kathy alloway - dept of health wa - wa state update
DESCRIPTION
Kathy Alloway, Senior Policy Officer, Activity Based Funding and Management (ABF/ABM) Team, Performance Activity and Quality, Department of Health Western Australia presented this at the 5th Annual Clinical Documentation, Coding and Analysis Conference. This event is the only case study led conference in Australia looking solely at clinical documentation, coding and analysis. For more information, please visit http://www.healthcareconferences.com.au/clinicaldocsTRANSCRIPT
Kathleen Alloway – Senior Policy Officer
Activity Based Funding and Management
Department of Health
Counting Activity Correctly and Consistently
Counts : The application and evaluation of
Admission, Readmission , Discharge and
Transfer Policy
Add something maybe about disclosing information to third parties no Add something maybe about disclosing information to third parties no
Slide 2
43,000 staff
Metro
5 teaching & 6 secondary
2 private/public
Community Health
Child & Adolescent Health
Country
13 health campuses
15 secondary, 51 small hosp
numerous nursing posts,
health centres
Slide 3
New Hospitals
Fiona Stanley
Albany
Midland
Childrens Hospital
Slide 4
WA coding update
ABF has stimulated re-alignment of coding , now
under Finance at both NMAHS and SMAHS.
ABF offered scholarships for further study which
many took up (not funded this year)
WA has no shortfall in coder workforce at the
moment.
Clinical Advisory Group keen to address clinical
documentation and coding education
Coding standards V ABF
Slide 5
Slide 6
Spending on Health is approximately 25%
of State total general expenditure
Cost increases in Health exceed
“standard” cost growth – IHPA indexation
= 4.7% for 2013-2014
Pressure from State Treasury to close the
gap between national price and state price
Reliability of ABF measures in explanation
of Health System performance
Managing resources and reconfiguration
of Health Services
Challenges for WA Health
Slide 7
What is the focus of the work?
Develop/enhance
processes, people or
tools so we:
Collect
Code
Classify
Cost
Count
Enables
us to
Understand our business (Revenue,
Cost and Performance)
Improve Accountability and
Performance Management
Improve service efficiency
Improve safety and quality
Make more informed decisions
Negotiate for Commonwealth Funds
Fund services appropriately
Benchmark Services
ACTIVITY
Slide 8
Clinical Casemix Handbook 2012-2014
The Clinical Casemix handbook is a
structured practical guide for clinicians.
The handbook has been developed in
collaboration with staff across WA Health, to
support clinicians to understand the
importance of timely and accurate
information about their patients and their
care.
Clinical documentation requirements for timely, accurate, and accountable
information are a key element in successful implementation of
Activity Based Funding and Management
Slide 9
The Handbook outlines:
The clinical coding process, from its use of
diagnoses and complications or co-
morbidities to determine care and complexity
levels, to the final assignment of DRGs.
How the DRG is then used to drive the
Activity Based Funding and Management
approach.
Improving clinical documentation is about making the patient‟s journey
through the health care system safer and smoother
Slide 10
The Handbook outlines:
The clinical coding process, from its use of
diagnoses and complications or co-
morbidities to determine care and complexity
levels, to the final assignment of DRGs.
How the DRG is then used to drive the
Activity Based Funding and Management
approach.
Improving clinical documentation is about making the patient‟s journey
through the health care system safer and smoother
Slide 11
The Handbook:
Highlights the importance of documenting
clinical information in the patient‟s medical
record and producing an accurate and
timely discharge summary.
Incorporates case studies from within WA
health demonstrating the impact of
documentation on patient safety, quality of
care, cost and revenue.
Incomplete, delayed or inaccurate documentation impairs both the data
available for safe and quality patient care, and that used for reporting,
coding, costing and subsequent funding to the health service
Slide 12
Vision for WA ABF/ABM
Activity Based Funding is the management tool that supports ABM to enhance
public accountability and drive technical efficiency in the delivery of health
services by:
Capturing consistent information on activity and the costs of delivery;
Creating an explicit relationship between funds allocated and services
provided;
Strengthening management‟s focus on outputs, outcomes, quality and
safety;
Managing variation in costs and practices to improve efficiency and
effectiveness; and
Providing mechanisms to reward good practice and support quality and
safety initiatives.
Slide 13
Change Management
“ Structured approach to transitioning individuals, teams
and organisations from a current state to a desired future
state”
Supporting people to be:
Ready Willing Able
Dimensions:
Culture Commitment Capability
Slide 14
Consistent classification and tracking of activity
provides access to reliable data so that we may
understand and manage our business better
National activity based funding program requires a
standardised approach
High quality robust data is an integral part of the
practical application of ABF/ABM
We need rules on how we count and classify
activity
Activity data is used for a range of applications
WA health services have an obligation to count and label activity in an accurate and consistent fashion
Slide 15
An admitted patient must meet the criteria for admission
related to the admission category and care type. These
include :
Expected levels of care
Documentation requirements
Same day specific criteria for emergency admissions
Procedure exclusions set by the Commonwealth
Assessment and Care planning
Activity Based Funding and Management as the principal resource allocation and funding mechanism means that correct labelling and
counting of activity is now especially important
The ARDT policy provides a framework, containing detailed rules and criteria to enable this to occur
Slide 16
The ARDT policy has range of benefits:
Ensuring health services are correctly funded
Accurate activity for use in clinical costing
Inform and position the state to align with national
hospital funding reforms
Provide a reliable care delivery profile to inform
clinical services planning
Key information from a range of related documents provides a
“one stop policy document” to support staff as they record and
classify this information
The ARDT policy had been developed through research into other
jurisdictions and in collaboration with staff across WA Health
Slide 17
Why is it so important ?
Activity Data
+ Costing Data
WAU & Price
Activity Classification WAU
ED URG: 6
Admitted, Triage 1, Circulatory 0.2528
Acute
Admitted
DRG: F10A Interventional
Coronary Procedures with AMI
without Catastrophic CC
2.1616
Non
Admitted
Tier 2 Clinic: 20.22
Cardiology Clinic 0.0610
For 2014-2015
health activity data
will directly inform
the amount of
Commonwealth
funding to WA
Slide 18
Policy Management Utopia
DoH
Consultation
Development
Distribution
Education
Operational Directive
Issues
Revision
Health Services
Implementation
Impact
Communication
Access
Audit compliance
Action non-compliance
Feedback issues
Slide 19
NON ADMITTED
1. ED ATTENDANCE
2. OUTPATIENT SERVICES
3. COMMUNITY AND
OUTREACH SERVICES
4. BOARDERS
5. CANCELLED PROCEDURES
6. REFUSED PROCEDURES
7. DEAD ON ARRIVAL
8. POSTHUMOUS ORGAN
DONATION
9. STILLBORN
Patients
ElectiveEmergency
Acute
ED Presentation Direct Admission Non-wait listWait list
ADMISSION
Sub-Acute
Non-Acute
Same Day Overnight
Non-Admitted
Procedures
(Type C)
Automatically
qualified for
admission (Type B)
Commonwealth
Legislation
Admitted
Procedures (Type B)
Non-Admitted
Procedures (Type C)
when certified
Same-day extended
medical treatment (SDE)
Band 1
Band 2
Band 3
Band 4
Special circumstances Clinical decision to
admit becoming…certified
Contracted CareOrgan donation
Overnight Adult (OA)
16 Admission criteria
Overnight Paediatric
(PA)
20 Admission criteria
Overnight Mental
Health (MH)
Additional legal and
social factors
Newborns
<9 days old
8 criteria to distinguish
b/w QN and UQN
Unqualified
(UQN)
Qualified
(QN)
1. Rehabilitation
2. Geriatric evaluation and management
3. Psychogeriatric
4. Palliative Care
5. Maintenance care
6. Nursing Home Type care
7. Aged / ‘Flexible’ care
Ambulatory Surgery
Slide 20
Slide 21
Policy research – DoH policy documents
Admission Policy for WA Hospitals (Technical Bulletin 17/3, 2002).
Transferred Patients (Technical Bulletin 50/0, 2002).
Neonatal care information reporting (Technical Bulletin 14/5, 2004).
Renal Dialysis (Technical Bulletin 4/5, 2002).
Reporting different episodes of care (Technical Bulletin 26/5, 2004).
Hospital Morbidity Information (Technical Bulletin 10/6, 2005).
Rehabilitation program – definitions and reporting requirements (Operational
Directive 0025/06, 2006).
Hospital in the Home care (Technical Bulletin 78/0, 2006).
Subacute and non-acute care (Technical bulletin: 20/6, 2004).
Discharge Policy in WA Hospitals (Technical bulletin: 40/1, 2001).
Geriatric Evaluation and Management (GEM) – Definitions and Reporting
Requirements (Technical Bulletin 79/0, 2006)
Palliative Care Program (Technical Bulletin 42/3, 2002)
Slide 22
Some Myths
Policy distributed = Implemented
Operation Directive = Law
Admission = Admitted Care
Consultation = Compliance
Communication = Consultation
Change management = Just do
what the policy says
Slide 23
Admitted Care
An admitted patient is defined as a person who
meets the criteria for admission and additional
criteria specific to the applicable admission
category and care type, and undergoes a hospital‟s
admission process (documented) to receive
treatment and/or care for a period of time
Slide 24
Non-admitted care
patients attending for a procedure on the non-admitted
procedures (Type C) list, without other justification for
admission documented by the treating medical
practitioner in the medical record
patients who receive their entire care within the
Emergency Department (excluding admissions to short
stay units).
dead on arrival (no active resuscitation)
babies who are stillborn, or show no sign of life at birth
patients attending an outpatient clinic/service
Slide 25
Outpatient clinic while an inpatient.
Outpatient (non- admitted) care provided to an inpatient
is included as part of the admitted care episode and is
not to be reported as separate activity, for example:
Inpatients receiving non-admitted care during an
admission, when attending an outpatient clinic or allied
health service.
Patients receiving non-admitted outpatient care on the
same day as admission, for example where the patient has
a procedure/treatment in an outpatient clinic requiring, or
followed by, subsequent same day or overnight admission.
Slide 26
Policy : Not should but could admit
The patient‟s condition and planned treatment may
meet admission criteria. This makes the patient
eligible to be considered for admission; it does not in
itself constitute admission. Care which technically
meets admission criteria may be provided as non-
admitted care. The policy is not directing that
patients should be admitted if they meet admission
criteria.
Slide 27
Admission Criteria
the person‟s condition requires clinical management
and/or facilities only available in an admitted care setting
the person requires regular and periodic observation in
order to be assessed or diagnosed
the person requires at least daily assessment of their
medication needs
the person requires a procedure(s) that cannot be
performed in a stand-alone facility, such as a doctor‟s
room, without specialised support facilities and/or
expertise available
there is a legal requirement for admission
Slide 28
Admission Same Day
Same day admission categories are:
same day extended medical treatment (Type E)
same day admitted procedures (Type B)
same day non-admitted procedures (Type C) when
certified
Same Day Rule
Only 1 admission per patient, per hospital, per day
Slide 29
Admission criteria for ED admissions
When an ED patient is admitted for short stay/same day,
admission to they must meet admission criteria:
Receive a minimum of four hours of continuous active
management; or
Are admitted to receive a procedure on the Type B
admitted procedures list
Exceptional cases which do not meet the admission
criteria, but which the treating medical officer decides
require admission
Slide 30
Emergency Department– Guide to Short Stay Admission Criteria
The decision to admit can ONLY be made by an authorised medical officer or nursing practitioner.
The decision to admit must be documented in the medical record.
Does the patient require a
procedure?
Does the patient require 4 or more hours of
continuous active management?
DO NOT
ADMIT
NO
Admission (Type E)
PLEASE NOTE that a patient is not eligible for admission just because/if:
o They are/will be in the Emergency Department for longer than 4 hours
o They are transferred to a short stay unit but do not meet admission criteria
o They are only waiting for: • review by an admitting team
• diagnostic tests or results
• transport home or transfer to another health care facility
• equipment or medications
o They receive their entire care within the Emergency Department
Admission (Type B) Admission (Type C)
Examples:
• Sedation/Anaesthesia
• Infusion/transfusion of blood/blood
products
• Closed reduction of fracture or
dislocations
• Infusion/transfusion of
pharmacological agent.
• Incision & drainage of abscess
• Arrest nasal haemorrhage
• Exc debridement skin & subc tissue
NB. IV therapy is the administration
by intravenous infusion of a
pharmacological/therapeutic agent.
Ancillary, preparatory and line
maintenance procedures are NOT
included as „therapy‟.
Examples:
• where general/regional anaesthesia
is required
• Where intravenous or inhalational
sedation is required
• Where the patient‟s co-morbidities
place the patient under high
dependency
NB. Reason for admission &
special circumstances must be
documented in the medical record
Reason for admission
Patient is to receive an admitted
Type B procedure.
Reason for admission
Patient is to receive a non-admitted
Type C procedure AND has a
condition or special circumstance that
justifies admission.
Reference: Admission, Readmission, Discharge and Transfer
(ARDT) Policy for WA Health Services and Operational Directive
http://www.health.wa.gov.au/circularsnew
YES YES
NB. Admission time commences when the patient physically
leaves the clinical area of ED for transfer to a ward, including
ED short stay unit, or operating theatre/procedure room
Identify which of the following the patient will require and
complete the associated documentation:
MANAGEMENT DOCUMENTATION REQUIRED
Serial
tests/investigations
Tests Required & intervals
Results and actions
documented
Regular periodic
observations Excludes: BP / pulse / temp
monitoring only
Required observations,
intervals and duration
4 hours of observation must be
documented
Continuous
monitoring
Type of monitoring
Active treatment (and
review)
Nature of treatment
Time of planned review
Slide 31
ED Admission Exclusions
A patient should not be admitted because they are or will
be in the ED for longer than 4 hours.
A patient should not be admitted if the reason for the
admission is they are waiting for:
review by an admitting team
diagnostic tests or results
transport home or to another health care facility
equipment or medications
Slide 32
ED admission exclusions
A patient should not be admitted if the reason is they are
resting prior to discharge, but do not require any ongoing
monitoring or care
Patients who require transfer to another hospital should
only be admitted
If they meet admission criteria and:
their condition requires stabilisation, which is not
possible in a non-admitted patient setting; or
their condition requires extensive active monitoring
or investigation prior to transfer
Slide 33
Key policy changes – effective 1 July 2013
Patients who receive their entire episode of
care within an Emergency Department (ED)
are not eligible for admission, even if they
meet the criteria for admission.
Admissions to a virtual ward within an
Emergency Department are invalid
Slide 34
Key policy changes – effective 1 July 2013
Admission Time is the time the patient physically
leaves the clinical area of the Emergency
Department for immediate transfer to a ward or
operating theatre/procedure room at the same
hospital.
Non-admitted services provided to a patient who is
subsequently classified as an admitted patient shall
not be regarded as part of the admitted episode.
Treatment in ED not coded
Slide 35
Criteria for same day extended medical
treatment (Type E)
Same day medical patients receive a minimum of four hours of
continuous active management consisting of:
regular observations (which may include diagnostic or investigative
procedures)
continuous monitoring
mental health patients requiring a period of safe
observation/assessment and discharge planning, including complex
evaluation of medical and ongoing psychosocial needs
Note: Continuous blood pressure and/or pulse monitoring alone is
not considered a sufficient level of continuous monitoring or regular
observations for this purpose.
Slide 36
Type c
These are procedures that would normally be undertaken
on a non-admitted basis and therefore not accepted as a
reason for admission in their own right.
Examples that would justify admitting a patient to perform
a Type C procedure include:
where general/regional anaesthesia is required
where intravenous or inhalational sedation is required
where the patient‟s co-morbidities place the patient under
high dependency
Slide 37
Overnight Admission
Overnight admission occurs when the patient is
expected to require admission for a minimum of one
night. Overnight admission includes:
Patients for whom a clinical decision is made to
commence treatment for a mental health diagnosis.
Treatment is anticipated to be for a minimum of one
night. Overnight admission excludes patients whose treatment is expected
to be concluded on the same day.
Slide 38
Admitted Care types
Slide 39
Slide 40
What are the care types?
Acute (includes involuntary mental health admitted care)
Subacute
-Rehab
-GEM
-Psych Geri
-Palliative
Non-acute- maintenance, nursing home type,
respite, care awaiting placement
Patients must meet the criteria
for admission for the care type
for a legitimate change to be
made and only one care type at
a time
Slide 41
Acute Care
manage labour (obstetric)
cure illness or provide definitive treatment of injury
perform surgery, diagnostic or therapeutic
procedures
relieve symptoms of illness or injury (excluding
palliative care)
protect against exacerbation and/or complication of
an illness and/or injury which could threaten life or
normal function, including involuntary psychiatric
admissions.
Slide 42
Subacute care
Evidence of a care type change (including the date of
handover, if applicable) must be clearly documented in
the patient‟s medical record.
A multidisciplinary management plan comprising a
series of documented and agreed initiatives or
treatments which are established through
multidisciplinary consultation and consultation with the
patient and/or carer(s).
It must contain specific program goals, actions and
timeframes.
Slide 43
Subacute care
Care delivered under the management of or
informed by a clinician with specialised expertise in
the subacute care type
The patient is expected to require admission for a
minimum of one night
2014 policy must be in a deisgnated program/unit
classified AN-SNAP. (30% not groupable)
GEM v Rehabilitation – one not both
Slide 44
Episode of care changes are not valid:
On the day of formal admission or discharge (new
policy inclusion)
For a temporary interruption/suspension due to a
change in patient condition
For a day procedure/treatment with planned return
For a non-admitted care attendance e.g. emergency
department, outpatients.
For the recovery period of an acute episode prior to
separation
Slide 45
Episode of care changes invalid
For the waiting period between acute care and
transfer to a subacute care facility
For a temporary change in ward or funding source
By the ward receiving the patient
To correct the care type due to a clerical error or
change of mind
Only one care type change per day
Only one admission per hospital per day
Slide 46
Transfer
Patients who are being transferred to another
hospital with no plan for return are to be discharged.
If the intention is for the patient to return within
seven days then the patient is placed on leave, not
discharged.
Internal transfers for same day procedure/treatment
are not to be statistically discharged
Slide 47
Outpatient clinic while an inpatient.
Outpatient (non- admitted) care provided to an inpatient
is included as part of the admitted care episode and is
not to be reported as separate activity, for example:
Inpatients receiving non-admitted care during an
admission, when attending an outpatient clinic or allied
health service.
Patients receiving non-admitted outpatient care on the
same day as admission, for example where the patient has
a procedure/treatment in an outpatient clinic requiring, or
followed by, subsequent same day or overnight admission.
Slide 48
Policy compliance evaluation
Corporate Governance Audit 2012:
70% of ED admissions, no valid clinical reason for admission
Up to 65% less than 4 hours in duration
Focus audit for < 4hr admissions from ED
59% no valid clinical reason for admission
50% did not leave ED (virtual ward)
Subacute Rehabilitation
Compliance with all admission criteria was 9%
23% of admissions >25 days should be non-acute
maintenance
38% of admissions <8 days were not valid rehabilitation
episodes
Slide 49
NEAT impact ?
Desire to meet the NEAT = Routinely admitting
patients to the virtual ward?
Admissions where entire stay from Triage to
Discharge < 4 hours
The clock does not stop until the patient is
discharged from ED admitted to a ward
Impact to NEAT performance after adjustment for
ED admissions < 4hours is minimal, ranging from 0 -
7 %, with an average 2% decrease across all
metropolitan hospitals.
Slide 50
Audit issues
In summary, health services are
non-compliant with the ARDT
policy
Invalid admissions are generating
additional activity and revenue
National alignment risk
Fraudulent claim of funding risk
It is a sad story Piglet and it does not improve with the telling
Activity is not being counted and costed in the correct
classification system
Incorrect activity data for use in costing, funding,
planning and other applications
Slide 51
Causal Factors and Actions
Awareness
Implementation
Conflict with NEAT
WHADILT
Documentation
Don‟t mean us?
Information Systems
inadequate
Governance of policy
Education & Training
Change Management
Communication
Activity 2013-14 adjusted
NEAT risks
Improve documentation
Information Systems
alignment
Slide 52
Currently
ED Continue with admitting practice and
cancel the invalid admissions later.
New service delivery models splitting the
acute episode across sites.
New hospital opening = large patient
transfers – activity counting and
classification challenge
HITH not HITH
Assessment Units – mixed non-
admitted/admitted
.
Slide 53
Change Management
The new environment of ABF/ABM
impacts on all aspects of health
service delivery
Purpose of existing data collections
Every admission is an invoice
requesting payment for
product/service delivered
Clinical practice alignment
Policy required to ensure appropriate
and legitimate funding of activity
Rules required to guide health
services
Slide 54
Lessons learnt
Impact on current business practices
Conflict with other policy/reforms
Culture ready for change
Humans will avoid/work around it
A ward is not always a ward
Policy ain‟t policy without good policy
management.
Policy alone is not going to cut it