Commissioning Quality Care:          Tools to support the         commissioning process   Stephen Callaghan:      Principa...
Defining commissioning.• Commissioning in the NHS is the process of  ensuring that the health and care services provided  ...
Quality - Donabedian (1966)• Structure – (Settings, qualification of staff, admin structure,  right institution providing ...
NHS outcome framework• Shared indicators between the NHS Outcomes Framework  & Public Health Outcomes Framework.  – Preven...
The Mandate• The Board is legally required to pursue the objectives  in the document.• The Board will need to demonstrate ...
Synthesising a CCGOI to show ‘quality in commissioning’: Objective - Improving functional ability in people with LTC      ...
Tools to support COPD Outcomes Strategy implementation    Workforce competences     NHS Implementation          document  ...
Model service specifications themes•   Key objectives•   National and local context•   Scope•   Service delivery•   Indica...
Why is pulmonary rehabilitation      important for improving outcomes?Case for change• Pulmonary rehabilitation has also b...
Adapted Logic Model• Internationally recognised approach to outcomes.• There are several versions/interpretations of the l...
Adapted Logic Model• The ‘Intervention stage’ is linked with quality,  standards, evidence-based practice etc. and it is t...
Impact                     PCT wide reduction in GP attendances (20% - Kings Fund)                           Reduction in ...
The Adapted Logic ModelProvides clinical and commissioning clarity on:• Who you should be caring for• What the evidence-ba...
Thank You for listeningsteve@eqehealth.co.uk                          14
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Breakout 2.2 Commissioning Quality Care: Tools to support the commissioning process - Stephen Callaghan

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Breakout 2.2 Commissioning Quality Care: Tools to support the commissioning process - Stephen Callaghan:
Principal Consultant, EQE Health.
Associate Consultant, Hope Street Centre.
Visiting Lecturer, University of Chester.
ANP, A&E University Hospitals Aintree
Part of a set of presentations from NHS Improvement event: Better value, better outcomes held on Thursday 21 February 2013,
Guoman Tower Hotel, London
How to deliver quality and value in chronic care:sharing the learning from the respiratory programme

Published in: Health & Medicine
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Breakout 2.2 Commissioning Quality Care: Tools to support the commissioning process - Stephen Callaghan

  1. 1. Commissioning Quality Care: Tools to support the commissioning process Stephen Callaghan: Principal Consultant, EQE Health. Associate Consultant, Hope Street Centre. Visiting Lecturer, University of Chester. ANP, A&E University Hospitals Aintree. Aims1. Raise awareness and understanding of the COPD Commissioning toolkits – 4 services2. Advise you to consider applying the toolkits locally to commission individual or integrated services3. Demonstrate the ‘adapted logic model’ to support the commissioning process and focus on outcomes4. Contextualise & define ‘Commissioning quality care’ 1
  2. 2. Defining commissioning.• Commissioning in the NHS is the process of ensuring that the health and care services provided effectively meet the needs of the population. It is a complex process with responsibilities ranging from assessing population needs, prioritising health outcomes, procuring products and services, and managing service providers. Department of Health. 2009 Health and Social Care Act 2012 Quality defined by: • Effectiveness • Experience • Safety 2
  3. 3. Quality - Donabedian (1966)• Structure – (Settings, qualification of staff, admin structure, right institution providing care etc).• Process – What is known to be ‘good’ care – & then applied (technical competence, how health & illness is managed, coordination & continuity of care, justification of diagnostic tests/therapy).• Outcome – (therapeutic impact, health gain, social restoration etc – something that is measurable). NICE QS10 - COPD quality standardQuality statement 6: Pulmonary rehabilitationOutcome:A. Improvements in exercise capacity as measured by a validated field exercise test, for example the 6-minute walk test or the incremental shuttle walking test.B. Improvements in health-related quality of life measured by a validated questionnaire, for example St Georges Respiratory Questionnaire (SGRQ). 3
  4. 4. NHS outcome framework• Shared indicators between the NHS Outcomes Framework & Public Health Outcomes Framework. – Preventing people from dying prematurely (Under 75 mortality rate for Respiratory disease). – Healthy life expectancy and preventable mortality (Mortality rate from Respiratory diseases in persons under 75 years of age). Shared PH & ASC indicator – prevention, early identification and management of risk factors 4
  5. 5. The Mandate• The Board is legally required to pursue the objectives in the document.• The Board will need to demonstrate progress against the five parts and all of the outcome indicators in the framework• The Commissioning Board is legally bound to pursue the goal of continuous improvement in the quality of health servicesThe Mandate: A mandate from the Government to the NHS Commissioning Board: April 2013to March 2015 Standards and high quality care There is no statutory provision Quality Standards are advice from NICE allowing NICE Quality Standards toimpact upon registration requirements to the NHS CB on high quality care. Regulation ( Enforcement against Registration Requirements) Commissioning guidance (NHS CB) CCG Outcome Indicator Set Registration Provider Payment Mechanisms requirements Proportion of services NICE quality standards Standard of services Unsafe Substandard Adequate Good Excellent 5
  6. 6. Synthesising a CCGOI to show ‘quality in commissioning’: Objective - Improving functional ability in people with LTC Domain 2. NICE Quality Standards – COPD No 6 People with COPD & MRC ≥3 referred People with COPD meeting appropriate to Pulmonary Rehabilitation criteria are offered an effective, timely and accessible multidisciplinary pulmonary rehabilitation programme.Quality commissioning& Quality assurance NICE Clinical Guideline 101 & NICE Pathways Examples of other resources• Outcomes Strategy for COPD & Asthma Other NICE Support in England – DH 2011 Audit support• COPD Commissioning Toolkit & PR Commissioning guides Service Specification – NHS Companion Costing support Documents Information resources & templates• Principles, definitions and standards for Quality Standards support PR – IMPRESS 2008 Service planningEtc…. Slide setsChallenge: To Improve Care & Outcomes Across Whole Pathway Smoking cessation Smoking cessation Smoking cessation Proactive chronic disease management and self-management Evidence based treatment/medicines managementAwareness raising Accurate diagnosis• Lung health Quality spirometry• Lung symptoms Physical activity Pulmonary rehab• Lung age testing Social Care/Re-ablement Case finding Early diagnosis Prompt therapy & follow-up in exacerbations Structured hospital admission with specialist care LTOT/NIV EOL 6
  7. 7. Tools to support COPD Outcomes Strategy implementation Workforce competences NHS Implementation document Prevention & Early Identification toolkit Asthma and Home oxygen Good practice guides Commissioning toolkits COPD indicators and dataset Tools to support commissioning• COPD Commissioning ToolkitModel service specifications1. Pulmonary Rehabilitation2. Service to manage COPD exacerbations3. COPD spirometry and assessment service4. Home oxygen assessment and review serviceAvailable - http://www.dh.gov.uk/health/2012/08/copd-toolkit/Published Aug 12 7
  8. 8. Model service specifications themes• Key objectives• National and local context• Scope• Service delivery• Indicators• Activity• Finance• (PR – Logic model) Why is pulmonary rehabilitation important for improving outcomes?Case for change• Providing pulmonary rehabilitation after discharge from hospital can reduce readmissions within three months from a third to just 7% of patients.1• PR is the only intervention to date shown to impact readmission rates in this way.1. Outpatient pulmonary rehabilitation following acute exacerbations of COPD.Seymour JM et al. Thorax 2010 May;65(5):423-8 8
  9. 9. Why is pulmonary rehabilitation important for improving outcomes?Case for change• Pulmonary rehabilitation has also been shown to improve health-related quality of life in COPD patients after suffering an exacerbation (e.g. dyspnoea, fatigue, and patient control over the disease).22. Puhan, M. et al. Pulmonary rehabilitation following exacerbations of chronicobstructive pulmonary disease Cochrane Database Syst Rev; 2009;(1):CD005305 Why is pulmonary rehabilitation important for improving outcomes?Case for change• It is substantially below the NICE threshold for cost effectiveness, at only £2,000-£8,000/QALY.• It has also been shown to be cost-saving. One recent study showed an overall cost saving of £152 per patient per PR.33. Griffiths et al. (2001) “Cost-effectiveness of an outpatient multi-disciplinarypulmonary rehabilitation programme” Thorax 56: 779 – 784 9
  10. 10. Adapted Logic Model• Internationally recognised approach to outcomes.• There are several versions/interpretations of the logic model.• Perigo/Callaghan1 adapted the model to make it clinically relevant and to support commissioners & providers of healthcare to focus on health outcomes.1. Perigo, G., Callaghan, S. (2011). Commissioning for Outcomes: A resource guide forcommissioners of health and social care. Online publicationhttp://www.fadelibrary.org.uk/wp/downloads/?did=306 Adapted Logic Model• Perigo/Callaghan synthesised the elements of quality, process, evidence, outcomes, guidelines and standards with the logic model to help commissioners and providers: – Link health outcomes to commissioning – Link health outcomes to strategy (National & Local) – Understand the long-term effects of interventions – Clearly identify what the intended outcomes should be – Measure pathways & design/re-design pathways – Develop a synopsis prior to a full service specification 10
  11. 11. Adapted Logic Model• The ‘Intervention stage’ is linked with quality, standards, evidence-based practice etc. and it is the (clinical) intervention that drives the outcome.• Helps people to clearly understand the relationship between outputs and outcomes.• It is widely used for service evaluation.• EQE Health adapted this model further to link commissioned services to the NHS & PH Outcomes Frameworks. The Adapted logic model & the NHS outcomes framework Long term effects that occur from the achievement of the outcomes. Impact What you expect to happen long after the intervention has finished A predicted measure of change that demonstrates a valid and significant Outcome therapeutic impact following an agreed intervention End of the intervention (i.e. number of people completed an Outputs intervention – Evidence of service delivery). Define completion. Action taken to prevent/improve a medical disorder based on EB literature, standards &Intervention guidance documents. Describes what a quality service should look like. Appropriate Patients/Clients: Inputs (i.e. Inclusion/Exclusion Criteria & Referral Guidance) S. Callaghan. www.eqehealth.co.uk 11
  12. 12. Impact PCT wide reduction in GP attendances (20% - Kings Fund) Reduction in hospital admissions (Sustained > 12 months post programme) Reduction in respiratory mortality.Outcome Increase in function exercise capacity Patients Achievement of patient set goal(s) disorder who have a with a chronic respiratory confirmed diagnosisunderstandingother PROM chronic progressive of COPD COPDother Improvement in HAD score or Improvement in andOutput conditions (e.g. bronchiectasis, assessment attend their appointment. lung 85% of eligible patients booked for their interstitial lung disease, chronic asthma and who attend for their personalhave a baseline assessment. 100% of eligible patients have disease. assessment performed. 95% of patients chest wallassessment Also, patients pre and post-thoracic surgery including lungthe PR programme (completion 75% of all eligible referred patients complete transplant). means that the patient has attended 75% of sessions). 90% of patients are satisfied with the service. Patients who consider themselves functionally disabled (MRCIntervention Pulmonary rehabilitation programme based on British Thoracic Society Guidelines and PCRS [IMPRESS] standards 2011. score of 3 or more) or those with an MRC score of two and For patients attending PR a formal assessment, delivery and final assessment of symptomatic. Those pulmonary rehabilitation programme recent a comprehensive patients who have had a as per guidelines should be delivered. exacerbation of COPD.Input Patients with a chronic respiratory disorder who have a confirmed diagnosis of COPD and other chronic progressive lung conditions (e.g. bronchiectasis, Exclusion criteria – unstable CVD, recent MI/AECOPD, interstitial lung disease, chronic asthma and chest wall disease. Also, patients pre and post-thoracic surgery including lung transplant). patients who are unable to walk or those people who cannot participate in or who consider themselves functionallysymptomatic. Those patients who Patients group for whatever reason. more) a those with an MRC score of two and disabled (MRC score of 3 or have had a recent exacerbation of COPD. Exclusion criteria – unstable CVD, recent MI/AECOPD, patients who are unable to walk or those people who cannot participate in a group for whatever reason. CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) DISCHARGE CARE BUNDLE Summary – This care bundle is a group of evidence based items that should be delivered to all patients being discharged from the hospital following an Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD). The care bundle aims to improve quality of care, patient experience and minimise the risk of re-hospitalisation. To ensure the bundle can apply to all we have prepared a combination of actions and documents to facilitate the discharge process. Inform the COPD CNS of all COPD patients within 24 hours of arrival including patients discharged . Extension _______ CARE BUNDLE STEPS All required documents are included in package. Patient Sticker 1. If patient is a smoker offer smoking cessation assistance For community referral Fax _____________ Completed Declined N/A Not Done For clinic referral Fax _____________ GO TO Patient COPD 2. Pulmonary rehabilitation -assessed for suitability Safe Discharge PRIOR TO DISCHARGE First point of contact, either by the CNS Nurses or Physiotherapist, who Completed Declined N/A Not Done DAY OF DISCHARGE will assess and refer patient. Nurse to contact if not done prior to discharge (fax referral form) Checklist 3. Written COPD patient information given including : To be completed by •British Lung Foundation Self Management Book Completed Not Done nurse with the patient. •Oxygen alert WALLET card •Information about the Breathe Easy Group Note: Ensure phone Call scheduled for 48-72 4. Satisfactory use of inhalers demonstrated and understood hours post discharge. (6) Please assess during medication rounds. Observe the patients using the Completed Not Done device(s) and document on electronic prescribing record adequate technique demonstrated. (Refer to pharmacist or CNS if extra support is needed). Nurse (Initials) Checklist 5. Outpatient follow up appointment made and given to patient Completed Patient should see respiratory medical specialist and COPD respiratory nursing specialist within 1 month of discharge. (Appointment should be scheduled Completed Not Done and patient made aware of location, time and date). Date:___/___/___ Place the faxed referral form(s) in the plastic sleeve during the patients stay, at discharge Care bundle components are based on: place with the COPD Discharge Checklist in the ‘Completed’ COPD Care Bundle Box located; NICE COPD guidelines 2004 (1-5) _________: Nurses Station (Maroon coloured boxes) A Patient Experience Survey CLAHRC team April 2009 (6) Systematic Literature Review supported by CLAHRC April 2009 (1-6) 12
  13. 13. The Adapted Logic ModelProvides clinical and commissioning clarity on:• Who you should be caring for• What the evidence-base interventions are• Evidence that the intervention(s) have taken place• An understanding on how to measure the intervention• An understanding of the long-term effects of the intervention Finally…and the key point about usingcommissioning toolkits & service specifications? To reduce variation in the commissioning and provision of servicesCollectively we need to:• Reduce unwarranted variation – underuse, overuse, under co-ordination• Improve outcomes for patients – provide best value health care – reduce waste, drive up quality• Introduce benchmarking to provide comparison across local healthcare services 13
  14. 14. Thank You for listeningsteve@eqehealth.co.uk 14

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