1. A joint Australian, State and Territory Government Initiative Experiences and lessons from benchmarking Older Persons Mental Health Services Dr Rod McKay. Braeside Hospital National Mental Health Benchmarking Project 27 November 2008

2. Goal of this presentation Describe results of participation in national benchmarking of mental health services for older people Demonstrate how KPI data was used to explore clinical practice

3. Method Review of documents utilised for the benchmarking forums was conducted Reflection upon the author’s experience of participation and discussion with other participants.

4. Who was involved? Seven older persons mental health services from five Australian states Selected as representative of ‘good practice’ Expected to have a history of using data within service Facilitator and 2 project staff 3 to 5 individuals from each service Combinations of Senior clinicians (multiple disciplines) Service managers Information support staff Service project staff

5. What did we focus on? Understanding indicators and how to use them Understanding each others services Length of stay and factors that may impact upon this Diagnosis Outcome measure profiles Allied Health Practice ECT practice Bed management

6. What did we find? All services provided ambulatory and community services to consumers with mental illnesses including psychotic illnesses, mood disorders and BPSD Consumer profiles on the HoNOS 65+ were consistent with nationally available data; and consistent with diagnostic mixes of services We had sufficient similarity to compare practice and performance; despite significant differences in the proportions of consumers with different diagnoses Available resources, and Proportion of patients who were born overseas All services had both strengths and weaknesses in profile and performance

7. What did we find- selected KPIs KPI Mean of services (06-07) Range2006-07 28 day readmission rate 5% 3% to 7% Mean Length of stay 45.6 days 36 to 65 days Treatment days / 3 month community care 7.1 days 4.6 to 8.8 days New Client Index 61% 38% to 91% Outcome readiness - inpatient - inpatient-community129%57% 89% to 193% 14% to 125% Post discharge care <7 days 59% 22% to 75%

8. Further KPIs KPI Mean of services (06- 07) Range2006-07 Av Acute Episode Cost $29,361 $21,748- $36,556 Cost/ 3 month community care $1,860 $893- $2,599 % target pop. community care 0.8%0.2-1.6% % target pop. inpatient care 0.16%0.08-0.26% Local access inpatient care 72%36-100%

9. More KPIs….. KPI Mean of services (06- 07) Range2006-07 New Client Index 61%38-91% Area per capita resources- ambulatory $30$9-$39 Area per capita resources- inpatient $57$32-$78 Preadmission community care 50%22-81% Post discharge community care 58%22-75%

10. What did we do regarding differing Length of Stay between services? All selected a sub set of patients staying less than, or more than 60 days to identify differences in Age Gender Language and residential care status HoNOS 65+ profile Diagnosis ECT use

11. What did we find - Length of stay Each service could identify groups who stayed longer, but the factors were not the same between all services Trend for LOS over 3 years was a slow gradual increase Extracts from benchmarking benchmarking workbook workbook

12. One service demographics >60 days <60 days male male44%42% Mean age 74yrs77yrs age <=70y.o. age <=70y.o.32%16% CALD24%49% requiring interpreter requiring interpreter25%26% Admission residence ……………………RACF 18%30% ……………………home82%58% …………………..other0%12% Discharge residence ……………………RACF 47% (26% hostel) 47% (8% hostel) ……………………home53%50% …………………..other0%3% Change in residence 41% 30% change

13. One service synthesis Factors that appear to be most associated with increased LOS are High scores on HoNOS65+ item 8 (‘other’) and item 9 (relationships’) Living at home at admission requiring hostel care on discharge Being aged <=70yrs Having a psychotic illness Factors with weaker associations are High score on HoNOS65+ item 1 (behaviour) and item 11 (living conditions) Requiring a change in residence

14. What did we do - Length of Stay Discussed findings of analysis Explored together different practice regarding Allied Health staff resources and roles Discharge practices Flow to other services, where available ECT practice Each service commenced their own improvement project based on their own needs Eg changes to bed flow, ECT practice, social worker practice, identifying consumers ‘at risk’ of long length of stay for more intense early discharge planning BUT these were mostly only starting implementation by the end of benchmarking

15. What was useful? Using HoNOS 65+ (Routine Outcome Measure) to understand clinical profiles of consumers within teams Extract from benchmarking benchmarking workbook workbook

16. What was useful? Improving understanding of the similarities and differences in service provision between organisations Identifying areas of key differences in service provision and performance Establishing informal networks and contacts Sharing intellectual resources (eg job descriptions, clinical tools uses)

17. What was useful? collaborating in generating projects to explore differences initiating local projects to improve practice. (with some limitations) the national KPI set and data from routine outcome measurement collections have been valuable tools to assist these processes. Improved understanding of the use, and limitations of the national Mental Health KPIs; and indicators and related data in general

18. What was problematic? Poorly compatible IT systems and financial systems across states Conducting ‘joint projects’ to change practice within services Range of data literacy of participants Ability to recruit support/ project staff Providing feedback to staff from participating organisations not attending forums Lack of rules regarding withdrawal from the forums Time frames of forums vs time for practice change Services finding time to do ‘homework’ Services integrating ‘benchmarking’ into ‘quality improvement’

19. Were there time trends?

24. BUT….. All this considers mental health services for older people as a ‘separate being’ to other mental health services What happens when we look into the results of the adult mental health service benchmarking?

25. What are there lessons to be learnt? For OPMH services? For Adult MH services? For the use and creation of KPIs?

26. Adult vs Older Persons mental health service performance KPI Older Persons Mean (06-07) Adult Mean (06-07) 28 day readmission rate 6%12% Mean Length of stay 45.6 days 13.9 Treatment days / 3 month community care 7.1 days 9.7 New Client Index 61%60% Outcome readiness - inpatient - inpatient-community129%57%89%36%

27. Adult vs Older Persons mental health service performance KPI Older Persons Mean (06-07) Adult Mean (06-07) Av Acute inpatient Episode Cost $29,361($584/day)$9,472($680/day) Cost/ 3 month community care $1,860$1,975 % target pop. community care 0.8%1.5% % target pop. inpatient care 0.16%0.3% Local access inpatient care 72%84%

28. Adult vs Older Persons mental health service performance KPI Older Persons Mean (06-07) Adult Mean (06-07) Area per capita resources- ambulatory $30$57 Area per capita resources- inpatient $57$43 Preadmission community care 50%60% Post discharge community care 58%89%

29. Conclusion Benchmarking can assist mental health services for older people to improve their understanding of differences in practice and performance; generate useful local actions based upon these KPI sets and routine outcome measurement assist these processes They can also assist discussions about differences between mental health services for different age groups; and their relative performance

30. Conclusion Rewards for services require Staff to be supported to develop appropriate skills Integrating benchmarking with service quality processes A willingness to question established ideas and practices Time