PBR • Activity based funding: Payment by volume of work done • Healthcare resource groups: Groupings of individual cases which are clinically similar and require similar amounts of resource for their treatment • Payment according to a national tariff: Payment fixed based on average cost of treating that type of patient across NHS
  5. 5. Justification of PBR • Negotiations focussed on access and quality and not on price • Removal of link between price (tariff) and cost incurred may promote greater efficiency and activity • Information systems will need to improve to develop better performance measures (appropriateness, effectiveness, outcomes) • May promote choice and a wider variety of providers
  6. 6. Lessons from Mental Health 1 • Adjustments for treatment variables needed (e.g. setting, age, comorbidity etc) • Condition assessed by enhanced HoNOS • Diagnosis did not predict cost • High cost variation for community based treatment • Provider characteristics explained cost variation better than patient characteristics
  7. 7. Lessons from Mental Health 2 • Highly demanding in terms of data requirements for collecting and coding information • Possible to develop clusters based on shared need which are the basis of care packages for the individual
  8. 8. Clusters and Care Pathways
  9. 9. WHAT IS IN A CARE PATHWAY Needs ClustersNeeds Clusters Interventions Outcomes
  10. 10. Non psychotic (mild, moderate, severe) 1. Common mental health problems (low severity) 2. Common mental health problems (low severity with greater need) 3. Non psychotic (moderate severity) 4. Non psychotic (severe)
  11. 11. Non psychotic (very severe and complex) 5. Non psychotic disorders (very severe) 6. Non psychotic disorder of over-valued ideas 7. Enduring non psychotic disorders (high disability) 8. Non psychotic chaotic and challenging disorders
  12. 12. Psychosis (first episode) 10. First episode psychosis
  13. 13. Psychosis (ongoing or recurrent) 11. Ongoing recurrent psychosis (low symptoms) 12. Ongoing or recurrent psychosis (high disability) 13. Ongoing or recurrent psychosis (high symptom and disability)
  14. 14. Psychotic Crisis 14. Psychotic crisis 15. Severe psychotic depression
  15. 15. Very Severe Engagement 16. Dual diagnosis 17. Psychosis and affective disorder – difficult to engage
  16. 16. Cognitive Impairment 18. Cognitive impairment (low need) 19. Cognitive impairment or dementia complicated (moderate need) 20. Cognitive impairment or dementia complicated (high need) 21. Cognitive impairment or dementia complicated (high physical or engagement)
  17. 17. Patient Journey Referral/Assess ment Cluster 2 Cluster 2 Patient Journey & System Record Assessment Assessment Review/Discha rge 6 Weeks 3 Weeks 6 Weeks Cluster 10 Clinical/Therapeutic Interventions e.g. Primar y Care e.g. Primar y Care
  18. 18. Local Area – Caseload Profile 124 75 173 566 213 114 155 158 26 100 314 219 112 56 90 128 107 5 19 10 10 0 0 100 200 300 400 500 600 1a 1b 2a 2b 3 4a 4b 5 6 7 8a 8b 9 10 11 12 13 14 15 16a 16b N otSpecified Clusters NoofServiceUsers
  19. 19. Cost, Price, Tariff
  20. 20. Currency Representation , Cluster Period start Weighting Period end Duration
  21. 21. Currencies and Care Transition Points Period start Period end Unscheduled Review Periodic Review Period end Period start Cluster 2 Care Transition Points Cluster 10
  22. 22. Service Redesign
  23. 23. Existing Service – Service User Distribution CRHTT ACUTE WARD PICU 2 -13 DAY SERVICES 13, 12, 11, 10, 9, 8, 7,6 ,5, 4, 3, 2 AOT 13, 12 Psychological Services/CBT 5, 4, 3, 2 Treatment Team/Recovery/CMHTs/Psychiatry 13, 12, 11, 10, 9, 8, 6, 5, 4, 3, 2, 1 EIS 7 (DUAL DIAGNOSIS)
  24. 24. Reallocating Resources CRHTT ACUTE WARD PICU Day Services 8a,8b,9,10,11,12,13 2a,2b,6 3,4,5 AOT (DD) 12,13 Psychological Services/CBT 2a,2b,6 3,4,5 Treatment Team/Recovery/CMHTS/Psychiatry8a,8b,9,10, 11 2a,2b,6 3,4,5 EIS 7 Crisis and Emergency Ongoing and Recurrent Psychosis Common Mental Health Problems Severe and Complex Non-Psychotic
  25. 25. Proposed Service Recovery & relapse prevention 8a,8b,9,10, 11 Crisis and Emergency Ongoing and Recurrent Psychosis Common Mental Health Problems Severe and Complex Non-Psychotic 1a, 1b ,2a, 2b, 6 3, 4a, 4b, 5 CRHTT ACUTE WARD PICU AOT (DD) 12,13 EIS 7 Day Services 8 -13 Residential Rehabilitation
  26. 26. Proposed Service– Workforce Planning based on Integrated Packages Ongoing and Recurrent Psychosis Common Mental Health Problems Severe and Complex Non-Psychotic Psychiatry CPNs SWs OTs UKCP Psychotherapi st Clinical Psychologists UKCP Psychotherapi sts CPNs SWs OTs Clinical Psychologists Medical Psychotherapi sts Clinical Psychologists UKCP Psychotherapi sts OTs CPNs Psychiatry Psychiatry Nursing SWs OTs Others UKCP Psychotherapists Clinical Psychologists Crisis and Emergency
  27. 27. Care Clusters Operational Overview
  28. 28. Care Clusters • To promote consistency in practice • To collect needs-related data for clinical decision making • To aid commissioning • To enhance service development • To spread best practice • To encourage consistency in delivery of care • To help inform decisions about configuration of services
  29. 29. Priorities • Integrate Care Clusters into existing business processes of Trust • Clarify transition from one care cluster to another • Allocate clusters to existing caseloads • Focus on data quality and outcomes • Continue work on LD clusters
  30. 30. Care Clusters Finance Overview
  31. 31. Department of Health Timescales for Mental Health PbR • 2010/11 – clusters available for use. Reference costs returned on cluster basis • 2011/12 – • all service users accessing Mental Health care (post GP or other referral) traditionally labelled working age (including EIS from age 14) and older people’s services, should be allocated to a cluster by 31st December 2011 • local prices should be agreed for use in 2012/13 and this will require understanding of local costs per cluster • 2012/13 – clusters (with local prices) become mandatory for contracting and payment purposes • 2013/14 – earliest possible date for national tariff for mental health (if evidence from use of national currency presents compelling case for a national price
  32. 32. Payment by Results (PbR) Analysis of activity for those patients allocated to Cluster 1 0 20 40 60 80 100 120 140 03/1887 Patient Activity SMS IP Alcohol SMS Eating Disorders Community SMS Alcohol OP Review OP OP Review OP IP Organic OP Day Care OP CMHT Adult OP Review Adult OP Other Adult OP New Adult IP PICU Adult IP Acute Adult EIS Adult Day Care
  33. 33. Payment by Results (PbR) - Challenges • 2010/11 reference cost submission • Obtaining sufficient activity data • Ensuring national consistency • Developing business rules • Information system resourcing • Organisational awareness National and Local Local
  34. 34. Payment by Results (PbR) – Risks • Centralised currency setting not reflect all service inputs • Tariff not capture all patient activity - duration • Use of reference costs means averages of averages • Information systems can’t capture intervention codes • Local work not fit with national process • Potential for non recovery of CWPT costs National and Local Local
  35. 35. Payment by Results (PbR) – Priorities • Reference Cost submission • Increase activity capture • Glossary of terminology • Overlay operational areas to ‘what we know’ about Care Clusters • Shadow contracts on Care Cluster basis • Development of local prices
  36. 36. Take Home Message • We are the front line • We carry out the clinical activity • We spend the money • We provide quality • We can be more efficient and productive • Lets lead the way • Lets have a coherent message
  37. 37. Productive Series Reviews CPA PbR Outcomes DataQuality LD – transforming services Adult MH Service Re-design Specialist Services IAPT SPE CAMH S TCS SMS MAKING SENSE OMAH
  38. 38. Test

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