Rehabilitation Activity Based Funding and Activity Based ... · Rehabilitation Activity Based...

Rehabilitation

Activity Based Funding and

Activity Based Management

ACI- Rehabilitation Network July 2014

Sharon Smith- Manager of Sub Acute

and Mental Health Workstreams

Aim

For participants to understand how ABF

principles apply to rehabilitation care

For participants to understand how ABM can

assist in managing services in an ABF

environment

Where we are: How is rehab being funded in NSW?

What is likely to happen in the future?

What has changed?

Purchasing Principles

$

Beds

G&S

Staff

Traditional approaches to funding health care

involve providing $ for inputs for example:

ABF Purchasing Principles

ED

Acute

SNAP

• Funding now linked to outputs or activity

NAP

$

• LHD determines the

inputs

• Activity is measured

(counted) in National

Weighted Activity

Units (NWAU)

The ABF Formula

A method by which health services are funded for what they do, not who they are (output funding instead of input)

Price

Price

weight

(NWAU)

Volume

Funding Under ABF =

NSW ABF – The main components

Agreed Target Level of activity or services

Weight Activity – relative resource intensity of

treatment for patients.

State price at which each activity will be paid

Transition payments to keep the system safe and

operating

Price

$4,583

Price

weight

(NWAU)

Volume

Activity targets

Target Setting

Negotiation between MoH and

LHD’s regarding the level of activity

to be “purchased” in the upcoming

year

Targets set by “stream” i.e. Acute,

ED, SNAP, NAP, Mental Health

Targets set at LHD level

Targets set in NWAU

Targets based on historical activity

(trends) and any agreed variations-

growth,

capacity changes,

model of care changes

Targets for 14/15 based on activity in

10/11, 11/12, 12/13 and first 6

months of 13/14

Target Setting

Schedule C Part 1

A B C D E F* G H I

NSW

Target

Volume

(NWAU13)

Volume(Admissions

& Attendances)

Indicative

only

State

Price per

NWAU13

Projected

Average

Cost per

NWAU13

Initial Budget

2013/14

($ '000)

2012/13

Annualised

Budget ($ '000) #

Variance

Initial

Budget and

Annualised

($ '000)

Variance

(%)

Volume

Forecast

2012/13

(NWAU13)

Acute 834,728 861,372 $3,883,936 $3,718,027 $165,909 4.5% 816,159 Incl. Provision for additional Acute, PICU, NICU & ICU capacity

ED 152,374 1,309,595 $709,201 $652,728 $56,473 8.7% 148,996

Non Admitted Patients (Outpatient Services)^ 218,119 4,521,254 $770,583 $742,411 $28,172 3.8% 215,018

A Total 1,205,221 6,692,221 $5,363,720 $5,113,166 $250,554 4.9% 1,180,173

Sub-Acute Services - Admitted 67,807 35,015 $315,582 $265,792 $49,790 18.7% 64,335 Incl. Provision for Palliative Care Services & additional Subacute capacity (Schedule D)

Sub-Acute Services - Non Admitted^ 20,485 503,852 $77,932 $75,083 $2,849 3.8% 20,349

B Total 88,291 538,867 $393,514 $340,874 $52,640 15.4% 84,684

Mental Health - ABF Hospitals 89,600 161,951 4,671$ 4,836 $417,244 $391,952 $25,292 6.5% 85,864 Incl. Provision for additional MH Acute & Subacute capacity (Schedule D)

Mental Health - Block Funded Hospitals $11,539 $11,322 $217 1.9%

Mental Health - Non Admitted (Block) $254,415 $249,633 $4,782 1.9%

Mental Health - Transition Grant $50,900 $49,944 $957 1.9%

C Total 89,600 161,951 $734,097 $702,850 $31,247 4.4% 85,864

Block Funding Allocation

Block Funded Hospitals (Small Hospitals) $572,872 $562,104 $10,768 1.9%

Block Funded Services In-Scope

- Teaching, Training and Research $205,645 $201,780 $3,865 1.9%

- Other Non Admitted Patient Services $104,715 $102,747 $1,968 1.9%

D Total $883,232 $866,631 $16,601 1.9%

State Only Block Funded Services

E Total $948,001 $930,182 $17,819 1.9%

F Transition Grant (excluding Mental Health) $203,576 $199,749 $3,826 1.9%

G Gross-Up (Private Patient Service Adjustments) $219,769 $215,638 $4,131 1.9%

Provision for Specific Initiatives (not included above)

Operating Costs of Radiotherapy $6,362

Nurses - Additional CNS $6,218

H Total $12,580 $12,580

I SP&T Expenses $121,839 $121,839 $

J Depreciation (General Funds only) $298,035 $298,035 $

K Total Expenses (K=A+B+C+D+E+F+G+H+I+J) $9,178,362 $8,788,964 $389,397 4.4%

L Other - Gain/Loss on disposal of assets etc $7,022 $7,022 $

M LHD Revenue -$8,938,723 -$8,808,605 -$130,118

N Net Result (N=K+L+M) $246,660 -$12,619

Sch

edu

le C

Par

t 1

xxx LHD - Budget 2013/142013/14 BUDGET Comparative Data

4,671$ 4,836$

Weighted activity step 1-

Classification

Classifications used in ABF

Activity is grouped using classifications

– Clinically meaningful

– Resource use homogenous

Acute admitted – Separations (AR-DRG)

Emergency department – Presentations

(URG/UDG)

Non-admitted – Service Events (Tier 2)

Sub and non-acute – Episodes / Phases

(AN-SNAP)

AN-SNAP

Rehabilitation

Impairment

FIM

Age

Palliative Care

Phase

RUG

Age

GEM

FIM

Age

Maintenance

Maintenance Type

RUG

Psychogeriatric

HoNOS

NWAU Example: Stroke

Class Description

3204 Stroke, motor 63-91, cognition 20-35




3208 Stroke, motor 14-46, age >=75

3209 Stroke, motor 14-46, age <=74

Weighted Activity Step 1-

calculate NWAU

What is an NWAU

(National Weighted Activity Unit)?

Ave=1 NWAU

DRG A01Z

Insertion of Ventricular

Assist Device (VAD)

= 68.5150 NWAU

Tier 2:

20.22 Cardiology = 0.0652

NWAU

The NWAU is the ‘currency’ used to express the price

weights for all services funded on an activity basis.

Adjustments for: paediatrics 196%, regionality (7-21%),

Indigenous patients (17%) , private patients (varies by

care type)

NWAU

NWAU are determined annually

based on the patient level costing

data submitted to IHPA

The better the cost data the more

accurate the NWAU

NWAU Calculation Rehabilitation

NWAU Calculation for Rehab is a

combination of class and LOS

NWAU Calculation Rehabilitation:

LOS

Lower Bound Upper Bound

Short Stay outliers

Inlier Inlier

Long Stay Outliers

NWAU Example: Stroke

Class Description ALOS Lower

Bound

Upper

Bound

3204 Stroke, motor 63-91, cognition 20-35 16 6 29




3208 Stroke, motor 14-46, age >=75 36 16 41

3209 Stroke, motor 14-46, age <=74 48 28 53

NWAU Calculation: AN-SNAP

Short Stay Outlier

LOS x Outlier Per Diem

LOS 6:

6 x 0.2225

Inlier

LOS x Inlier Per Diem

1 Episode Weight

LOS 15:

(15 x 0.1367) + 1.7894

Long Stay Outlier

Inlier Per Diem x Upper

Bound

1 Episode Weight

Outlier Per Diem x No.

days above Upper Bound

LOS: 40

(33 x 0.1367) + (7 x 0.2225) + 1.7894

3-205 Stroke, motor 63-91, cognition 5-19

Lower Bound 8- Upper Bound 33

NWAU Example: Stroke classes 28 day

LOS

Class Description NWAU 14 Funding

3204 Stroke, motor 63-91, cognition 20-35 5.6170 $25,743

3205

Stroke, motor 63-91, cognition 5-19

4.8606 $22,276


3207


5.6411 $25,853

3208 Stroke, motor 14-46, age >=75 5.8391 $26,761

3209 Stroke, motor 14-46, age <=74 7.1353 $32,701

What about activity without a SNAP

class?

NWAU calculated on basis of care

type and LOS

IHPA purchasing framework states no

NWAU for episodes without SNAP data

from 2015/16 onward

NWAU Example: Stroke classes 28 day

LOS

Class Description NWAU 14 Funding


3205


4.8606 $22,276


3207


5.6411 $25,853

3208 Stroke, motor 14-46, age >=75 5.8391 $26,761

3209 Stroke, motor 14-46, age <=74 7.1353 $32,701

NA No SNAP data has been collected 4.3876 $20,108

NWAU Example- Brain Injury

ED

URG 3,

Admitted

Triage 1,

Injury

NWAU

0.4334;

$1,986

SNAP

AN-SNAP

3210

Brain

Dysfunction

FIM Motor

56-91 FIM

Cog 32-35,

LOS 20

NWAU 3.8008

$ 17,419

Acute

DRG B78A

Intracranial

Injury + CSCC

NWAU 2.7283

$ 12,503

Non

Admitted

40.12

Rehabilitation

Allied Health

10 visits

NWAU 0.468

$2,145

Adjustments for: paediatrics, regionality,

aboriginality, private patients

Caretype Definitions

New National Definitions

Rehabilitation Care

Rehabilitation care is care in which the primary clinical

purpose or treatment goal is improvement in the functioning

of a patient with an impairment, activity limitation or

participation restriction due to a health condition. The

patient will be capable of actively participating.

Rehabilitation is always:

Delivered under the management of or informed by a clinician

with specialised expertise in rehabilitation, and

Evidenced by an individualised multidisciplinary management

plan, which is documented in the patient’s medical record

that includes negotiated goals within specified time frames

and formal assessment of functional ability.


Maintenance Care

Maintenance (or non acute) care is care in which the

primary clinical purpose or treatment goal is support for a

patient with impairment, activity limitation or participation

restriction due to a health condition. Following assessment

or treatment the patient does not require further complex

assessment or stabilisation. Patients with a care type of

maintenance care often require care over an indefinite

period.

Includes care provided to a patient, who would normally

not require hospital treatment and would be more

appropriately treated in another setting, which is

unavailable in the short term or where there are factors in

the home environment making it inappropriate to

discharge the patient in the short term.


Geriatric Evaluation and Management (GEM)

Geriatric Evaluation and Management care is care in which the primary clinical

purpose or treatment goal is improvement in the functioning of a patient with multi-

dimensional needs associated with medical conditions related to ageing, such a

tendency to fall, incontinence, reduced mobility and cognitive impairment. The

patient may also have complex psychosocial problems.

Geriatric Evaluation and Management is always:

• delivered under the management of or informed by a clinician with specialised

expertise in geriatric Evaluation and Management, and

• evidenced by an individualised multidisciplinary management plan, which is

documented in the patient’s medical record that covers the physical, psychological,

emotional and social needs of the patient and includes negotiated goals within

indicative time frames and formal assessment of functional ability

National Care Type Change Rules

Only one care type at a time

Care type should reflect the primary clinical purpose of

care currently provided- not intended at some point in

the future

If more there is more than one primary clinical purpose

chose the care type that best describes/reflects care

Independent of location

National Care Type Change Rules

If care is transferred, the care type is assigned by the

receiving clinician

If care is not transferred a change in the clinical purpose of

care must be evident in record

(Linked to $ so assume will be audited)

“Unlikely that more than one change in care type will occur

in a 24 hr period”

“Unlikely that a care type change to/from sub acute will

occur on the day of formal separation/discharge”

NSW Policy also states….

When an acute patient is waiting for Rehabilitation, but Rehabilitation

care has not yet commenced, a care type change to Rehabilitation cannot

occur. The patient must remain in an acute care type until rehabilitation

care begins. In some instances a care type change to maintenance may

be warranted.

If Rehabilitation is occurring on an acute ward, the Rehabilitation care

type should be used, as care type is independent of patient location.

The period of recovery at the end of an acute episode prior to separation

(for example, the final 1-2 days after a joint replacement) is not

necessarily a separate episode and should not trigger a care type change

to rehabilitation. Even though the care has lower resource intensity and

the patient may receive some allied health involvement, unless the

definition of Rehabilitation (as stated above) is met, the care type

remains acute.

A multidisciplinary management plan comprises a series

of documented and agreed initiatives or treatments

(specifying program goals, actions and timeframes)

which have been established through multidisciplinary

consultation and consultation with the patient and/or

carers.

Patients who receive acute same day interventions, such

as dialysis, during the course of a Rehabilitation episode

of care do not change care type. Instead, procedure

codes for the acute same day intervention(s) and an

additional diagnosis (if relevant) should be added to the

record of the Rehabilitation episode of care.

Interventions such as radiotherapy, chemotherapy, and

surgery are considered part of the palliative episode if

they are undertaken specifically to provide symptom

relief.

NSW Policy also states….

NSW SNAP data collection

How we collect Data?

SYNAPTIX

What system will be next?

Known Issues for SYNAPTIX

Psycho geriatrics (fixed)

Same Day activity

No ability to import data

Linking SNAP data to admitted

patient data

SNAP Monthly LHD NWAU

Reports

Began in Sept. 13

Purpose:

To provide a linked patient level data set (APDC and

SNAP) for local analysis

To provide YTD NWAU data for all sub acute activity

To provide feedback regarding key issues such as level

of activity, SNAP data coverage and data errors

Provided to LHD’s by the 10th of each month

Data Sources: Monthly NWAU

Reports

NWAU

Report

HIE

SYNAPTIX

SNAPshot

Summaries

Activity Summary by Episode of Care Type,

LHD total excluding mental health

Episode Care Type No. of Episodes# Occupied Bed Days NWAU13s Ave NWAU13s per Day

2-Rehabilitation 512 6473 1044 0.16

3-Palliative Care 232 1092 194 0.18

4-Maintenance 1081 11584 1524 0.13

7-GEM 869 15529 2412 0.16

8-Psychogeriatri 11 127 26 0.21

Total 2705 34805 5199 0.15

# Including episodes that have not been ended in the reporting period

Provided at a facility

level also

SNAP data collection status

Episodes Occupied Bed Days NWAU13s

Ave NWAU13s per

Day

ABF in

Scope Facility G UG %G G UG %G G UG %G G UG

Y A 72 1232 6.00% 519 9702 5.00% 56 1356 4.00% 0.11 0.14

B 161 211 43.00% 4788 4521 51.00% 719 669 52.00% 0.15 0.15

C . 92 . . 2346 . . 329 . . 0.14

D 374 562 40.00% 7419 5491 57.00% 1214 853 59.00% 0.16 0.16

Sub Total 607 2097 22.00% 12726 22060 37.00% 1989 3207 38.00% 0.16 0.15

N E . 1 . . 19 . . 3 . . 0.18

Sub-total . 1 . . 19 . . 3 . . 0.18

Total 607 2098 22.00% 12726 22079 37.00% 1989 3210 38.00% 0.16 0.15

# Includes episodes that have not ended in the reporting period

Table 4: Activity by AN-SNAP Data Collection Status and Facility

Data Errors

Error Type

Episode

is Acute

in PAS

No Episode

recorded in

PAS

Different

Care Type in

PAS

1 PAS Episode

matches 2 or

more SNAP

Episodes

1 PAS Episode

matched 2 or

more SNAP

Episodes

Start

Date

mismatch

End date

mismatch Total

Facility

A 4 . . . 91 2 3 100

B . 1 11 2 . 48 29 91

C 2 . 29 10 . 60 61 162

Total 6 1 40 12 91 110 93 353

Note: Some episodes/phases may be counted more than once if more than one type of error is recorded

Table 7: Error Episodes / Phases by Facility and Error Type

Ungrouped Activity

Ward Facility

Care Type

Total

Rehabilitation Palliative Care Maintenance GEM

AAA A 6 17 235 81 339

BBB A 123 30 104 30 287

CCC A 17 106 19 142

DDD A 55 18 40 15 128

EEE A 22 1 54 29 106

FFF B 1 66 30 97

GGG A 30 1 40 16 87

HHH D 1 81 82

III B 4 3 14 60 81

JJJ B 2 34 35 4 75

Note “ungrouped cases” sheet now includes

Medical Officer (MO) code

Table 10: Hospital wards that had the largest number of ungrouped

episodes

Ungrouped Activity

Facility Specialty Unit Specialty Name

Care Type

Total

Rehabilitation Palliative Care Maintenance GEM

A GER Medical 34 25 278 132 469

NEU Medical 137 31 112 3 283

ORT Orthopaedic 29 1 74 34 138

RES Medical 34 5 22 7 68

RHU Medical 7 3 36 15 61

REM Renal Dialysis 4 8 42 1 55

B GP Medical 1 66 32 99

GER Medical 2 1 2 66 71

C GP Medical 1 82 83

D GER Medical 1 8 124 93 226

MED Medical 6 91 77 5 179

REH Medical 11 16 6 33

RES Medical 1 8 8 1 18

NEU Medical 2 13 1 16

SUR General Surgery 1 4 9 14

E GP Medical 1 1

Table 11: Specialty units that had the largest number of ungrouped

episodes

Data Monitoring- Would you

expect?

Ungrouped subacute episodes by specialty

Specialty Unit

Episode of Care Type

2-Rehabilitation 3-Palliative Care 4-Maintenance 7-GEM Total

GER 134 . 8 2 144

NEU 31 1 23 . 55

RES 16 15 21 1 53

REH 23 . . . 23

GAS 16 2 26 . 44

PAL . 21 . . 21

HAE 1 43 2 . 46

ACG 107 59 43 67 276

GM 6 1 19 1 27

MDO 6 4 1 . 11

RNL 9 3 3 1 16

GS 29 1 5 . 35

GNC 25 1 19 . 45

OBS 15 1 10 . 26

ED 14 . 1 . 15

ABM

Activity Based Management

ABM

Using information to attain strategic

and operational objectives

Analysis of Variation – Clinical and

Financial

The ABM Portal provides:

Comparisons of activity, costs and prices

for

The ability to benchmark costs and LOS

LHDs

Facilities

ABF

Workstreams

Patients

Eg. ED, acute, non-

admitted

Patient

level costing

LHD/SHN

GL Data

LHD/SHN

Patient

Data

Where does the data come from?

CE

sign off

Submit to

Ministry of

Health

ABM

Portal Updated every 6

months

Maturity in costing practice

No patient level

data available;

Total cost / total

activity;

Cost modelling

Some patient level

data;

All cost centres

point to an

outpatient area;

Total cost / total

activity

Cost modelling

Mostly patient

level data;

All cost centres

point to an

outpatient area;

Service activity

data used to

allocate S&W;

Average cost

allocated to

patients for:

- Pharmacy

- Imaging

- Pathology

- etc.

A combination of

both Level 5 and

Level 3 scenarios

is implemented

Some feeder

system data

Some average

cost allocation

Full patient level

data;

Cost centres are

identified for each

service unit

Duration / charge

data used to

allocate S&W;

Feeder system

data used to

allocate:

- Prosthesis

- Pharmacy

- Imaging

- Pathology

- etc.

Level

1

Level

2

Level

3

Level

4

Level

5

ABM Portal

SNAP App

Outcome data

Benchmarking

Ability to produce ad hoc reports

Activity against target

Goal

Provide the tools for world class

healthcare

Sustainability

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