1. Care Pathways & Payment-by-Results David Kingdon University of Southampton NHS South Central/Hampshire Partnership FT

2. What’s a care pathway? An integrated care pathway (ICP) is a multidisciplinary/ multi-agency outline of anticipated care, placed in an appropriate timeframe, to help a patient* with a specific condition or set of symptoms move progressively through a clinical experience to positive outcomes * also for general population, carers, primary care, general medical services, non-statutory sector, mental health services and commissioners

3. What’s a care pathway? Clinical care pathways are “both a tool and a concept that embed guidelines, protocols and locally agreed, evidence-based, patient-centred, best practice, into everyday use for the individual patient. In addition, and uniquely to ICPs [Integrated Care Pathways], they record deviations from planned care in the form of variances” [Defining and monitoring quality]tool ‘Bandolier’ description [providing information for …] –Diagnosis: Treating the right patient) Guidelines –Treatment: Treating the right patient right) –Organisation: Treating the right patient right at the right time –Pathway: Treating the right patient right at the right time and in the right way

4. Care pathways, clusters and tariffs Clusters define current need Clusters span Disorder care pathways Disorders define pathways (e.g. NICE) Interventions and specific outcome measures relate to CPs. How do we relate pathways to clusters? PbR

5. CARE PATHWAYS AND CLUSTERS Trust ATrust BTrust C Emotional difficulties: 1: Common Mental Health Problems (low severity) 1021035150 2: Common Mental Health Problems (low severity with greater need) 2731368462 3: Non-Psychotic (Moderate Severity) 1002978729 4: Non-Psychotic (Severe) 17012034369 5: Non-Psychotic (very severe) 2731368735 7: Enduring Non-Psychotic Disorders (high disability) 9279421239 15. Severe Psychotic Depression 13510875 6: Non-Psychotic Disorders of overvalued ideas [Eating disorders & OCD] 234435300 8: Non-Psychotic Chaotic and Challenging Disorders [ ‘Borderline PD’] 7771068150 Psychosis: 000 10: First Episode in Psychosis 13509631638 14: Psychotic Crisis 435228762 11: Ongoing Recurrent Psychosis (low symptoms) 7027501035 12: Ongoing or Recurrent Psychosis (high disability) 11617021101 13: Ongoing or Recurrent Psychosis (high symptom and disability) 267010263030 16: Dual Diagnosis = ‘Psychosis with drug abuse’ 13773961638 17: Psychosis and Affective Disorder Difficult to Engage 11282941146 Memory difficulties: 000 18: Cognitive impairment (low need) 10261701702 19: Cognitive impairment or Dementia Complicated (Moderate need) 136820101062 20: Cognitive impairment or Dementia Complicated (High need) 5341035207 21: Cognitive impairment or Dementia (High physical or engagement needs) 7021638402 Total patients 178772007916932

6. Care pathways Payment-by-Results Emotional difficulties Memory difficulties Psychosis Anxiety/depression & related conditions ‘Rapid cycling’Rapid cycling’ Borderline Personality Disorder Bipolar disorder Eating disorders Acute Persistent Stable Acute Persistent Stable Acute Persistent Stable Acute Persistent Stable Acute Persistent Stable Low Moderate High High (P&E)

7. Care PathwayAcute (Acute care pathway - CRHT/Inpatient) Persistent (Community pathway/AOT/EIP) Stable (Community/recovery pathway/IAPT) Psychosis 14: 14: Psychotic Crisis10: 10: First Episode in Psychosis 13: 13: Ongoing or Recurrent Psychosis (high symptom and disability) 16: 16: Dual Diagnosis = ‘Psychosis with drug abuse’ 17: 17: Psychosis and Affective Disorder (Difficult to Engage) 11: 11: Ongoing Recurrent Psychosis (low symptoms) 12: 12: Ongoing or Recurrent Psychosis (high disability) Bipolar disorder 5: 5: Non-Psychotic (very severe) 14: 14: Psychotic Crisis 15. 15. Severe Psychotic Depression 3: 3: Non-Psychotic (Moderate Severity) 4: 4: Non-Psychotic (Severe) 7: 7: Enduring Non-Psychotic Disorders (high disability) 17: 17: Psychosis and Affective Disorder (Difficult to Engage) 1: 1: Common Mental Health Problems (low severity) 2: 2: Common Mental Health Problems (low severity with greater need) Anxiety/ depression 5: 5: Non-Psychotic (very severe) 15. 15. Severe Psychotic Depression 3: 3: Non-Psychotic (Moderate Severity) 4: 4: Non-Psychotic (Severe) 7: 7: Enduring Non-Psychotic Disorders (high disability) 1: 1: Common Mental Health Problems (low severity) 2: 2: Common Mental Health Problems (low severity with greater need) ‘Borderline PD’ 8: 8: Non-Psychotic Chaotic and Challenging Disorders [ ‘Borderline PD’]‘Borderline PD’] 3: 3: Non-Psychotic (Moderate Severity) 4: 4: Non-Psychotic (Severe) 7: 7: Enduring Non-Psychotic Disorders (high disability) 1: 1: Common Mental Health Problems (low severity) 2: 2: Common Mental Health Problems (low severity with greater need) Eating disorders 6: 6: Non-Psychotic Disorders of overvalued ideas [Eating disorders & OCD]Eating disorders 3: 3: Non-Psychotic (Moderate Severity) 4: 4: Non-Psychotic (Severe) 7: 7: Enduring Non-Psychotic Disorders (high disability) 6: 6: Non-Psychotic Disorders of overvalued ideas [Eating disorders & OCD]Eating disorders 1: 1: Common Mental Health Problems (low severity) 2: 2: Common Mental Health Problems (low severity with greater need)

8. Care PathwayAcutePersistentStable Psychosis Often requires period of stabilisation, sometimes PICU, MSU or finding new community accommodation; risk & substance misuse issues. Home treatment not often accepted for engagement reasons/agitation/ accommodation instability. Psychiatric & care coordinator; course of CBT psychosis (accepted by most); family work where agreed with family (relatively uncommon). EIP & AOT for proportion. Some NHS rehab accom Meds – clozapine & depot Psychiatrist &/or care coordinator (longer-term). Social support. CBT for psychosis if not previously received. Bipolar disorder Usually for mania and relatively brief admission; occasionally even briefer admn for depression. Rarely stabilisation & new accom. Some use of HT Psychiatric management – sometimes care coordinator. Psychological input (often offered & accepted) Psychiatrist or care coordinator (longer-term). Anxiety/ depression Rarely admission needed for suicidal risk; should be brief. HT more commonly needed. Step 1 & 2: Primary care & IAPT Step 3 & 4: CMHT + CBT, day care/social support Primary care/self-help Psychiatrist or care coordinator (usually brief). ‘Borderline PD’ Admission generally contra- indicated but some brief for risk/rapid stabilisation. HT frequent in crisis periods. Intensive CMHT involvement; family work; social support; DBT. Brief NHS rehab accom. Psychiatrist or care coordinator (brief/intermediate). Social support. Eating disorders Where admission needed, specialist unit & can be intensive & lengthy. HT have role. ED team + CMHT; psychologist. Psychiatrist or care coordinator (longer-term).

9. Care PathwayAcutePersistentStable Psychosis Often requires period of stabilisation, sometimes PICU, MSU or finding new community accommodation; risk & substance misuse issues. Home treatment not often accepted for engagement reasons/ agitation/accommodation instablility. Psychiatric & care coordinator; course of CBT psychosis (accepted by most); family work where agreed with family (relatively uncommon). EIP & AOT for proportion. Some NHS rehab accom Psychiatrist &/or care coordinator (longer-term). Social support. CBT for psychosis if not previously received. Bipolar disorder Usually for mania and relatively brief admission; occasionally even briefer admn for depression. Rarely stabilisation & new accom. Some use of HT Psychiatric management – sometimes care coordinator. Psychological input (often offered & accepted) Psychiatrist or care coordinator (longer-term). Anxiety/ depression Rarely admission needed for suicidal risk; should be brief. HT more commonly needed. Step 1 & 2: Primary care & IAPT Step 3 & 4: CMHT + CBT, day care/social support Primary care/self-help Psychiatrist or care coordinator (usually brief). ‘Borderline PD’ Admission generally contra- indicated but some brief for risk/rapid stabilisation. HT frequent in crisis periods. Intensive CMHT involvement; family work; social support; DBT. Brief NHS rehab accom. Psychiatrist or care coordinator (brief/intermediate). Social support. Eating disorders Where admission needed, specialist unit & can be intensive & lengthy. HT have role. ED team + CMHT; psychologist. Psychiatrist or care coordinator (longer-term).

10. Care Pathway Acute (Acute pathway (AP): CRHT/ Inpatient/PICU) Persistent (Community pathway (CP) /AOT/EIP) Stable (Community pathway (CP) /IAPT) Psychosis £ Acute bed day cost (AP) * av. LOS = £P-A Bipolar disorder Anxiety/ depression ‘Borderline PD’ Eating disorders LOS – length of stay * = x (multiply)

11. Care Pathway Acute (Acute pathway (AP): CRHT/ Inpatient/PICU) Persistent (Community pathway (CP) /AOT/EIP) Stable (Community pathway (CP) /IAPT) Psychosis £ Acute bed day cost (AP) * av. LOS = £P-A £Community day cost (CP) * weighting * days = £P-P Bipolar disorder £ AP * av. LOS = £BD- A Anxiety/ depression £ AP * av. LOS = £AD-A ‘Borderline PD’ £ AP * av. LOS = £BPDA Eating disorders £ AP * av. LOS = £ED-A Weighting – measured or estimated (e.g. Persistent = 2 x Stable; actual costs for IAPT) LOS – length of stay * = x (multiply)

12. Care Pathway Acute (Acute pathway (AP): CRHT/ Inpatient/PICU) Persistent (Community pathway (CP) /AOT/EIP) Stable (Community pathway (CP) /IAPT) Psychosis £ AP (acute bed day cost) * av. LOS = £P-A £Community day cost (CP) * weighting * days = £P-P £CP * weighting * days = £P-S Bipolar disorder £ AP * av. LOS = £BD- A £CP * weighting * days = £BP-P Anxiety/ depression £ AP * av. LOS = £AD-A £CP * weighting * days = £AD-P ‘Borderline PD’ £ AP * av. LOS = £BPDA £CP * weighting * days = £BPD-P Eating disorders £ AP * av. LOS = £ED-A £CP * weighting * days = £ED-P Weighting – measured or estimated (e.g. Persistent = 2 x Stable; actual costs for IAPT) LOS – length of stay * = x (multiply)

13. Care Pathway Acute (Acute pathway (AP): CRHT/ Inpatient/PICU) Persistent (Community pathway (CP) /AOT/EIP) Stable (Community pathway (CP) /IAPT) Psychosis £ AP (acute bed day cost) * av. LOS = £P-A £CP * weighting * days = £P-P £CP * weighting * days = £P-S Bipolar disorder £ AP * av. LOS = £BD- A £CP * weighting * days = £BP-P Anxiety/ depression £ AP * av. LOS = £AD-A £CP * weighting * days = £AD-P [IAPT + £CP] * weighting * days = £AD-S ‘Borderline PD’ £ AP * av. LOS = £BPDA £CP * weighting * days = £BPD-P £CP * weighting * days = £BPD-S Eating disorders £ AP * av. LOS = £ED-A £CP * weighting * days = £ED-P Weighting – measured or estimated (e.g. Persistent = 2 x Stable; actual costs for IAPT) LOS – length of stay * = x (multiply)

14. Care PathwayAcute (CRHT/Inpatient) Persistent (high need community pathway/AOT/EIP) Stable (community/recovery pathway/IAPT) Psychosis 14: 14: Psychotic Crisis 10: 10: First Episode in Psychosis 13: 13: Ongoing or Recurrent Psychosis (high symptom and disability) 16: 16: Dual Diagnosis = ‘Psychosis with drug abuse’ 17: 17: Psychosis and Affective Disorder (Difficult to Engage) 11: 11: Ongoing Recurrent Psychosis (low symptoms) 12: 12: Ongoing or Recurrent Psychosis (high disability) Bipolar disorder 5: 5: Non-Psychotic (very severe) 14: 14: Psychotic Crisis 15. 15. Severe Psychotic Depression 3: 3: Non-Psychotic (Moderate Severity) 4: 4: Non-Psychotic (Severe) 7: 7: Enduring Non-Psychotic Disorders (high disability) 1: 1: Common Mental Health Problems (low severity) 2: 2: Common Mental Health Problems (low severity with greater need) Anxiety/ depression 5: 5: Non-Psychotic (very severe) 15. 15. Severe Psychotic Depression 3: 3: Non-Psychotic (Moderate Severity) 4: 4: Non-Psychotic (Severe) 7: 7: Enduring Non-Psychotic Disorders (high disability) 1: 1: Common Mental Health Problems (low severity) 2: 2: Common Mental Health Problems (low severity with greater need) ‘Borderline PD’ 8: 8: Non-Psychotic Chaotic and Challenging Disorders [ ‘Borderline PD’]‘Borderline PD’] 3: 3: Non-Psychotic (Moderate Severity) 4: 4: Non-Psychotic (Severe) 7: 7: Enduring Non-Psychotic Disorders (high disability) 1: 1: Common Mental Health Problems (low severity) 2: 2: Common Mental Health Problems (low severity with greater need) Eating disorders 6: 6: Non-Psychotic Disorders of overvalued ideas [Eating disorders & OCD]Eating disorders 3: 3: Non-Psychotic (Moderate Severity) 4: 4: Non-Psychotic (Severe) 7: 7: Enduring Non-Psychotic Disorders (high disability) 6: 6: Non-Psychotic Disorders of overvalued ideas [Eating disorders & OCD]Eating disorders 1: 1: Common Mental Health Problems (low severity) 2: 2: Common Mental Health Problems (low severity with greater need)

15. Deriving Cluster Tariffs Worked Example! £14. Psychotic crisis (tariff) = [(No. of 14. Psychotic crisis with Psychosis x £P-A) + (No. of 14. Psychotic crisis with Bipolar x £BP-A)] / No. of Patients in Cluster 14.

16. Developing a tariff Cost each CP category (A, P, S) Use clusters to assess need; Cluster * CP for tariff Base weighted costs on current or estimated usage Commence with using annual census (initially then increase frequency to 6 to eventually monthly) Account for new entrants and exits from pathways PbR

17. Questions: Can diagnostic care pathway, LOS & cluster info be gathered on all patients? How will we do it? Are clusters allocated appropriately to pathways? How do we deal with dual diagnosis; –use primary diagnosis only or e.g. psychosis [drugs or not?] How do we cost pathways? –Acute: HTT + Acute + PICU (combine or split) What about ‘delayed discharges’? –Community: What is a community reference cost? Persistent – care coordinator & psych (2x cost) + psychology - i.e. = CPA (?) –Do we separate EIT, AOT & high-cost CMHT? Liaison & Perinatal services? Stable – care coordinator or psychiatrist, i.e. = non-CPA? Allow for supervision & training costs; accounting for overheads How do we link to outcomes? [HoNOS, DIALOG, & specific measures eg IAPT] Exceptions – e,g. very high-cost & possibly forensic patients