Kathy Alloway - Dept of Health WA - WA State Update

Kathleen Alloway – Senior Policy Officer

Activity Based Funding and Management

Department of Health

Counting Activity Correctly and Consistently

Counts : The application and evaluation of

Admission, Readmission , Discharge and

Transfer Policy

Add something maybe about disclosing information to third parties no Add something maybe about disclosing information to third parties no

43,000 staff

Metro

5 teaching & 6 secondary

2 private/public

Community Health

Child & Adolescent Health

Country

13 health campuses

15 secondary, 51 small hosp

numerous nursing posts,

health centres

New Hospitals

Fiona Stanley

Albany

Midland

Childrens Hospital

WA coding update

ABF has stimulated re-alignment of coding , now

under Finance at both NMAHS and SMAHS.

ABF offered scholarships for further study which

many took up (not funded this year)

WA has no shortfall in coder workforce at the

moment.

Clinical Advisory Group keen to address clinical

documentation and coding education

Coding standards V ABF

Spending on Health is approximately 25%

of State total general expenditure

Cost increases in Health exceed

“standard” cost growth – IHPA indexation

= 4.7% for 2013-2014

Pressure from State Treasury to close the

gap between national price and state price

Reliability of ABF measures in explanation

of Health System performance

Managing resources and reconfiguration

of Health Services

Challenges for WA Health

What is the focus of the work?

Develop/enhance

processes, people or

tools so we:

Collect

Code

Classify

Cost

Count

Enables

us to

Understand our business (Revenue,

Cost and Performance)

Improve Accountability and

Performance Management

Improve service efficiency

Improve safety and quality

Make more informed decisions

Negotiate for Commonwealth Funds

Fund services appropriately

Benchmark Services

ACTIVITY

Clinical Casemix Handbook 2012-2014

The Clinical Casemix handbook is a

structured practical guide for clinicians.

The handbook has been developed in

collaboration with staff across WA Health, to

support clinicians to understand the

importance of timely and accurate

information about their patients and their

care.

Clinical documentation requirements for timely, accurate, and accountable

information are a key element in successful implementation of


The Handbook outlines:

The clinical coding process, from its use of

diagnoses and complications or co-

morbidities to determine care and complexity

levels, to the final assignment of DRGs.

How the DRG is then used to drive the


approach.

Improving clinical documentation is about making the patient‟s journey

through the health care system safer and smoother

The Handbook:

Highlights the importance of documenting

clinical information in the patient‟s medical

record and producing an accurate and

timely discharge summary.

Incorporates case studies from within WA

health demonstrating the impact of

documentation on patient safety, quality of

care, cost and revenue.

Incomplete, delayed or inaccurate documentation impairs both the data

available for safe and quality patient care, and that used for reporting,

coding, costing and subsequent funding to the health service

Vision for WA ABF/ABM

Activity Based Funding is the management tool that supports ABM to enhance

public accountability and drive technical efficiency in the delivery of health

services by:

Capturing consistent information on activity and the costs of delivery;

Creating an explicit relationship between funds allocated and services

provided;

Strengthening management‟s focus on outputs, outcomes, quality and

safety;

Managing variation in costs and practices to improve efficiency and

effectiveness; and

Providing mechanisms to reward good practice and support quality and

safety initiatives.

Change Management

“ Structured approach to transitioning individuals, teams

and organisations from a current state to a desired future

state”

Supporting people to be:

Ready Willing Able

Dimensions:

Culture Commitment Capability

Consistent classification and tracking of activity

provides access to reliable data so that we may

understand and manage our business better

National activity based funding program requires a

standardised approach

High quality robust data is an integral part of the

practical application of ABF/ABM

We need rules on how we count and classify

activity

Activity data is used for a range of applications

WA health services have an obligation to count and label activity in an accurate and consistent fashion

An admitted patient must meet the criteria for admission

related to the admission category and care type. These

include :

Expected levels of care

Documentation requirements

Same day specific criteria for emergency admissions

Procedure exclusions set by the Commonwealth

Assessment and Care planning

Activity Based Funding and Management as the principal resource allocation and funding mechanism means that correct labelling and

counting of activity is now especially important

The ARDT policy provides a framework, containing detailed rules and criteria to enable this to occur

The ARDT policy has range of benefits:

Ensuring health services are correctly funded

Accurate activity for use in clinical costing

Inform and position the state to align with national

hospital funding reforms

Provide a reliable care delivery profile to inform

clinical services planning

Key information from a range of related documents provides a

“one stop policy document” to support staff as they record and

classify this information

The ARDT policy had been developed through research into other

jurisdictions and in collaboration with staff across WA Health

Why is it so important ?

Activity Data

+ Costing Data

WAU & Price

Activity Classification WAU

ED URG: 6

Admitted, Triage 1, Circulatory 0.2528

Acute

Admitted

DRG: F10A Interventional

Coronary Procedures with AMI

without Catastrophic CC

2.1616

Non

Admitted

Tier 2 Clinic: 20.22

Cardiology Clinic 0.0610

For 2014-2015

health activity data

will directly inform

the amount of

Commonwealth

funding to WA

Policy Management Utopia

DoH

Consultation

Development

Distribution

Education

Operational Directive

Issues

Revision

Health Services

Implementation

Impact

Communication

Access

Audit compliance

Action non-compliance

Feedback issues

NON ADMITTED

1. ED ATTENDANCE

2. OUTPATIENT SERVICES

3. COMMUNITY AND

OUTREACH SERVICES

4. BOARDERS

5. CANCELLED PROCEDURES

6. REFUSED PROCEDURES

7. DEAD ON ARRIVAL

8. POSTHUMOUS ORGAN

DONATION

9. STILLBORN

Patients

ElectiveEmergency

Acute

ED Presentation Direct Admission Non-wait listWait list

ADMISSION

Sub-Acute

Non-Acute

Same Day Overnight

Non-Admitted

Procedures

(Type C)

Automatically

qualified for

admission (Type B)

Commonwealth

Legislation

Admitted

Procedures (Type B)

Non-Admitted

Procedures (Type C)

when certified

Same-day extended

medical treatment (SDE)

Band 1

Band 2

Band 3

Band 4

Special circumstances Clinical decision to

admit becoming…certified

Contracted CareOrgan donation

Overnight Adult (OA)

16 Admission criteria

Overnight Paediatric

(PA)

20 Admission criteria

Overnight Mental

Health (MH)

Additional legal and

social factors

Newborns

<9 days old

8 criteria to distinguish

b/w QN and UQN

Unqualified

(UQN)

Qualified

(QN)

1. Rehabilitation

2. Geriatric evaluation and management

3. Psychogeriatric

4. Palliative Care

5. Maintenance care

6. Nursing Home Type care

7. Aged / ‘Flexible’ care

Ambulatory Surgery

Policy research – DoH policy documents

Admission Policy for WA Hospitals (Technical Bulletin 17/3, 2002).

Transferred Patients (Technical Bulletin 50/0, 2002).

Neonatal care information reporting (Technical Bulletin 14/5, 2004).

Renal Dialysis (Technical Bulletin 4/5, 2002).

Reporting different episodes of care (Technical Bulletin 26/5, 2004).

Hospital Morbidity Information (Technical Bulletin 10/6, 2005).

Rehabilitation program – definitions and reporting requirements (Operational

Directive 0025/06, 2006).

Hospital in the Home care (Technical Bulletin 78/0, 2006).

Subacute and non-acute care (Technical bulletin: 20/6, 2004).

Discharge Policy in WA Hospitals (Technical bulletin: 40/1, 2001).

Geriatric Evaluation and Management (GEM) – Definitions and Reporting

Requirements (Technical Bulletin 79/0, 2006)

Palliative Care Program (Technical Bulletin 42/3, 2002)

Some Myths

Policy distributed = Implemented

Operation Directive = Law

Admission = Admitted Care

Consultation = Compliance

Communication = Consultation

Change management = Just do

what the policy says

Admitted Care

An admitted patient is defined as a person who

meets the criteria for admission and additional

criteria specific to the applicable admission

category and care type, and undergoes a hospital‟s

admission process (documented) to receive

treatment and/or care for a period of time

Non-admitted care

patients attending for a procedure on the non-admitted

procedures (Type C) list, without other justification for

admission documented by the treating medical

practitioner in the medical record

patients who receive their entire care within the

Emergency Department (excluding admissions to short

stay units).

dead on arrival (no active resuscitation)

babies who are stillborn, or show no sign of life at birth

patients attending an outpatient clinic/service

Outpatient clinic while an inpatient.

Outpatient (non- admitted) care provided to an inpatient

is included as part of the admitted care episode and is

not to be reported as separate activity, for example:

Inpatients receiving non-admitted care during an

admission, when attending an outpatient clinic or allied

health service.

Patients receiving non-admitted outpatient care on the

same day as admission, for example where the patient has

a procedure/treatment in an outpatient clinic requiring, or

followed by, subsequent same day or overnight admission.

Policy : Not should but could admit

The patient‟s condition and planned treatment may

meet admission criteria. This makes the patient

eligible to be considered for admission; it does not in

itself constitute admission. Care which technically

meets admission criteria may be provided as non-

admitted care. The policy is not directing that

patients should be admitted if they meet admission

criteria.

Admission Criteria

the person‟s condition requires clinical management

and/or facilities only available in an admitted care setting

the person requires regular and periodic observation in

order to be assessed or diagnosed

the person requires at least daily assessment of their

medication needs

the person requires a procedure(s) that cannot be

performed in a stand-alone facility, such as a doctor‟s

room, without specialised support facilities and/or

expertise available

there is a legal requirement for admission

Admission Same Day

Same day admission categories are:

same day extended medical treatment (Type E)

same day admitted procedures (Type B)

same day non-admitted procedures (Type C) when

certified

Same Day Rule

Only 1 admission per patient, per hospital, per day

Admission criteria for ED admissions

When an ED patient is admitted for short stay/same day,

admission to they must meet admission criteria:

Receive a minimum of four hours of continuous active

management; or

Are admitted to receive a procedure on the Type B

admitted procedures list

Exceptional cases which do not meet the admission

criteria, but which the treating medical officer decides

require admission

Emergency Department– Guide to Short Stay Admission Criteria

The decision to admit can ONLY be made by an authorised medical officer or nursing practitioner.

The decision to admit must be documented in the medical record.

Does the patient require a

procedure?

Does the patient require 4 or more hours of

continuous active management?

DO NOT

ADMIT

NO

Admission (Type E)

PLEASE NOTE that a patient is not eligible for admission just because/if:

o They are/will be in the Emergency Department for longer than 4 hours

o They are transferred to a short stay unit but do not meet admission criteria

o They are only waiting for: • review by an admitting team

• diagnostic tests or results

• transport home or transfer to another health care facility

• equipment or medications

o They receive their entire care within the Emergency Department

Admission (Type B) Admission (Type C)

Examples:

• Sedation/Anaesthesia

• Infusion/transfusion of blood/blood

products

• Closed reduction of fracture or

dislocations

• Infusion/transfusion of

pharmacological agent.

• Incision & drainage of abscess

• Arrest nasal haemorrhage

• Exc debridement skin & subc tissue

NB. IV therapy is the administration

by intravenous infusion of a

pharmacological/therapeutic agent.

Ancillary, preparatory and line

maintenance procedures are NOT

included as „therapy‟.

Examples:

• where general/regional anaesthesia

is required

• Where intravenous or inhalational

sedation is required

• Where the patient‟s co-morbidities

place the patient under high

dependency

NB. Reason for admission &

special circumstances must be

documented in the medical record

Reason for admission

Patient is to receive an admitted

Type B procedure.

Reason for admission

Patient is to receive a non-admitted

Type C procedure AND has a

condition or special circumstance that

justifies admission.

Reference: Admission, Readmission, Discharge and Transfer

(ARDT) Policy for WA Health Services and Operational Directive

http://www.health.wa.gov.au/circularsnew

YES YES

NB. Admission time commences when the patient physically

leaves the clinical area of ED for transfer to a ward, including

ED short stay unit, or operating theatre/procedure room

Identify which of the following the patient will require and

complete the associated documentation:

MANAGEMENT DOCUMENTATION REQUIRED

Serial

tests/investigations

Tests Required & intervals

Results and actions

documented

Regular periodic

observations Excludes: BP / pulse / temp

monitoring only

Required observations,

intervals and duration

4 hours of observation must be

documented

Continuous

monitoring

Type of monitoring

Active treatment (and

review)

Nature of treatment

Time of planned review

http://www.health.wa.gov.au/circularsnew/circular.cfm?Circ_ID=12915

ED Admission Exclusions

A patient should not be admitted because they are or will

be in the ED for longer than 4 hours.

A patient should not be admitted if the reason for the

admission is they are waiting for:

review by an admitting team

diagnostic tests or results

transport home or to another health care facility

equipment or medications

ED admission exclusions

A patient should not be admitted if the reason is they are

resting prior to discharge, but do not require any ongoing

monitoring or care

Patients who require transfer to another hospital should

only be admitted

If they meet admission criteria and:

their condition requires stabilisation, which is not

possible in a non-admitted patient setting; or

their condition requires extensive active monitoring

or investigation prior to transfer

Key policy changes – effective 1 July 2013

Patients who receive their entire episode of

care within an Emergency Department (ED)

are not eligible for admission, even if they

meet the criteria for admission.

Admissions to a virtual ward within an

Emergency Department are invalid

Key policy changes – effective 1 July 2013

Admission Time is the time the patient physically

leaves the clinical area of the Emergency

Department for immediate transfer to a ward or

operating theatre/procedure room at the same

hospital.

Non-admitted services provided to a patient who is

subsequently classified as an admitted patient shall

not be regarded as part of the admitted episode.

Treatment in ED not coded

Criteria for same day extended medical

treatment (Type E)

Same day medical patients receive a minimum of four hours of

continuous active management consisting of:

regular observations (which may include diagnostic or investigative

procedures)

continuous monitoring

mental health patients requiring a period of safe

observation/assessment and discharge planning, including complex

evaluation of medical and ongoing psychosocial needs

Note: Continuous blood pressure and/or pulse monitoring alone is

not considered a sufficient level of continuous monitoring or regular

observations for this purpose.

Type c

These are procedures that would normally be undertaken

on a non-admitted basis and therefore not accepted as a

reason for admission in their own right.

Examples that would justify admitting a patient to perform

a Type C procedure include:

where general/regional anaesthesia is required

where intravenous or inhalational sedation is required

where the patient‟s co-morbidities place the patient under

high dependency

Overnight Admission

Overnight admission occurs when the patient is

expected to require admission for a minimum of one

night. Overnight admission includes:

Patients for whom a clinical decision is made to

commence treatment for a mental health diagnosis.

Treatment is anticipated to be for a minimum of one

night. Overnight admission excludes patients whose treatment is expected

to be concluded on the same day.

Admitted Care types

What are the care types?

Acute (includes involuntary mental health admitted care)

Subacute

-Rehab

-GEM

-Psych Geri

-Palliative

Non-acute- maintenance, nursing home type,

respite, care awaiting placement

Patients must meet the criteria

for admission for the care type

for a legitimate change to be

made and only one care type at

a time

Acute Care

manage labour (obstetric)

cure illness or provide definitive treatment of injury

perform surgery, diagnostic or therapeutic

procedures

relieve symptoms of illness or injury (excluding

palliative care)

protect against exacerbation and/or complication of

an illness and/or injury which could threaten life or

normal function, including involuntary psychiatric

admissions.

Subacute care

Evidence of a care type change (including the date of

handover, if applicable) must be clearly documented in

the patient‟s medical record.

A multidisciplinary management plan comprising a

series of documented and agreed initiatives or

treatments which are established through

multidisciplinary consultation and consultation with the

patient and/or carer(s).

It must contain specific program goals, actions and

timeframes.

Subacute care

Care delivered under the management of or

informed by a clinician with specialised expertise in

the subacute care type

The patient is expected to require admission for a

minimum of one night

2014 policy must be in a deisgnated program/unit

classified AN-SNAP. (30% not groupable)

GEM v Rehabilitation – one not both

Episode of care changes are not valid:

On the day of formal admission or discharge (new

policy inclusion)

For a temporary interruption/suspension due to a

change in patient condition

For a day procedure/treatment with planned return

For a non-admitted care attendance e.g. emergency

department, outpatients.

For the recovery period of an acute episode prior to

separation

Episode of care changes invalid

For the waiting period between acute care and

transfer to a subacute care facility

For a temporary change in ward or funding source

By the ward receiving the patient

To correct the care type due to a clerical error or

change of mind

Only one care type change per day

Only one admission per hospital per day

Transfer

Patients who are being transferred to another

hospital with no plan for return are to be discharged.

If the intention is for the patient to return within

seven days then the patient is placed on leave, not

discharged.

Internal transfers for same day procedure/treatment

are not to be statistically discharged

Outpatient clinic while an inpatient.

Outpatient (non- admitted) care provided to an inpatient

is included as part of the admitted care episode and is

not to be reported as separate activity, for example:

Inpatients receiving non-admitted care during an

admission, when attending an outpatient clinic or allied

health service.

Patients receiving non-admitted outpatient care on the

same day as admission, for example where the patient has

a procedure/treatment in an outpatient clinic requiring, or

followed by, subsequent same day or overnight admission.

Policy compliance evaluation

Corporate Governance Audit 2012:

70% of ED admissions, no valid clinical reason for admission

Up to 65% less than 4 hours in duration

Focus audit for < 4hr admissions from ED

59% no valid clinical reason for admission

50% did not leave ED (virtual ward)

Subacute Rehabilitation

Compliance with all admission criteria was 9%

23% of admissions >25 days should be non-acute

maintenance

38% of admissions <8 days were not valid rehabilitation

episodes

NEAT impact ?

Desire to meet the NEAT = Routinely admitting

patients to the virtual ward?

Admissions where entire stay from Triage to

Discharge < 4 hours

The clock does not stop until the patient is

discharged from ED admitted to a ward

Impact to NEAT performance after adjustment for

ED admissions < 4hours is minimal, ranging from 0 -

7 %, with an average 2% decrease across all

metropolitan hospitals.

Audit issues

In summary, health services are

non-compliant with the ARDT

policy

Invalid admissions are generating

additional activity and revenue

National alignment risk

Fraudulent claim of funding risk

It is a sad story Piglet and it does not improve with the telling

Activity is not being counted and costed in the correct

classification system

Incorrect activity data for use in costing, funding,

planning and other applications

Causal Factors and Actions

Awareness

Implementation

Conflict with NEAT

WHADILT

Documentation

Don‟t mean us?

Information Systems

inadequate

Governance of policy

Education & Training

Change Management

Communication

Activity 2013-14 adjusted

NEAT risks

Improve documentation

Information Systems

alignment

Currently

ED Continue with admitting practice and

cancel the invalid admissions later.

New service delivery models splitting the

acute episode across sites.

New hospital opening = large patient

transfers – activity counting and

classification challenge

HITH not HITH

Assessment Units – mixed non-

admitted/admitted

.

Change Management

The new environment of ABF/ABM

impacts on all aspects of health

service delivery

Purpose of existing data collections

Every admission is an invoice

requesting payment for

product/service delivered

Clinical practice alignment

Policy required to ensure appropriate

and legitimate funding of activity

Rules required to guide health

services

Lessons learnt

Impact on current business practices

Conflict with other policy/reforms

Culture ready for change

Humans will avoid/work around it

A ward is not always a ward

Policy ain‟t policy without good policy

management.

Policy alone is not going to cut it

Kathy Alloway - Dept of Health WA - WA State Update

Health & Medicine

Transcript of Kathy Alloway - Dept of Health WA - WA State Update