Care Pathways
&
Payment-by-Results
David Kingdon
University of Southampton
NHS South Central/Hampshire
Partnership FT
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
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]
• ‘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
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
Trust A
Trust B
Trust C
1: Common Mental Health Problems (low severity)
102
1035
150
2: Common Mental Health Problems (low severity with greater need)
273
1368
462
3: Non-Psychotic (Moderate Severity)
1002
978
729
4: Non-Psychotic (Severe)
1701
2034
369
5: Non-Psychotic (very severe)
273
1368
735
7: Enduring Non-Psychotic Disorders (high disability)
927
942
1239
15. Severe Psychotic Depression
135
108
75
6: Non-Psychotic Disorders of overvalued ideas [Eating disorders & OCD]
234
435
300
8: Non-Psychotic Chaotic and Challenging Disorders [ ‘Borderline PD’]
777
1068
150
0
0
0
1350
963
1638
14: Psychotic Crisis
435
228
762
11: Ongoing Recurrent Psychosis (low symptoms)
702
750
1035
12: Ongoing or Recurrent Psychosis (high disability)
1161
702
1101
13: Ongoing or Recurrent Psychosis (high symptom and disability)
2670
1026
3030
16: Dual Diagnosis = ‘Psychosis with drug abuse’
1377
396
1638
17: Psychosis and Affective Disorder Difficult to Engage
1128
294
1146
0
0
0
18: Cognitive impairment (low need)
1026
1701
702
19: Cognitive impairment or Dementia Complicated (Moderate need)
1368
2010
1062
20: Cognitive impairment or Dementia Complicated (High need)
534
1035
207
21: Cognitive impairment or Dementia (High physical or engagement needs)
702
1638
402
17877
20079
16932
CARE PATHWAYS AND CLUSTERS
Emotional difficulties:
Psychosis:
10: First Episode in Psychosis
Memory difficulties:
Total patients
Care pathways
Persistent
Acute
Stable
Psychosis
Stable
Low
Memory
difficulties
Moderate
High
Persistent
Anxiety/depression
Acute
& related
conditions
Acute
Eating
disorders
Persistent
Stable
Emotional
difficulties
Acute
Acute
‘Rapid cycling’
Borderline Personality
Disorder
Persistent
Bipolar disorder
Persistent
Stable
Stable
Payment-by-Results
High (P&E)
Care Pathway
Acute
Persistent
Stable
(Acute care pathway CRHT/Inpatient)
(Community
pathway/AOT/EIP)
(Community/recovery
pathway/IAPT)
Psychosis
14: Psychotic Crisis
10: First Episode in Psychosis
13: Ongoing or Recurrent
Psychosis (high symptom and
disability)
16: Dual Diagnosis =
‘Psychosis with drug abuse’
17: Psychosis and Affective
Disorder (Difficult to Engage)
11: Ongoing Recurrent
Psychosis (low symptoms)
12: Ongoing or Recurrent
Psychosis (high disability)
Bipolar
disorder
5: Non-Psychotic (very severe)
14: Psychotic Crisis
15. Severe Psychotic Depression
3: Non-Psychotic (Moderate
Severity)
4: Non-Psychotic (Severe)
7: Enduring Non-Psychotic
Disorders (high disability)
17: Psychosis and Affective
Disorder (Difficult to Engage)
1: Common Mental Health
Problems (low severity)
2: Common Mental Health
Problems (low severity with
greater need)
Anxiety/
depression
5: Non-Psychotic (very severe)
15. Severe Psychotic Depression
3: Non-Psychotic (Moderate
Severity)
4: Non-Psychotic (Severe)
7: Enduring Non-Psychotic
Disorders (high disability)
1: Common Mental Health
Problems (low severity)
2: Common Mental Health
Problems (low severity with
greater need)
‘Borderline PD’
8: Non-Psychotic Chaotic and
Challenging Disorders [ ‘Borderline
PD’]
3: Non-Psychotic (Moderate
Severity)
4: Non-Psychotic (Severe)
7: Enduring Non-Psychotic
Disorders (high disability)
1: Common Mental Health
Problems (low severity)
2: Common Mental Health
Problems (low severity with
greater need)
Eating
disorders
6: Non-Psychotic Disorders of
overvalued ideas [Eating disorders &
OCD]
3: Non-Psychotic (Moderate
Severity)
4: Non-Psychotic (Severe)
7: Enduring Non-Psychotic
Disorders (high disability)
6: Non-Psychotic Disorders of
overvalued ideas [Eating
1: Common Mental Health
Problems (low severity)
2: Common Mental Health
Problems (low severity with
greater need)
Care Pathway
Acute
Persistent
Stable
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 contraindicated 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).
Care Pathway
Acute
Persistent
Stable
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 contraindicated 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).
Care
Pathway
Acute
Persistent (Community Stable
(Acute pathway (AP):
CRHT/ Inpatient/PICU)
pathway (CP) /AOT/EIP)
Psychosis
£ Acute bed day
cost (AP) * av. LOS
= £P-A
Bipolar
disorder
Anxiety/
depression
‘Borderline
PD’
Eating
disorders
LOS – length of stay
* = x (multiply)
(Community pathway (CP)
/IAPT)
Care
Pathway
Acute
Persistent (Community Stable
(Acute pathway (AP):
CRHT/ Inpatient/PICU)
pathway (CP) /AOT/EIP)
Psychosis
£ Acute bed day
£Community day cost
cost (AP) * av. LOS (CP) * weighting *
= £P-A
days = £P-P
Bipolar
disorder
£ AP * av. LOS
= £BD- A
(Community pathway (CP)
/IAPT)
£ AP * av. LOS
Anxiety/
depression = £AD-A
‘Borderline £ AP * av. LOS
PD’
= £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)
Care
Pathway
Acute
Persistent (Community Stable
(Acute pathway (AP):
CRHT/ Inpatient/PICU)
pathway (CP) /AOT/EIP)
Psychosis
£ AP (acute bed
£Community day cost
day cost) * av. LOS (CP) * weighting *
= £P-A
days = £P-P
Bipolar
disorder
£ AP * av. LOS
= £BD- A
£CP * weighting * days
= £BP-P
£ AP * av. LOS
Anxiety/
depression = £AD-A
£CP * weighting * days
= £AD-P
‘Borderline £ AP * av. LOS
PD’
= £BPDA
£CP * weighting * days
= £BPD-P
Eating
disorders
£ AP * av. LOS =
£ED-A
(Community pathway (CP)
/IAPT)
£CP * weighting *
days = £P-S
£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)
Care
Pathway
Acute
Persistent (Community Stable
(Acute pathway (AP):
CRHT/ Inpatient/PICU)
pathway (CP) /AOT/EIP)
Psychosis
£ AP (acute bed
£CP * weighting * days £CP * weighting *
day cost) * av. LOS = £P-P
days = £P-S
= £P-A
Bipolar
disorder
£ AP * av. LOS
= £BD- A
(Community pathway (CP)
/IAPT)
£CP * weighting * days £CP * weighting *
= £BP-P
days = £BP-P
£ AP * av. LOS
Anxiety/
depression = £AD-A
£CP * weighting * days [IAPT + £CP] *
= £AD-P
weighting * days =
£AD-S
‘Borderline £ AP * av. LOS
PD’
= £BPDA
£CP * weighting * days £CP * weighting *
= £BPD-P
days = £BPD-S
Eating
disorders
£ AP * av. LOS =
£ED-A
£CP * weighting * days £CP * weighting *
= £ED-P
days = £ED-P
Weighting – measured or estimated (e.g. Persistent = 2 x Stable; actual costs for IAPT)
LOS – length of stay
* = x (multiply)
Care Pathway
Acute
Persistent (high Stable
(CRHT/Inpatient)
need community
pathway/AOT/EIP)
(community/recovery
pathway/IAPT)
Psychosis
14: Psychotic Crisis
10: First Episode in Psychosis
13: Ongoing or Recurrent
Psychosis (high symptom and
disability)
16: Dual Diagnosis =
‘Psychosis with drug abuse’
17: Psychosis and Affective
Disorder (Difficult to Engage)
11: Ongoing Recurrent
Psychosis (low symptoms)
12: Ongoing or Recurrent
Psychosis (high disability)
Bipolar
disorder
5: Non-Psychotic (very severe)
3: Non-Psychotic (Moderate
Severity)
4: Non-Psychotic (Severe)
7: Enduring Non-Psychotic
Disorders (high disability)
1: Common Mental Health
Problems (low severity)
2: Common Mental Health
Problems (low severity with
greater need)
Anxiety/
depression
5: Non-Psychotic (very severe)
15. Severe Psychotic Depression
3: Non-Psychotic (Moderate
Severity)
4: Non-Psychotic (Severe)
7: Enduring Non-Psychotic
Disorders (high disability)
1: Common Mental Health
Problems (low severity)
2: Common Mental Health
Problems (low severity with
greater need)
‘Borderline PD’
8: Non-Psychotic Chaotic and
Challenging Disorders [ ‘Borderline
PD’]
3: Non-Psychotic (Moderate
Severity)
4: Non-Psychotic (Severe)
7: Enduring Non-Psychotic
Disorders (high disability)
1: Common Mental Health
Problems (low severity)
2: Common Mental Health
Problems (low severity with
greater need)
Eating
disorders
6: Non-Psychotic Disorders of
overvalued ideas [Eating disorders &
OCD]
3: Non-Psychotic (Moderate
Severity)
4: Non-Psychotic (Severe)
7: Enduring Non-Psychotic
Disorders (high disability)
6: Non-Psychotic Disorders of
overvalued ideas [Eating
disorders & OCD]
1: Common Mental Health
Problems (low severity)
2: Common Mental Health
Problems (low severity with
greater need)
14: Psychotic Crisis
15. Severe Psychotic Depression
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.
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
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