A joint Australian, State and Territory Government Initiative

Experiences and lessons from benchmarking Older Persons

Mental Health Services

Dr Rod McKay .

Braeside Hospital

National Mental Health Benchmarking Project

27 November 2008

Goal of this presentation

Describe results of participation in national benchmarking of mental health services for older people

Demonstrate how KPI data was used to explore clinical practice

Method

Review of documents utilised for the benchmarking forums was conducted

Reflection upon the author’s experience of participation and discussion with other participants.

Who was involved? Seven older persons mental health services

from five Australian states Selected as representative of ‘good practice’ Expected to have a history of using data within

service Facilitator and 2 project staff 3 to 5 individuals from each service

Combinations of Senior clinicians (multiple disciplines) Service managers Information support staff Service project staff

What did we focus on?

Understanding indicators and how to use them Understanding each others services Length of stay and factors that may impact

upon thisDiagnosisOutcome measure profilesAllied Health PracticeECT practiceBed management

What did we find?

All services provided ambulatory and community services to consumers with mental illnesses including psychotic illnesses, mood disorders and BPSD

Consumer profiles on the HoNOS 65+ were consistent with nationally available data; and consistent with diagnostic mixes of services

We had sufficient similarity to compare practice and performance; despite significant differences in the proportions of consumers with different diagnoses Available resources, and Proportion of patients who were born overseas

All services had both strengths and weaknesses in profile and performance

What did we find- selected KPIsKPIKPI Mean of Mean of

services services (06-(06-07)07)

Range Range

2006-072006-07

28 day readmission 28 day readmission raterate

5%5% 3% to 7%3% to 7%

Mean Length of stayMean Length of stay 45.6 days45.6 days 36 to 65 days36 to 65 days

Treatment days / 3 Treatment days / 3 month community month community carecare

7.1 days7.1 days 4.6 to 8.8 days4.6 to 8.8 days

New Client IndexNew Client Index 61%61% 38% to 91%38% to 91%

Outcome readinessOutcome readiness

- inpatient- inpatient

-community-community

129%129%

57%57%89% to 193%89% to 193%

14% to 125%14% to 125%Post discharge care Post discharge care <7 days<7 days

59%59% 22% to 75%22% to 75%

Further KPIs

KPIKPI Mean of Mean of services services (06-07)(06-07)

Range Range

2006-072006-07

Av Acute Episode Av Acute Episode CostCost

$29,361$29,361 $21,748- $21,748- $36,556$36,556

Cost/ 3 month Cost/ 3 month community carecommunity care

$1,860$1,860 $893- $2,599$893- $2,599

% target pop. % target pop. community carecommunity care

0.8%0.8% 0.2-1.6%0.2-1.6%

% target pop. % target pop. inpatient careinpatient care

0.16%0.16% 0.08-0.26%0.08-0.26%

Local access Local access inpatient careinpatient care

72%72% 36-100%36-100%

More KPIs…..

KPIKPI Mean of Mean of services services (06-07)(06-07)

Range Range

2006-072006-07

New Client IndexNew Client Index 61%61% 38-91%38-91%

Area per capita Area per capita resources- resources- ambulatoryambulatory

$30$30 $9-$39$9-$39

Area per capita Area per capita resources- resources- inpatientinpatient

$57$57 $32-$78$32-$78

Preadmission Preadmission community carecommunity care

50%50% 22-81%22-81%

Post discharge Post discharge community carecommunity care

58%58% 22-75%22-75%

What did we do regarding differing Length of Stay between services?

All selected a sub set of patients staying less than, or more than 60 days to identify differences inAgeGenderLanguage and residential care statusHoNOS 65+ profileDiagnosisECT use

What did we find - Length of stay

Each service could identify groups who stayed longer, but the factors were not the same between all services

Trend for LOS over 3 years was a slow gradual increase

Extracts fromExtracts from benchmarkingbenchmarking workbookworkbook

One service demographics>60 days>60 days <60 days<60 days

malemale 44%44% 42%42%

Mean ageMean age 74yrs74yrs 77yrs77yrs

age <=70y.o.age <=70y.o. 32%32% 16%16%

CALDCALD 24%24% 49%49%

requiring interpreterrequiring interpreter 25%25% 26%26%

Admission Admission residence residence …………………… ……………………RACFRACF

18%18% 30%30%

…………………………………………homehome

82%82% 58%58%

……………………………………..othe..otherr

0%0% 12%12%

Discharge Discharge residence residence …………………… ……………………RACFRACF

47% (47% (26% hostel26% hostel)) 47% (8% hostel)47% (8% hostel)

…………………………………………homehome

53%53% 50%50%

……………………………………..othe..otherr

0%0% 3%3%

Change in Change in residenceresidence

41%41% 30% change30% change

One service synthesis

Factors that appear to be most associated with increased LOS are High scores on HoNOS65+ item 8 (‘other’) and item 9

(relationships’) Living at home at admission requiring hostel care on discharge Being aged <=70yrs Having a psychotic illness

Factors with weaker associations are High score on HoNOS65+ item 1 (behaviour) and item

11 (living conditions) Requiring a change in residence

What did we do - Length of Stay

Discussed findings of analysis Explored together different practice regarding

Allied Health staff resources and roles Discharge practices Flow to other services, where available ECT practice

Each service commenced their own improvement project based on their own needs Eg changes to bed flow, ECT practice, social worker practice,

identifying consumers ‘at risk’ of long length of stay for more intense early discharge planning

BUT these were mostly only starting implementation by the end of benchmarking

What was useful?

Using HoNOS 65+ (Routine Outcome Measure) to understand clinical profiles of consumers within teams

Extract fromExtract from benchmarkingbenchmarking workbookworkbook

What was useful?

Improving understanding of the similarities and differences in service provision between organisations

Identifying areas of key differences in service provision and performance

Establishing informal networks and contacts Sharing intellectual resources (eg job

descriptions, clinical tools uses)

What was useful?

collaborating in generating projects to explore differences

initiating local projects to improve practice. (with some limitations)

the national KPI set and data from routine outcome measurement collections have been valuable tools to assist these processes.

Improved understanding of the use, and limitations of the national Mental Health KPIs; and indicators and related data in general

What was problematic?

Poorly compatible IT systems and financial systems across states

Conducting ‘joint projects’ to change practice within services

Range of data literacy of participants Ability to recruit support/ project staff Providing feedback to staff from participating

organisations not attending forums Lack of rules regarding withdrawal from the forums Time frames of forums vs time for practice change Services finding time to do ‘homework’ Services integrating ‘benchmarking’ into ‘quality

improvement’

Were there time trends?

BUT…..

All this considers mental health services for older people as a ‘separate being’ to other mental health services

What happens when we look into the results of the adult mental health service benchmarking?

What are there lessons to be learnt?

For OPMH services? For Adult MH services? For the use and creation of KPIs?

Adult vs Older Persons mental health service performanceKPIKPI Older Older

Persons Persons Mean Mean (06-07)(06-07)

Adult Mean (06-Adult Mean (06-07)07)

28 day 28 day readmission ratereadmission rate

6%6% 12%12%

Mean Length of Mean Length of staystay

45.6 days45.6 days 13.913.9

Treatment days / Treatment days / 3 month 3 month community carecommunity care

7.1 days7.1 days 9.79.7

New Client IndexNew Client Index 61%61% 60%60%

Outcome Outcome readinessreadiness

- inpatient- inpatient

-community-community

129%129%

57%57%89% 89%

36%36%

Adult vs Older Persons mental health service performance

KPIKPI Older Older Persons Persons Mean Mean (06-(06-07)07)

Adult Mean Adult Mean (06-07)(06-07)

Av Acute Av Acute inpatient Episode inpatient Episode CostCost

$29,361$29,361($584/day)($584/day)

$9,472$9,472($680/day)($680/day)

Cost/ 3 month Cost/ 3 month community carecommunity care

$1,860$1,860 $1,975$1,975

% target pop. % target pop. community carecommunity care

0.8%0.8% 1.5%1.5%

% target pop. % target pop. inpatient careinpatient care

0.16%0.16% 0.3%0.3%

Local access Local access inpatient careinpatient care

72%72% 84%84%

Adult vs Older Persons mental health service performance

KPIKPI Older Older Persons Persons Mean Mean (06-(06-07)07)

Adult Mean Adult Mean (06-07)(06-07)

Area per capita Area per capita resources- resources- ambulatoryambulatory

$30$30 $57$57

Area per capita Area per capita resources- resources- inpatientinpatient

$57$57 $43$43

Preadmission Preadmission community carecommunity care

50%50% 60%60%

Post discharge Post discharge community carecommunity care

58%58% 89%89%

Conclusion Benchmarking can assist mental health services

for older people to improve their understanding of differences in practice

and performance; generate useful local actions based upon these

KPI sets and routine outcome measurement assist these processes

They can also assist discussions about differences between mental health services for different age groups; and their relative performance

Conclusion

Rewards for services requireStaff to be supported to develop appropriate skills Integrating benchmarking with service quality

processesA willingness to question established ideas and

practices Time