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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.

Aims

1. Raise awareness and understanding of the COPD Commissioning toolkits – 4 services

2. Advise you to consider applying the toolkits locally to commission individual or integrated services

3. Demonstrate the ‘adapted logic model’ to support the commissioning process and focus on outcomes

4. Contextualise & define ‘Commissioning quality care’

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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

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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 standard

Quality statement 6: Pulmonary rehabilitation

Outcome:

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 George's Respiratory Questionnaire (SGRQ).

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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

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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 services

The Mandate: A mandate from the Government to the NHS Commissioning Board: April 2013 to March 2015

Unsafe Substandard Adequate Good Excellent

Provider Payment Mechanisms

CCG Outcome Indicator Set

Commissioning guidance (NHS CB)

NICE quality standards

Standard of services

Proportion of services

Registration requirements

Regulation ( Enforcement against Registration Requirements)

There is no statutory provision allowing NICE Quality Standards to

impact upon registration requirements

Quality Standards are advice from NICE to the NHS CB on high quality care.

Standards and high quality care

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Synthesising a CCGOI to show ‘quality in commissioning’: Objective - Improving functional ability in people with LTC

Domain 2. People with COPD & MRC ≥3 referred

to Pulmonary Rehabilitation

NICE Quality Standards – COPD No 6 People with COPD meeting appropriate

criteria are offered an effective, timely and accessible multidisciplinary pulmonary

rehabilitation programme.

NICE Clinical Guideline 101 & NICE Pathways

Examples of other resources • Outcomes Strategy for COPD & Asthma

in England – DH 2011 • COPD Commissioning Toolkit & PR

Service Specification – NHS Companion Documents

• Principles, definitions and standards for PR – IMPRESS 2008

Etc….

Other NICE Support Audit support Commissioning guides Costing support Information resources & templates Quality Standards support Service planning Slide sets

Quality commissioning & Quality assurance

Smoking cessation Smoking cessation Smoking cessation

Awareness raising • Lung health • Lung symptoms • Lung age testing

Case finding Early diagnosis

Social Care/Re-ablement

Accurate diagnosis Quality spirometry

Physical activity

Proactive chronic disease management and self-management

Pulmonary rehab

Evidence based treatment/medicines management

LTOT/NIV

EOL

Challenge: To Improve Care & Outcomes Across Whole Pathway

Prompt therapy & follow-up in exacerbations Structured hospital admission with specialist care

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Tools to support COPD Outcomes Strategy implementation

Workforce competences

Prevention & Early

Identification toolkit

NHS Implementation

document

Asthma and Home oxygen

Good practice guides

Commissioning toolkits

COPD indicators and dataset

Tools to support commissioning

• COPD Commissioning Toolkit

Model service specifications

1. Pulmonary Rehabilitation

2. Service to manage COPD exacerbations

3. COPD spirometry and assessment service

4. Home oxygen assessment and review service

Available - http://www.dh.gov.uk/health/2012/08/copd-toolkit/

Published Aug 12

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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

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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).2

2. Puhan, M. et al. Pulmonary rehabilitation following exacerbations of chronic obstructive 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.3

3. Griffiths et al. (2001) “Cost-effectiveness of an outpatient multi-disciplinary pulmonary rehabilitation programme” Thorax 56: 779 – 784

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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 for commissioners of health and social care. Online publication http://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

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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.

Inputs

Intervention

Outputs

Outcome

Impact

Long term effects that occur from the

achievement of the outcomes.

What you expect to happen long

after the intervention has finished

Appropriate Patients/Clients:

(i.e. Inclusion/Exclusion Criteria

& Referral Guidance)

Action taken to prevent/improve a medical

disorder based on EB literature, standards &

guidance documents.

Describes what a quality service should look like.

End of the intervention

(i.e. number of people completed an

intervention – Evidence of service

delivery). Define completion.

A predicted measure of change that

demonstrates a valid and significant

therapeutic impact following

an agreed intervention

The Adapted logic model & the NHS

outcomes framework

S. Callaghan. www.eqehealth.co.uk

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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 Achievement of patient set goal(s) Improvement in HAD score or other PROM Improvement in understanding COPD

Output 85% of eligible patients booked for their assessment attend their appointment. 100% of eligible patients have their personal assessment performed. 95% of patients who attend for assessment have a baseline assessment. 75% of all eligible referred patients complete the PR programme (completion means that the patient has attended 75% of sessions). 90% of patients are satisfied with the service.

Intervention Pulmonary rehabilitation programme based on British Thoracic Society Guidelines and PCRS [IMPRESS] standards 2011. For patients attending PR a formal assessment, delivery and final assessment of a comprehensive pulmonary rehabilitation programme as per guidelines should be delivered.

Input Patients with a chronic respiratory disorder who have a confirmed diagnosis of COPD and other chronic progressive lung conditions (e.g. bronchiectasis, interstitial lung disease, chronic asthma and chest wall disease. Also, patients pre and post-thoracic surgery including lung transplant). Patients who consider themselves functionally disabled (MRC score of 3 or more) or those with an MRC score of two and symptomatic. Those patients who 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.

Patients with a chronic respiratory disorder who have a

confirmed diagnosis of COPD and other chronic progressive

lung conditions (e.g. bronchiectasis, interstitial lung disease,

chronic asthma and chest wall disease. Also, patients pre

and post-thoracic surgery including lung transplant).

Patients who consider themselves functionally disabled (MRC

score of 3 or more) or those with an MRC score of two and

symptomatic. Those patients who 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 _______

1. If patient is a smoker offer smoking cessation assistance For community referral Fax _____________ For clinic referral Fax _____________

2. Pulmonary rehabilitation -assessed for suitability First point of contact, either by the CNS Nurses or Physiotherapist, who will assess and refer patient. Nurse to contact if not done prior to discharge (fax referral form)

3. Written COPD patient information given including : •British Lung Foundation Self Management Book •Oxygen alert WALLET card •Information about the Breathe Easy Group

5. Outpatient follow up appointment made and given to patient Patient should see respiratory medical specialist and COPD respiratory nursing specialist within 1 month of discharge. (Appointment should be scheduled and patient made aware of location, time and date).

4. Satisfactory use of inhalers demonstrated and understood Please assess during medication rounds. Observe the patients using the device(s) and document on electronic prescribing record adequate technique demonstrated. (Refer to pharmacist or CNS if extra support is needed).

Place the faxed referral form(s) in the plastic sleeve during the patients stay, at discharge place with the COPD Discharge Checklist in the ‘Completed’ COPD Care Bundle Box located; _________: Nurses Station (Maroon coloured boxes)

Care bundle components are based on: NICE COPD guidelines 2004 (1-5) A Patient Experience Survey CLAHRC team April 2009 (6) Systematic Literature Review supported by CLAHRC April 2009 (1-6)

GO TO Patient COPD

Safe Discharge Checklist

CARE BUNDLE STEPS All required documents are included in package.

PR

IOR

TO

DIS

CH

AR

GE

DA

Y O

F D

ISC

HA

RG

E

Patient Sticker

Checklist Completed

Date:___/___/___

To be completed by nurse with the patient.

Note: Ensure phone Call scheduled for 48-72

hours post discharge. (6)

Nurse (Initials)

Completed Not Done

Completed Not Done

Completed Not Done

Completed Declined N/A Not Done

Completed Declined N/A Not Done

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The Adapted Logic Model

Provides 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

To reduce variation in the commissioning and provision of services

Collectively 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

Finally…and the key point about using

commissioning toolkits & service specifications?

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Thank You for listening

steve@eqehealth.co.uk