f4 rapid fire: patient focused funding in bc - l. vertesi and d. pope
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Patient Focused Funding in BC
A Revolution or Just a System Tweak?
Les Vertesi
BCPSQ Forum March 9, 2012
Why Change at All?
• Are you satisfied with the current state of health care in which you work? – Waitlists (20% > a year) – Crowding & Delays in Emergency Departments? – ALC rates near 20% of In-hospital Days – “Quality” is an uphill struggle
– And one more small thing …
2
Ignore This at Your Peril
3
Changing the Game
• A Conversation with Government (2006)
• If you could fix One Thing in Healthcare …? – Will You Pay for it?
– No? Why not?
• What if it were fixed and the bill was …. ?
• What if you only had to pay if it was fixed?
4
A New Game in Town
• Governments are less willing to put money in when they don’t think they are getting Quality – Would YOU be willing to keep paying for something you
are not getting? – Who is best placed to manage the RISK of success or
failure?
• Can government be a “purchaser” and let the Health Authorities be (competitive) providers?
5
Where to Start?
• Fall of 2006: – ED Congestion chosen as Top Priority by Senior Executive
of Cabinet – Unwilling to continue putting out money on faith – But Willing to Pay if it was “Solved”
• i.e. for Success Only
• RESULT: – $16.5M to a P4P formula at 4 Vancouver Hospital
Emergency Departments
6
EDP4P Basics • All Money earned goes to the Hospital
– Believe that best decisions are ones made locally – Sense of “provider ownership” created by control of money – But nobody keeps any money
• EDP4P is not an improvement strategy in itself
– Money must be invested in improvement (QI) processes – Relatively easy improvements can generate confidence & cash to
fund more difficult changes
• Hospitals are free to invest as they see fit, but must report how money has been used
7
What P4P is NOT
• It is NOT a way to make People work Faster – It is a Way of making them Pay Attention and re-think
their approach to the Patient Experience • Money is NOT the Incentive
– Improvement is the real incentive
• If Money is “not a reward”, then why is it tied to Performance? • Because it is a Shared RISK strategy
8
Did It Work?
1,000
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2,000
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3,000
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3,800
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No.
of A
dmits
Mee
ting
Targ
ets
No.
of C
TAS
Pts
Mee
ting
Targ
ets
First Year of EDP4P
Numbers of Pts Meeting Targets All VCH Hospitals
# Non-adm CTAS 1-2-3
# Admitted
9
Did It Really Work?
40%
45%
50%
55%
60%
65%
70%
First Year of EDP4P
Percentages Meeting Transition Time Targets (All VCH Hospitals)
Pct of CTAS 1-2-3
Pct of Admissions
10
Later Things Became More Difficult
40%
45%
50%
55%
60%
65%
70%
First 30 Months of EDP4P
Percentages Meeting Transition Time Targets (All VCH Hospitals)
Pct of CTAS 1-2-3
Pct of Admissions
11
One of the Reasons Why
0.90
0.95
1.00
1.05
1.10
1.15
1.20
Pct C
hang
e fr
om B
ase
First 30 Months of EDP4P
Pct Change in Volumes of Visits & Admissions All VCHA Hospitals
% Change in Visit Volume
% Change in Admissions
12
13
EDP4P Experience at Lion’s Gate
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600
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Fiscal Period
Number and Percentage of Admitted Patients Waiting in Emergency Department for < 10 hours
(Lion Gate Hospital, April 2007 - March 2010)
% of Patients
# Patients
BEFORE PFF
ACCESS to Care at LGH Did Improve • Reduced length of stay (by 20%) • ALC dropped from 11% to 4% • Reduced occupancy levels (to 96%) • Shortened wait times in ED (38% to 65% within target)
BUT … • More patients arrived to ED & required admission • More transfers from other hospitals since beds now available • Lower cost ALC days were reduced • Average Cost per patient day increased
The budget went from breakeven to $4M deficit!
14
The Fixed Budget PUNISHED Quality
Why?
Because Patient Care Costs Money … and Money Comes in Boxes
Things Work Best When the Money & the Patients are in the Same Place
15
The Message about Quality
• For Quality to be Sustainable, Patients & Money have to be Matched
• It is Hard to Move Patients, but Easy to Move Money
• Activity Based Funding is NOT necessarily a stimulus
• It is a way of Making Sure Money can move to Support Care Where it is Most Needed
16
So What are We Actually Doing in BC? Patient Focused Funding is an Umbrella Term
Activity Based
Funding
Procedural Care
(Bulk Purchasing)
Community Initiatives
Pay for Performance
Quality Improvement
Common Theme: Funding Follows Patients not the Facilities
17
Supporting a Continuum of Care
Home/Community Home Support decreases need for Residential Care
ED P4P Improved Emergency Department Access & Flow
ALC decrease
ED Admissions ABF supports ED Admit Transfers to Wards
ABF lowers LOS & enables shift to Day Procedures Inpatient Flow
ABF funding eases discharge & lowers ALC population
18
19
Mythbuster Myth:
Activity Based Funding drives increased volume
Truth:
ABF provides incentive to care for the sickest patients in acute care, and others in same day or community care
It is up to US!
Slide Courtesy of Duncan Campbell Chief Financial Officer
Vancouver Coastal Health Authority
From Theory to Reality
The Vancouver Coastal Health Experience with Patient Focused Funding
20
Vancouver Coastal Health Patient Focused Funding
What Have We Achieved and Where Will It Take Us
Quality Forum Darcia Pope, Executive Director, Transformation
March 9, 2012
22
Vancouver Coastal Health Strategic Framework Lens People First
Vision We will be leaders in promoting wellness and ensuring care by focusing on quality and innovation.
Mission We are committed to supporting healthy lives in healthy communities with our partners through care, education and research.
Values Service Integrity Sustainability
Drivers Patient/Community Focus Engaged Team Operational Excellence Financial Sustainability
Goa
ls
Obj
ectiv
es
Provide the best quality of care.
Promote better health for our communities.
Optimize our workforce and prepare for the
future.
Use our resources efficiently to sustain a viable health care system.
Use a standardized, rigorous process to accelerate the creation and broad use of evidenced-based protocols in all clinical areas and programs.
Develop a regional program for Mental Health and Addiction and Cardiac Sciences to improve quality of care.
Build a regional medication reconciliation system across the continuum.
Reduce health inequities in the populations we serve through focused improvements in core public health programs. Build on VCH integration strategies to support implementation of the MoHS directive to deliver integrated primary care, home and community care and community mental health services.
Enhance workforce utilization and match staffing to clinical volumes and patient acuity. Recruit and retain the best people by fostering a culture of excellence, recognition and respect. Build organizational capacity by strengthening leadership and management competencies.
Embed LEAN thinking at all levels to fulfill objectives and to deliver quality outcomes. Develop and implement best practices in care management to reduce unnecessary days of stay. Deliver administrative and support efficiencies through the shared services organization and consolidation.
Respond to provincial patient-centered funding model.
Develop service
agreements with funders and service providers.
Develop and
implement a strategy to secure increased capital funding.
Continue our
commitment to “Green Care” alternatives by reducing waste and our carbon footprint.
Respond to provincial patient-centered funding model. Develop service agreements with funders and service providers. Develop and implement a strategy to secure increased capital funding.
Continue our commitment to “Green Care” alternatives by reducing waste and our carbon footprint.
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Drivers Engaged Team Patient/Community Focus
Optimize our workforce and prepare for the
future.
Provide the best quality of care.
Promote better health for our communities.
Use our resources efficiently to sustain a viable health care system.
Operational Excellence Financial Sustainability
23
A Systems View
• Treat people in the most appropriate care location • Deliver the highest quality of care • Ensure effective use of resources • Emphasize scalability of services
Home Care
Home ED Home
Residential
Acute
Community
24
Examples of Pay for Performance at VCH
1. P4P in the Emergency Department 2. Activity Based Funding in Acute Care 3. Procedural Care 4. National Surgical Quality Improvement Program
(NSQIP) Implementation 5. Community Initiatives
25
Treat People Effectively in the ED
Treat people effectively in the ED (ED P4P) • Improve access to care, including reducing wait times • Improve quality of care • Increase efficiencies • Maintain existing new initiatives and reward further improvement
Home Care
Home ED Home
Residential
Acute
Community
26
VCH - Success with ED P4P
Three separate streams of patients with independent targets to reduce wait times and improve access: 1. Admitted Patients (to an inpatient bed within 10 hours)
2. Not admitted patients, High Priority (discharged within 4 hours)
3. Not admitted patients, Low Priority (discharged within 2 hours)
Additional 36,000 patients treated within target wait time in 2010/12
27
ED Admits Volumes vs Admit EDLOS
In P5 admitted 1480 patients with an average EDLOS of 9.2 hours.
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Avg
EDLO
S (A
dmitt
ed P
atie
nts)
# ED
Adm
issio
ns
Fiscal Period
VGH ED Admits Volumes vs Admit EDLOS(Fiscal Yr 04/05 to 11/12 YTD)
ED Admits Volumes Admit EDLOS (avg hrs)
28
Optimize Acute Care Services
Optimize Acute Care Services • Activity Based Funding – RIW based funding provides
incentive to care for the sickest patients and shift inpatient surgery to daycare
• Procedural Care Program – Reduce wait times • NSQIP Implementation – improve the quality of surgical care
Home Care
Home ED Home
Residential
Acute
Community
28
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Activity vs. Gobal Funding for Acute Care
• The shift from global funding to activity based funding has helped VCH to achieve desired performance, behaviour change and transformation of systems across acute, community and primary care service
• Goal: To move acute care to outpatient services To decrease length of stay
30
Activity Based Funding at VCH
• The ABF model for inpatient and same day procedures provides a tool for VCH to focus on service level changes and reallocate resources accordingly
• The marginal funding rate fosters the requirement for efficiency and cost management
• VCH continues to work with physicians and Health Records to improve quality and timeliness to ensure funding reflects acuity levels accurately
• The ED P4P earnings + RIW earnings equals the cost of opening extra beds
31
Procedural Care Program
• The Procedural Care Program was established to reduce the wait times for patients waiting the longest for care:
• “Top 10” Day Surgeries • VCH Selected Procedures with High Wait Times • Surgical and Medical Procedures Mainly Performed in
Procedure Rooms • Magnetic Resonance Imaging (MRI) Exams
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-03
Month End
Top 10 Day Surgery - Average Wait Time (Weeks) for Cases Waiting
Contracted Cases at Contracted Facilities
IHA
FHA
VCHA
VIHA
BC
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MRI Wait Times
0
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0
500
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09 P
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P4
09 P
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09 P
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10 P
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10 P
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11 P
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P8
11 P
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P7
12 P
10
Aver
age
Wai
t Ti
me
(Mon
ths)
MRI
Vol
ume
Year Fiscal Period
VCH MRI Volumes and Average Wait Time
Total MRI
Average Wait Time
LMIIF6,456 Exams
HSPOAnnualized total
6,304 Exams
33
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NSQIP Program
• Thesis: improve overall surgical outcomes by joining the American College of Surgeons’ National Surgical Quality Improvement Project
• In October of 2002, the U.S. Institute of Medicine named NSQIP the “best in the nation” for measuring and reporting surgical quality and outcomes
• Data can be used to help: – increase patient satisfaction – reduce the median length of stay – reduce postoperative mortality rates
35
Overall* 30-Day Morbidity
* Includes General and Vascular Surgery Cases
Observed rate: 17.69% Expected Rate: 10.46% O/E Ratio: 1.69 Status: Needs Improvement
Before
36
Overall* 30-Day Morbidity
* Includes General and Vascular Surgery Cases
Observed Rate: 11.88%Expected Rate: 10.88%O/E Ratio: 1.09Status: As Expected
2010 Report
After
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Invest in Community, Home Support and Primary Care
Home Care
Invest in Community and Home Support • Reduce ED visits • Reduce length of stay • Reduce ALC • Reduce Acute and Residential Care Admissions • Reduce Readmissions
Home Home
Residential
Acute
Community
ED
38
Avoidance of Unnecessary Residential Care and Acute Admissions (AURAA)
• A comprehensive set of community-based services designed to provide proactive care to prevent exacerbation of known complex disease
• Will prevent avoidable ED, Acute and Residential Care admissions and reduce LOS amongst the population at highest risk, while improving overall health status at home
• Targets: – Decrease RC use by 6 months per client
– Reduction in ALC days by 30% per client continued…
39
Avoidance of Unnecessary Residential Care and Acute Admissions (AURAA)
• 118 patients enrolled across 6 communities in VCH – All 118 patients were waitlisted or eligible for residential care – Over 90% of these patients are still in the community and have
not had to be admitted to residential care
• Patients waiting @ home have – declined RC bed when available – Shown marked functional and mental improvement
• Collaboration between acute and community has evolved
– Partnering in care planning across patient journey – Issue tracking promotes continuous learning
• Culture shift in clients expectations for RC placements
40
0
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1400
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# of RC Registrations (Total) by Fiscal Year (P11 YTD)
Vancouver
# of RC Registrations (P11 YTD) Average 08/09 to 10/11 (P11 YTD)
41
PFF can Lead to Better, Earlier Discharges: AURAA
41
VCH-RichmondAverage # of ALC Clients
40 39 38 38
35
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19 18
2123
2725 24 25
20 20 20 20 20 20 20 20 20 20 20 20 20 20
0
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Period
Clie
nts
Clients Target
Source: VCH Decision Support Prepared by: Ana Himani, Business Analyst
P2: Start of Home First Initiative
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Total Residential Care Placements by Period
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18 18
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25
15
10
13
1011
4
7
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1211
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0 0
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1 1
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Period
# of
Pla
cem
ents
Acute to Facility Community Community Emergency
Source : Priority Access Prepared by Ana Himani, Business Analyst
43 You can lead a horse to water but can
you make it drink? 43
44
Embracing PFF at VCH to Provide Better Patient Care
Educate and Inform Managers on Funding Model
Education
Provide real time information for decision making and analysis of scenarios
Real Time Information
Provide day to day business and financial support to clinical operations
Business Support
Ensure revenue flows to the clinical area where service is delivered
Revenue
Educate Front-Line Managers and Directors
Baseline
Volume
Baseline Baseline workload expressed
in both case volume and RIW No gain in ABF revenue until
workload is above baseline Loss in revenue if workload
is below baseline
Activity Based Funding (ABF) Funding mechanism for
acute and same day care cases with some exceptions Funding unit is Resource
Intensity Weight (RIW)
Case
Case
Daycare $3,800 / RIW Max RIW is 10% above
baseline
Inpatient $1,520 / RIW Max RIW is 3% above
baseline
Case
Case
ABF Volume (RIW)
45
46
Utilizing Emendo Cap Plan to Forecast Patient Volume and ABF Revenue
How VCH is utilizing the tool: • Includes 3 years of history and current activity to forecast demand and trends • Shift from producing a manual retrospective report to look at ABF revenue to
forecasting ABF revenue and analyzing “what if” scenarios • Determine impact on capacity and strive to exceed projected discharge targets to
create capacity • Develop a plan and budget and project revenue stream • Establish baseline, input RIWs and see how volumes have increased or decreased Objectives of Cap Plan Forecasting Tool at VCH: • Optimize the match between staffing and clinical volumes • Optimize productive hours per patient day and reduce overtime by planning for
fluctuations in demand • Exceed Discharge targets to create capacity for incoming volumes • Predict ABF Revenue
47
Provide Strategic Direction, Information and Business Support
Clinical Operations
Infrastructure and Business Support to Enable Clinical Operations
Transformation Team Strategy, Project Management, Project Coordination, Education, Communication
Decision Support Reporting Tools and Evaluation
Financial Planning Business and analytical support, reporting on progress to targets, expenses, revenues and volumes
48
In Conclusion – Key Factors for Success 1. Don’t chase money – funding needs to enable behaviour change to
support the right clinical actions
2. Not one time money- at VCH approach here to stay and grow
3. Accountability is key
4. Pay acute operations based on RIW funding – earnings drives understanding
5. Need to resource real -time information and analytics
6. Revenue and cash flow received must flow to operations monthly
7. Coding accuracy and timing is key – need to compute RIW internally
8. Must incentivize patient flow across the continuum of care – cannot concentrate on a single area in a bigger system.
9. Part of the strategic direction
49
Questions?
50
Appendices
51
Patient Focused Funding Period 7 YTD Earnings Summary for VCH
($ million) Procedural Care
Program Community Programs²
ED P4P funded by HSPO (New Floor)
ABF Payable
Total HSPO Funding
Vancouver 0.717 0.354 2.560 $ 2.13 $ 5.761 PHC 1.305 1.625 $ (0.67) $ 2.260 Coastal 1.352 0.114 0.912 $ 1.01 $ 3.388 Richmond 0.750 0.084 0.728 $ 1.63 $ 3.192 MRI (P6 YTD) 1.221 $ 1.221 Regional 0.005 $ 0.005 NSQIP¹ 0.996 $ 0.996
Less: MoH expected growth (unallocated) $ (0.82)
$ (0.82)
Total VCH $ 6.341 $ 0.557 $ 5.825 $ 3.28 $ 16.003 Annual contract $ 14.630 $ 11.560 ¹NSQIP - National Surgical Quality Improvement Program ²Community Programs (incl. start up funds)
52
VCH – Period 7 YTD ABF $ Change from 2011/12 Baseline
ABF Facilities (Included Procedures)
52
($ million)
2011/12
Change from 11/12 baseline 2011/12
Change from 11/12 baseline 2011/12
Change from 11/12 baseline
2011/12 Annual
Notional ABF
Allocation ABF
Payable
VGH/UBC 10.33$ (0.13)$ 45.31$ 2.26$ 55.64$ 2.13$ -$ 2.13$
PHC 8.40$ 0.36$ 26.59$ (1.03)$ 34.99$ (0.67)$ -$ (0.67)$
LGH 4.36$ 0.07$ 13.67$ 0.92$ 18.04$ 0.98$ -$ 0.98$
Squamish 0.56$ 0.03$ n/a n/a 0.56$ 0.03$ -$ 0.03$
RH 2.58$ 0.29$ 10.10$ 1.35$ 12.68$ 1.63$ -$ 1.63$
(0.18)$ (0.65)$ -$ (0.82)$ (0.82)$
Grand Total 26.23$ 0.44$ 95.67$ 2.85$ 121.91$ 3.29$ 10.10$ 3.29$
Notes:- Procedural Care Program RIWs excluded- Unused funds in one HA can be earned by another HA subject to HSPO approval and up to the totalmaximum earnings available for all HAs.
Same Day ABF $ Inpatient ABF $ Total ABF $
Less: MOH expected growth (unallocated)
53
VCH PFF Community Projects • Avoidance of Unnecessary Residential Care and Acute
Admissions (AURAA)
• Early Supported Discharge – Chronic Disease
• ED Adverse Drug Events Screening
• Home Based Treatment for Mental Health and Addiction
• Supporting Transition of Seniors from Emergency
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