15 th November 2013 Steve Byng- PbR Implementation Lead DWMH Trust- Facilitator of Regional Quality and Outcome Group Mike Jones- Project Manager, South.

PbR Quality and Outcome Measures- Current Position15th November 2013

Steve Byng- PbR Implementation Lead DWMH Trust- Facilitator of Regional Quality and Outcome Group

Mike Jones- Project Manager, South Staffordshire and Shropshire NHS Foundation Trust

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Aims of Presentation

Update on current position of the Quality and Outcome Agenda

Role of the Regional Quality and Outcome Group

What are Quality and Outcome Measures?

14/15 Guidance – Next Steps

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Regional Quality and Outcome Group

•Sub Group of Regional PbR Steering Group

•Attended by regional Trusts:-

•Dudley Walsall Mental Health Partnership NHS Trust•North Staffordshire Combined Healthcare NHS Trust•South Staffordshire and Shropshire NHS Foundation Trust •Birmingham Solihull Mental Health NHS Foundation Trust•Black Country Partnership NHS Foundation Trust•Worcester Health and Care NHS Trust•Coventry and Warwick Partnership NHS Trust

•Clinical Representation

•Links into Finance & Informatic Sub Group

•Recent links with West Midlands Strategic Clinical Network- Neurological conditions, Dementia & Mental Health.

•New Links to National Group and Work streams

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‘Quality and Outcome measures are particularly important for mental health, because of the longer term nature of an individuals interaction with providers and the need to understand whether people are getting good quality care, are recovering, and for commissioners to be able to compare one provider with another’- Monitor Oct 13

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Quality and Outcomes- Background and Context•PbR currencies - Quality and Outcome Measures fundamental part of the new currency

•Quality and Outcome Measures to be mandated for all 21 Care Clusters

•Long term vision of Quality and Outcome Measures – intrinsically linked to the construction of national care cluster tariffs and PbR currencies.

•Payment of full cluster Tariff on delivery and demonstration of the 4 measures by Trusts

•Quality and Outcome agenda driven by National Quality and Outcome Group – Development of appropriate measures has been and remains problematic

•Regional Quality and Outcome Group - support Trusts in developing their awareness and understanding around this agenda

Quality and Outcome Measures – What are they and what do they mean?

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Patient Rated Experience

Measures (PREM)

Patient Rated Outcome Measure

(PROM)

The Clinician Rated Outcome measure

(CROM)

A set of quality indicators, reported

via MHMDS have been analysed with 10 recommended

for use

PREM- Patient Reported Experience Measure

•There is no universally or agreed way to assess and report Patient Experience.

•Commissioners and Providers should agree local activity to assess patient experience. Consideration should also be given to the appropriate use of the ‘friends and family’ question.

•The scale below should be used to answer the ‘friends and family’ question:

1. Extremely Likely2. Likely3. Neither likely or unlikely4. unlikely5. Extremely unlikely6. Don’t know

•PREM’s should be collected in line with the Care Cluster Allocation Tool: At initial assessment, routine review, significant change in presenting needs and at discharge.

•It is not expected that either Proms or Patient Experience data will be linked to payment during 14/15, but commissioners and providers should consider how this could be used in the future.

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PREM- Patient Reported Experience Measure•It is recommended providers ask follow up questions at the time of the family and friends question. The number and wording of these questions should be determined locally.

•Consideration should be given to the top 12 questions rated by service users form the CQC community survey:

1. Did you feel carefully listened to the last time you seen your NHS health care worker?

2. Did this person take your views into account?

3. Did you have trust and confidence in this person?

4. Do you understand what is in your NHS care plan?

5. Do you have a telephone number to contact your mental health service out of hours?

6. In the last 12 months have you received any sort of talking therapy from NHS mental health services?

7. In the last 12 months have you had a care review meeting to discuss your care?

8. Do you think your views were taken into account when deciding what was in you NHS care plan?

9. Do you think your views were taken into account when deciding which medication to take?

10. Overall rating of the service you have received?

11. In the last 12 months has your NHS worker checked how you are getting on with your medication?

12. Time period for last seeing someone form mental health services

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Use of PROM- Patient Reported Outcome Measure

•National Q&O Group acknowledge it has not been possible to identify a single PROM that adequately reflects the priorities for all of the clusters.

•It is suggested that where no PROM is currently being used within an organisation, WEMWEBS should be the PROM of choice.

•Additional or different PROMs may also be used

•Commissioners and Providers should ensure a PROM is being used for all of the clusters

•Use of PROM should be tied in with Cluster reviews.

•A quarterly review of the data relating to this should be undertaken.

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Quality Indicators

Recommended Indicators Additional Indicators

1. The proportion of users with a Crisis Plan in place, limited to those on CPA

2. The accommodation status of all users (as measured by an indicator of settled status and an indicator of accommodation problems)

3. The completeness of ethnicity recording

4. The proportion of users on CPA who have had a review in the last 12 mths

5. The proportion of users who have a valid ICD 10 diagnosis code recorded

6. The intensity of care (Bed days as a proportion of care days)

7. The intensity of care (OBD)

8. Proportion of in scope patients assigned to a cluster

9. Proportion of initial cluster allocations adhering to red rules

10. Proportion of patients within cluster review periods

1. Distribution of Actual Cluster Review Periods

2. Distribution of Actual Cluster Episode Period Duration

3. Distribution of Actual MH Cluster Review Period Duration

4. Re-referral Rate (to any in scope services

5. Proportion of Reviews (CPA) with a corresponding Clustering review

6. Indicator of accommodation problems

7. Cluster Profile

8. Step Up/ Step Down/ Little change/ Discharge

The Recommended Indicators will be reported nationally from MHMDS submissions during14/15.

Additional indicators can be used locally to inform service improvement.

Providers and commissioners may wish to assess how they could be used as part of a local payment.

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Use of CROM- Clinical Reported Outcome Measure The HONOS four Factor Model is the mandated generic clinician rated outcome measure which will be one of the methods used to demonstrate outcome for PbR

The model allows reliable change to be reported across total and factor scores showing clinical significance. The four factors are derived from the HoNOS ratings extracted from the cluster tool.

The 4 factors are:

1. Personal Well Being2. Emotional Well Being 3. Social Well Being 4. Severe Disturbance

Further information is expected regarding the methodology used to analyse and report on outcome data using the four factor model including total score and clinical significance.

HONOS scores to be completed at:

•Initial assessment•routine review•significant change in presenting needs•Discharge.

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0 1 2 3 4

No problem Minor problem require no action

Mild problem but Definitely present

Moderately severe

problem

Severe to verysevere problem

FACTOR 1Personal

Well Being

FACTOR 2EmotionalWell Being

FACTOR 3Social

Well Being

FACTOR 4Severe

Disturbance

Item 4: Cognitive Problems

Item 2:Non-accidental Injury

Item 3: Problem-drinking or drug taking

Item 1: Overactive, aggressive, disruptive or agitated behaviour

Item 5: Physical Illness or disability or disability problems

Item 7:Problems with depressed mood

Item 9: Problems with relationships

Item 6: Problems associated with hallucinations & delusions

Item 10: Problems with activities of daily living

Item 8:Other mental and behavioural problems

Item 11: Problems with living conditions

Item 12: Problems with occupation and activities

Item 12: Problems with occupation and activities

4 Factor Model (Speak et al 2013)- Based on the Health of the Nation Outcome Scales (HoNOS 12 Questions)

HoNOS Scale Factor

CARE CLUSTER

1 2 3 4 5 6 7 810

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1819

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21

Cognitive Problems 4

Personal Well-Being

S S S S S S M M S S M M S S M M S M M M

Physical Illness 5 S S S S S S M M S S M M S S M M S M M M

Activities of daily living 10 S S S S S S M M S S S S S S M M S M M M

Occupation & Activities 12 S S S S S S S S S S S S S S S S S S V V

Non-accidental self injury 2

Emotional Well-Being

M M M M S S S S S S S S S S S S S S V V

Depressed mood * 7 S S S S S S M M S S M M S S M M M V V V

Other mental & behavioural problems

8 S S S S S S M M S S M M S S M M M V V V

Problem drinking or drug taking

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Social Well-Being

M M M M S S S S S S S S S S S S S S V V

Relationships 9 S S S S S S M M S S S S S S M M S M M M

Living conditions 11 S S S S S S M M S S S S S S M M S M M M

Occupation & Activities 12 S S S S S S S S S S S S S S S S S S S V

Overactive, aggressive, disruptive or agitated behaviour

1Severe Disturbance

M M M M S S S S S S S S S S S S S S V V

Hallucinations and Delusions

6 S S S S S S M M S S M M S S M M M V V V

LEGEND

S Expected Improvement/Significant Change

M Minimum Improvement/No change in presentation

V Worsening of Symptoms/Deterioration in Condition

4 Factor Model (Speak et al 2013)

Care Clusters & Weighted Domains

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HoNOS Scale Factor Accumulated Score

Individual Score

Weighted Domains

4 Cognitive Problems

Personal Well-Being 6 (16)

1 M

5 Physical Illness 1 M

10 Activities of daily living 3 S

12 Occupation & Activities 3 S

2 Non-accidental self injury

Emotional Well Being 5 (12)

0 S

7 Depressed mood * 2 M

8 Other mental & behavioural problems: Sleep 3 M

3 Problem drinking or drug taking

Social Well-Being 4 (16)

0 S

9 Relationships 2 S

11 Living conditions 1 S

12 Occupation & Activities 3 S

1Overactive, aggressive, disruptive or agitated

behaviourSevere Disturbance 6 (8)

3 S

6 Hallucinations and Delusions 4 M

Care Cluster 14 Psychotic Crisis TOTALS 21 (48) 26

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Acute Care Plan- Multi Disciplinary- Focus

- Severe Disturbance- Emotional Well-being

- Home Treatment or Inpatient Care

Plan- Diagnose- Treat acute symptoms- Manage and reduce risk/behaviours- Liaise with & support family/carers

Expected Outcomes with Clinical Significance- Reduction/management of symptoms- Medication compliance- Reduction in risk/behaviours

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THE EFFECTIVENESS OF CARE PACKAGES: FACTOR SPECIFIC OUTCOME EVALUATION

Patient A - Comparison Chart

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1

2

3

4

4 5 10 12 2 7 8 3 9 11 12 1 6

HoNOS Scale

Ho

NO

S R

atin

g

Review 10 August 2013

Review 06 September 2013

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14/15 Guidance- Next Steps

National Guidance mandates the use of one outcome measure.

Pilot sites have been selected to start collecting PROM/PREM information to understand how they are to be used, interpreted and be linked to full tariff payment.

Updates are expected out during 2014 to inform 15/16 contracting agreements

Opportunity for local development of PREMs and PROMs  

As PREMs and PROMs remain in development, HONOS, reported through MHMDS extracts would be the natural Outcome choice for Trusts.

One of the quality indicators is to be reported per cluster and mandated within contracts ( Reported through MHMDS)

14/15 guidance is suggesting that for next year, adherence to review periods will be a quality measure - not mandated within 14/15 contracts.

For more detail on Quality and Outcome Measures, please see Draft guidance on mental health currencies and payment- 3rd October 2013.

Any Questions?

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