Measuring and fundingRehabilitation care

in NSWAssociate Professor Friedbert Kohler, Conjoint Associate

Professor UNSW,Director of Rehabilitation Medicine, Sydney South West Area

Health Service Co Chair ICF subcommittee ISPRM

Chair: Braeside Liverpool Fairfield Rehabilitation Research Group

Outline of presentationModels of Rehabilitation Care in NSWClassification system Funding modelMeasurement in rehabilitation servicesDevelopments

Models of Rehabilitation Care in NSW

In reach to acute Early rehabilitation by an MDT in the acute care setting

Subacute inpatient Collocated or stand alone

Ambulatory Care/ day hospital

Comprehensive MDT rehab programme in an outpatient setting

Ambulatory Care/outpatients

Discipline specific therapy provided in an outpatient setting

Ambulatory Care/ Home basedOutreach “Hub” and “spoke” model

Classifications available

In reach to acute No classification

Subacute inpatient AN-SNAP v2

Ambulatory Care/ day hospital

AN-SNAP v2 poorly validated

Ambulatory Care/outpatients

AN-SNAP v2 poorly validated

Ambulatory Care/ Home based

No classification

Outreach No classification

Measurement tools

In reach to acute Therapy specific assessments, sometimes condition specific assessments and rehabilitation medical assessments

Subacute inpatient FIM and discipline specific assessments

Ambulatory Care/ day hospital

FIM/Lawton

Ambulatory Care/outpatients

Lawton

Ambulatory Care/ Home based

Possibly FIM /Lawton

Outreach

Do we need a sub acute classification/funding

system? Differential cost bases:

acute episodes • Treatment focus: disease • principal diagnosis/procedure

subacute episodes• Treatment focus: Function or consequences of disease:

participation/activity limitation, environmental manipulation symptom control behavioral control

• Principal medical diagnosis is not adequate in explaining the need/cost of services

The AN-SNAP Casemix Classification

Australian National Subacute / Nonacute patient Casemix Classification for sub and non-acute care in

• overnight and • ambulatory settings.

Developed in 1997 Involved over 100 hospitals

in all States/Territories public and private sectors.

Revised 2007

Important Data For Rehabilitation Case type

Impairment Code: Stroke/amputation/etc

Admission FIM Score Age

AN SNAP Classification Version 2

Overnight Rehabilitation Branch

Assessment onlyClass 201

2 classesClasses 202 (Brain, neuro,

spine) and 203

FIM Motor =13

Classes 204 - 245

most of which are split onFIM Motor,

FIM Cognitionand Age

10 major impairmentgroups

FIM Motor >13

Overnight Rehabilitation

Stroke Impairment Classes2204 FIM motor 63-91, FIM cognition 20-35

2205 FIM motor 63-91, FIM cognition 5-19

2206 FIM motor 47-62, FIM cognition 16-35

2207 FIM motor 47-62, FIM cognition 5-15

2208 FIM motor 14-46, age>=75

2209 FIM motor 14-46, age<=74

Funding model: Blended Payment Model

• A mixed model: Blended payment modelPer episode, with outlier funding

The LOS of the patient will determine if they are:1.Short Stay Outlier or..

– Outlier per diem payment for each day of care2.Inlier or..

• Inlier per diem payment for each day of care• Plus episode payment

3.Long Stay Outlier• Inlier per diem payment up to high trim point• Plus episode payment• Plus outlier per diem payment for each day after the high trim

point

Why blended funding? ALOS longer than acute care episodes - 4 vs

19 days - risks are higher The concept of ‘swings and roundabouts’ that

underpins most DRG (episode) funding models doesn’t work with small volumes -risks are higher

Majority of costs are staff ie “fixed costs”

Class 202

$0

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

$70,000

$80,000

$90,000

$100,000

1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70 73 76 79 82 85 88

LOS

BPM Episode per Diem

Some Limitations of AN-SNAPResources for data collection Accuracy of cost and relative cost weightsDegree of explanation of variance of cost Accuracy of classification and FIM Effects of introduction of ABF Limited classification which does not

include all models of care

Explanation of variance of Cost

47.29% of variance of cost in overnight episode

31.3% FIM FRG AN DRG 31.4% of medical overnight

admissions 50.83 if surgical and same day cases included

Explanation of LOS/Functional Improvement:

Stroke: LOS

• 33.4% SNAP; • 38.9 motor admission FIM

Functional improvement• 32.3 SNAP• 37.4 motor admission FIM

Orthopaedics LOS

• 25.2% SNAP; • 27.9 motor admission FIM

Functional improvement• 38.2 SNAP• 47.4 motor admission FIM

Functional Independence Measure (FIM)

Used to assess performance during tasks that can be broadly categorized as activities of daily living, mobility and cognition

A total of 18 items 13 motor items 5 cognitive items Score ranging from 1 (complete dependence) to 7

(complete independence) Minimum score 18 to maximum score of 126

Lawton Activity Index

Instrumental activity of daily living index Ability to use Phone Shopping Food preparation House keeping Laundry Mode of transportation Responsibility for own medications Ability to handle finances

Some potential issues with measures

Individual scales with floor and ceiling effects

Tendency for “silo” effect Psychometric propertiesCultural applicability

Alternatives

Possibilities of broader scales/classification which can be used across the various settings of the model of care.

The ICF may be useful for this: Large number of potential items can pick items to

minimize floor and ceiling effects in the scale. Inbuilt qualifiers Internationally accepted Non commercial

ADL activity ICF Code Kappa Agreement

Eating d550 0.765 Substantial

Drinking d560 1.0 Perfect

Caring for body parts d520 0.773 Substantial

Washing oneself d510 0.693 Substantial

Dressing d540 0.724 Substantial

Toileting d530 0.647 Substantial

Urination functions b620 0.319 Fair

Defecation functions b525 0.562 Moderate

Change basic body position d410 0.621 Substantial

Walking short distances d4500 0.624 Substantial

Moving around using equipment d465 0.555 Moderate

Climbing d4551 0.847 Near perfect

Receiving spoken messages d310 0.194 Slight

Speaking d330 0.352 Fair

Basic personal Interactions d710 0.498 Moderate

Solving Problems d175 0.423 Moderate

Memory functions b144 0.483 Moderate

FIM ItemInterrater

KappaInterrater Agreement

Chart/clinician comparison

ICF interrater agreement

Eating 0.577 Moderate Near perfect Substantial/Perfect

Grooming 0.758 Substantial Substantial Substantial

Bathing 0.669 Substantial Substantial Substantial

Dressing Upper Body 0.769 Substantial Substantial Substantial

Dressing Lower Body 0.742 Substantial Substantial Substantial

Toileting 0.701 Substantial Moderate Substantial

Bladder management 0.479 Moderate Slight Fair

Bowel Management 0.303 Fair Slight Moderate

Transfer Bed/Chair/WC 0.613 Substantial Fair Substantial

Transfer toilet 0.519 Moderate Moderate

Transfer bath/shower 0.665 Moderate Moderate

Walking 0.615 Substantial Substantial Substantial/Moderate

Stairs 0.584 Moderate Fair Near perfect

Comprehension 0.311 Fair Slight Slight

Expression 0.247 Fair Slight Fair

Social Interaction -0.029 Chance Chance Moderate

Solving Problems 0.231 Chance Slight Moderate

Memory functions 0.208 Slight Chance Moderate

ADL activityICF Code

Admission Median

Discharge Median

Significance on Wilcoxon Signed Rank

test

Eating d550 0 0 <0.01

Drinking d560 0 0 <0.01

Caring for body parts d520 1 0 <0.01

Washing oneself d510 1 1 <0.01

Dressing d540 1 0 <0.01

Toileting d530 1 0 <0.01

Urination functions b620 0 0 0.019

Defecation functions b525 0 0 0.025

Change basic body position d410 1 0 <0.01

Walking short distances d4500 1 0 <0.01

Moving around using equipment d465 10

<0.01

Climbing d4551 1 1 <0.01

Receiving spoken messages d310 0 0 0.317

Speaking d330 0 0 0.102

Basic personal Interactions d710 0 0 0.957

Solving Problems d175 0 0 0.573

Memory functions b144 0 0 0.931

Median ICF qualifier scores at pre-amputation, one week post amputation,discharge and three months follow-up (* indicates less than 15 valid scores)

ICF code pre-amputation post-amputation discharge follow-up

(n=20) (n=20) (n=18) (n=17)

b130 Energy and drive functions 0 2 1 1b144 Memory functions 0 0 0 0b164 Higher-level cognitive functions 0 0 0 0b28015 Pain in lower limb 2 2 1 1b810 Protective functions of the skin 0 2 1.5 0 d230 Carrying out daily routine 0 4 2 1d410 Changing basic body position 0 3 1.5 2d415 Maintaining a body position 0 2.5 1 2d420 Transferring oneself 0 3.5 1 0d4500 Walking short distances 0 4 1 1d4501 Walking long distances 3 4 4 4d4502 Walking on different surfaces 0.5 4 4 4d4551 Climbing (such as climbing steps) 1 4 4 2d4601 Moving in buildings other than home 2 4 * 3d4602 Moving outside the home and other buildings 0 * * 3d465 Moving around using equipment * * 2 2d470 Using transportation 0 * * 4d510 Washing oneself 0 3 1.5 0d520 Caring for body parts 0 1.5 1 0d530 Toileting 0 3 1 0d540 Dressing 0 2.5 1 0d920 Recreation and leisure 2 0 * *e1151 Assistive products and technology * * * +2

for personal use in daily livinge1201 Assistive products and technology for * * +2 +2

personal indoor & outdoor mobility & transportatione310 Immediate family (support ) 0 0 0 +1

ICF Code

Description Pre-amputation

(n=20)

Post-amputation

(n=20)

Discharge(n=18)

Follow-up(n=17)

d4500 Walking short distances 0 4 1 1

d4602 Moving outside the home and other buildings

0 * * 3

d4502 Walking on different surfaces 0.5 4 4 4

d4601 Moving in buildings other than home

2 4 * 3

d4501 Walking long distances 3 4 4 4

Thank You