Health informatics implications of Sub-acute transition to activity based funding

Health informatics implications of Sub-acute transition to activity based funding HIC2012 Carrie Schulman

What is Sub-acute care? Patients receiving sub-acute care generally require much longer stays in hospital than patients receiving acute care. For example, rehabilitation patients typically stay in hospital for two to three weeks or longer. Sub-acute care is defined as encompassing five care types in the National Partnership Agreement: 1. Rehabilitation 2. Palliative care 3. Geriatric Evaluation Management (GEM) 4. Psycho-geriatric care 5. Maintenance Sub-acute patients (who represent just 2.5% of patients) occupy 13% of Australian public hospital beds. Source: Australian Institute of Health and Welfare 2010. National health data dictionary. Version 15. National health data dictionary series. Cat. no. HWI 107. Canberra: AIHW 2

Classifying Subacute with AN-SNAP V2 All sub-acute and nonacute care Overnight admitted Ambulatory 11 classes 22 classes Assessment only * Provider type Palliative care Phase Phase RUG-ADL RUG-ADL Age Severity Age 45 classes 15 classes Assessment only Sameday/Outp/Comm Rehabilitation Impairment code Provider type FIM motor Impairment FIM cognition FIM motor Age FIM total * 6 classes 7 classes Assessment only * Assessment only Psycho-geriatric Short-term / ongoing Sameday/Outp/Comm HoNOS total Phase: Acute/other HoNOS items HoNOS 6 classes 8 classes Assessment only * Assessment only GEM FIM cognition Sameday/Outp/Comm FIM motor Provider type Age Age FIM motor 12 classes 16 classes Assessment only * Assessment only Maintenance short-term/ Sameday/Outp/Comm ongoing, Provider type maintenance type Age RUG-ADL RUG-ADL The Australian National Sub- Acute and Non- Acute Patient Classification (ANSNAP) The assessment tools used by AN-SNAP are: FIM for Rehabilitation and GEM RUG-ADL for Palliative care HoNOS for Psychogeriatric * Included in AN-SNAP V2, but not AN-SNAP V1 3

Counting Sub-acute Activity Data 4

Counting Sub-acute Activity Data Data availability and quality issues AN-SNAP is not a comprehensive product classification system for the identified subacute services funded under ABF. Other issues include inconsistent patient counting of output units for ambulatory subacute services, and differentiating patient complexity within classes, across States. Costing data for subacute services appears to be problematic in that unit costs are not comparing like services across states. Greater consistency in measurement that reflects a fair unit cost will also be an important consideration before implementation in 2013/14. Source: IHPA Draft Pricing Framework (December 2011) Uptake of AN SNAP and use in funding New South Wales and Queensland have good uptake in admitted designated units. There has not historically been AN-SNAP data collected in Victoria, South Australia and the ACT. In Western Australia, fewer than 29% of inpatient sub-acute episodes had an AN-SNAP classification. The uptake of AN-SNAP in the ambulatory settings is either non-existent, or very low both because of the administrative burden in use of the FIM tool and that AN-SNAP does not adequately explain costs for the range of ambulatory services provided. Source: Review of Subacute Classification and Cost Drivers (February 2012) 8

Separations by care type, states and territories (2009-10) Care type NSW Vic Qld WA SA Tas ACT NT Total Public hospitals Acute care 1,473,067 1,377,417 880,728 489,249 366,576 97,527 81,422 97,365 4,863,351 Rehabilitation care 29,329 14,796 18,786 8,511 6,510 1,358 2,788 614 82,692 Palliative care 10,279 6,208 5,953 1,284 1,627 310 651 321 26,633 GEM 3,689 13,250 1,671 668 1,327 35 639 31 21,310 Psychogeriatric care 744 0 544 708 260 48 31 1 2,336 Other admitted patient care 83,923 56,686 50,803 23,897 18,248 4,928 6,093 3,906 248,484 Total 1,601,031 1,468,357 958,485 524,317 394,548 104,206 91,624 102,238 5,244,806 Sub total: sub-acute 44,041 34,254 26,954 11,171 9,724 1,751 4,109 967 132,971 Private hospitals Acute care 852,910 857,955 808,647 374,076 251,138 358,854 Rehabilitation care 99,562 16,189 29,893 1,757 17,776 168,972 Palliative care 419 594 1,696 1,998 220 5,016 GEM 0 0 45 4 34 88 Psychogeriatric care 0 7,177 22 902 0 8,102 Other admitted patient care 24,774 3,864 21,325 10,960 1,693 2,967,517 Total 977,665 885,779 861,628 389,697 270,861 3,508,549 Sub total: sub-acute 99,981 23,960 31,656 4,661 18,030 182,178 Public hospitals sub-acute as % of total 2.8% 2.3% 2.8% 2.1% 2.5% 1.7% 4.5% 0.9% 2.5% All hospitals sub-acute as % of total 5.6% 2.5% 3.2% 1.7% 4.2% 1.7% 4.5% 0.9% 3.6% Source: Australian Institute of Health and Welfare 2011. Australian hospital statistics 2009 10. Health services series no. 40. Cat. no. HSE 107. Canberra: table S7.5 on page 174 9

1.40% 1.20% 1.00% 0.80% 0.60% 0.40% 0.20% 0.00% Public hospital sub-acute episodes per capita, by care type and State Psychogeriatric care GEM Palliative care Rehabilitation care All States/Territories with the exception of Victoria code over 60% of their sub-acute inpatient episodes to Rehab Victoria is the only State/Territory with over 30% of their sub-acute inpatient episodes coded as GEM. ACT has coded nearly twice as many sub-acute episodes per capita as any other State/Territory, Tasmania and NT have the lowest per capita use of all State/Territories. Palliative care ranges from 11% of episodes in WA to 33% in NT with most jurisdictions between 15 and 25%. Psycho-geriatric care represents only 1.8% of all episodes, the highest use being in WA and the lowest in Victoria and NT. Source: Australian Institute of Health and Welfare 2011. Australian hospital statistics 2009 10. Health services series no. 40. Cat. no. HSE 107. Canberra: Estimated resident population as at 31 Dec 2009 from ABS Cat 3101.0, Table 4 10

Explaining cost variation with AN-SNAP (RIV) 11

Explaining cost variation with AN-SNAP (RIV) Care Type Current RIV Additional Data Elements Enhanced RIV Rehab (Admitted) 1 VIC 25% los 21% cost NSW 18% los 29% cost Daily functioning and mobility at admission Type of impairment Co-morbidities Patient age at admission Measures of social support: marital status, and carer availability Remoteness based on postcode of the patient VIC 35% cost NSW 48% cost Palliative Care (Admitted) NSW 8% los 5% cost Change in RUG-ADL Patient diagnosis Co-morbidity, as measured by count of recorded diagnoses RUG-ADL at admission Change in dependency Age Overall palliative findings: Application of classification at the phase level is superior to application at the episode level Maximum episode RIV achieved using phase-level information was 50% Maximum RIV achieved using episode-level information with first phase only was 20% The recording of 10 phases is sufficient for classification purposes NSW 43% los 44% cost Source: Review of Subacute Classification and Cost Drivers (February 2012) 1. Source: 2009/10 Rehab cost and activity data for 2300 NSW episodes & 7000 VIC episodes 13

Funding sub-acute under ABF 14

Funding sub-acute under ABF Public hospital Sub-acute activity was block grant funded in 2012/13 by agreement between the State and the Commonwealth The implementation of nationally consistent ABF approaches for any remaining nonadmitted services, mental health and sub-acute services will commence on 1 July 2013. The IHPA may determine that there are different base prices for discrete categories of treatment, for example admitted care, sub-acute care, non-admitted emergency department care and outpatient care. Source: National Health Reform Agreement (August 2011) Eligibility criteria for public hospital services Source: IHPA Draft Pricing Framework (December 2011) 6. Was the service a non-admitted subacute service (rehabilitation or palliative care) that: a. Was provided through a designated subacute services facility/unit/program? AND b. Was provided to the patient at a public hospital, in a community-based setting or at home? AND c. Was funded by a public hospital? Impacts Are there reliable activity counts subacute service? Are all these based on designated services and funded by a public hospital? How will sub-acute price relate to long stay DRG? How does this impact model of care? Is there a consistent approach / policy re: care type and phase of care change, transition in and out of care types. 16

Key messages in improving informatics in Subacute 1. Engage clinicians in uptake of classification and data quality... accurate completion of assessment instruments unpacking statistical variation in subacute activity (care models) practices around care type assignment and care type changing What will the impact of ABF be on their current business model? What is capability around reporting of activity and cost data how confident are they in the data? How do their costs compare to peers? How is this knowledge informing efficiency initiatives? 17

Key messages in improving informatics in Subacute 1. Engage clinicians in uptake of classification and data quality... accurate completion of assessment instruments What will the impact of ABF be on their current business model? unpacking statistical variation in subacute activity (care models) What is capability around reporting of activity and cost data how confident are they in the data? practices around care type assignment and care type changing How do their costs compare to peers? How is this knowledge informing efficiency initiatives? 2. Consider collection of additional data items (the likely modifications to AN-SNAP inclusion of known cost drivers) 3. Watch for more information on funding methodology development 19