Development of the Nottingham NUH OPAT service a Study analyzing the Figures behind the Funding

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1 Development of the Nottingham NUH OPAT service a Study analyzing the Figures behind the Funding Dr Susan Snape Consultant in Infectious Diseases and Microbiology

2 The Quest for the Holy Grail A recurrently funded officially commissioned OPAT service To help others achieve commissioned OPAT services OPAT - What is it? - What are the benefits? Patient perspective No brainer Hospital perspective No brainer Commissioners perspective we can see the patient and hospital benefits BUT is it in our financial interests?

3 Evidence Gathering Evidence in the literature Feasibility Study Help with writing an business case The Dragons Den - Backing from senior management Serendipity - Temporary non-recurrent funding 44,330 for 6 months 2 Nurses Presentations of progress - including to commissioners - Again the same issue - we can see the patient and hospital benefits BUT is it in our financial interests? Temporary year-long funding QIPP (Quality, QIPP Innovation, Productivity and Prevention) project 214,00 3 Nurses, 1 Support worker, 0.2WTE Band 5 Pharmacy Technician, 0.15WTE Band 8b Pharmacist 2PAs Consultant time

4 What population does the current NUH OPAT service serve? Majority cohorts - Early discharge: Orthopaedics and trauma bone and joint infections Diabetes - Diabetic foot infections Respiratory - Infective exacerbations in bronchiectatic patients Minority cohorts - Admission avoidance: Infectious diseases recurrent abscess (mycobacterial infection) Recurrent Infective exacerbation of bronchiectatic patients Predominantly patients taught to administer their own iv antibiotics when study performed patients had to compound their own antibiotics or a few attended hospital daily for administration of iv Abx - limited numbers of slots available. ( ie no pre-filled devices/ no home healthcare worker delivered service)

5 INPATIENT How Patient Episodes of Care are Funded Patient length of stay in hospital HRG code applied Trim point Set number of days of care paid for as a set lump sum Bed days over Trim paid for on a daily basis the amount is dependent on the HRG code Commissioners are happy to pay for the HRG (Healthcare Resource Group) coded tariff (nationally agreed). Commissioners will pay the Post Trim bed days (nationally agreed) but feel that the episode of care should have been covered already. EG DZ12A Infected exacerbation of Bronchiectasis; Number of days covered by HRG 31; Excess Bed Day cost 190

6 HRG code applied What impact can OPAT have on payments? Trim point Inpatient stay OPAT care A B C D A OPAT allows discharge pre Trim point Trust wins financially commissioners do not want to pay more B OPAT allows discharge post Trim point commissioners have had to pay more for the same episode of care and if OPAT achieves this then the commissioners win financially C If OPAT allows discharge pre Trim for care that goes over the Trim point and beyond both Trust and commissioners win. D OPAT allows admission avoidance NO HRG code is applied and hence the commissioners do not pay for the care BUT the hospital loses out on income commissioners win/trust loses

7 Study performed whilst receiving Non- Recurrent Funding - Savings (1) Consecutive data collected from Dec 2011 to Dec 2012 Early discharge patient episodes were analysed for individual HRG codes, Trim points and excess costs beyond Trim points Admission avoidance 10 patient episodes were analysed for the HRG code, Trim point and excess costs beyond Trim point that would have been applied if the patient had been admitted was calculated Individual Commissioning Groups wanted CCG level data

8 Study performed whilst receiving Non- Early Discharge HRG code applied Recurrent Funding - Savings (2) Trim point Inpatient stay OPAT care A B C Totals 2146 OPAT bed days saved 2343 OPAT bed days saved Trust benefits Commissioners benefit 176 episodes of patient care resulted in a saving of 4489 bed days of hospital admission 2146 bed days (48%) were pre Trim point (A and part of C) viewed as Trust savings 2343 bed days (52%) were post Trim point (B and part of C) - 528,786 savings for the commissioners

9 Study performed whilst receiving Non- Admission Avoidance Recurrent Funding - Savings (3) NO HRG code applied Trim point OPAT care D Totals Commissioners benefit 10 episodes of patient care resulted in a saving of 392 bed days of hospital admission resulting in a saving to the commissioners of 79,708

10 Study performed whilst receiving Non- Recurrent Funding - Costs PAY Consultant PAs (4.5 total 3 funded from OPAT budget) 30,000 Band 7 Nurse (1 WTE) 44,500 Band 6 Nurses (2 WTE) 74,000 Band 3 Support Nurse (1 WTE) 21,886 Band 5 Pharmacy technician (0.2 WTE) 6,100 Band 8b Pharmacist (0.15 WTE) 9,350 NON-PAY Drugs and Consumables 73,723 Miscellaneous 6,000 Overheads (20%) 53,111 TOTAL 318,670

11 Conclusions on Savings and QIPP Costs Total savings to the Commissioners 608,494. Total cost of the OPAT service 318,670. Commissioners have funded the NUH OPAT service in full on a recurrent basis as they are still realised savings of 289,824. Mechanism of funding through recording Outpatient, Ward Attendance and Nurse Home Visit activity. Trust and Clinical Commissioning Groups have agreed to spilt the QIPP benefit 50:50 because the benefits were so evenly. The Trust and Commissioners have agreed a bed day price of 250 having analysed the HRG codes.

12 Acknowledgements OPAT Team Nurses: Amanda Bort, Collen Jackson, Sarah Williams, Sandra Orme Pharmacist: Tim Hills Fellow Drs: Liz Hart, Roshina Gnanaduria, Ivo Elliott Business manager Sally Forster Corporate analyst/ liaison with commissioners Juliette Looker

13 Proposal to the Commissioners as to how the NUH OPAT service can be commissioned on a Recurrent Basis OUTPATIENT New patient tariff Follow up tariff Follow up tariff Follow up tariff Follow up tariff ID ward attendance visit One-off Nurse Home Visit Payment of ID tariff for outpatient clinic attendance for New patients 208 for Follow ups Payment of ID follow up tariff ( 208) for ward attendance for iv antibiotic administration Payment of 180 for nurse home visit at start of iv antibiotic administration at home