BEACON UK beaconhs.co.uk July 10,

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1 Outcomes Based Commissioning for mental health: Two new approaches to contracting for integrated mental health care June BEACON UK beaconhs.co.uk July 10,

2 Commissioning has to be improved as current commissioning models do not align reimbursement with outcomes Many patients have multiple needs. However, commissioning is fragmented as commissioners contract separately with each provider Payment mechanisms include any combination of a payment for activity, block payment and payments for specific indicators (e.g., CQUINs) Reimbursement is mainly aligned to legacy Multiple providers may be involved in any individual s care but are not coordinated in a meaningful way There is a lack of both incentives for providers to work together and shared outcomes for individuals that all can work towards BEACON UK beaconhs.co.uk July 10,

3 New commissioning models are emerging to commission across traditional silo settings GPs are keen to improve commissioning CCGs lack meaningful data about what outcome they get for their money, especially when commissioning mental health care GP Acute Trust Outcomes based commissioning is an innovative contractual model that is increasingly applied across the NHS by CCGs to improve outcomes for distinct populations, such as the whole of mental health care provision or sub-populations such as dementia 3 rd Sector MH Trust Social Care Commissioners contract with a number of providers together in one contract An increasing proportion of contract value is at risk based on delivering defined outcomes Multiple providers are incentivised to collaborate, share data and aligned towards achieving locally set outcomes for people with multiple health problems BEACON UK beaconhs.co.uk July 10,

4 To improve mental health contracting - Super clusters can be used to inform reimbursement In Oxfordshire, we subdivided the population of people with mental health problems into three superclusters. Note: 51% of OH mental health trust spend is on 4,900 people with psychosis. The most frequent age category for people with psychosis is 45 to 49 years old. Only 15% of people with psychosis are employed. 67% of people are either unemployed and seeking work or are long-term sick/disabled and receiving benefits. 40% of people with psychosis live in a residential home setting a.mild/mod/ severe A. Nonpsychotic b. very severe & complex Working-aged Adults and Older People with Mental Health Problems NB blank in DH currency c. substance abuse a. first episode b. ongoing/ recurrent B. Psychosis C. Organic c. psychotic crisis d. very severe engagement a. cognitive impairment Cluster Numbers * Delayed until 2014 Example of COBIC for substance misuse in Milton Keynes includes outcomes related to employment, housing and crime. We propose that people with cognitive impairment are included as part of Frail Elderly outcome based contract across Oxford combining mental health & physical health care BEACON UK beaconhs.co.uk July 10,

5 EXAMPLE OF AN OUTCOMES HIERARCHY: FOR PEOPLE WITH DEMENTIA Tier 1 Health Status Achieved or Retained Tier 2 Process of Recovery Survival Degree of recovery / health Time to recovery or return to normal activities Disutility of care or treatment process (e.g., treatment-related discomfort, complications, adverse effects, diagnostic errors, treatment errors) 10 year survival rate year after diagnosis. Extent of return to normal daily living and self care. Preserved function within community. Quality of life scores: e.g. EQ-5D Time from diagnosis/ admission to returning home. Discharged with adequate care plan. Time from admission to re-enablement. Missed diagnosis Patient safety/ dignity not maintained Tier 3 Sustainability of Health Sustainability of recovery or health over time Long-term consequences of therapy (e.g., care-induced illnesses) Number of years service user remains living at home. Rate of progression of psychological and cognitive symptoms. Admission to a care home. Lack of support for carers. BEACON UK beaconhs.co.uk July 10,

6 Beacon s methodological approach for integrating mental health care: Applying Levels of Care criteria BEACON UK beaconhs.co.uk July 10,

7 MH co-morbidity drives spending among members with chronic diseases MEDICAL, MH AND RX AVERAGE PMPM SPEND, $4,000 $3,807 $3,000 $2,601 MH Non-MH $2,000 $1,692 $1,698 $1,000 $0 $296 $125 MH 1 Chronic $303 $648 2 Chronic $534 $1,072 3 Chronic $866 4 Chronic $1,301 5 Chronic 6 Chronic Client claims data before BEACON engagement BEACON UK beaconhs.co.uk July 10,

8 MH co-morbidity drives spending among members with chronic diseases MEDICAL, MH AND RX AVERAGE PMPM SPEND, $4,000 $3,000 $2,000 $1,000 $ % of patients on an acute hospital ward (inpatient) will be experiencing a mental health problem. 60% of people aged over 65 account for two-thirds $2,601 of hospital bed occupancy in the NHS. For the vast majority of patients, their mental health condition will not have been treated by the time $1,692they are $1,698 discharged from hospital. $125 $296 MH 1 Chronic $303 $648 2 Chronic $534 $1,072 3 Chronic $866 4 Chronic $1,301 5 Chronic $3,807 6 Chronic MH Non-MH Client claims data before BEACON engagement BEACON UK beaconhs.co.uk July 10,

9 In the UK: The high user cohort of people with mental AND physical health care needs is a new area of much needed focus Goal: To improve outcomes through improved coordination of care for people who are the highest utilisers of mental health, acute secondary care and social care services, under the age of 65 and over Identify the 500 most frequent users of mental, physical health and social care services using data on inpatient mental health, acute admissions & A&E attendances and Adult Social Care Data over the preceding 36 months. Aim to enroll 250 people in the intervention (NB: up to 40% may have no stable housing/employment). Peer mentors will play a key role in this engagement and recruitment process. For an intervention period of circa 24 months, super case managers oversee CMHT care coordinators, pivoting existing mental health care teams to address physical health and social care needs, avoiding duplication of existing community services. 4 Capturing patient experience, outcomes and utilisation data. BEACON UK beaconhs.co.uk July 10,

10 What are the implications of contracting for integrated mental health care for patients Improved clinical outcomes for patients Reduced number of inpatient admissions and outpatient appointments Reduced overall lengths of stay and bed days Ensuring patients with co-morbid long-term conditions receive better treatment while using fewer health care resources Treating and reducing costs for patients with medically unexplained symptoms Improving coordination of care Better patient and carer experience Potential impact on community services Increased number of patients supported in the community Improved coordination of care and relationships with Acute /Mental Health Trusts Focus on clinical outcomes recording information that matters Dr Emma Stanton BEACON UK beaconhs.co.uk July 10,