business case for level 2 specialist neuro … case for level 2 specialist neuro-rehabilitation beds...

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BUSINESS CASE FOR LEVEL 2 SPECIALIST NEURO-REHABILITATION BEDS : SLIDE PACK & FINANCIAL MODEL

V8

June 2015

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Add • Executive summary Slides 3 - 5

• Business Case on a Page Slide 6

• Model methodology Index/ Summary Slide 7

A. Methodology for calculating DTOC, beds and costs: Slide 8

1. Nos. of Neuro Rehab patients experiencing DTOC Slide 9

2. Nos. of required Neuro Rehab beds Slide 10

3. Cost of Level 2 Neuro Rehab beds Slide 11

• Summary methodology for investment Slide 12

B. Benefits Methodology – Steps: Slide 13

1. Calculate # of Neuro Rehab patients experiencing DTOC per provider Slide 14

2. Calculate average bed days lost per DTOC Slide 15

3. Summary of benefits - Neuro-rehab DTOC Slide 16

4. Summary of Benefits – ongoing care Slide 17

• Funding Arrangements – Options Appraisal Slide 18 to 31

Index

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Add Specialist rehabilitation is the total active care (assessment, treatment and management) of patients with a disabling condition, and their families, by a multi-professional team who have undergone recognised specialist training in rehabilitation, led /supported by a consultant trained and accredited in rehabilitation medicine (RM). (Professor Stokes- Turner 2010).

This summary slide sets out the business case and financial modelling for the commissioning of additional capacity for Level 2 Specialist Neuro-Rehabilitation Service (SNRS). The identified capacity resource needed to meet current recognised need is equivalent to a total of 19 SNRS Level 2 beds.

The proposed service model will provide a more flexible model of bed based and non-bed based/specialist outreach service to meet the varying needs for specialist neuro-rehabilitation for either bedded or community based interventions – linking both acute and community pathways.

The business case has identified that meeting this recognised need will result in immediate clinical and economic outcomes for patients across West London, Central London and Hammersmith and Fulham CCGs, namely:

• Provide positive patient experience by substantially reducing unwarranted delay to their next phase of care • Reduce additional cost in the acute hospital costs associated with increased length of stay in hospital • Measurable improvement in patent outcomes due to improved functional gain as a result of timely

interventions and reductions avoidable complications; • Quantifiable reduction in long-term (continuing care) costs due to a measurable reduction in the person’s

weekly on-going care costs. • Supporting transitions in care back to localities following rehabilitation.

Executive Summary: introduction

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Currently state:

• 10 commissioned SNRS block beds across the Triborough. This is currently being provided at the Albany Unit, Queens Square, London and provided by the University College of London Hospitals Foundation Trust (UCLH).

• Significant and increasing Delayed Transfers Of Care (DTOC) in hospitals – 6 to 10 weeks

• DTOC not only impacts on patient experiences of care, but also reduces the benefits to be gained from early intervention on reducing dependency levels

• Ad hoc out of area spot purchasing , and lost of opportunity in enhancing clinical outcomes and reducing longer term cost for on-going care.

Future state:

Financial Model quantifies the capacity and investment required to provide a clinical and cost efficient model of care which will significantly reduce:

• DTOC pressures and acute bed days lost for this patient cohort by 85%

• Reduce dependency levels leading to reductions in on-going care costs by atleast £481 per week per patient.

This is a first step in understanding and monitoring demand and capacity required for this cohort of patients. This is due to lack of complete data. However there is sufficient data set on neuro-rehab demand and delays to analyse, extrapolate and to make an informed estimation on current demand. This is explained in slides 7 and 8 onwards.

Executive summary: demand & capacity

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Add The Business Case for additional capacity has been determined through extensive sector work - coordinated through Imperial College Health Partners (ICHP) – the designated regional clinical and academic science network involving:

• Patients and their families/carers, and representative groups e.g. Health Watch

• Clinical input from a range of clinicians, practitioners and managers across Acute Hospital Trusts, Clinical Commissioning Groups, Community Health Care providers,

• Adult Social Care, and Third Sector (Headway)

The following four options were examined in the business case are:

• Do nothing and maintain the status quo;

• Commission 19 additional SNRS beds resource to provide both a bedded and non-bedded/ Community Outreach model of care within the Triborough CCGs areas;

• Commission 19 additional SNRS beds within the Triborough area plus the 10 beds currently at the Albany Rehabilitation Unit;

• Undertake a whole service redesign of the full care pathway.

This business case recommends option 2 – to commission additional capacity equivalent to 19 SNRS Level 2 beds resource to meet the current and future demand requirements. This will ensure the provision of flexible model

of care to meet the varying needs for specialist neuro-rehabilitation.

Executive summary: engagement & recommendation

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Add Business Case on a Page – patient flows

Long Acute Hospital stays

Home

Longer waits in Hospital for limited Out of Area Level 2

provision

Longer LOS Reduced outcomes

Local level 2 Specialist Neuro-Rehab Service

(SNRS) Beds

Transfer to local community based Specialist Neuro-Rehab Outreach

Service (SNROS) Level 2

Nursing Home

Community Independence Services (CIS) and Community Rehab Teams (CRTs)

Long-term care in Independent Hospitals

Key:

Community

CIS/CRTs

Hospital

Nurs/Res Care

Existing flows to reduced benefits = costs

New flows to increase benefits = reduce costs

Black arrows show current flows for most patients requiring bedded Neuro-rehab

Increased dependency &

avoidable complications

Reduced wait & Timely transfer

Local Neuro Rehab

Reduced dependency & improved outcomes

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Costs Benefits

Model Methodology – Index / Summary

Neuro Rehab

DTOC patients

Neuro Rehab

DTOC patients

(ICHT)

Neuro Rehab

DTOC patients

(Chelwest)

Required Level

2 Beds

Cost of Neuro

Rehab Level 2

Bed

Average Bed days

lost per DTOC

Savings from avoiding a

DTOC (DTOC cost

reduction)

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2

3

Financial

Summary

Neuro Rehab

DTOC patients

Savings in

Long-term care

costs (weekly) 4

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Calculate the number of neuro

rehabilitation DTOC patients

Data sources :

•ICHT DTOC data (13-14 and 14-15)

•National DTOC data

Calculate required number of neuro

rehabilitation beds

Commissioner Assumptions:

•Bed occupancy rates

•LOS

Calculate the cost of a Level 2 neuro

rehabilitation bed

Benchmarking analysis

•National Tariff

•Level 2 Guide base rates

•OBD shadow tariff (Putney)

ARU Contractual value (10 beds)

Methodology for calculating – DTOC, beds & costs

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Add 1) Calculating the number of Neuro rehabilitation DTOC patient numbers

ICHT Neuro Rehab DTOC Data

(13/14)

Imperial Chelwest

81 28

Estimated ChelWest 14/15

Neuro Rehab DTOC patients

Chelwest

26

Total Triborough Estimated

Neuro Rehab DTOC Patients

14/15

Imperial Chelwest

77 26

Total: 103

Assumption

*34.6%

Known Data

Key:

*34.6% calculated from comparing total number of Neuro

Rehab DTOCs from ChelWest to those from ICHT based on

2013/2014 data and methodology.

• Imperial Neuro-Rehab DTOC patients 13/14 – 81

• Chelwest Neuro-Rehab DTOC patients 13/14 - 28

• Calculation : 81/28= 0.346 (34,6%)

ICHT Neuro Rehab DTOC

Patients Data (14/15)

(prorated for full year)

Imperial

77

ICHT Neuro Rehab DTOC

Patients Data (8 months

in 14/15)

Imperial

51

Extrapolated using

monthly averages

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2) Calculating the number of neuro rehabilitation beds required to reduce DTOC’s

Length of Stay Target bed occupancy

rate

Neuro Beds required

56 85% 19 (18.6)

Assumption

Known Data

Key: Calculation:

• ((Total neuro rehab DTOC’s* LOS)/ Target Occupancy)/365

• ((103*56) / 85%)/ 365

103

Neuro Rehabilitation

DTOC (2014/15)

*LOS and occupancy rate : Standard Occupancy rate

assumptions for Level 2 bed unit, based on Albany Unit

information – provided by Ray Boateng

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Add Average benchmark analysis - £3,605 per week:

• Calculating the average cost of current provision and 14-15 national tariff plus MFF: National tariff (£3,715 per week)

• Hospital based Level 2 beds guide base rate (Hillingdon Hospitals – Alderbourne and Mount Vernon units, Albany unit £2,741 per week)

• Occupied Bed Day for Independent hospital (Putney) - £4,359 per week

The average cost provides basis for market testing.

Commissioning envelope - £3715 per week

Recommended that the commissioning investment based on conservative scenario to be based National Tariff Plus MFF. Therefore commissioning financial envelope:

• 19 beds x £3,715 weekly bed cost x 52 weeks = £3,591,340

• Weekly rate per bed = £531

3) Calculate the cost of a Level 2 Neuro-rehab bed

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Add Summary methodology for investment

Investment

Patients experiencing DTOC for neuro rehabilitation (Imperial and Chelwest)

103

Average LOS Level 2 Rehab bed 56

Assumed target bed occupancy 85%

Total shortage of beds 19

14-15 National Tariff + MFF for Level 2 cost (weekly cost per bed) £3,715

Additional required 19 Neuro Beds cost £3,591,340

Benchmark Analysis

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2

3

Calculate the number of neuro rehabilitation DTOC patients

Calculate required number of neuro rehabilitation beds

Calculate the cost of a Level 2 neuro rehabilitation bed

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Add Benefits Methodology

Calculate the number of neuro

rehabilitation DTOC patients per

provider

Data sources :

•ICHT DTOC data (13-14 and 14-15)

•National DTOC data

Calculate average bed days lost per

DTOC

Data sources and assumptions:

•ICHT and National DTOC data (13-14 and 14-15)

•85% reduction target on DTOCs

Calculate the cost of a DTOC (neuro

rehabilitation)

Rehabilitation cost analysis

•Triborough Data

•Cost of £282 per bed day

Calculate Long-term Care savings

due to neuro rehab

Source: 2005 research studies evidencing reduction in on-going care: £481 per week.

This is used as conservative estimate.

National benchmarking average from 2012 – 2014/15 suggest saving to be £534

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Add 3) Calculate cost of a DTOC - Benefits Breakdown

Imperial DTOC

Savings (£274,574)

ChelWest DTOC

Savings (£95,095)

Total Benefits

(£369,669)

77 Patients at

£282/day for

15 DTOC days at 85% reduction rate

77 x 282 x 15 x 85% = £274,574

26 Patients at

£282/day for

15 DTOC days at 85% reduction rate

26 x 282 x 15 x 85% = £95,095

£282/day for DTOC derived from cost data set provided by H&F CCG (Sharon Robson)

15 days is average DTOC, calculated from a two year average calculation of Imperial patients experiencing

DTOC (see slide 7) divided by the total number of DTOC days they experienced.

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Add 2) Calculate average bed days lost due to DTOC

Average Bed days lost per DTOC Final Two year average Bed

days lost per DTOC

(*) 2013-2014 (*) 2014-2015 13-14 and 14-15 data

19.6 10.4 15.0

(*) Methodology:

• Total Bed days lost / Number of DTOC patients

85% reduction rate of total DTOC bed days

12 (12.7)

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Add Financial Summary of Benefits - DTOC

Benefits (*)

Patients experiencing DTOC for neuro rehabilitation (Imperial) 77

Average bed days 15.0

% Reduction of total DTOC (assumption) 85%

Average DTOC cost per bed (daily) £282

Savings from reduced DTOC (Imperial) -£274,574

Patients experiencing DTOC for neuro rehabilitation (Chelwest) 26

Average bed days 15.0

% Reduction of total DTOC (assumption) 85%

Average DTOC cost per bed (daily) £282

Savings from reduced DTOC (ChelWest) (*) -£95,095

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2

3

1

2

3

1

2

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Calculate the number of neuro rehabilitation DTOC patients per provider Calculate average bed days lost per DTOC

Calculate the cost of a DTOC (neuro rehabilitation)

* Note on Chelwest DTOC savings: Reflected to show financial impact, but savings have already been identified in other WL CCG QIPP schemes, quantifying DTOC savings (WL003)

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Add 4) Financial Summary – savings on on-going care

Evidence from research Study 1 (See Business Case: Turner Stokes et. al, 2005) show that in 2005 the mean

average for long-term care cost saving impact following a specialist neuro-rehabilitation intervention was £481 per

week per patient – due to the reduction in dependency levels. This is what has been used for the business case.

Current UK Rehabilitation Outcomes Collaborative (UKROC) benchmarking data (see appendix – slide 28) show that

the 3 year mean average from 2012/13 – 2014/15 is £534 per week. Therefore the calculations for long-term care

savings are very prudent and conservative. (see appendix)

The table below provides a 3 years projection on the minimum cumulative financial impact on long-term savings for

the SRNS supporting a projected average of 103 patients each year – assuming each patient survives during the 3

year period. The projected long-term cost savings for the 3 year contract life is estimated at £15.5m

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2117444/

Long-term care (LTC)

savings per year Patients 2016/2017 2017/2018 2018/2019 Total impact

LTC savings Year 1 103 £2,576,102 £2,576,102 £2,576,102 £7,728,307

LTC savings Year 2 103 £2,576,102 £2,576,102 £5,152,204

LTC saving Year 3 103 £2,576,102 £2,576,102

Total LTC savings 309 £2,576,102 £5,152,205 £7,728,307 £15,456,613

DTOC savings per year £369,669 £369,669 £369,669 £1,109,007

Total financial benefit 309 £2,945,771 £5,521,874 £8,097,976 £16,565,621

CCGs investments per Year £3,591,340 £3,591,340 £3,591,340 £10,774,020

Net costs(+)/benefits (-) +£645,568 -£1,930,534 -£4,506,636 -£5,791,601



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FUNDING ARRANGEMENTS

Options appraisal for funding

split per CCG

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Add Options for funding split

1) Equal 3 way split

2) % split based on Albany usage for 14/15 - CL (37%), WL (36%), H&F (27%)

3) % split based on Albany usage 2yr average (2013 -14 /15) : CL (41.5%), WL (36%), H&F ( 22.5%). Please note 2013/14 usage - CL (46%), WL (36%), H&F (18%)

4) % split based on Imperial DTOC for 14-15 – DTOC % till Feb 2015 are 40% HF, 38% CL , and WL 22% (this is heavily weighted against HF)

5) Combined averages for options 3 and 4

OPTION 1 OPTION 2 OPTION 3 OPTION 4 OPTION 5

CCG Equal Split Activity Activity - 2 yr

Avg DTOC

Ratio (Option 3&4)

CL 33.33% 37.00% 41.50% 38.00% 39.75%

WL 33.33% 36.00% 36.00% 22.00% 29.00%

H&F 33.33% 27.00% 22.50% 40.00% 31.25%

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Add OPTION 1

• As was recommended in the latest edition of the Business Case, a three way CCG split is the most sensible and pragmatic approach for initial investment. This simplicity of this can be re-balanced based on actual usage activity. CCG Finance Leads may accrue up to an additional 20% (as worst case scenario) and re-evaluate financial positions once activity data became available.

OPTIONS 2 (Albany usage % for 2013/14 ) & OPTION 3 (Albany usage % for 2013/14 – 2015/16)

• Albany does not provide for the full spectrum of Level 2 beds – therefore data on usage is only useful for understanding demand for certain patient cohorts only e.g Stroke patients.

• Whereas this may provide Central and West London CCGs with some indication of their usage, access is limited for H&F CCG - therefore provides only a partial indication of demand for H&F in addition to the limitations above. This is especially the case for 2013-2014 period.

OPTION 4

• National DTOC reporting categorises Neuro-delays under Category C – Further Non-acute NHS care. Category C includes NHS Cont Care and End of Life Care etc. Therefore ICHT data accurately captures the totality of neuro-delays. ICHT is also the biggest referrer for Neuro-rehab.

• However, the ICHT DTOC data for neuro-rehab is heavily weighted towards H&F CCG in particular – as patients are unlikely to end up in Chelwest. Monthly neuro - DTOC from Chelwest is unavailable.

Caveats – Limitations

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Add Option 1) Equal Three way split: Financial Summary (2016-2017)

2016/2017 FYE H&F WL CL Total Drivers

Current Investment (15/16)

£418,845 £1,278,238 £1,011,490 £2,708,573 2015/2016 full year investment identified for SNRS resource

New Investment (16/17)

£778,264 -£81,125 £185,623 £882,767 2016/2017 additional FYE investment for SNRS resource

Total Investment (16/17)

£1,197,113 £1,197,113 £1,197,113 £3,591,340 2016/2017 full year investment for SNRS resource

Gross Benefits (DTOC)

-£123,223 -£123,223 -£123,223 -£369,669 Reduction in DTOCs

Total Net Investment

£1,073,890 £1,073,890 £1,073,890 £3,221,670 Time Frame : April 2016 - Mar 2017

The full year financial investments for 2016/17 are set below. This is a three way split part year effect, and will be rebased at the end of year based on usage.


Avg DTOC Ratio

CL 33.33% 37.00% 41.50% 38.00% 39.75%

WL 33.33% 36.00% 36.00% 22.00% 29.00%

H&F 33.33% 27.00% 22.50% 40.00% 31.25%

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Add Option 2) Albany Activity usage Split (2013/14): Financial Summary (2016-2017)





£550,813 £14,644 £317,306 £882,767 2016/2017 additional FYE investment for SNRS resource


£969,662 £1,292,882 £1,328,796 £3,591,340 2016/2017 full year investment for SNRS resource




£869,851 £1,159,801 £1,192,018 £3,221,670 Time Frame : April 2016 - Mar 2017

The full year financial investments for 2016/17 are set below. This is an option that represents funding arrangements based on Albany Rehabilitation Unit Activity


Avg DTOC Ratio

CL 33.33% 37.00% 41.50% 38.00% 39.75% WL 33.33% 36.00% 36.00% 22.00% 29.00%

H&F 33.33% 27.00% 22.50% 40.00% 31.25%

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Add Option 3 - 2 year Average Albany Activity usage: Financial Summary (2016-2017)





£389,207 £14,644 £478,916 £882,767 2016/2017 additional FYE investment for SNRS resource


£808,051 £1,292,882 £1,490,406 £3,591,340 2016/2017 full year investment for SNRS resource





The full year financial investments for 2016/17 are set below. This is an option that represents funding arrangements based on Albany Rehabilitation Unit Activity (2 year period)


Avg DTOC Ratio

CL 33.33% 37.00% 41.50% 38.00% 39.75%

WL 33.33% 36.00% 36.00% 22.00% 29.00% H&F 33.33% 27.00% 22.50% 40.00% 31.25%

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Add Option 4) Split based on DTOC activity: Financial Summary (2016-2017)





£1,017,691 -£488,143 £353,219 £882,767 2016/2017 additional FYE investment for SNRS resource


£1,436,536 £790,095 £1,364,709 £3,591,340 2016/2017 full year investment for SNRS resource




£1,288,668 £708,768 £1,224,235 £3,221,670 Time Frame : April 2016 - Mar 2017

The full year financial investments for 2016/17 are set below. This is an option that represents funding arrangements based on DTOC Activity (ICHT)


Avg DTOC Ratio

CL 33.33% 37.00% 41.50% 38.00% 39.75%

WL 33.33% 36.00% 36.00% 22.00% 29.00%

H&F 33.33% 27.00% 22.50% 40.00% 31.25%

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Add Option 5) Combined averages split: Financial Summary (2016-2017)





£703,449 -£236,749 £416,068 £882,767 2016/2017 additional FYE investment for SNRS resource


£1,122,294 £1,041,489 £1,427,558 £3,591,340 2016/2017 full year investment for SNRS resource





The full year financial investments for 2016/17 are set below. This is an option that represents funding arrangements based on an average of the three previous split options


Avg DTOC Ratio

CL 33.33% 37.00% 41.50% 38.00% 39.75%

WL 33.33% 36.00% 36.00% 22.00% 29.00% H&F 33.33% 27.00% 22.50% 40.00% 31.25%

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Add Governance approval timelines

Ops Group Submission Date Meeting Date

Central London TRG May 5th May 13th

West London Ops May 8th May 12th

H&F Ops May 8th May 12th

F&P Submission Date Meeting Date

Central London F&P May 18th May 27th

West London F&P May 18th May 26th

H&F F&P May 14th May 26th

Governing Body Submission Date Meeting Date

Central London GB June 29th July 8th

West London GB July 13th July 21st

H&F GB July 7th July 14th

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Add Issue advert & ITT

documentation

Procurement advertised on Contracts Finder and all

procurement documents made available to potential Bidders

through the E-Procurement portal

Early August 2015

Bidder Briefing Event CCGs host a Bidder Briefing Event to ensure good understanding by

Bidders of the service requirements and Procurement process –

following market testing

Mid to late August 2015

Deadline for the receipt of

clarification questions

Deadline for Bidders to submit clarifications to the CCGs 1 week before ITT submission

deadline (see below) ITT Submission DEADLINE Deadline by when Bidders must have fully completed and submitted

their Bids – this presumes 7 weeks (can be shortened / lengthened)

End of September 2015

ITT Bid evaluation stage Period when Bids will be evaluated and CCG clarification questions

responded to by bidders. Evaluation panel individually review and

score bids, followed by moderation event to agreed consensus

scores and section of the Preferred Bidder(s)

Early October 2015 (allow 1 or 2

weeks), including Evaluation Panel

Moderation meeting immediately

toward end of this couple of weeks

Post procurement outcomes

report

Preparation of report detailing the evaluation approach and

outcome, with recommendation regarding award of contract

Mid October 2015

CCG authorisation to award

contract(s)

CCG governance to consider post-procurement recommendation

report regarding contract award. CCG authorise contract award.

By end of October 2015 – TBC

pending meeting dates

Preferred Bidder initial

notification and standstill

period regarding Confirmation

The expected dates when Bidders will be notified of the outcome of

the evaluation and observance of the recommended Standstill

Period

End of October 2015

Contract signature The expected date for the signing of the Contracts between the

CCGs and the successful Provider

From mid-November 2015

Service mobilisation period Period when the Preferred Bidder plans and delivers mobilisation

activities to prepare for service commencement

From November 2015 – duration

dependent upon mobilisation plan

TBA with preferred bidder –

assume at least 3 or 4 months Full service commencement Date when commencement of the new Services expected 1st April 2016 possible

Procurement timelines

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APPENDIX Additional slides

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Add Levels of need & service categories/levels

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Add The national benchmarking data set below supports both the clinical impact/outcomes

(measurable functional gains), as well as the economic impact (measurable reduction in on-

going care) that specialist neuro-rehabilitation service make.

National /ARU benchmarking summary data evidencing clinical & economic impact of SNRS

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Source: UK Rehabilitation Outcomes Collaborative (UK ROC)

National /ARU benchmarking summary data evidencing clinical & economic impact of SNRS

business case for level 2 specialist neuro … case for level 2 specialist neuro-rehabilitation beds...

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