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SUS Release 11 Best Practice & Readmissions

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Presentation on theme: "SUS Release 11 Best Practice & Readmissions"— Presentation transcript:

1 SUS Release 11 Best Practice & Readmissions
Training Presentation SUS PbR Policy - Best Practice & Readmissions 1

2 Agenda Purpose of today’s session Best Practice Readmissions

3 APC Best Practice 2012/13

4 APC Best Practice Introduction
The Department of Health introduced Best Practice in Tariffs 2010/11 with the aim of reimbursing providers for improving the quality of care. The aim is to incentivise Providers to provide High Quality and Cost Effective care. The incentive is a National Best Practice Tariff. Best Practice initially addressed four high volume areas; cataracts, fragility hip fracture, gall bladder and acute stroke, chosen due to the significant and unexplained variation in practice and clear consensus of what clinical best practice constituted. In 2011/12 Best Practice was extended to cover a further five clinical areas and to cover the use of Daycase admissions.

5 APC Best Practice APC Best Practice – Adjustment to Tariff
Best Practice Tariff (BPT) in SUS is treated as an adjustment to tariff and not a separate National Best Practice tariff The Adjustment may take the National Tariff down to a ‘Base Tariff’ which is then used locally as a base to uplift to an increased Tariff once local data has been reviewed e.g. fragility hip fracture and stroke Other BP adjustments are negative with no local uplift as the Best Practice tariff for relevant activity is set at a level lower than the standard elective (or non-elective) APC tariff – DH policy

6 APC Best Practice APC Best Practice has been extended again in 2012/13 with the following effects: There are now approximately 40 service areas that are assigned BPT flags that may be eligible for Best Practice Tariff adjustment Best Practice Tariff (BPT) adjustments applied to APC Spells only

7 APC Best Practice BPT BPT Description SUS/GRP BP01
BP01 Fragility hip fracture GRP BP28 Simple mastectomy with or without axillary surgery BP04 Cataract Best Practice SUS BP29 Excision of breast BP05 Stroke BP30 Excision of breast with sentinel lymph node biopsy or axillary sample BP10 Repair of umbilical hernia BP31 Sentinel lymph node biopsy/Axillary sample BP11 Primary Repair of inguinal hernia BP32 Axillary clearance BP12 Repair of recurrent inguinal hernia BP33 Tonsillectomy BP13 Repair of femoral hernia BP34 Septoplasty BP14 Operations to manage female incontinence BP35 Epileptic seizure BP15 Therapeutic arthroscopy of shoulder BP36 Abdominal pain BP16 Bunion operations BP37 Lower gastro-intestinal haemorrhage BP17 Dupuytrens fasciectomy BP38 Self harm BP18 Endoscopic resection of prostate (TUR) BP39 Cellulitis BP19 Endoscopic resection of prostate using laser BP40 Chest pain BP20 Primary hip replacement BP41 Syncope BP21 Primary knee replacement BP42 Appendicular fractures not requiring immediate fixation BP22 Embolisation for GI bleed BP43 Acute headache BP23 Thoracic EVAR BP44 Asthma BP24 Angioplasty and stenting for peripheral artery disease BP45 Lower respiratory tract infections without COPD BP25 Angioplasty and stenting for diabetic foot disease BP46 Pulmonary embolism BP26 TIPS BP47 Renal/ureteric stones BP27 Percutaneous excision of benign breast lesions BP48 DVT

8 APC Best Practice Specialised Service Codes and Best Practice Flags
This year the Grouping process will output separate Specialised Service Codes (SSC) and Best Practice flags The format of these flags is the same between the Local Payment grouper and the SUS Grouper The Grouper formats are: Specialised Service Code (SSC) = SSnn e.g. SS08 Best Practice = BPnn e.g. BP36 Note: Making this change ensures that the difference between BPT and SSC flags is much clearer for users from a processing and output perspective.

9 APC Best Practice Flags from the Grouper for Best Practice are produced at Spell level Flags from the Grouper for Best Practice are DISTINCT i.e. only one distinct value per Spell. However you can have multiple flags per Spell (but not the same flag multiple times) Local Grouper outputs the SSC and BPT flags into a file ‘xxx_File_rel’ (where xxx is the filename provided at run time) Example output from Local/SUS Grouper RowNo ProvSpNo Iteration SpellFlag 118 1 SS08 BP36 2 BP39 396 BP41 405 SS23

10 APC Best Practice BPT Action Indicators BPT Indicator 1
BPT Indicator 1 Action BPT Indicator 2 BPT Indicator 2 Action BPT Indicator 3 BPT Indicator 3 Action BPT Indicator 4 BPT Indicator 4 Action BPT Indicator 5 BPT Indicator 5 Action All Best Practice Flags whether they are SUS or Grouper derived will be ordered from the Lowest to Highest e.g. (BP01 to BP47) The five Best Practice Indicators will be populated by the first five flags from the ordered Best Practice flags

11 APC Best Practice Invalid Combinations

12 APC Best Practice New BPT Action Indicator attribute displays status of BPT flag Values are:- Invalid (Failed Combination Check) Adj Tariff (The BPT has a National BPT Adjustment) Opt Tariff (The BPT has an Optional Adjustment) Multi (The BPT has an Optional and National Adjustment) No Tariff (the BPT has no adjustments) BPT Indicators where the ACTION Indicator is NULL will be used to derive a Best Practice Tariff adjustment BPT Indicators where the ACTION Indicator is Invalid will NOT be used to derive a Best Practice Tariff adjustment Note: The BP Combination Indicator(APC Spell extract) contains “Null” as this attribute is no longer used.

13 APC Best Practice Short Stay Emergency (SSEM)
To apply Best Practice for Spells that have an HRG and Length of Stay that qualifies for a Short Stay Emergency Tariff SUS will apply the following rules. Record the HRG Short Stay Emergency Tariff on the Spell Record the HRG National Non Elective Emergency Tariff on the Spell Using the Spell attributes that contribute to a BPT adjustment check if the Spell is qualified for an adjustment There are two outcomes possible: (see next slide)

14 APC Best Practice Short Stay Emergency (SSEM)
 Outcome 1: Tariff adjustment is qualified and will: Apply the National Non Elective Emergency Tariff as the Initial Tariff Apply the adjustment to the Initial Tariff Record ‘Adj Tariff’ in the BPT Action attribute Remove the recorded Short Stay Tariff as it is no longer relevant.

15 Best Practice Short Stay Emergency (SSEM)
Outcome 2: NO BPT adjustment is qualified and will:  Apply the Short Stay Emergency Tariff as the Initial Tariff Record ‘No Tariff’ in the BPT Action attribute Remove the recorded National Non Elective Emergency Tariff as it is no longer relevant.

16 APC Best Practice Apply BPT Adjustments
In SUS PbR 2012/13 the following attributes from the Spell will be used to match against reference data to derive if an adjustment for BPT is qualified.

17 APC Best Practice Apply BPT Adjustments
In SUS PbR 2012/13 the following attributes are retrieved from the reference data table when a BPT adjustment is qualified. Note: SUS will apply each of the BPT Indicators together with the required attributes. If a match is found the Tariff Adjustment will be recorded and the appropriate BPT Indicator Action will be populated with the value taken from BPT ACTION INDICATOR in the reference data. Note: An Optional Tariff is output for information & local purposes and does not contribute to the Final PbR Tariff or any Market Forces Factor calculations.

18 APC Best Practice Row 1 Row 2 Row 3 Row 4 HRG CODE UNBUNDLED HRG CODE
BP INDICATOR ADM TYPE ADM SUBTYPE SPELL MIN AGE SPELL MAX AGE SPELL MIN LOS SPELL MAX LOS CDS GROUP TYPE BPT ACTION INDICATOR TARIFF ADJUSTMENT OPT TARIFF ADJUSTMENT Column1 Column2 Column3 CZ05Y ALL BP33 ELE 130 32000 APC Adj Tariff -342 CZ13V BP34 DAY 999 Multi Tariff 10 34 Spell Core HRG Admission Type (Derived) BPT Indicator 1 BPT Indicator 1 Action BPT Indicator 2 BPT Indicator 2 Action BPT Indicator 3 BPT Indicator 3 Action BPT Indicator 4 BPT Indicator 4 Action BPT Indicator 5 BPT Indicator 5 Action Tariff Initial Amount National Tariff Financial Adjustment National Optional APC BPT Adjustment PbR Final Tariff £1,078 -£342 £736 No Tariff £1,235 £10 £34 £1,245 Row 1 Row 2 Row 3 Row 4

19 APC Best Practice APC Spell Extract attributes BPT Flags SSC Flags
BPT Indicator BPT Action Indicator Tariff Adjustment Optional Tariff Adjustment

20 APC Best Practice Number of BPT Indicators Number of distinct Best Practice Tariff Indicators (BPTs) - count regardless of a BPT Adjustment being applied or BPT Invalid Combinations. This reflects the number of BPT that have been allocated by the Grouper or SUS Count does not include phantom Spells or Spells where all episodes have been deleted. Where this occurs count will be NULL

21 APC Best Practice Number of Specialised Service Code Indicators
The Number of distinct Specialised Service Codes (SSCs) based on Grouper output - count for PbR Included activity only. Whether the SSC is eligible for a top-up is not considered for this count Count does not include phantom Spells (Spells where all episodes have been deleted). Where this occurs count will always be NULL

22 APC Best Practice Optional APC BPT Adjustment
While the field may contain a £s value, it is for information only and does not contribute to the Final Tariff. The adjustment may be applied locally but will not attract Market Forces Factor (MFF) Note: The BPT Action Indicator will contain “Multi” if both Tariff Adjustment £ (+/- value in £) which is added to the total payment for the Spell and Optional Tariff Adjustment £ are populated within APC extracts

23 APC Best Practice Length of Stay (LOS)
A new length of stay check (LOS) check has been introduced for all APC Spells with a BPT flag when applying adjustment Spells are checked to ensure that the length of time that a patient spends in hospital is BETWEEN a maximum and minimum Spells which fall outside of the maximum or minimum length of stay for that procedure will not qualify for appropriate adjustments. The BPT Action will be ‘No Tariff’

24 Readmissions

25 Readmissions Readmissions in 2011/12 – High Level Detail
Readmissions policy was introduced in April This meant that Commissioners could retain funds for Spells that are deemed a readmission in order to make investments in other areas in an attempt to reduce the number of readmissions. To support this policy, readmission activity in SUS for 2011/12 was processed using readmission pathway logic with details output in a Managed Service “Readmissions” extract available to Commissioners only.

26 Readmissions High Level Detail
For 2012/13 SUS Readmissions logic will cover: Multiple Years – covers 2011/12 and 2012/13 SUS will flag Spells in a pathway that are: ‘Parent’ (First Admission), ‘Child’ (Follow-on Admission) or ‘Both’ Validation results will now be shown at a Spell level as opposed to at a Pathway level

27 Readmissions How a Readmissions Pathway is created:
Child Spells Identified Child Spells Validated Readmissions Path Created Parent & Child Spells identified in Pathway Parent & Child Spells Validated

28 Readmissions Step 1 – Identifying Eligible Child Spells
SUS will look at incoming APC Spells to find eligible child Spells using the criteria shown below. Where it finds a match RAP Spell Type and RAP Eligible Child will be populated. Only Spell that are Admission Sub Type = EMR - The admission must be an emergency Spell In PbR/Not in PbR = 0 - The PbR qualified indicator must be zero, telling SUS that the Spell is to be tariffed Total National Tariff > = 0 – the Tariff Total National must be greater than or equal to ZERO If all are passed then RAP Eligible Child = ‘Y’ and RAP Spell Type = ‘Child’ If a Spell passes (a) but fails on either (b) or (c) then RAP Eligible Child = ‘N’ and RAP Spell Type = ‘Child’

29 Readmissions Step 2 - Validate Child Spells
Only Spells which are marked as RAP Eligible Child = Y are picked up by SUS for validation against the Reference Data. Once a Spell is validated against the reference data: A Spell that passes (no hits) then DH TARIFF ADJ CHILD = ‘Y’ A Spell that fails (has a hit) then DH TARIFF ADJ CHILD = ‘N’

30 Readmissions Attributes used in Child Validations PBR QUALIFIED IND
CHILD SPELL PATIENT AGE CHILD SPELL CORE HRG CHILD SPELL UNB HRG CHILD SPELL PRIM DIAG CHILD SPELL SECND DIAG COUNTRY CODE CHILD SPELL TFC CHILD SPELL MAIN SPECIALITY CHILD SPELL ADM SUBTYPE

31 Readmissions Step 3 – Create Readmissions Pathway
Once child Spells have been identified and validated SUS will link the Spells that fall within the interval (30 days) from child Spell admission date to parent Spell discharge date into a readmissions pathway To ensure that same day readmissions are included the gap between the Discharge Date and Readmission date is calculated from the actual discharge date The data used to find potential parents of the identified child Spells is all held in the post reconciliation marts

32 Readmissions Step 4 - Identify Parent & Child Spells within the Readmissions Pathway SUS will now identify Parent from Child Spells with the Readmissions pathway always working from the last Child back in time. Step 5 – Apply Validations SUS will perform Parent validation checks on pairs of eligible Spells.

33 Readmissions New Readmission Attributes in 2012/13 Attribute Values
Meaning RAP Eligible Parent Y or N Y = Eligible N = Not Eligible RAP Eligible Child RAP DH Tariff Adjustment Parent Y = Valid as a Parent according to DH business Rules N = Invalid as a Parent defined by DH business Rules RAP DH Tariff Adjustment Child Y = Available for adjustment according to DH business Rules N = Excluded from adjustment by DH business Rules

34 Readmissions Processing Outcomes
Spell ID Adm Subtype RAP Spell Type Spell in PBR / Not in PBR RAP_Elig_Child DH_ADJ_Child RAP_Elig_Parent DH_ADJ_Parent Validation Parent Validation Child S1 ELE PARENT Y S2 EMR CHILD Processing Outcomes Using the matching criteria and processing steps this is the simplest pathway with just two Spells. Spell This Spell has been identified as an elective admission, is a Parent Spell with a PQI of zero and is eligible for adjustment. Spell 2 - This Spell has been identified as an emergency admission and is Child Spell only with a PQI of zero and is eligible for adjustment. Both Spells have passed validation tests as the DH ADJ Parent and DH ADJ Child are both set to ‘Y’ and the Validation Parent and Validation Child are both NULL.

35 Readmissions Processing Outcomes
Spell ID Adm Subtype RAP Spell Type PQI RAP_Elig_Child DH_ADJ_Child RAP_Elig_Parent DH_ADJ_Parent Validation Parent Validation Child S1 ELE PARENT Y S2 EMR BOTH S3 CHILD Processing Outcomes Using the matching criteria and processing steps here are some of the possible outcomes Spell This Spell has been identified as an elective admission, is a Parent Spell with a PQI of zero and is eligible for adjustment. Spell 2 - This Spell has been identified as an emergency admission and is both a Parent and Child Spell with a PQI of zero and is eligible for adjustment on both Spells before further validations. Spell 3 - This Spell has been identified as an emergency admission and is Child Spell only with a PQI of zero and is eligible for adjustment.

36 Readmissions Further Validations
Spell ID Adm Subtype RAP Spell Type PQI RAP_Elig_Child DH_ADJ_Child RAP_Elig_Parent DH_ADJ_Parent Validation Parent Validation Child S1 ELE S2 EMR BOTH Y N VC4  S3 CHILD Further Validations Spell 2 - This Spell has been identified as an emergency admission with a PQI of zero and is both a Parent and Child Spell. When further validations on pairs of Parent and Child Spells are carried out , Spell 2 - Spell Type - Both, has VC4 populated in the Validation Child column causing the DH_ADJ_Child. To be set to ‘N’ S2 is not a Valid Child therefore it does not need a Parent, however S2 is a valid Parent to spell S3.

37 Readmissions Spell ID Adm Sub type RAP Spell Type PQI RAP Elig Child DH ADJ Child RAP Elig Parent DH ADJ Parent Validation Parent Validation Child Admission Date Discharge Date S1 ELE PARENT Y 01/04/2013 15/04/2013 S2 EMR ERROR 10/04/2013 30/04/2013 S3 CHILD 02/05/2013 Errors Spell S2 is considered as an ERROR since the Admission date (10th April) is before the previous Discharge date (15th April). A Spell that is considered as ‘ERROR’ is not used in any processing in readmissions.

38 Readmissions Same Day Transfers
SUS will flag same day transfers between providers in a Readmissions pathway using reference data from 2012/13. Only Spells which fall within this financial year are can be identified as a same day transfer and can be seen in the Readmissions extract in the attributes Transfer Out and Transfer In. RAP Spell Transfer Out Identifies whether an emergency or non-emergency transfer forms part of the RAP and identifies the TRANSFER OUT Spell. Transfer processing will be applied at Spell level and the Spell relating to the transferring Provider will be identified as TP1 A Spell can be both a TRANSFER OUT and a TRANSFER IN or may be NULL RAP Spell Transfer In Identifies whether an emergency or non-emergency transfer forms part of the RAP and identifies the TRANSFER IN Spell. Transfer processing will be applied at Spell level and the Spell relating to the receiving Provider will be identified as TC1 A Spell can be both a TRANSFER OUT and a TRANSFER IN or may be NULL

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