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Cancer Commissioning Toolkit (CCT)
Delivering Care In The Most Appropriate Setting – 21st October 2008
Reducing inpatients & moving to ambulatory care
How the toolkit can inform your strategyTeresa Moss
Director, National Cancer Action
Team
Agenda
• Background on inpatient care• CCT inpatient section and key questions answered by the toolkit
• How do we turn information into a local strategy for moving from an inpatient to ambulatory service
• How do we use the information to focus on different patient groups
• Lessons from NHS Improvement
Why focus on inpatient care?It matters to patients• Most patients have at least one
admission• Opportunity to improve patient
experience
England has higher bed utilisation for cancer than other countries
• Accounts for a large proportion of total cancer expenditure
• Opportunity to redirect resources
Inpatient care has received very little attention to date
We have mostly focused on referral to first treatment
NOT mentioned in NHS Cancer Plan or NICE Guidance
1
2
3
Statistics on cancer bed days reveal heavy bed usageCancer bed days
• Over 14,500 cancer patients are in hospital at any one time
• This equates to around 29 occupied beds per 100,000 population and around 435 for a network with a population of 1.5 million
• 60% of these beds are occupied by patients admitted non-electively
Cancer bed usage trends
Inpatient admissions have risen by 25% in the last 8 years (625,000 to 785,000)
Emergency inpatient admissions have risen fastest – an increase of 47% in past 8 years (equivalent elective increase is 8.6%)
Average length of stay has reduced but bed days for cancer are rising by 1% each year
• Emergency bed days rising by 2.5% p.a.• Elective bed days reducing by 1% each year
Cancer accounts for 12% of all bed days
HES Total Cancer %
FCEs (Inpatient) Emergency
4,565,021
409,228 9%
FCEs (Inpatient) Elective
5,560,362
558,386 10%
Bed days 44,358,492
5,263,210 12%
HES cancer activity - % total activity (excluding mental health)
Strategies for reducing inpatient admissions and bed use
• Focus on different categories of patients– Patients admitted electively for surgery– Patients admitted electively for oncology /
haematology– Patients admitted as an emergency due to side
effects of treatment / progressive disease– Patients presenting / admitted as an emergency
who are subsequently diagnosed with cancer
How do we turn information into an inpatient to ambulatory care strategy?
Define who needs to be engaged + Define who will drive the project
Trusts are motivated to reduce bed days
PCTs are motivated to reduce inappropriate admissions, bed days
over trim points
Clinical engagement is essential
User perspective is essential
Network team / service improvement skills essential
What do we know about current inpatients (quantity and cost)?Analysis of Hospital Episode
Statistics (HES) provides information on Bed utilisation
Elective vs. emergency splits
Utilisation by tumour group
Admissions by specialty
Cost (applying HRGs to admissions)
CCT Inpatients section – Moving towards ambulatory care
The CCT Inpatient chapter is divided into 3 key sections
Provider activity and efficiency reports
Inpatient activity by resident population
Quality reports
Local bed use can be analysed at a Hospital Trust or PCT level
How many beds in the hospital / trust are
occupied by patients to due cancer on any one day
(emergency and elective)?
Key questions answered in the
toolkit 1
1) Data compiled by trust, “provider” network, “provider” SHA
How many bed days / beds does this amount to each
year (emergency and elective)?
How many emergency / elective episodes (FCEs) of the total trust activity are
due to cancer each year?
What is the difference in bed usage across the tumour types for all of the above?
Which specialities are looking after patients with
cancer?
How do lengths of stay compare with elsewhere?
Cancer inpatient care in local NHS(F) trusts
What is the approximate income from cancer
inpatient care?
Local bed use can be analysed at a Hospital Trust or PCT level
How does our population use of emergency bed
days / FCEs compare with elsewhere?
Key questions answered in the
toolkit
How many of the PCT’s / network’s resident
population are in hospital due to cancer on any day (emergency and elective
per 100k population)?
How many excess cancer bed days
(emergency/elective) over trim point is the
PCT funding?
How many emergency /
elective episodes (FCEs) are due to cancer each year?
What PCT activity and cost is going to each trust by
tumour?
Inpatient care for PCT / Network resident population
Strategies for reducing inpatient admissions and bed use
• Focus on different categories of patients• Patients admitted electively for surgery• Patients admitted electively for oncology /
haematology• Patients admitted as an emergency due to side
effects of treatment / progressive disease• Patients presenting / admitted as an emergency
who are subsequently diagnosed with cancer
How do we turn information into an inpatient to ambulatory care strategy?
Reducing elective surgical lengths of stay
• Key actions trusts can take–Develop pre-admission systems with
advanced discharge planning–Define timed care pathways, with proactive
daily decision making and clear escalation triggers
–Team approach to care, empowered to discharge, supported by protocol National priorities are to move to
• Day case / 23 hour breast mastectomy
• Laparoscopic colorectal surgery with an enhanced recovery programme (national programme)
Reducing breast surgery lengths of stay – how the CCT can help
you
Breast inpatient Bed
Saver Calculator example
Average Length of Stay by Procedure
Compare ALOS against other trusts and then use the Bed Saver Calculator to determine the cost saving of ALOS
reduction
Trust
(Trust \ Average)
Illustrative
Reducing elective oncology admissions• Medical oncology, clinical oncology,
haematological oncology elective admissions account for 25% of all cancer elective admissions
• Key questions are–Is an inpatient admission necessary (PCT)–Is the LOS appropriate (Trust)
Examples of key actions
• Agree a list of regimens that can / should be given on an outpatient basis
• Develop models of giving long infusions (chemo / hydration) on an outpatient basis
• Introduce “on-call oncologist” with daily ward rounds to reduce delays in discharge
Reducing elective oncology admissions – how the CCT can
help you
Illustrative
Inpatient bed occupancy and change over time
Reducing emergency admissions for patients with known cancer Key questions
• How does emergency bed use for cancer compare with elsewhere?
• Is use increasing (emergency FCEs / emergency bed days)?
• Are there long lengths of emergency stays?
• How many emergency admissions end in death compared to elsewhere?
Examples of key actions
• Develop protocols for supportive care to minimise side effects
• Monitor patients proactively (e.g. phone calls) and educate patients for early identification of problems
• Agree emergency symptoms pathway direct to an agreed location (not A&E) - where possible stabilise patient and treat in an ambulatory setting
• Establish links with hospice, community based teams, etc.
Reducing emergency admissions for patients with known cancer –
how the CCT can help you
Inpatient bed occupancy and change over time
Illustrative
Reducing number of patients admitted as an emergency who
are then diagnosed with cancer – diagnose promptly
Key questions
• Is the local health economy “fully engaged”?
• Are there emergency communication alert systems for GPs, A&E, etc. to gain rapid specialty assessment?
Examples of key actions
• Don’t admit to assess – Assess to admit (A&E, SAU, MAU)
• If possible stabilise and discharge patient / bring back on very urgent pathway
Commissioning for Reduced In Patient Care: The Levers
- National Guidance• A successful CRU strategy should consist of three elements:
1. Strategic use of information tools to diagnose where CRU should be targeted (e.g. by demographic, by
GP practice)
2. Ensure hospital admissions are
appropriate – right care in the right
place at the right time, every time
3. Ensure sufficient alternatives to
hospital admissions exist in community
or primary care, and divest in acute care appropriately
Diagnostic tools:• Utilisation reviews• PBC toolkits (e.g. MIDAS)• Ambulance control information
• LTC management• Care management• Disease management• Self management• Population-wide prevention
Alternative provision:• Crisis resolution teams in mental health• Long-term conditions strategies (case
management and self-care)• Tailored local intervention
Iterate e.g. UM information can be used in strategic community investment plans
National Guidance published: “Care and Resource Utilisation – Ensuring Appropriateness of Care”
Commissioning for Reduced In Patient Care: The Levers
- National ContractCRU linked to National Contract Specification
• For example:–A period of ensuring the new model works (e.g. 3 months)
–A target set in the PCT/Trust contract e.g. 5% reduction in first year, increasing thereafter
–Monthly monitoring of activity and routine meetings
–Prior approval schemes agreed–Contract penalties if appropriate
Commissioning for Reduced In Patient Care: The Levers
- PbR / Local Tariff• Examples of flexibilities to support
change:-–Tariff sharing–Unbundled tariff–Tariffs for telephone advice
Commissioning for Reduced In Patient Care: The Levers
- Conclusion• Change must be clinically appropriate• Change must be clinically driven• Performance and contractual levers
available to support implementation
Ann DriverDirector, NHS Improvement
How the toolkit can inform your improvement strategy
Identifying the opportunity for improvement
• The commissioning tool provides the starting point – the indicator
• Next step is to find out what lies beneath the numbers
• Find out why your LOS is X and bed days Y
• Don’t look at the numbers in isolation from the whole improvement picture for the patient
• Don’t jump to solutions without identifying the real problem
• How can you manage length of stay if you do not really know what the right length of stay is?
• Do not get complacent there is always room for improvement
Commissioning Guide/Tool provide the baseline position
and capture the impact of improvement
Patients admitted electively for
surgery
Patients admitted electively for
oncology / haematology
Patients admitted as an emergency
due to side effects of
treatment / progressive
disease
Patients presenting /
admitted as an emergency who
are subsequently diagnosed with
cancer
The Transforming Inpatient Care Programme
• Return to the basics of service improvement
• Scope the work – e.g. identify the top three tumours re bed days, emergency or elective
• Map the detailed pathway• Identify and understand the variation• Local baseline – a real-time snap shot• Baseline from different perspectives
–Patient experience: Patient tracking, diaries, discovery interviews
–Pathway efficiency: Identify the delays, duplication, non-value adding time for staff and patients
–Value for money
Identifying the opportunity for improvement
Patient Pathway – Before and After
IMPACT OF CHANGE
Pre-admission
Early discharge planning
No drains
Nurse led discharge
Moving from inpatient to 23 hour model
Total saving of 5 days
Comparative costs at City Hospital Birmingham – Breast cancer surgery, early discharge testing Illustrative
• Proactive length of stay management vs. reactive bed management
• Defined emergency pathways & entry points• Communication: rapid alert systems• Checking in while booking out model: setting
patient expectations• 6-23 hour delivery models• Shared symptom response strategies
(GP/Acute)• Clinical decision making models• Shared triage (A/E, Oncology)• Streamlining the elective pathway• Procedures in alternative settings• Enhanced recovery programmes• Changes in clinical practice
Opportunities to streamline & design new models of delivery
Testing Identified: Winning Principles
• Unscheduled (emergency) patients should be assessed prior to the decision to admit–Emergency admission should be the exception not the norm
• All patients should be on a defined inpatient pathways based on their tumour type and reasons for admission
• Clinical decisions should be made on a daily basis to promote proactive case management
• Patient and carers need to know about their condition and symptoms to encourage self-management and to know who to contact when needed
www.improvement.nhs.uk
This publication is available from 18th June 2008
Next Steps
• NHS Improvement / NCAT top priority – Transforming Inpatient Care Programme
• Local testing and spreading through Trusts / Networks
• Publications June 2008 at NHS Confederation
• Improvement Event late summer 2008• Looking for new test sites Primary Care /
Social care• Linking learning and capturing impact
with Cancer Commissioning Toolkit and NHS Improvement System
Transforming Inpatient Care Programme
Interested in becoming a test site contact, looking for primary, acute
and social care sites contact
Ann.driver@improvement.nhs.ukAngie.robinson@improvement.nhs.uk
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