Patient Focused Funding in BC

A Revolution or Just a System Tweak?

Les Vertesi

BCPSQ Forum March 9, 2012

Why Change at All?

• Are you satisfied with the current state of health care in which you work? – Waitlists (20% > a year) – Crowding & Delays in Emergency Departments? – ALC rates near 20% of In-hospital Days – “Quality” is an uphill struggle

– And one more small thing …

2

Ignore This at Your Peril

3

Changing the Game

• A Conversation with Government (2006)

• If you could fix One Thing in Healthcare …? – Will You Pay for it?

– No? Why not?

• What if it were fixed and the bill was …. ?

• What if you only had to pay if it was fixed?

4

A New Game in Town

• Governments are less willing to put money in when they don’t think they are getting Quality – Would YOU be willing to keep paying for something you

are not getting? – Who is best placed to manage the RISK of success or

failure?

• Can government be a “purchaser” and let the Health Authorities be (competitive) providers?

5

Where to Start?

• Fall of 2006: – ED Congestion chosen as Top Priority by Senior Executive

of Cabinet – Unwilling to continue putting out money on faith – But Willing to Pay if it was “Solved”

• i.e. for Success Only

• RESULT: – $16.5M to a P4P formula at 4 Vancouver Hospital

Emergency Departments

6

EDP4P Basics • All Money earned goes to the Hospital

– Believe that best decisions are ones made locally – Sense of “provider ownership” created by control of money – But nobody keeps any money

• EDP4P is not an improvement strategy in itself

– Money must be invested in improvement (QI) processes – Relatively easy improvements can generate confidence & cash to

fund more difficult changes

• Hospitals are free to invest as they see fit, but must report how money has been used

7

What P4P is NOT

• It is NOT a way to make People work Faster – It is a Way of making them Pay Attention and re-think

their approach to the Patient Experience • Money is NOT the Incentive

– Improvement is the real incentive

• If Money is “not a reward”, then why is it tied to Performance? • Because it is a Shared RISK strategy

8

Did It Work?

1,000

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No.

of A

dmits

Mee

ting

Targ

ets

No.

of C

TAS

Pts

Mee

ting

Targ

ets

First Year of EDP4P

Numbers of Pts Meeting Targets All VCH Hospitals

# Non-adm CTAS 1-2-3

# Admitted

9

Did It Really Work?

40%

45%

50%

55%

60%

65%

70%

First Year of EDP4P

Percentages Meeting Transition Time Targets (All VCH Hospitals)

Pct of CTAS 1-2-3

Pct of Admissions

10

Later Things Became More Difficult

40%

45%

50%

55%

60%

65%

70%

First 30 Months of EDP4P

Percentages Meeting Transition Time Targets (All VCH Hospitals)

Pct of CTAS 1-2-3

Pct of Admissions

11

One of the Reasons Why

0.90

0.95

1.00

1.05

1.10

1.15

1.20

Pct C

hang

e fr

om B

ase

First 30 Months of EDP4P

Pct Change in Volumes of Visits & Admissions All VCHA Hospitals

% Change in Visit Volume

% Change in Admissions

12

13

EDP4P Experience at Lion’s Gate

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0%

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20%

30%

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90%

Fiscal Period

Number and Percentage of Admitted Patients Waiting in Emergency Department for < 10 hours

(Lion Gate Hospital, April 2007 - March 2010)

% of Patients

# Patients

BEFORE PFF

ACCESS to Care at LGH Did Improve • Reduced length of stay (by 20%) • ALC dropped from 11% to 4% • Reduced occupancy levels (to 96%) • Shortened wait times in ED (38% to 65% within target)

BUT … • More patients arrived to ED & required admission • More transfers from other hospitals since beds now available • Lower cost ALC days were reduced • Average Cost per patient day increased

The budget went from breakeven to $4M deficit!

14

The Fixed Budget PUNISHED Quality

Why?

Because Patient Care Costs Money … and Money Comes in Boxes

Things Work Best When the Money & the Patients are in the Same Place

15

The Message about Quality

• For Quality to be Sustainable, Patients & Money have to be Matched

• It is Hard to Move Patients, but Easy to Move Money

• Activity Based Funding is NOT necessarily a stimulus

• It is a way of Making Sure Money can move to Support Care Where it is Most Needed

16

So What are We Actually Doing in BC? Patient Focused Funding is an Umbrella Term

Activity Based

Funding

Procedural Care

(Bulk Purchasing)

Community Initiatives

Pay for Performance

Quality Improvement

Common Theme: Funding Follows Patients not the Facilities

17

Supporting a Continuum of Care

Home/Community Home Support decreases need for Residential Care

ED P4P Improved Emergency Department Access & Flow

ALC decrease

ED Admissions ABF supports ED Admit Transfers to Wards

ABF lowers LOS & enables shift to Day Procedures Inpatient Flow

ABF funding eases discharge & lowers ALC population

18

19

Mythbuster Myth:

Activity Based Funding drives increased volume

Truth:

ABF provides incentive to care for the sickest patients in acute care, and others in same day or community care

It is up to US!

Slide Courtesy of Duncan Campbell Chief Financial Officer

Vancouver Coastal Health Authority

From Theory to Reality

The Vancouver Coastal Health Experience with Patient Focused Funding

20

Vancouver Coastal Health Patient Focused Funding

What Have We Achieved and Where Will It Take Us

Quality Forum Darcia Pope, Executive Director, Transformation

March 9, 2012

22

Vancouver Coastal Health Strategic Framework Lens People First

Vision We will be leaders in promoting wellness and ensuring care by focusing on quality and innovation.

Mission We are committed to supporting healthy lives in healthy communities with our partners through care, education and research.

Values Service Integrity Sustainability

Drivers Patient/Community Focus Engaged Team Operational Excellence Financial Sustainability

Goa

ls

Obj

ectiv

es

Provide the best quality of care.

Promote better health for our communities.

Optimize our workforce and prepare for the

future.

Use our resources efficiently to sustain a viable health care system.

Use a standardized, rigorous process to accelerate the creation and broad use of evidenced-based protocols in all clinical areas and programs.

Develop a regional program for Mental Health and Addiction and Cardiac Sciences to improve quality of care.

Build a regional medication reconciliation system across the continuum.

Reduce health inequities in the populations we serve through focused improvements in core public health programs. Build on VCH integration strategies to support implementation of the MoHS directive to deliver integrated primary care, home and community care and community mental health services.

Enhance workforce utilization and match staffing to clinical volumes and patient acuity. Recruit and retain the best people by fostering a culture of excellence, recognition and respect. Build organizational capacity by strengthening leadership and management competencies.

Embed LEAN thinking at all levels to fulfill objectives and to deliver quality outcomes. Develop and implement best practices in care management to reduce unnecessary days of stay. Deliver administrative and support efficiencies through the shared services organization and consolidation.

Respond to provincial patient-centered funding model.

Develop service

agreements with funders and service providers.

Develop and

implement a strategy to secure increased capital funding.

Continue our

commitment to “Green Care” alternatives by reducing waste and our carbon footprint.

Respond to provincial patient-centered funding model. Develop service agreements with funders and service providers. Develop and implement a strategy to secure increased capital funding.

Continue our commitment to “Green Care” alternatives by reducing waste and our carbon footprint.

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Drivers Engaged Team Patient/Community Focus

Optimize our workforce and prepare for the

future.

Provide the best quality of care.

Promote better health for our communities.

Use our resources efficiently to sustain a viable health care system.

Operational Excellence Financial Sustainability

23

A Systems View

• Treat people in the most appropriate care location • Deliver the highest quality of care • Ensure effective use of resources • Emphasize scalability of services

Home Care

Home ED Home

Residential

Acute

Community

24

Examples of Pay for Performance at VCH

1. P4P in the Emergency Department 2. Activity Based Funding in Acute Care 3. Procedural Care 4. National Surgical Quality Improvement Program

(NSQIP) Implementation 5. Community Initiatives

25

Treat People Effectively in the ED

Treat people effectively in the ED (ED P4P) • Improve access to care, including reducing wait times • Improve quality of care • Increase efficiencies • Maintain existing new initiatives and reward further improvement

Home Care

Home ED Home

Residential

Acute

Community

26

VCH - Success with ED P4P

Three separate streams of patients with independent targets to reduce wait times and improve access: 1. Admitted Patients (to an inpatient bed within 10 hours)

2. Not admitted patients, High Priority (discharged within 4 hours)

3. Not admitted patients, Low Priority (discharged within 2 hours)

Additional 36,000 patients treated within target wait time in 2010/12

27

ED Admits Volumes vs Admit EDLOS

In P5 admitted 1480 patients with an average EDLOS of 9.2 hours.

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dmitt

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nts)

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Adm

issio

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Fiscal Period

VGH ED Admits Volumes vs Admit EDLOS(Fiscal Yr 04/05 to 11/12 YTD)

ED Admits Volumes Admit EDLOS (avg hrs)

28

Optimize Acute Care Services

Optimize Acute Care Services • Activity Based Funding – RIW based funding provides

incentive to care for the sickest patients and shift inpatient surgery to daycare

• Procedural Care Program – Reduce wait times • NSQIP Implementation – improve the quality of surgical care

Home Care

Home ED Home

Residential

Acute

Community

28

29

Activity vs. Gobal Funding for Acute Care

• The shift from global funding to activity based funding has helped VCH to achieve desired performance, behaviour change and transformation of systems across acute, community and primary care service

• Goal: To move acute care to outpatient services To decrease length of stay

30

Activity Based Funding at VCH

• The ABF model for inpatient and same day procedures provides a tool for VCH to focus on service level changes and reallocate resources accordingly

• The marginal funding rate fosters the requirement for efficiency and cost management

• VCH continues to work with physicians and Health Records to improve quality and timeliness to ensure funding reflects acuity levels accurately

• The ED P4P earnings + RIW earnings equals the cost of opening extra beds

31

Procedural Care Program

• The Procedural Care Program was established to reduce the wait times for patients waiting the longest for care:

• “Top 10” Day Surgeries • VCH Selected Procedures with High Wait Times • Surgical and Medical Procedures Mainly Performed in

Procedure Rooms • Magnetic Resonance Imaging (MRI) Exams

32

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-03

Month End

Top 10 Day Surgery - Average Wait Time (Weeks) for Cases Waiting

Contracted Cases at Contracted Facilities

IHA

FHA

VCHA

VIHA

BC

33

33

MRI Wait Times

0

2

4

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0

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1,000

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09 P

109

P4

09 P

709

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1310

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10 P

610

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10 P

1211

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11 P

511

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11 P

1112

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12 P

412

P7

12 P

10

Aver

age

Wai

t Ti

me

(Mon

ths)

MRI

Vol

ume

Year Fiscal Period

VCH MRI Volumes and Average Wait Time

Total MRI

Average Wait Time

LMIIF6,456 Exams

HSPOAnnualized total

6,304 Exams

33

34

NSQIP Program

• Thesis: improve overall surgical outcomes by joining the American College of Surgeons’ National Surgical Quality Improvement Project

• In October of 2002, the U.S. Institute of Medicine named NSQIP the “best in the nation” for measuring and reporting surgical quality and outcomes

• Data can be used to help: – increase patient satisfaction – reduce the median length of stay – reduce postoperative mortality rates

35

Overall* 30-Day Morbidity

* Includes General and Vascular Surgery Cases

Observed rate: 17.69% Expected Rate: 10.46% O/E Ratio: 1.69 Status: Needs Improvement

Before

36

Overall* 30-Day Morbidity

* Includes General and Vascular Surgery Cases

Observed Rate: 11.88%Expected Rate: 10.88%O/E Ratio: 1.09Status: As Expected

2010 Report

After

37

Invest in Community, Home Support and Primary Care

Home Care

Invest in Community and Home Support • Reduce ED visits • Reduce length of stay • Reduce ALC • Reduce Acute and Residential Care Admissions • Reduce Readmissions

Home Home

Residential

Acute

Community

ED

38

Avoidance of Unnecessary Residential Care and Acute Admissions (AURAA)

• A comprehensive set of community-based services designed to provide proactive care to prevent exacerbation of known complex disease

• Will prevent avoidable ED, Acute and Residential Care admissions and reduce LOS amongst the population at highest risk, while improving overall health status at home

• Targets: – Decrease RC use by 6 months per client

– Reduction in ALC days by 30% per client continued…

39

Avoidance of Unnecessary Residential Care and Acute Admissions (AURAA)

• 118 patients enrolled across 6 communities in VCH – All 118 patients were waitlisted or eligible for residential care – Over 90% of these patients are still in the community and have

not had to be admitted to residential care

• Patients waiting @ home have – declined RC bed when available – Shown marked functional and mental improvement

• Collaboration between acute and community has evolved

– Partnering in care planning across patient journey – Issue tracking promotes continuous learning

• Culture shift in clients expectations for RC placements

40

0

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400

600

800

1000

1200

1400

08/09 09/10 10/11 11/12

# of RC Registrations (Total) by Fiscal Year (P11 YTD)

Vancouver

# of RC Registrations (P11 YTD) Average 08/09 to 10/11 (P11 YTD)

41

PFF can Lead to Better, Earlier Discharges: AURAA

41

VCH-RichmondAverage # of ALC Clients

40 39 38 38

35

27

19 18

2123

2725 24 25

20 20 20 20 20 20 20 20 20 20 20 20 20 20

0

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11-11 11-12 11-13 12-01 12-02 12-03 12-04 12-05 12-06 12-07 12-08 12-09 12-10 12-11

Period

Clie

nts

Clients Target

Source: VCH Decision Support Prepared by: Ana Himani, Business Analyst

P2: Start of Home First Initiative

42

Total Residential Care Placements by Period

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14

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18 18

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25

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13

1011

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1211

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Period

# of

Pla

cem

ents

Acute to Facility Community Community Emergency

Source : Priority Access Prepared by Ana Himani, Business Analyst

43 You can lead a horse to water but can

you make it drink? 43

44

Embracing PFF at VCH to Provide Better Patient Care

Educate and Inform Managers on Funding Model

Education

Provide real time information for decision making and analysis of scenarios

Real Time Information

Provide day to day business and financial support to clinical operations

Business Support

Ensure revenue flows to the clinical area where service is delivered

Revenue

Educate Front-Line Managers and Directors

Baseline

Volume

Baseline Baseline workload expressed

in both case volume and RIW No gain in ABF revenue until

workload is above baseline Loss in revenue if workload

is below baseline

Activity Based Funding (ABF) Funding mechanism for

acute and same day care cases with some exceptions Funding unit is Resource

Intensity Weight (RIW)

Case

Case

Daycare $3,800 / RIW Max RIW is 10% above

baseline

Inpatient $1,520 / RIW Max RIW is 3% above

baseline

Case

Case

ABF Volume (RIW)

45

46

Utilizing Emendo Cap Plan to Forecast Patient Volume and ABF Revenue

How VCH is utilizing the tool: • Includes 3 years of history and current activity to forecast demand and trends • Shift from producing a manual retrospective report to look at ABF revenue to

forecasting ABF revenue and analyzing “what if” scenarios • Determine impact on capacity and strive to exceed projected discharge targets to

create capacity • Develop a plan and budget and project revenue stream • Establish baseline, input RIWs and see how volumes have increased or decreased Objectives of Cap Plan Forecasting Tool at VCH: • Optimize the match between staffing and clinical volumes • Optimize productive hours per patient day and reduce overtime by planning for

fluctuations in demand • Exceed Discharge targets to create capacity for incoming volumes • Predict ABF Revenue

47

Provide Strategic Direction, Information and Business Support

Clinical Operations

Infrastructure and Business Support to Enable Clinical Operations

Transformation Team Strategy, Project Management, Project Coordination, Education, Communication

Decision Support Reporting Tools and Evaluation

Financial Planning Business and analytical support, reporting on progress to targets, expenses, revenues and volumes

48

In Conclusion – Key Factors for Success 1. Don’t chase money – funding needs to enable behaviour change to

support the right clinical actions

2. Not one time money- at VCH approach here to stay and grow

3. Accountability is key

4. Pay acute operations based on RIW funding – earnings drives understanding

5. Need to resource real -time information and analytics

6. Revenue and cash flow received must flow to operations monthly

7. Coding accuracy and timing is key – need to compute RIW internally

8. Must incentivize patient flow across the continuum of care – cannot concentrate on a single area in a bigger system.

9. Part of the strategic direction

49

Questions?

50

Appendices

51

Patient Focused Funding Period 7 YTD Earnings Summary for VCH

($ million) Procedural Care

Program Community Programs²

ED P4P funded by HSPO (New Floor)

ABF Payable

Total HSPO Funding

Vancouver 0.717 0.354 2.560 $ 2.13 $ 5.761 PHC 1.305 1.625 $ (0.67) $ 2.260 Coastal 1.352 0.114 0.912 $ 1.01 $ 3.388 Richmond 0.750 0.084 0.728 $ 1.63 $ 3.192 MRI (P6 YTD) 1.221 $ 1.221 Regional 0.005 $ 0.005 NSQIP¹ 0.996 $ 0.996

Less: MoH expected growth (unallocated) $ (0.82)

$ (0.82)

Total VCH $ 6.341 $ 0.557 $ 5.825 $ 3.28 $ 16.003 Annual contract $ 14.630 $ 11.560 ¹NSQIP - National Surgical Quality Improvement Program ²Community Programs (incl. start up funds)

52

VCH – Period 7 YTD ABF $ Change from 2011/12 Baseline

ABF Facilities (Included Procedures)

52

($ million)

2011/12

Change from 11/12 baseline 2011/12

Change from 11/12 baseline 2011/12

Change from 11/12 baseline

2011/12 Annual

Notional ABF

Allocation ABF

Payable

VGH/UBC 10.33$ (0.13)$ 45.31$ 2.26$ 55.64$ 2.13$ -$ 2.13$

PHC 8.40$ 0.36$ 26.59$ (1.03)$ 34.99$ (0.67)$ -$ (0.67)$

LGH 4.36$ 0.07$ 13.67$ 0.92$ 18.04$ 0.98$ -$ 0.98$

Squamish 0.56$ 0.03$ n/a n/a 0.56$ 0.03$ -$ 0.03$

RH 2.58$ 0.29$ 10.10$ 1.35$ 12.68$ 1.63$ -$ 1.63$

(0.18)$ (0.65)$ -$ (0.82)$ (0.82)$

Grand Total 26.23$ 0.44$ 95.67$ 2.85$ 121.91$ 3.29$ 10.10$ 3.29$

Notes:- Procedural Care Program RIWs excluded- Unused funds in one HA can be earned by another HA subject to HSPO approval and up to the totalmaximum earnings available for all HAs.

Same Day ABF $ Inpatient ABF $ Total ABF $

Less: MOH expected growth (unallocated)

53

VCH PFF Community Projects • Avoidance of Unnecessary Residential Care and Acute

Admissions (AURAA)

• Early Supported Discharge – Chronic Disease

• ED Adverse Drug Events Screening

• Home Based Treatment for Mental Health and Addiction

• Supporting Transition of Seniors from Emergency