Value Based Commissioning and Mental Health Tariff

Dr David Davies GPClinical Lead VBC for Mental Health

Islington Clinical Commissioning Group

Wendy WallaceChief Executive

Camden and Islington NHS Foundation Trust

Care for patients with Severe Mental Illness – Camden and Islington

• What do we have now?

• Why do we need to look at change?

• How can we deliver it?

What we have now?Excess Mortality

What we have now SMI and LTC in C&I

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Prevalence of long term conditions among people diagnosed with serious mental illness compared to Camden and Islington's registered population aged 18 and over,

September 2012

SMI General Population

Source: Camden and Islington's GP PH Dataset, 2012

Whose Fault is it Anyway?

• Government?

• Providers?

• Commissioners?

• Patients?

Why do we need to look at Change?The Moral Case for Change

• Patients with an SMI will die 15 to 20 years earlier than their peers

• Causes of death will be the same as for the general population.

• Suicides are an important risk in people with SMI, but suicides do not account for the early mortality

Why do we need to look at Change?Patients have asked us.

Why do we need to Change?The Economic Case

QIPP

Whittington

C&IFT & LBI

UCLH

Royal Free

£2019 £2014

Integrated Practice Unit

‘Value’ in healthcare

Value =Health outcomes

Cost

To reduce cost, the best approach might be to spend more on some services to reduce the

need for others

Excellent care is frequently the lowest cost

Refers to total costs of the full cycle of care for the

customer’s medical condition, not the cost of

individual services

The full set of outcomes that constitute the quality of care for the customer over the complete care

cycle

VALUE-BASED COMMISSIONING means changing how healthcare is organised, measured and reimbursed in

order to improve the value of services

The unit of analysis is the individual not the organisation

Source: Michael Porter, VBHCD Course 2012, Harvard Business School

• Define your Health Outcomes

• Work with Providers, Users and Commissioners

• Build an IPU

VBC – How to do it

• Listen

• Acknowledge

• Share

• Try

VBC – How to do it (2)

Value Based Outcome Hierarchy

Survival

Degree of health or recovery

Time to recovery and time to return to normal activities

Disutility of care or treatment process

Sustainability of health or recovery and nature of reoccurrences

Long term consequences of therapy

Tier 1Health status Achieved or retained

Tier 2 Process of Recovery

Tier 3Sustainabilityof Health

NCL OUTCOMES FOR PEOPLE WITH SERIOUS MENTAL ILLNESS (SMI)

OBJECTIVE MEASURE

CSOM (Clinical & Social Outcome

Measure )

PROM (Patient Reported Outcome Measure)

Existing Survey

PDOM (Patient Defined

Outcome Measure) New Survey

Measure availability for this population

segment

1a. Mortality: A measure of overall mortality (shown as: i) overall mortality rate, ii) premature mortality rate and iii) suicide rate) ✔

2a. Quality of Life: A measure of Quality of Life ✔2b. Activities: A measure of ability to undertake routine daily activities ✔

3a. Symptom Control: A measure of feeling in control of symptoms (e.g. hallucinations, delusions) ✔

3b. Self-management: A measure of ability to manage care/medication ✗3c. Control: A measure of feeling in control of one's life ✔

4a. Speed/timeliness of access: A measure of timely access to services, including during crises ✔

4b. Dignity, respect and stigma: A measure of i) feeling treated with dignity and respect, and ii) feeling free from stigma ✔

4c. Personalised care: A measure of i) feeling my treatment plan (inc crisis plan) is personal to me ii) feeling that care is coordinated, iii) feeling involved in decisions about my care, and iv) being able to shape care services

✔

5a. Medication: A measure of adverse side effects from anti-psychotic medication✔

6a. Smoking: A measure of smoking activity ✔6b. Substance Misuse: A measure of substance misuse (alcohol and illicit drugs) ?6c. Diabetes: A measure of diabetes ✔6d. Diabetes: A measure of diabetes control ✔6e. Respiratory Disease: A measure of respiratory disease ?

7a. Meaningful activity: A measure of maintaining participation in 'meaningful' activity ✔

7b. Housing: A measurement of safe and comfortable housing ✔7c. Supporting carers: A measure of carer support ✔

LONG-TERM SOCIAL OUTCOMES

TYPE OF OUTCOME MEASURE OPTIONS

SUBJECTIVE MEASURE

EXPERIENCE OF CARE

RECOVERY / IMPROVEMENT OF SYMPTOMS

SURVIVAL

2. Patient identified outcomes related to Quality of Life

3. Self-Management and Self-Knowledge

ADVERSE EFFECTS FROM CARE

LONG-TERM PHYSICAL HEALTH OUTCOMES

• Define a new Operating Model or ‘Integrated Practice Unit (IPU)’.

Patient

Primary Care

Social Care

Acute Care/

Mental Health

Community Services

What happens today…- Services are organised

around clinical departments/specialties.

- Cost accounting is driven by ‘charges’ and not ‘cost’

- Patient visits different services, that are not entirely integrated and do not communicate with each other efficiently across the whole care cycle.

- We measure PROCESSES

How is tomorrow?- Services are organised

around patients with similar sets of needs which span professional bounderies

- Cost accounting is driven by “cost” and not ‘charges’

- IPU’s are responsible for the full cycle of care, that is is co-located and always coordinated centrally in an IPU.

- We measure OUTCOMES

IPU key characteristics – design & Build

Source: Michael Porter, VBHCD Course 2012, Harvard Business School

An IPU Case Study- NCL CVA Care

Next steps

Contracting Options Local agreement after consensus on

IPU design/financial model

Bundle Payments and Financial Incentives

Costing core care to understand financial envelope and developing performance and payment band

structures

Service re-design & IPU implementation

Consensus on outline IPU design/clinical model

Outcomes Base-lining and PROMs Strategy

Base-lining CSOMs and preparing PROMs collection process

Next Steps: Contracting options

In Summary- VBC for patients with SMI

• What do we have now?

• Why do we need to look at change?

• How can we deliver it?

So how does this all fit with MH Tariff?• Based on needs based groups• Activity count is year of care • Same next steps

Workingwith family

Medication

High quality

assessment

RECOVERY

Doing something

with my time

cA

RE

P L A N

NE

ED

S

Support to meet old

friends again

Relapse/Prevention

Reducing drug use

Help withbenefits

Keeping well

and fit

Mindfulness

MULTIPLE INTERLINKED CONCEPTS

Integrated Practice

Units

Care Pathways

Value based

outcomes

Contracting models

Service line / Value chain

management

Population segmentation

Needs

• Clear specifications for service delivery

• Packages of interventions aligned to need

• Full understanding of costs of delivery across care pathways

• To align costs with activity, quality & outcomes (to enable SLM)

• Use of benchmarking to understand priority areas for improvement

• Culture of innovation to maximise outcomes for given resources

• Rigour on data quality• Relates to social care &

personalisation

• Evident use of research, best practice, NICE Guidance, clinical audit etc,

• Rigorous interrogation of flow, conversion rates, equalities etc, to understand the efficacy of treatments & staff performance for all sub groups to fuel innovation and high quality performance

• Clinical Teams owning improvement and stretch, hardwired into team objectives and supervision

Provider

MHT and Value Maximisation

Maximise

Stretch

ResourcesOutcomes

Psychosis Integrated care pathway

• People Living with Psychosis corresponding to:– the SMI definition used by

NICE and used by Public Health and for QOF

– care clusters 10-17 for Mental Health Tariff

• Aged 18 years and over• Physical Health Needs

Service Criteria

• All activities related to delivering core mental health care related to People Living with Psychosis

• All activities related to delivering core physical health care (non-specialist), including care for common physical co-morbidities

• Exclusions for specialist e.g. Forensic or Surgery

People Criteria

Lynn J, Straube BM, Bell KM, Jencks SF, Kambic RT (2007) Using population segmentation to provide better health for all: the ‘bridges to health’ model. The Milbank Quarterly 85(2): 185-208

1. Interventions list

2. Intervention protocols based on NICE etc

3. Workforce skills required

% service users

Needs Evidenced based intervention required

High frequent

Psychotic delusions

Medication X 

High frequent

Depression CBT & medication Y

Common Obesity Wellbeing advice

Common Diabetes Advice, & medication

Some Homeless Housing officer support

Rare Sleep disturbance

Sleep clinic

   

Needs Analysis Mental Health, Social & Physical Health Care

Integrated care unit approach

Total Numbers per super cluster/ group/cluster cf to prevalence = % treatment secondary care

Vision for Tariff Outcomes

Service user rated

outcomes

Patient experience measures

Clinician rated outcomes

HONoS Agreed& implemented

Pilot measure 2014/15Optional implementation

Not yet agreed

Value Based Outcome Hierarchy

Survival

Degree of health or recovery

Time to recovery and time to return to normal activities

Disutility of care or treatment process

Sustainability of health or recovery and nature of reoccurrences

Long term consequences of therapy

Tier 1Health status Achieved or retained

Tier 2 Process of Recovery

Tier 3Sustainabilityof Health

NCL OUTCOMES FOR PEOPLE WITH SERIOUS MENTAL ILLNESS (SMI)

OBJECTIVE MEASURE

CSOM (Clinical & Social Outcome

Measure )

PROM (Patient Reported Outcome Measure)

Existing Survey

PDOM (Patient Defined

Outcome Measure) New Survey

Measure availability for this population

segment

1a. Mortality: A measure of overall mortality (shown as: i) overall mortality rate, ii) premature mortality rate and iii) suicide rate) ✔

2a. Quality of Life: A measure of Quality of Life ✔2b. Activities: A measure of ability to undertake routine daily activities ✔

3a. Symptom Control: A measure of feeling in control of symptoms (e.g. hallucinations, delusions) ✔

3b. Self-management: A measure of ability to manage care/medication ✗3c. Control: A measure of feeling in control of one's life ✔

4a. Speed/timeliness of access: A measure of timely access to services, including during crises ✔

4b. Dignity, respect and stigma: A measure of i) feeling treated with dignity and respect, and ii) feeling free from stigma ✔

4c. Personalised care: A measure of i) feeling my treatment plan (inc crisis plan) is personal to me ii) feeling that care is coordinated, iii) feeling involved in decisions about my care, and iv) being able to shape care services

✔

5a. Medication: A measure of adverse side effects from anti-psychotic medication✔

6a. Smoking: A measure of smoking activity ✔6b. Substance Misuse: A measure of substance misuse (alcohol and illicit drugs) ?6c. Diabetes: A measure of diabetes ✔6d. Diabetes: A measure of diabetes control ✔6e. Respiratory Disease: A measure of respiratory disease ?

7a. Meaningful activity: A measure of maintaining participation in 'meaningful' activity ✔

7b. Housing: A measurement of safe and comfortable housing ✔7c. Supporting carers: A measure of carer support ✔

LONG-TERM SOCIAL OUTCOMES

TYPE OF OUTCOME MEASURE OPTIONS

SUBJECTIVE MEASURE

EXPERIENCE OF CARE

RECOVERY / IMPROVEMENT OF SYMPTOMS

SURVIVAL

2. Patient identified outcomes related to Quality of Life

3. Self-Management and Self-Knowledge

ADVERSE EFFECTS FROM CARE

LONG-TERM PHYSICAL HEALTH OUTCOMES

Financial envelop expanded

MHMH Tariff

Plus social care

Plus additional physical healthcare

Next steps – dialogue between providers & commissioners

• Data quality- where best? Cohort stability? Activity volatility?

• What is current data saying?• Assess activity impact of access initiatives • Agree which data sets use for contract monitoring.• Will money move on activity and /or outcomes?

– If outcome based do you have robust measurement with norms for patient group?

• Will money move on all clusters or some?• Will it be based on super cluster, group or cluster level?• Confidence in current pricing• If activity based, per unit, stepwise, cap and collar?