Department of Health and NHS Improvement: update on CR work streams and outcomes

Prof Patrick Doherty Associate clinical lead for cardiac rehabilitation

(NHS Improvement)

Cardiac Rehabilitation

DH & NHS Improvement

partnerships, work streams & outputs

National Audit of Cardiac

Rehabilitation

(NACR)

Commissioning

for Quality and Innovation

(CQUIN)

Quality

Outcomes

Framework

(QOF)

Post MI & HF

Post Discharge

Tariff

(PDT)

Recovery

Rehabilitation

Reablement

(RRR)

Outpatient tariffs

Commissioning Outcomes

Framework (COF)

NHS CB & CCGs

CVD Strategy

Synergies in Rehabilitation & Prevention

DH CR Commissioning

Pack

NICE

CMG 39 &40,

CG48, 94 & 126

BACPR standards and

core components

• Aligned with DH CR Commissioning Pack plus commissioner outcomes • Working with BACPR to align with core components • First of the cardiac audits to independently gain ECC approval and

commended for quality • Made first steps in reporting at CR service level (HQIP requirement) • Guiding good practice through the new report (2012)

– showing that CR outcome is negatively related to the extent of comorbidity

• Informed the COF indicator data and potentially involved in collecting CR completion for CCGs

• Commenced ‘Information standard’ approval process to quality assure public data on CR which is an emerging requirement for all audits

National Audit of Cardiac

Rehabilitation

(NACR)

• National CR CQUIN proposals are being considered by NHS CB • Time limited indicators for CR with a final report in 2014 • Aim is to improve referral practices across services and for

commissioners to confirm that practice has changed • Monthly reporting on referral and attending numbers • Example of CQUINs indicator for CR

– % of patients attending rehabilitation within 90 days of referral following a Cardiac Event or diagnosis (if not admitted)

Commissioning

for Quality & Innovation

(CQUIN)

How CQUINs relate to the NHS Operating Framework • Domain 1: Under 75 mortality rate from CVD • Domain 2: Health-related quality of life for people with long-term

conditions: Enhancing quality of life for carers • Domain 3: Stopping conditions from getting worse and helping older

people to recover their independence: Emergency admissions and readmissions:

• Domain 4: Improving responsiveness to patient needs:

• Participation in rehabilitation for patients with CVD and heart failure can significantly improve quality of life, improve functional ability, allow the patient to retain employment, facilitate self-management thus avoiding unnecessary readmissions at 30 day post discharge. CR can also reduce levels of disability and morbidity which has been shown to enable patients to continue to function at home.

Commissioning

for Quality and Innovation

(CQUIN)

• For the first time ever CR will be on the GPs payment plan from April 2013

• NICE QOF – HF patients to be referred for exercise based CR – Post MI patients to be offered comprehensive CR

• These recommendations are based on evidence reviews by NICE

• The decision about when to start was based on the integrity and robustness of CR data available within the NHS IC (HSC IC) which hosts NACR

• Audit data once again comes to the aid of CR

Quality

Outcomes

Framework

(QOF)

Post MI & HF

• DH, PbR and NHS Improvement were asked by the SoS for Health to review the evidence for CR in reducing 30 day readmissions

• CR was one of four rehab approaches selected • Piloting was successful and the PDT tariff will be mandated from

April 2013 • Sir Bruce Keogh has stressed that savings, from reducing

readmissions, are to be reinvested in services that produce the benefits

• To make the most of this opportunity CR will need to be delivered early and differently

• Early MDT assessment with patient led goal setting plus early commencement of a structured and tailored CR programme with reassessment after the delivery of the core components

Post Discharge

Tariff

(PDT)

• RRR aims to facilitate the translation of care across sector specific approaches to care

• An example in CR is intermediate care

– Integrate care by linking provision thus bridging the gap and supporting transition between home/hospital or reverse)

– Involves agreement between different sectors (acute/primary/social care) tailored for different levels of severity or condition type (e.g. acute illness, recovery, or management of long term conditions)

– PDT is an incentive aimed at improving readmissions reduction but also facilitate RRR through integrated provision

• Involves unbundling of acute tariffs to enable outpatient services

Recovery

Rehabilitation

Reablement

(RRR)

• The NHS CB will hold the 212 CCGs to account through a series of Commissioning Outcome Framework (COF) indicators

• These will be aligned with each of the main condition groups for example CVD

• The indicators are few in number and need to reflect a quality outcome for the service

• ‘Completion of CR’ has made it through the initial review of COF indicators and we are pushing to have it included in the final list for 2013

• The HSC IC is the proposed mechanism for the collection of this indicator and they will use NACR data (which they host)

Commissioning Outcomes

Framework (COF)

NHS CB & CCGs

• The NSF CHD was successful in the period 2000 to 2010 but the situation has changed with the new NHS CB and funding challenges

• A new strategy is emerging to position the NHS to deliver better CVD health from 2013 onwards

• Rehabilitation and prevention are considered key elements but not as you know it!

• Synergies in the management of CVD rehabilitation and prevention strategies will be sought

• This will not undermine specialist therapeutic input but will ensure that, where appropriate, patients are offered tailored CVD rehabilitation and prevention programmes

• Consultation on the draft strategy by the end of 2012 with the strategy being embedded within the NHS CB by the summer of 2013.

CVD Strategy

Synergies in Rehabilitation &

Prevention

• The DH CR Pack is now fully operational and recommended by NICE in recent service commissioning guides (CMG 39 & 40)

• CR phases are replaced by integrated care based on early assessment of patient needs which are met through a comprehensive CR programme

• The NHS CB through the Local Area Teams (replacing SHAs) are being encouraged to use the CR Pack to inform the specification of services

DH CR Commissioning

Pack

• NICE CMG 39 for heart failure and CMG 40 for Post MI both recommend CR

• These two guides were instrumental in tipping the scale towards securing QOF

• It’s not all positive as CG126 stable angina failed to support comprehensive CR but did support life style change

• More research is needed, for stable angina, to evaluate the effectiveness of CR

• NICE CG48 (Sec Prev MI) is under review and will make recommendations, based on recent evidence (positive and negative), by the end of 2013

NICE

CMG 39 &40,

CG48, 94 & 126

• Updated version of the standards and core components published in 2012

• Seven standards and core components that raise expectations in how CR should be delivered

• Endorsed by patients through the HCP (UK)

• BACPR continues to position itself alongside other key groups (e.g. NHS Improvement and NACR) and is playing its part in defining the future shape of CR

BACPR standards and

core components