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Microsoft PowerPoint - Demand Management2

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					                                              This workshop covers the following:

                                                The financial crisis
                                                The policy backdrop
                                                What commissioners/providers need to know
                                                Better Care Better Value indicators
                                                Demand management dashboards
                                                Consequence / What if Modelling
                                                Reviewing the recent evidence




                                              The Headlines
This workshop covers the following:

  The financial crisis
  The policy backdrop
  What commissioners/providers need to know
  Better Care Better Value indicators
  Demand management dashboards
  Consequence / What if Modelling
  Reviewing the recent evidence




This workshop covers the following:           The Policy Backdrop

  The financial crisis                          PbR is a financial framework that incentivises treatment of
                                                people within the hospital and incentivises increased demand
  The policy backdrop
                                                Payment by Volume is not Payment by Results.
  What commissioners/providers need to know
                                                Less (hospital treatment) may be More (efficient)
  Better Care Better Value indicators
                                                Commissioners are waking up to this and the looming
  Demand management dashboards                  financial freeze will be like an ice cold shower!
  Consequence / What if Modelling               A cap is being introduced whereby admissions above agreed
  Reviewing the recent evidence                 levels attract only a small proportion of full tariff
                                                “We would strongly encourage CQUIN to bring about change
                                                in pathways” - Department of Health CQUIN framework policy lead Flora Swanborough
Terminology                                                                   This workshop covers the following:
  Demand management
  Date reviewed: 25-11-09                                                         The financial crisis
                                                                                  The policy backdrop
  "The term demand management refers to actions taken by primary
  care trusts and/or GP practices to moderate the demand for health               What commissioners/providers need to know
  care services. Hospital demand management refers to actions taken               Better Care Better Value indicators
  to moderate the rate of referrals of patients to hospitals. A referral
  management centre assesses the clinical appropriateness of GP                   Demand management dashboards
  referrals before treatment is allowed to proceed." (1)
                                                                                  Consequence / What if Modelling
                                                                                  Reviewing the recent evidence




What does a commissioner need to know?                                        What does a provider need to know?

  Where can demand be safely reduced so that outcomes                             How will PCT purchasing power impact my trust?
  become no worse?                                                                Which services are most at risk?
  Where are the “low hanging fruit”?                                              Can we reduce our own cost base in response to falling
  Do we need to incentivise providers to provide what we                          demand?
  want?                                                                           Can we expand our services as a result of market re-
  Can we promote new cost-effective care pathways?                                shaping?
  What are the consequences of strategic shift (moving                            Should we consider vertical integration of some
  care from secondary to primary care settings)?                                  services?




                                                                           The Evidence – how can you make a hole in £20
                                                                           billion within 5 years??
This workshop covers the following:

  The financial crisis
  The policy backdrop
  What commissioners/providers need to know                                Collective BCBV demand
  Better Care Better Value indicators                                      management
                                                                           opportunities account for
  Demand management dashboards                                             £9m – £22.5m per
                                                                           organisation i.e little over
  Consequence / What if Modelling
                                                                           10% of the target, at
  Reviewing the recent evidence                                            higher estimates, but it is
                                                                           a start.
 There is a need to challenge the underlying
                                                                                                                                                 Drilling into PCT demand management issues
 assumptions.
                                     Net savings estimates                           Net savings estimates
                                     may be too low                                  may be too high
                                     BCBV uses top 25th                              Commissioner-level
                                     percentile of national                          demand metrics involve
                                     performance? Are we                             care shifts rather than
                                     saying 25% of organisations                     reductions in resource use
                                     should be looking for no
                                     improvement?
                                     Cost functions are stepped                      Populations are ageing.
                                     – eat into demand far
                                     enough and right-sizing of
                                     estate yields higher savings

                                     Standardising for IMD                           Expectations are rising.
                                     dampens the potential for
                                     strategic shift
                                                                                                                                                                                            Rates are benchmarked against national peer but
                                                                                                                                                                                            regional position and ONS cluster group are
                                                                                                                                                                                            possible




Name                                                                                                                                            Name
               Managing variation in surgical thresholds                                                                                                             Managing variation in emergency admissions
Numerator                                                                                                                                       Numerator
               Actual spells1                                                                                                                                        Actual spells1
Numerator
                                                                                                                                                Numerator source
source         Data submission to CHKS                                                                                                                               Data submission to CHKS/HES

Denominator                                                                                                                                     Denominator
               Expected2 spells                                                                                                                                      Expected2 spells

Denominator                                                                                                                                     Denominator source   Number of spells at All England level by age/sex is from HES DATA BASE divided by age/sex composition
               Number of spells at All England level by age/sex is from HES DATA BASE divided by age/sex composition of All England and                              of All England and other PCTs taken from ONS populations
source
               other PCTs is from ONS populations
                                                                                                                                                Expressed as
                                                                                                                                                                     Ratio i.e (Actual/Expected)*100. 1 dec place
Expressed as
               Ratio i.e (Actual/Expected)*100. 1 dec place
                                                                                                                                                                     This is Age/Sex standardised2 admission rate * Age sex Profile of any PCT
               This is Age/Sex standardised2 admission rate * Age sex Profile of any PCT
                                                                                                                                                                     1 Actual spells for the basket of ICD10 coded diagnoses for influenza/pneumonia, vaccine preventable,
               1Actual spells for the following basket of procedures (defined by one or more OPCS4 codes as follows
                                                                                                                                                                     diabetes complications, nutritional deficiencies, iron deficiency anaemia, hypertension, congestive heart
               Abdominal excision of uterus Q07
               Myringotomy with/without grommets D15 (excluding E081,E201,F291,F34,D191 in any position)
                                                                                                                                                                     failure, angina, COPD, Asthma, dehydration and gastroenteritis, convulsions/epilepsy, ENT infections, dental
               Tonsillectomy F341-F344                                                                                                                               conditions, perforated bleeding ulcer, ruptured appendix, pyelonephritis, pelvic inflammatory disease,
               Dilation and curettage/hysteroscopy Q103,Q18 (O04 is not primary diagnosis)                                                                           cellulitis and gangrene
               Vaginal excision of uterus Q08
                                                                                                                                                                     2this is calculated as follows
               Lumbar spine procedures V25,V26,V33,V34,V382-4,V393-5,V433,V473,V485-6,V493
                                                                                                                                                                     For every age/sex combination of any PCTs population an expected level of admissions can be calculated
                                                                                                                                                                     by applying the national age/specific rate e.g.
               2this is calculated as follows
Calculation    For every age/sex combination of any PCTs population an expected level of admissions can be calculated by applying the           Calculation
                                                                                                                                                                     Males aged 0 {Spells male,aged 0 (national)/male,aged 0 population (national)}* male,aged 0 population any
               national age/specific rate e.g.                                                                                                                       PCT
                                                                                                                                                                     Males aged 1-5 etc. {Spells male,aged 1-5 (national)/male,aged 1-5 population (national)}*male aged 1-5
               Males aged 0 {Spells male,aged 0 (national)/male,aged 0 population (national)}* male,aged 0 population any PCT
                                                                                                                                                                     population any PCT
               Males aged 1-5 etc. {Spells male,aged 1-5 (national)/male,aged 1-5 population (national)}*male aged 1-5 population any PCT

               Expected spells are the sum of all age/sex combinations.                                                                                              Expected spells are the sum of all age/sex combinations.
               Note BCBV uses the following standardisation technique..                                                                                              Note BCBV uses the following standardisation technique..
               Age is defined in the case-mix adjustment as 10-year bands (0-4, 5-14,..,75+). Deprivation is based on the Index of Multiple                          Age is defined in the case-mix adjustment as 10-year bands (0-4, 5-14,..,75+). Deprivation is based on the
               Deprivation (IMD) 2004 for each lower-layer of the Super Output Area (SOA)                                                                            Index of Multiple Deprivation (IMD) 2004 for each lower-layer of the Super Output Area (SOA)
               CHKS has not used this because we prefer to use 5 year age bands and feel that use of IMD is inappropriate for standardisation                        CHKS has not used this because we prefer to use 5 year age bands and feel that use of IMD is
               of this indicator.                                                                                                                                    inappropriate for standardisation of this indicator.




Name                                                                                                                                            Name
                          Managing variation in rates of first outpatient appointments - selected specialties                                                        Outpatient follow up rates


Numerator
                          Actual first outpatient appointments in ENT, general surgery, orthopaedics, urology and gynaecology
                                                                                                                                                Numerator            Number of follow up appointments (attendance code 5 or 6) with a first attendance indicator
                                                                                                                                                                     NOT= 1
Numerator source
                          Data submission to CHKS/HES outpatient database


                                                                                                                                                Numerator source
                                                                                                                                                                     Data submission to CHKS/HES data outpatient database
Denominator
                          Expected1 outpatient appointments in selected specialties



Denominator source
                          Data submission to CHKS/HES outpatient database                                                                       Denominator          Number of first outpatient appointments (attendance code 5 or 6) with a first attendance
                                                                                                                                                                     indicator = 1

Expressed as
                          Ratio i.e (Actual/Expected)*100. 1 dec place
                                                                                                                                                Denominator source
                                                                                                                                                                     Data submission to CHKS/HES outpatient database


                          This is an unadjusted admission rate * Population of any PCT

                          1
                            this is calculated as follows:                                                                                      Expressed as
Calculation               For every PCTs population an expected level of admissions can be calculated by applying the national rate
                                                                                                                                                                     Ratio (1 numerator/denominator) to 2 dec places
                          to age sex profile


                                                                                                                                                                     Numerator/Denominator
                                                                                                                                                Calculation
Name
                     Managing 14 day emergency readmissions                                                                           The Evidence @ specialty level – variation in
Numerator            Numerator is expressed as a count of admissions where there has been a subsequent readmission within 14
                     days of discharge of a spell - see 1 below                                                                       surgical thresholds
Numerator source
                     Data submission to CHKS/HES
Denominator
                     Denominator is expressed as a count of admissions by a trust - see 2 below
Denominator source
                     Data submission to CHKS/HES
Expressed as
                     Numerator/Denominator



                     Note 1 The readmission must meet the criteria below and can be to the same trust or any other trust.
                     •The discharge of the first admission must be within the quarter time period or less than 14 days prior to the
                     quarter. The second admission must be within the quarter time period.
                     •The first admission is either Elective or Emergency (this is where the indicator is split).
                     •The second admission is coded as 21, 22, 23, 24 or 28.
                     •2nd admission date is within 14 days of discharge date of the spell.
                     •Includes day cases
                     •1st Admission does not include Main specialty coded 700-715 , 560, 610
                     •Main diagnosis does not include anything under Mental Health, Cancer, Chemotherapy or Benign Cancer
                     where the primary diagnosis starts with "O"
Calculation          •2nd Admission does not include Main specialty coded 700-715 , 560, 610
                     •Main diagnosis does not include anything under Mental Health, Cancer, Chemotherapy or Benign Cancer
                     where the primary diagnosis starts with "O"
                     •
                     Note 2 Discharge from spell is within the quarter.
                     •Admissions do not include those where Main specialty coded 700-715 , 560, 610
                     •Main diagnosis does not include anything under Mental Health, Cancer, Chemotherapy or Benign Cancer
                     where the primary diagnosis starts with "O"
                     •Day case admissions are not included
                     •Admissions with a discharge coded as "death" are not included                                                               PREDICTION Assumptions will become more radical/aggressive and
                                                                                                                                                  eligibility criteria for demand reduction will widen




       This workshop covers the following:                                                                                               Demand management for Commissioners
                                                                                                                                         – wider criteria
              The financial crisis
                                                                                                                                                 Key components of demand
              The policy backdrop                                                                                                                management
              What commissioners/providers need to know                                                                                          Elective care
              Better Care Better Value indicators                                                                                                 Preventing admissions of dubious effectiveness
                                                                                                                                                  Reducing general elective hospitalisation rates
              Demand management dashboards                                                                                                       Outpatients
              Consequence / What if Modelling                                                                                                     Reducing admitted care conversion rates
                                                                                                                                                  Reducing new outpatient referral rates
              Reviewing the recent evidence                                                                                                       Reducing follow up rates

                                                                                                                                                 Non elective care
                                                                                                                                                  Reducing general non elective hospitalisation rates
                                                                                                                                                  Reducing preventable admissions for key target group patients




                                                                                                                                        The Demand Management Dashboard




                                                                                                                                                   SHA – level view
This workshop covers the following:                             What does a commissioner need to know?

  The financial crisis                                            Where can demand be safely reduced so that outcomes
  The policy backdrop                                             become no worse? Benchmarking and clinical/public engagement
  What commissioners/providers need to know                       Where are the “low hanging fruit”? Benchmarking and clinical/public
                                                                  engagement
  Better Care Better Value indicators
                                                                  Do we need to incentivise providers to provide what we
  Demand management dashboards                                    want? CQUIN and policy directives
  Consequence / What if Modelling                                 Can we promote new cost-effective care pathways?
  Reviewing the recent evidence                                   CQUIN and policy directives

                                                                  What are the consequences of strategic shift (moving
                                                                  care from secondary to primary care settings)? Consequence
                                                                  / what if modelling




Consequence / what if modelling – Commissioner
                                                                What does a provider need to know?
Agenda

  Which services need stimulus for change?                        How will PCT purchasing power impact my trust?
                                                                  Consequence modelling
  What is the predicted effect on secondary care budgets?
                                                                  Which services are most at risk? Consequence modelling
  What is the predicted impact on secondary care
  infrastructure?                                                 Can we reduce our own cost base in response to falling
                                                                  demand? Consequence modelling
  What is the predicted effect on secondary services
  viability?                                                      Can we expand our services as a result of market re-
                                                                  shaping? Consequence modelling
  What are the likely impacts on primary care/private care/
  social care/ other sectors?                                     Should we consider vertical integration of some
                                                                  services? Consequence modelling
  Can these sectors cope or do they need additional
  support?




                                                              Evidence based Income at Risk Algorithms
Consequence / what if modelling – Provider
Agenda

  Which services are at risk?
  Where is this risk originating?
  What is the predicted effect on income?
  What is the predicted impact on cost base?
  What is the predicted effect on service viability?
  Are there opportunities for vertical integration?
Evidence based Cost Base improvement from risk                                               Theme‐sub theme‐indicator
                                                                    Key Reporting            Budget improvement classification
                                                                                             Attribution
                                                                    fields for               Next best alternative
                                                                                             PCT
                                                                    consequence              Spells avoided
                                                                                             Bed days or bed days equivalent of spells avoided
                                                                    modelling                Units redirected admissions APC
                                                                                             Units redirected ‐ day case
                                                                                             Units redirected first OP
                                                                                             Units redirected ‐ susequent OP
                                                                                             Units redirected ‐ primary care
                                                                                             Units redirected ‐ other
                                                                                             Tariff of Units redirected ‐ day case
                                                                                             Tariff of Units redirected first OP
                                                                                             Tariff of Units redirected ‐ susequent OP
                                                                                             Tariff of Units redirected ‐ primary care
                                                                                             Tariff of Units redirected ‐ other
                                                                                             Tariff applied per unit redirected
                                                                                             Gross Budget Saving (£s)
                                                                                             Gross Budget impact of next best alternative (£s)
                                                                                             Net Budget impact (£)
                                                                                             Bed day impact of improvement
                                                                                             Bed equivalent impact of improvement
                                                                                             Provider variable cost savings from impact of improvement
                                                                                             Provider fixed cost savings from impact of improvement




  This workshop covers the following:

    The financial crisis
    The policy backdrop
    What commissioners/providers need to know
    Better Care Better Value indicators
    Demand management dashboards
    Consequence / What if Modelling
    Reviewing the recent evidence




                                                                               Emergency admissions are growing at more than
                                                                               twice the rate of previous years




                                                                    Who has been most successful at managing
                                                                    demand?



                                                                                                                                               GP referral
                                                                                                                                                toolkit




                                                                                                                                               Community
                                                                                                                                                Matrons

                                                                           There were only 7 PCTs who had falling levels of admissions overall
                                                                           In all instances, these PCTs had average or above average admission
                                                                           rates when benchmarked against their ONS matched cluster (traffic
                                                                           lights for 08/9). There were no instances where a PCT with relatively
                                                                           low admission rates also exhibited falling rates.
              Elective admissions are growing at similar rates to          Can we learn anything from PCTs with “representative” admission rates
              previous years with one very obvious exception               which have reduced over time?
                                                            Risk stratification techniques

                                                              Stratify – referral management
                                                              system linking secondary and
                                                              primary care data (Redbridge
                                                              PCT)

                                                              Combined Predictive Model
                                                              (Kings Fund/Health Dialog)

                                                              John Hopkins ACGs




Conclusions

 We hope you found this interesting, or more importantly,
 useful!
 Please contact sryder@chks.co.uk if you would like to
 discuss how CHKS can help you with the demand
 management agenda.

				
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Description: Microsoft PowerPoint - Demand Management2