Michael Stewart, Ontario Ministry of Health and Long Term Care: Best Care is a Right, Not a Privilege

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Information about Michael Stewart, Ontario Ministry of Health and Long Term Care: Best...
Health & Medicine

Published on February 24, 2014

Author: informaoz

Source: slideshare.net


Michael Stewart, Lead Decision Support and Knowledge Transfer, Ontario Ministry of Health and Long-term Care delivered this presentation at the 2014 Activity Based Funding conference at Toronto Convention Centre. Presentations at the event explored the risks, benefits and experiences of activity-based funding from around the world. For more information about the annual event, please visit the conference website: http://www.healthcareconferences.ca/activitybasedfunding

Best Care is a Right, Not a Privilege Quality-Based Procedures Activity-Based Funding Conference January 29, 2014 Michael Stewart Executive Lead, Decision Support and Knowledge Transfer Ministry of Health and Long-Term Care

Background and Overview • Ontario‟s Action Plan • Activity-based Funding • Transition from global budgets towards a patient-focused funding system 2

4 Pillars of Transformation Ontario‟s Action Plan creates a system that improves quality care for patients as it delivers more value for taxpayers Wellness & Prevention Right Care, Right Place, Right Time Empowering people to make healthier choices and improving health outcomes for children Maximizing investments by shifting services to more appropriate and cost effective settings and optimizing existing resources Funding Reform Integration & Execution Paying for health care services based on the on needs of the patient and performance to drive quality, efficiency and effectiveness in the system Strengthening coordinated care to improve access to health care services and maximizing quality and value 3

We are moving from the global provider-focused funding model to one that revolves around the person Health System Funding Reform Global Funding A historical approach where health service providers received lump sum funding • Hospitals, on average, received 75-90% of their funding from global budgets • Majority of the funding is in the form of: o Base annualized funding o New incremental funding o Remaining funding acquired from other sources (i.e. preferred accommodation, alternative revenue etc. ) An evidence-based approach with incentives to deliver high quality care based on: • • • • Best available evidence and best practices Needs of the population served Services delivered 4 Number of patients

Activity Based Funding (ABF) What is ABF? • Method of funding health-care providers (i.e. acute-care hospitals, long-term care facilities, rehabilitation facilities) for the care and services they provide1 • Under ABF, health providers receive funding based on the number and type of “activities” they perform2 • Payment model based on the volume and type of services provided to each patient for hospital care. Its main objectives are to increase efficiency and reduce wait times. 3 Where is it being used? Numerous countries are already using some form of ABF. Examples include, but not limited to: • Australia • United Kingdom • United States • Europe References: 1 [CIHI: https://secure.cihi.ca/free_products/ActivityBasedFundingManualEN-web_Nov2013.pdf 2 [http://www.policyalternatives.ca/sites/default/files/uploads/publications/BC%20Office/2012/01/CCPA-BC_ABF_2012.pdf] 3 [http://www.cadth.ca/products/environmental-scanning/health-technology-update/ht-update-12/activity-based-funding-models-in-canadian-hospitals] 5

Ontario‟s Health System Funding Reform approach will draw from over 25 years of international Activity Based Funding experience • Patient focused funding systems reimburse providers at an established rate, based upon quality care for standard patient groups • Ontario is one of the last leading jurisdictions to move down this path. Patient Focused Funding Adoption Timeline 6

Benefits of ABF include, but not limited to: • Focus on improving clinical processes and patient outcomes • Improving quality • Decreasing wait times/improved access to care • Reducing unit costs per admission • Reducing variation in both costs and clinical practice • Ensuring pricing and funding transparency, and the accurate and visible allocation of funding to Health Services based on the activities they perform 7

Risks of ABF • More potential fluctuation in budget dollars • Less flexibility for facilities to manage all their programs and services • Potential focus shift from the quality of patient care to volume of service o Hospitals may be inclined to treat simple cases over complex cases o Rural and small health care facilities could be negatively impacted • May create perverse incentives such as: o Over-servicing o Discharging patients too early, without appropriate safeguards against readmission o Upcoding (coding patients in more resource-intensive groups for increased compensation) 8

Implementation of ABF needs to be closely monitored for potential adverse effects rising due to … • Insufficient funded volumes • Poor data quality • Inability to measure key indicators • Timeliness 9

Canadian doctors for Medicare support experiments with ABF, if it does not undermine the public system … “If not implemented and monitored carefully, ABF can provide a disincentive for hospitals to provide low-volume but needed care and lead to hospital closures in rural communities” Reference: [http://www.canadiandoctorsformedicare.ca/Activity-Based-Funding/abf-bulletins.html] 10

Health System Funding Reform • Health-Based Allocation Model • Quality-Based Procedures (focus area of today‟s presentation) 11

Health System Funding Reform (HSFR) has two funding components HSFR Health-Based Allocation Model (HBAM) Quality-Based Procedures (QBPs) Global Funding (Non-HSFR) • HBAM is a „made in Ontario' funding model that determines optimal amount of funding based on patient demographics, clinical data and financial data • QBPs are clusters of patients with clinically related diagnoses/ treatments and functional needs identified by an evidence-based framework as providing opportunity for: 1. Aligning incentives to facilitate adoption of best clinical evidence-informed practices 2. 3. Appropriately reducing variation in costs and practice across the province while improving outcomes Ensuring we are advancing right care, at the right place, at the right time Note: At the culmination of HSFR, HSPs will account for approximately 70% of funding 12

QBPs have been selected using an evidence-based framework… 13

The “Quality” in Quality-Based Procedures • Best practices informed by clinical consensus and best available evidence • Engage in clinical process improvement/ re-design and adopt best practices • Best practice pricing to strengthen the linkage between quality and funding • Develop indicators to evaluate and monitor actual practice • Broaden scope of QBPs to strengthen the continuity of care • Ensure every patient gets the right care, at the right place, at the right place 14

Developing best practices through the QBP Clinical handbooks Agencies Ministry had asked the agencies (such as Health Quality Ontario) to convene Clinical Expert Advisory Groups for each assigned QBP Clinical Expert Advisory Groups Deliverables Expert Panel Members included multi-disciplinary (i.e. specialists, family physicians, nurses, health disciplines, patients, decision support managers), multi-sectoral and cross-provincial representation Expert Panels deliverables included: • Defining patient inclusion/ exclusion criteria • Developing best practices • Recommending performance indicators and implementation strategies for the defined episode of care. These deliverables have been compiled in a ‘QBP Clinical Handbook’ 15

A staged approach has been adopted to develop and implement the QBPs PHASE 1 – Clinical Foundation PHASE 3 – Implementation PHASE 2 – Development of Best Practice Price Key Advisors Agencies Clinical Experts Clinical Experts and Technical Advisory Clinical Experts & Stakeholders (i.e. LHINs, HSPs etc.) Measure and monitor key indicators Stage 1 Evidence Stage 2 Stage 3 Stage 4 Stage 5 Stage 6 Stage 7 Best Practice “Interim” QBP Price Local Adaptation to Practice and Price Best Practice Price Regional Capacity Plan Performance Evaluation/ Feedback Clinical Engagement/ Knowledge Transfer Alignment with quality levers such as Quality Improvement Plans etc. 16

Developing and implementing QBPs Acute Inpatient • Entering Year 3 (FY 2014/15) of QBP implementation • To date (FY 2012/13 and FY 2013/14), QBPs represent 11% of the total provincial budget Transition from Acute Inpatient Admissions • Existing QBPs expanded to address transition from inpatient admission/episode Community • Concurrent work underway to define community-focused QBPs Integrated Indicator Scorecard • Provide a starting point for monitoring and evaluating the impact of the introduction of each QBP 17

Lessons learned to date from QBP implementation (1) 1. National and international experiences 2. Improving quality is ongoing 3. Need for strong structural supports • Establishment of HQO • Agencies such as CCO, CCN, PCMCH as a partner • Expert panels 4. Risk and consequence of imperfect data and poor understanding of cost structures and historical condition-specific utilization patterns 5. Need for focused change management • Change is difficult 18

Lessons learned to date from QBP implementation (2) 6. Continue to communicate, communicate, communicate • Need for robust, multi-faceted communications strategy at varied levels • Identify system champions early on 7. Lay out a multi-year plan to better understand the financial consequences 8. Communicate clear guiding operational principles • Establish an integrated project management approach that clearly delineates roles and responsibilities of various project partners 19

Coding and data quality: raising the bar It‟s not the Ministry‟s data: it‟s the organization‟s • Overt and transparent link between coded patient data and funding • Improved data quality benefits everyone • Documentation (physician and departmental) challenges need to be resolved, need for issues to be escalated • Likely need new data elements; keeping abreast of standards even more important Patient Assignment to all QBPs based on coded data • Funds to be paid for different QBPs will vary • Not all patients fit a QBP criteria • Capacity planning…it‟s not just about volume reconciliation Planning and budgeting; conducting internal impact analysis, combining clinical (coded), utilization (volumes), and financial data 20

One example of data challenge: A five year review of case volumes was commissioned. The results showed that the hospital had seen a significant decrease in case weights over the five years. All programs and physicians refuted the charge, saying they were working harder than previously and the data was wrong. However, the numbers told a different story. 21

Observations and result: Upon review: • The analysis had not ensured that all patients be regrouped to the same CMG year • A comparison based on five differing weighting values was useless Result: The programs felt the system and information was useless and unusable and vowed amongst themselves to only trust their own data 22

The Trouble with Data Data not understood is bad data No matter how much data we have, we always want more No matter how good and validated the data is, we always want it to be better No matter how quick it is, it could always be available quicker Everyone else has better information systems than we do The darn data never answers the questions it should The data doesn‟t always prove what we know is right 23

Capacity Planning Health Service Providers must build expertise in impact analysis. They must understand: • Their case mix • Trend in patient populations and illnesses • Discharge disposition patterns • Utilization by patient population Coding review to ensure standards are followed and all patients are assigned to their most appropriate CMG Review and understand utilization by patient groups. 24

Supporting the sector… Education and other transitional communication supports are available to assist HSPs with change management Outreach Sessions Face-to-face outreach sessions with HSPs with representation from frontline staff as well as senior management to obtain feedback and identify improvement opportunities for QBP implementation Education Comprehensive education resources available to assist HSPs in understanding and learning about HSFR e.g. Online Self-Study Modules Support Resources Support resources continually added to ensure HSFR field knowledge is up-to-date e.g. Methodology Guidelines, FAQs, Memorandums, HBAM Manual, Summary of Changes to HSFR Funding Model Technical Tools Specific tools developed to assist HSPs to examine HBAM’s impact on their facility e.g. Variance, Service, Unit Cost Websites Public and private websites contain extensive repository e.g. HBAM results, recorded webcasts and presentations Helpline Telephone and email helpline available to provide opportunity to HSPs to 25 submit HSFR-related questions

Success Stories - Examples LHIN Best Practice Initiatives St. Joseph’s Integrated Comprehensive Care Project Innovative pilot project that ensures seamless transitions for patients from the hospital to the community. Success Factors include, but not limited to: • Integrated Care Coordinators (ICC) follow patients through the various care settings and work collaboratively with existing providers including primary care • Single contact number to access the team on a 24/7 basis. Waterloo Wellington LHIN Developed a regional, cross-continuum stroke system of care focused on building downstream capacity Toronto East General Hospital Changes to processes related to Hip and Knee replacement improved the patient experience and Length of Stay Mount Sinai Hospital Incorporated QBP’s into strategic planning and budgeting process Health Sciences North Developed strong Data Quality culture and put emphasis on data capture and reporting done by front line staff Additional success stories are available on the public and private websites: http://www.health.gov.on.ca/en/pro/programs/transformation/care_stories.aspx http://www.hsimi.on.ca 26

In summary…. Best Care is a Right, not a Privilege • Aim for improved patient outcomes • Define best care • Implement best care • Encourage routine/ scheduled updating of best care standards • Allow for creativity and innovation • Use funding to incent adoption • Goal is a sustainable financial system 27

Contact Our Helpline with Your Questions! Please email or direct your enquiries related to HSFR to the ministry‟s health system funding Helpline: HSF@ontario.ca or call 416-327-8379 28

Appendix 29

Activity Based Funding Across Canada In 2008, four Vancouver hospitals enrolled in the Emergency Department Improvement Initiative, through which hospitals receive additional payments for treating patients within a specified time frame. The Vancouver Coastal Health Authority affirms that the overall health care delivery has since improved. Other provinces have the support from their health ministry to move ahead with activity-based funding. For example, Alberta started to implement the new model in their province in April 2010. New Brunswick also may be headed in this direction, and Quebec has received recommendations from its former health minister, Claude Castonguay, to adopt this approach as a way to sustain its health care budget. Reference: http://www.cadth.ca/products/environmental-scanning/health-technology-update/ht-update-12/activity-based-funding-models-in-canadian-hospitals11 30

QBPs have been selected using an evidence-based framework… • • • • • Does the clinical group contribute to a significant proportion of total costs? Is there significant variation across providers in unit costs/ volumes/ efficiency? Is there potential for cost savings or efficiency improvement through more consistent practice? How do we pursue quality and improve efficiency? Is there potential areas for integration across the care continuum? • • Is this aligned with Transformation priorities? Will this contribute directly to Transformation system re-design? • Is there a clinical evidence base for an established standard of care and/or care pathway? How strong is the evidence? • Is costing and utilization information available to inform development of reference costs and pricing? • What activities have the potential for bundled payments and integrated care? • Are there clinical leaders able to champion change in this area? • Is there data and reporting infrastructure in place? • Can we leverage other initiatives or reforms related to practice change (e.g. Wait Time, Provincial Programs)? • • Is there variation in clinical outcomes across providers, regions and populations? Is there a high degree of observed practice variation across providers or regions in clinical areas where a best practice or standard exists, suggesting such variation is inappropriate? 31

QBP Clinical Handbooks • • Serve as a compendium of the evidence-based rationale and clinical consensus guiding QBP implementation Intended for a broad clinical and administrative audience o Do not mandate health care providers to provide services in accordance with the recommendations o The recommendations included are not intended to take the place of the professional skill and judgment of health care providers Key Principles • • • Recommended practices should reflect the best care possible, regardless of cost or barriers to access Costing or pricing are out-of-scope Recommended practices, supporting evidence, and policy applications will be reviewed and updated at least every two years 32

QBP Multi-Year Roll-out Plan Year QBPs FY2012/13 1. 2. Primary hip replacement* Primary knee replacement* 3. 4. Cataract Chronic kidney disease FY2013/14 1. 2. 3. Chronic obstructive pulmonary disease* Stroke* Congestive heart failure* 4. 5. 6. Non-cardiac vascular Chemotherapy Gastrointestinal endoscopy FY2014/15 Wave 1 1. Hip fracture* 2. Pneumonia 3. Tonsillectomy 4. Neonatal jaundice Wave 2 5. Coronary artery disease 6. Aortic valve replacement 7. Cancer Surgery 8. Colposcopy 9. Knee Arthroscopy 10. Retinal Disease *These QBPs have or are being further developed and expanded to address transition to post-acute phase in Year 3 (FY 2014/15). 33

The approach to developing an Integrated QBP Integrated Scorecard and indicators for acute care QBPs will be adapted for the CCAC QBPs Ministry - based on internal & external expert consultations and review literature Introduction of QBP based funding Objectives of QBP Key evaluation questions Key provincial indicators QBP Clinical Expert Advisory Group QBP Best Practice QBP Specific indicator GUIDING PRINCIPLES: Relevance The integrated scorecard should measure the response of the system to introducing QBPs Importance To facilitate improvement, the indicators in the scorecard should be meaningful for the various stakeholders (clinicians, administrators, LHINs, MOHLTC and patients) Alignment The integrated scorecard should align with other indicator-related initiatives where appropriate Evidence The indicators of the integrated scorecard need to be scientifically sound or at least measure what is intended and accepted by the community (clinicians, administrators and/or policy-decision makers) 34

Example: Integrated Scorecard approach with associated key provincial indicators and resulting (acute) stroke QBP indicators CONTENT (QBP SPECIFIC INDICATORS AND RESULTS) DIRECTION (AREAS OF NEEDED INFORMATION IF RELEVANT FOR RESPECTIVE QBP) Domain (QBP Goal) What is being measured? What are the outcomes of care received by patients? Do results vary across providers? Can any variance be explained by population characteristics? Is care provided without causing harm? Key provincial indicators Appropriateness Is patient care being provided according to scientific knowledge and in a way that avoids overuse, underuse or misuse? Proportion of QBPs that improved outcomes Proportion of QBPs that reduced variation in outcome (risk-adjusted differences in outcome across hospitals) 3. Proportion of (relevant) QBPs that reduced rates of adverse events and infections 4. 5. Proportion of QBPs that reduced variation in utilization (age-gender adjusted) Proportion of (relevant) QBPs that saw a substitution from inpatient to outpatient/day surgery 6. 7. Proportion of (relevant) QBPs that saw a substitution to less invasive procedures Proportion of (relevant) QBPs that saw an increase in discharge dispositions into the community 8. Effectiveness 1. 2. Proportion of QBPs that showed a reduction in LOS QBP-specific indicators (Stroke) • Risk-adjusted 30-day mortality rate • • • Volume of QBP stroke cases Discharge destination following acute admission Percentage of patients receiving CT/MRI within 24 hrs. Distribution of severity among inpatient rehabilitation patients Percentage ALC relative to Total LOS Time from referral to home-care visit • • • • • • • • Integration Are all parts of the health system organized, connected and work with another to provide high quality care? 9. 10. 30-day readmissions rate Improved access to appropriate care providers for diagnosis/ treatment/ follow-up care Efficiency Does the system make best use of available resources to yield maximum benefit ensuring that the system is sustainable for the long term? 11. Proportion of QBPs with actual costs ≤ QBP price Access Are those in need of care able to access services when needed? 12. 13. 14. 15. Wait times for QBPs / for specific populations for QBP Wait times for other procedures Distance patients have to travel to receive the appropriate care related to the QBP Proportion of providers with a significant change in resource intensity weights (RIW) Patient Experience - under development - Is the patient/user at the center of the care delivery and is there respect for and involvement of patients’ values, preferences and expressed needs in the care they receive? 16. 17. 18. Patient involvement in treatment decisions (TBD) Coordination of care (TBD) Involvement of family (TBD) 30-day readmission rate Risk-adjusted 90-day readmissions 90-day readmission (revisits) rate of ED Time between discharge from an acute facility and admission to a rehab facility (7 days) Proportion of eligible ischemic patients arriving in ED within 3.5 hours receiving thrombolysis Post-discharge follow-up visit primary care • QBPs with actual costs ≤ QBP price • No recommendations from Stroke Clinical Expert Advisory Group Under Development 35 * Indicators in italics will be calculated for all QBPs (where relevant) even if they are not recommended by the Clinical Expert Advisory Groups as they relate to other ministry priorities and/or have been deemed important to evaluate the impact of QBP implementation. QBP-specific Indicators in grey text are currently being calculated / developed in collaboration with ministry partners.

Integrated QBP Scorecard: Future thinking: Provincial level (public) dashboard (example)* High level Provincial summary of impact QBPs Goals QBP Effectiveness Summary Very Good: 25 QBPs improved their outcomes and variation in outcomes and adverse events across providers have been reduced. Details by QBP QBP of Interest Actual performance on indicators (Provincial / LHIN level) Hip replacement Hip Very good: Integration Value > Provincial/LHIN variation in Deep Vein Thrombosis rate (hospital level) Poor: Only 10% (3) of the QBPs improved their readmission rate. Good: In almost half (10) of the QBPs relevant hospitals the actual costs were ≤ QBP price. Almost all QBS showed a decrease in LOS. Cataract Knee Appropriateness Fair: Half (15) of the QBPs reduced their variation in utilization while numerous QBPs saw in increase towards less invasive procedures. > Provincial/LHIN rate of revisions within 365 days after primary joint replacement Access CKD Fair: > Provincial/LHIN variation in revisions (hospital level) …  Provincial/LHIN level Deep Vein Thrombosis rate Fair: No increase in wait times for QBPs Patient Experience > Provincial/LHIN level Pulmonary Wound Infection rate Fair: Patients increasingly experience that care is provided seamlessly across continuum of care but still wants to be more involved in treatment decisions 36 *Format adopted from CCO’s Cancer System Quality Index

Activity Based Funding is about Patients Ambulatory Nursing Clinical Laboratories Health Disciplines Pharmacy Medical Imaging Peri Operative Services Infrastructure 37

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