Breakout 2.2 Commissioning Quality Care: Tools to support the commissioning process - Stephen Callaghan: Principal Consultant, EQE Health. Associate Consultant, Hope Street Centre. Visiting Lecturer, University of Chester. ANP, A&E University Hospitals Aintree Part of a set of presentations from NHS Improvement event: Better value, better outcomes held on Thursday 21 February 2013, Guoman Tower Hotel, London How to deliver quality and value in chronic care:sharing the learning from the respiratory programme

1. Commissioning Quality Care:
Tools to support the
commissioning process
Stephen Callaghan:
Principal Consultant, EQE Health.
Associate Consultant, Hope Street Centre.
Visiting Lecturer, University of Chester.
ANP, A&E University Hospitals Aintree.
Aims
1. Raise awareness and understanding of the COPD
Commissioning toolkits – 4 services
2. Advise you to consider applying the toolkits locally to
commission individual or integrated services
3. Demonstrate the ‘adapted logic model’ to support the
commissioning process and focus on outcomes
4. Contextualise & define ‘Commissioning quality care’
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2. Defining commissioning.
• Commissioning in the NHS is the process of
ensuring that the health and care services provided
effectively meet the needs of the population.
It is a complex process with responsibilities ranging
from assessing population needs, prioritising
health outcomes, procuring products and services,
and managing service providers.
Department of Health. 2009
Health and Social Care Act 2012
Quality defined by:
• Effectiveness
• Experience
• Safety
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3. Quality - Donabedian (1966)
• Structure – (Settings, qualification of staff, admin structure,
right institution providing care etc).
• Process – What is known to be ‘good’ care – & then applied
(technical competence, how health & illness is managed,
coordination & continuity of care, justification of diagnostic
tests/therapy).
• Outcome – (therapeutic impact, health gain, social
restoration etc – something that is measurable).
NICE QS10 - COPD quality standard
Quality statement 6: Pulmonary rehabilitation
Outcome:
A. Improvements in exercise capacity as measured by a
validated field exercise test, for example the 6-minute
walk test or the incremental shuttle walking test.
B. Improvements in health-related quality of life measured
by a validated questionnaire, for example St George's
Respiratory Questionnaire (SGRQ).
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4. NHS outcome framework
• Shared indicators between the NHS Outcomes Framework
& Public Health Outcomes Framework.
– Preventing people from dying prematurely (Under 75
mortality rate for Respiratory disease).
– Healthy life expectancy and preventable mortality
(Mortality rate from Respiratory diseases in persons
under 75 years of age).
Shared PH & ASC indicator
– prevention, early identification and management of
risk factors
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5. The Mandate
• The Board is legally required to pursue the objectives
in the document.
• The Board will need to demonstrate progress against
the five parts and all of the outcome indicators in the
framework
• The Commissioning Board is legally bound to pursue
the goal of continuous improvement in the quality of
health services
The Mandate: A mandate from the Government to the NHS Commissioning Board: April 2013
to March 2015
Standards and high quality care
There is no statutory provision
Quality Standards are advice from NICE
allowing NICE Quality Standards to
impact upon registration requirements to the NHS CB on high quality care.
Regulation
( Enforcement against Registration Requirements)
Commissioning guidance (NHS CB)
CCG Outcome Indicator Set
Registration Provider Payment Mechanisms
requirements
Proportion of services
NICE quality standards
Standard of services Unsafe Substandard Adequate Good Excellent
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6. Synthesising a CCGOI to show ‘quality in commissioning’:
Objective - Improving functional ability in people with LTC
Domain 2. NICE Quality Standards – COPD No 6
People with COPD & MRC ≥3 referred People with COPD meeting appropriate
to Pulmonary Rehabilitation criteria are offered an effective, timely and
accessible multidisciplinary pulmonary
rehabilitation programme.
Quality commissioning
& Quality assurance NICE Clinical Guideline 101
& NICE Pathways
Examples of other resources
• Outcomes Strategy for COPD & Asthma Other NICE Support
in England – DH 2011 Audit support
• COPD Commissioning Toolkit & PR Commissioning guides
Service Specification – NHS Companion Costing support
Documents Information resources & templates
• Principles, definitions and standards for Quality Standards support
PR – IMPRESS 2008 Service planning
Etc…. Slide sets
Challenge: To Improve Care & Outcomes Across Whole Pathway
Smoking cessation Smoking cessation Smoking cessation
Proactive chronic disease management
and self-management
Evidence based treatment/medicines management
Awareness raising Accurate diagnosis
• Lung health Quality spirometry
• Lung symptoms Physical activity Pulmonary rehab
• Lung age testing
Social Care/Re-ablement
Case finding
Early diagnosis
Prompt therapy & follow-up in exacerbations
Structured hospital admission with specialist care
LTOT/NIV
EOL
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7. Tools to support COPD Outcomes Strategy implementation
Workforce competences
NHS Implementation
document
Prevention & Early
Identification toolkit
Asthma and Home oxygen
Good practice guides
Commissioning toolkits
COPD indicators and dataset
Tools to support commissioning
• COPD Commissioning Toolkit
Model service specifications
1. Pulmonary Rehabilitation
2. Service to manage COPD exacerbations
3. COPD spirometry and assessment service
4. Home oxygen assessment and review service
Available - http://www.dh.gov.uk/health/2012/08/copd-toolkit/
Published Aug 12
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8. Model service specifications themes
• Key objectives
• National and local context
• Scope
• Service delivery
• Indicators
• Activity
• Finance
• (PR – Logic model)
Why is pulmonary rehabilitation
important for improving outcomes?
Case for change
• Providing pulmonary rehabilitation after discharge
from hospital can reduce readmissions within
three months from a third to just 7% of patients.1
• PR is the only intervention to date shown to
impact readmission rates in this way.
1. Outpatient pulmonary rehabilitation following acute exacerbations of COPD.
Seymour JM et al. Thorax 2010 May;65(5):423-8
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9. Why is pulmonary rehabilitation
important for improving outcomes?
Case for change
• Pulmonary rehabilitation has also been shown to
improve health-related quality of life in COPD
patients after suffering an exacerbation (e.g.
dyspnoea, fatigue, and patient control over the
disease).2
2. Puhan, M. et al. Pulmonary rehabilitation following exacerbations of chronic
obstructive pulmonary disease Cochrane Database Syst Rev; 2009;(1):CD005305
Why is pulmonary rehabilitation
important for improving outcomes?
Case for change
• It is substantially below the NICE threshold for cost
effectiveness, at only £2,000-£8,000/QALY.
• It has also been shown to be cost-saving. One
recent study showed an overall cost saving of £152
per patient per PR.3
3. Griffiths et al. (2001) “Cost-effectiveness of an outpatient multi-disciplinary
pulmonary rehabilitation programme” Thorax 56: 779 – 784
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10. Adapted Logic Model
• Internationally recognised approach to outcomes.
• There are several versions/interpretations of the logic
model.
• Perigo/Callaghan1 adapted the model to make it
clinically relevant and to support commissioners &
providers of healthcare to focus on health outcomes.
1. Perigo, G., Callaghan, S. (2011). Commissioning for Outcomes: A resource guide for
commissioners of health and social care. Online publication
http://www.fadelibrary.org.uk/wp/downloads/?did=306
Adapted Logic Model
• Perigo/Callaghan synthesised the elements of
quality, process, evidence, outcomes, guidelines
and standards with the logic model to help
commissioners and providers:
– Link health outcomes to commissioning
– Link health outcomes to strategy (National & Local)
– Understand the long-term effects of interventions
– Clearly identify what the intended outcomes should be
– Measure pathways & design/re-design pathways
– Develop a synopsis prior to a full service specification
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11. Adapted Logic Model
• The ‘Intervention stage’ is linked with quality,
standards, evidence-based practice etc. and it is the
(clinical) intervention that drives the outcome.
• Helps people to clearly understand the relationship
between outputs and outcomes.
• It is widely used for service evaluation.
• EQE Health adapted this model further to link
commissioned services to the NHS & PH Outcomes
Frameworks.
The Adapted logic model & the NHS
outcomes framework
Long term effects that occur from the
achievement of the outcomes.
Impact What you expect to happen long
after the intervention has finished
A predicted measure of change that
demonstrates a valid and significant
Outcome therapeutic impact following
an agreed intervention
End of the intervention
(i.e. number of people completed an
Outputs intervention – Evidence of service
delivery). Define completion.
Action taken to prevent/improve a medical
disorder based on EB literature, standards &
Intervention guidance documents.
Describes what a quality service should look like.
Appropriate Patients/Clients:
Inputs (i.e. Inclusion/Exclusion Criteria
& Referral Guidance)
S. Callaghan. www.eqehealth.co.uk
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12. Impact PCT wide reduction in GP attendances (20% - Kings Fund)
Reduction in hospital admissions (Sustained > 12 months post programme)
Reduction in respiratory mortality.
Outcome Increase in function exercise capacity
Patients Achievement of patient set goal(s) disorder who have a
with a chronic respiratory
confirmed diagnosisunderstandingother PROM chronic progressive
of COPD COPDother
Improvement in HAD score or
Improvement in
and
Output conditions (e.g. bronchiectasis, assessment attend their appointment.
lung 85% of eligible patients booked for their interstitial lung disease,
chronic asthma and who attend for their personalhave a baseline assessment.
100% of eligible patients have disease. assessment performed.
95% of patients
chest wallassessment Also, patients pre
and post-thoracic surgery including lungthe PR programme (completion
75% of all eligible referred patients complete transplant).
means that the patient has attended 75% of sessions).
90% of patients are satisfied with the service.
Patients who consider themselves functionally disabled (MRC
Intervention Pulmonary rehabilitation programme based on British Thoracic Society
Guidelines and PCRS [IMPRESS] standards 2011.
score of 3 or more) or those with an MRC score of two and
For patients attending PR a formal assessment, delivery and final assessment of
symptomatic. Those pulmonary rehabilitation programme recent
a comprehensive patients who have had a as per guidelines should
be delivered.
exacerbation of COPD.
Input Patients with a chronic respiratory disorder who have a confirmed diagnosis of
COPD and other chronic progressive lung conditions (e.g. bronchiectasis,
Exclusion criteria – unstable CVD, recent MI/AECOPD,
interstitial lung disease, chronic asthma and chest wall disease. Also, patients
pre and post-thoracic surgery including lung transplant).
patients who are unable to walk or those people who cannot
participate in or who consider themselves functionallysymptomatic. Those patients who
Patients group for whatever reason.
more)
a those with an MRC score of two and disabled (MRC score of 3 or
have had a recent exacerbation of COPD.
Exclusion criteria – unstable CVD, recent MI/AECOPD, patients who are unable
to walk or those people who cannot participate in a group for whatever reason.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) DISCHARGE CARE BUNDLE
Summary – This care bundle is a group of evidence based items that should be delivered to all patients being discharged from the hospital following
an Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD). The care bundle aims to improve quality of care, patient experience and
minimise the risk of re-hospitalisation. To ensure the bundle can apply to all we have prepared a combination of actions and documents to facilitate
the discharge process.
Inform the COPD CNS of all COPD patients within 24 hours of arrival including patients discharged . Extension _______
CARE BUNDLE STEPS
All required documents are included in package. Patient Sticker
1. If patient is a smoker offer smoking cessation assistance
For community referral Fax _____________ Completed Declined N/A Not Done
For clinic referral Fax _____________ GO TO
Patient COPD
2. Pulmonary rehabilitation -assessed for suitability
Safe Discharge
PRIOR TO DISCHARGE
First point of contact, either by the CNS Nurses or Physiotherapist, who Completed Declined N/A Not Done
DAY OF DISCHARGE
will assess and refer patient. Nurse to contact if not done prior to
discharge (fax referral form) Checklist
3. Written COPD patient information given including : To be completed by
•British Lung Foundation Self Management Book Completed Not Done nurse with the patient.
•Oxygen alert WALLET card
•Information about the Breathe Easy Group Note: Ensure phone Call
scheduled for 48-72
4. Satisfactory use of inhalers demonstrated and understood hours post discharge. (6)
Please assess during medication rounds. Observe the patients using the Completed Not Done
device(s) and document on electronic prescribing record adequate technique
demonstrated. (Refer to pharmacist or CNS if extra support is needed). Nurse (Initials)
Checklist
5. Outpatient follow up appointment made and given to patient Completed
Patient should see respiratory medical specialist and COPD respiratory nursing specialist
within 1 month of discharge. (Appointment should be scheduled Completed Not Done
and patient made aware of location, time and date). Date:___/___/___
Place the faxed referral form(s) in the plastic sleeve during the patients stay, at discharge Care bundle components are based on:
place with the COPD Discharge Checklist in the ‘Completed’ COPD Care Bundle Box located; NICE COPD guidelines 2004 (1-5)
_________: Nurses Station (Maroon coloured boxes) A Patient Experience Survey CLAHRC team April 2009 (6)
Systematic Literature Review supported by CLAHRC April 2009 (1-6)
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13. The Adapted Logic Model
Provides clinical and commissioning clarity on:
• Who you should be caring for
• What the evidence-base interventions are
• Evidence that the intervention(s) have taken place
• An understanding on how to measure the
intervention
• An understanding of the long-term effects of the
intervention
Finally…and the key point about using
commissioning toolkits & service specifications?
To reduce variation in the commissioning and
provision of services
Collectively we need to:
• Reduce unwarranted variation
– underuse, overuse, under co-ordination
• Improve outcomes for patients
– provide best value health care
– reduce waste, drive up quality
• Introduce benchmarking to provide comparison across
local healthcare services
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14. Thank You for listening
steve@eqehealth.co.uk
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