DH Cardiac RehabilitationCommissioning Pack:highlights and process

Prof Patrick Doherty

BACR conference

Liverpool 2010

CR commissioning pack working groups:led by SCDU and NHS Improvement

1. A reference group including leaders from rehabilitation, cardiology and GPsthat helped design the service specification

– Six meetings to develop the clinical service specification

– The first draft shared with clinicians & commissioners in May 2010

– The reference group signed off the pack specification July 2010– The reference group signed off the pack specification July 2010

2. Pricing and economic team (pricing tool)

– Support from the DH pricing team and health economists

– Case for change and pricing tool

3. Contracting and procurement team

– Legal aspects of contracting

– Quality assurance in commissioning best practice

This was a collaborative approach that involved the DH, SCDU,

NHS Improvement, PbR, NHS IC, BACR, NACR and the BHF

Scope of the CR pack: patientsHigh priority shall be given to the primary diagnosis of:

1. Acute coronary syndrome (ACS) which includes STEMI, NSTEMI andunstable angina (NICE Guidance CG 48 and CG 94)

a. Should include all patients undergoing reperfusion (e.g. CABG, PCIor PPCI)

2. Chronic heart failure of new diagnosis or chronic heart failure with a2. Chronic heart failure of new diagnosis or chronic heart failure with astep change in clinical presentation of (NICE Guidance CG 108)

The costing model for the cardiac rehabilitation commissioning pack isbased on the high priority inclusion.

As cardiac rehabilitation services develop and are successful with highpriority inclusion then CR services should be extended to include:

3. Heart transplant patients and patients with ventricular assist devices (VADs)

4. Patients that have undergone surgery for implantable cardioverter

defibrillator (ICD) or Cardiac resynchronisation therapy (CRT) for reasons

other than ACS or heart failure

5. Heart valve replacement patients for reasons other than ACS or heart failure

6. Patients with a confirmed diagnosis of exertional angina

A full list of codes covering the above patient groups can be found at Annex 1.

Providers shall include other conditions where there is a clear clinical basis andbenefit for referral to cardiac rehabilitation. This situation can exist where thenumbers of patients is generally too small to produce rigorous evidence but theperceived benefits are obvious. An example could be certain adult patients withcongenital heart conditions.

Cardiac Rehabilitation Pathway (all stages)

Stage 1 – Manage Referral and Recruit Patient toCardiac Rehabilitation Programme

Stage 2 – Assess Patient for Cardiac Rehabilitation

Core components for cardiac rehabilitation

PATIENTNEEDSPATIENTNEEDS

The Provider shall offer choice and inform thepatient of the types of cardiac rehabilitationinterventions and locations of thoseinterventions offered by the service and agreewith the patient whether the patient is readyand willing to commence all relevant aspects ofthe programme of cardiac rehabilitation inaccordance with the Care Plan developed inStage 3.

Due to the behavioural and self motivationalemphasis of cardiac rehabilitation the evidencesupports patient preference as important andsuggests that patients benefit the most if they

Care Plan

Lifestyle

Risk factor management

Cardio protective drug therapy& devices

Psychosocial wellbeing

Education

Long-term management

Co

reco

mp

on

en

ts

PATIENT PREFERENCESEVIDENCE BASEDAPPROACHES

Care Plan

Lifestyle

Risk factor management

Cardio protective drug therapy& devices

Psychosocial wellbeing

Education

Long-term management

Co

reco

mp

on

en

ts

PATIENT PREFERENCESEVIDENCE BASEDAPPROACHES

suggests that patients benefit the most if theypursue a programme they feel works for them.No single approach can accommodate the rangeof patient preferences; therefore the Providershall offer a range of evidence based approachesand venues at times that suit patient choice.

Stage 3 – Develop Patient Care Plan

Stage 4 – Deliver comprehensive cardiac rehabilitation

Stage 5 – Conduct final assessment

Cardiac Rehabilitation Pathway (all stages)

Major differences to what exists

• There are no phases

• No set time frames for patients but it is priced on a20 sessions basis ( including 16 sessions fordelivery of core components)delivery of core components)

• Successful CR is based more on patient outcomethan process completion

– Some process and productivity measures are includedthat are deemed relevant to service provision

• Linked to primary care services where relevant toavoid replication of provision

Acute initialAdmissions cost

Current CR CostAcute cost ofReadmissions

+ +=Existing CardiacCost

Summary Costing

Staff CostingPathwayElements

Total Loadedstaff costs

Commissionerspecific costs

Initial Costs(Spread over the

contract life)X

= + +

CR pack cost analysis

Acute initialAdmissions cost

Estimated CR Cost(based on higher volume)

Acute cost ofReadmissions

(based on lower volume)

+ +=New CardiacService Cost

Vs

If the New Cardiac Service Cost is lower than the Existing Cardiac Cost this would indicate a net financial benefit of commissioning the CardiacRehab Pathway.

The cost benefit is made up of a the following tabs;● HES Readmission Calculation - This defines how the readmissions were calculated for the following tabs● Cost Benefit Assumptions - This defines the assumptions being made, some commissioner input is required● PCT Consortium - This allows you so select several PCT's to group up your activity● PCT Pathway Summary - This shows the difference between costs for existing cardiac care programme and after the implementation of theproposed CR pathway at single patient level● PCT Financial Summary - This shows the financial impact of implementing the pack in total financial terms● Several Analysis Graphs to show the Selected PCT's relative position when compared with all PCTs

Key indicators for the CR service

• Uptake

• Completion

• Readmissions (where appropriate)• Readmissions (where appropriate)

• Patient satisfaction

NACR is recommended as the mechanism for data collection

Outcome measures for patientsAim is to measure baseline trends to inform patient agreedgoals and then assess the extent of change between baselineand post rehabilitation in respect of relevant outcomes.

For each patient these could include:– Psychological well being (HADs)– Psychological well being (HADs)

– Functional capacity (fitness) SWT, SMWT etc

– BMI measures for all and waist circumference measures for patientswith a BMI <35 kg/m2 (CG 43)

– Quality of Life (Dartmouth or MLWHF)

– Smoking cessation

– Compliance with medication

– Compliance with healthy eating plan

NACR is recommended as the mechanism for data collection

Next steps

• GP commissioner online testing completed on1st Oct

• Survey information collated and alterations tocontracting and procurement made

• CR pack will be set up on the DH website onthe 15th October

• Launch last week in October

• NHS Improvement commissioning priorityprojects commence on the 4th November 2010

Conclusion

• The DH, SCDU, NHS Improvement, BACR, NACR andBHF are all committed to this new joined up initiative

• The case for change and evidence base is very strongand makes a compelling case to commissioners

• The cost analysis has already made a significant• The cost analysis has already made a significantcontribution to enabling providers to engage in serviceredesign and procurement

• 2010/11 will see the roll out of the packs and astrengthening of CR

• NHS Improvement looks forward to next year’sconference were we hope to share the success of anew wave of innovative CR programmes

NHS Improvement:www.improvement.nhs.uk/heart/cardiacrehabilitation

Thank You!

See the NHS Improvement stand formore information.