outcome-based pathways & outcome-based...

Outcome-Based Pathways & Outcome-Based Reimbursement

Proof of Concept Lessons Learned

20 June 2013 David Fry, Director Client Services Heather Binkle, Program Lead, eHealth Strategy

Acknowledgement

Materials included in today’s session reflect content generated from the

Service Provider Organizations and CCACs engaged in the Provincial OBP/OBR

Proof of Concept

Objectives • To continue to prepare CCAC’s and Service Provider

Organizations to implement OBP/OBR • To identify and share early data from participating CCACs

and Service Provider Organizations from the Proof of Concept for Outcome-Based Pathways

• To provide an overview of the OBP/OBR

Implementation Roadmap

Qualifiers

• Lessons identified from:

– January 25th Lessons Learned Event NSM/Central CCACs and Partner Providers

– May 24th Champlain CCAC and Partner Providers Day 0 Information Session

– Provincial OBP/OBR Implementation Working Group Discussions (September 2012 – May 2013)

– Volunteer SPO and CCAC POC site leads

Background

Creating change through eHealth programs

Driving change

Setting the stage for change

Action Plan & Drummond Report: Streamlining processes, paying for

quality; “obsessively patient-centred” care, seniors strategy

Strengthening Home Care Services in Ontario Strategy • Accountability • Better health

outcomes • Innovation and

flexibility in service provision

• Strengthening quality

2008

Excellent Care for All Act (ECFAA) • Quality and

accountability • Expanded role for

HQO

Health System Funding Reform Accelerating move to patient-based

funding

2010 February 2012 2012-2014

Enhancing the client experience, improving outcomes and providing better value for money

Accelerating Transformation

ICCP Client Care Model

Care Coordinati

on

CCAC Expanded

Role I&R QVHC OBP-OBR

Transformation Begins

at Home

Health Links

Home & Community Care Drivers

Quality &

Value in Home Care

The goal –

to better facilitate:

• Team-based care

• Improved health outcomes

• Quality measures

• Innovation in the home and community sector

Nursing Personal Support

Therapies Community Programs &

Primary Care Providers

Team-based care in the patient’s home (“Circle of Care”)

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Development Cycles

Outcome-Based Pathway

Outcome-Based Pathways identify the indicators for a patient’s episode of care that are expected to be achieved through the application of best practice guidelines, business and patient care efficiencies and innovations. The result is that patients will receive care of greater value, patient-centric and outcomes-driven. OBPs identify outcomes and process outputs for both the CCAC Care Coordinator and Service Provider Organization (SPO) team member in order to better meet the patient’s needs.

Outcome-Based Reimbursement

Traditionally, providers are paid based on a ‘fee for service’ model (i.e. reconciliation of service, visit frequencies and billing code submitted).

Outcome Based Reimbursement (OBR) occurs when an SPO is paid based on achieving the outcomes (determined by evidence-based, best practice guidelines) or provision of best practice at certain intervals, including the final milestone. Current Reimbursement Framework is relevant to Short Stay Clients only. Goals of OBR: • Design a reimbursement framework that incents a greater focus on producing high quality outcomes and improving cost efficiency; • Create a framework in which both the CCACs and SPOs share in efficiency gains achieved

10

OBP/OBR Early Adoption Proof of Concept Sites

Early Adoption Site Business Change Go-live

Pathways

Central 26 Nov 2012 Wound NSM 26 Nov 2012 Wound and Ortho

South East 21 Jan 2013 Ortho Mississauga Halton 31 Jan 2013 Wound

Champlain 11 Feb 2013 Wound and Ortho

Provincial Successes, Challenges &

Lessons Learned

Successes • Achieved significant movement towards clinical transformation across

multiple organizations.

• Collaborative provincial structures in place to support both strategic and operational work.

• Completed point-of-care testing that informed revisions to the Outcome-

Based Pathway content.

• Joint SPO/CCAC opportunity to directly inform business requirement enhancements for technology.

Challenges– Key Themes • Perceived inconsistency in vision and value of OBP/OBR as a future state.

• Required significant provincial implementation structures that were sector

wide that focused on clinical transformation across multiple organizations. • Governance model evolved during the implementation process. • Magnitude and pace of change is high and includes conceptual and business

process elements with significant impact to frontline. • Local variation in key processes posed challenges to SPOs looking to

standardize across multiple geographies. • Technology was not yet mature enough to fully support the efficiencies and

practice shifts in alignment with OBP/OBR.

5 C’s for OBP/OBR Implementation Success

Change management – Acknowledge the practice shift underway & level set expectations (“challenging work ahead”)

Collaboration - Joint work creates trust, respect, better understanding and helps get the work done efficiently

Communication –Regular and frequent updates at all levels and in multiple vehicles

Consistency – Provincial agreement to follow key business rules; need to focus on valuable key consistency elements only

Cross-portfolio Planning & Resources – Expertise across organizational departments

OUTCOME-BASED PATHWAYS – EARLY DATA

OBP/OBR POC Early Data

OACCAC June 2013

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Current State Introduction

• The following slides examine the current state of POC to date; this includes the following:

• All Wound and Orthopedic OBP categorized using the CHRIS functionality from November 28th, 2012 to June 3, 2013

• All non-cancelled OBPs • Both Discharged and Active Pathways • Data from 5 CCACs are included – CCAC volumes vary

across the province due to the staggered POC start

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Current State to Date: Wounds - Volumes

Count of Pathways CCAC Pathways Type MH CENT CHAM NSM Total

Arterial Leg Ulcer 18 54 13 11 96 Assessment 329 769 183 286 1567

Diabetic Foot Ulcer 99 259 122 64 544 Maintenance Wound

Initial 1 116 35 152

Maintenance Wound Recurring 14 3 17

Malignant Wound Initial 6 34 2 42

Malignant Wound Recurring 1 2 3

Non-Healing Wound Initial 5 18 1 24

Non-Healing Wound Recurring 3 8 2 13

Pilonidal Sinus 104 232 120 51 507 Pressure Ulcer 145 525 120 52 842

Surgical Wound 491 1389 789 304 2973 Traumatic Wound 168 639 307 132 1246 Venous Leg Ulcer 73 292 112 54 531

Grand Total 1443 4351 1766 997 8557

20

1%

18%

6% 2%

0% 1% 0%

0%

0%

6%

10% 35%

15%

6%

Proportion of All Wound Pathways across 4 POC sites

Arterial Leg Ulcer

Assessment

Diabetic Foot Ulcer

Maintenance Wound Initial

Maintenance Wound Recurring

Malignant Wound Initial

Malignant Wound Recurring

Non-Healing Wound Initial

Non-Healing Wound Recurring

Pilonidal Sinus

Pressure Ulcer

Surgical Wound

Traumatic Wound

Venous Leg Ulcer

• As of June 3rd, there has been over 8,500 wound outcome-based pathways ordered across 4 CCACs

Client Care Model

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Current State to Date: Wounds -Populations

• To examine the distribution of CCM population at the start of the wound pathway, only data from 2 CCACs could be included, due to varying exclusion POC criteria

22

0%10%20%30%40%50%60%70%80%90%

100%

% o

f Pat

hway

s

Client Population at the Start of Wound Pathways MH and CENT CCACs only

Adult - Complex

Adult - Chronic

Adult - Community Independence

Adult - Short Stay

Current State to Date: Orthopedic

Count of Pathways CCAC Pathways SE CHAM NSM Total Total Hip

Replacement Post-Op

53 123 218 394

Total Hip Replacement Pre-Op 148 148

Total Knee Replacement

Post-Op 121 145 47 313

Grand Total 174 268 413 855

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• As of June 3rd, there has been over 850 Orthopedic outcome-based pathways ordered across 3 CCACs

• 98% of Ortho Pathways started as Short Stay Population

46%

17%

37%

Proportion of All Ortho Pathways across 3 POC sites

Total Hip ReplacementPost-Op

Total Hip ReplacementPre-Op

Total Knee ReplacementPost-Op

Length of Stay Introduction

• The following slides examine information related to length of stay; however, given that POC has been 6 months, the following data criteria applied for Length of Stay analysis:

• Only those pathways whose “Day X” was prior to May 15th, 2013 are included

• Pathways may be either discharged or still active • For pathways that are discharged, all pathway discharge dispositions

are included

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Pathway Max Pathway Start Date Arterial Leg Ulcer 9-Jan-13

Assessment 4-May-13 Diabetic Foot Ulcer 9-Jan-13

Pilonidal Sinus 14-Feb-13 Pressure Ulcer 7-Nov-12

Surgical Wound 14-Feb-13 Traumatic Wound 14-Feb-13 Venous Leg Ulcer 19-Dec-12

Total Hip Replacement Post-Op 9-Jan-13 Total Hip Replacement Pre-Op 3-Apr-13

Total Knee Replacement Post-Op 9-Jan-13

Length of Stay Wound Pathways

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Pathways Count of Pathways

# Pathways Discharged

Expected Pathway LOS

(# Days)

Average pathway LOS

(# Days)

% Discharged within Pathway LOS

% Discharged within Day X

Arterial Leg Ulcer 19 19 84 78.47 47% 89% Diabetic Foot Ulcer 87 80 84 64.66 66% 84%

Pilonidal Sinus 159 153 60 44.22 67% 84% Surgical Wound 1003 973 60 41.50 75% 90%

Traumatic Wound 406 391 60 43.55 71% 87% Venous Leg Ulcer 67 61 98 59.93 72% 88%

Assessment 1417 1371 7 6.57 73% 82% Total 3158 3048 27.40 73% 86%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Arterial LegUlcer

Diabetic FootUlcer

PilonidalSinus

SurgicalWound

TraumaticWound

Venous LegUlcer

Assessment

% o

f Pat

hway

s

Discharge Dispositions Proportions

Not Yet Discharged as of June 3rd, 2013

Discharge: Transfer to different Pathway

Discharge: Pathway completed - goal not met

Discharge: Pathway completed - goal met

Only those pathways whose “Day X” was prior to May 15th, 2013 are included Pathways may be either discharged or still active For pathways that are discharged, all pathway discharge dispositions are included

Assessment Pathway Breakdown



Discharge: Transfer to different Pathway

Not Yet Discharged as of June 3rd, ‘13 Total

Count of Pathways

Total %

CCAC Count of Pathways % Count of Pathways % Count of Pathways %

Count of Pathways %

6-MH 107 38% 37 13% 129 46% 6 2% 279 100%

8-CENT 239 34% 56 8% 381 53% 37 5% 713 100% 11-

CHAM 23 15% 9 6% 118 77% 3 2% 153 100% 12-

NSM 166 61% 7 3% 99 36% 0% 272 100% Grand Total 535 38% 109 8% 727 51% 46 3% 1417 100%

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Length of Stay Orthopedics

27

Pathways Count of Pathways

# Pathways Discharged

Expected Pathway LOS

Average pathway LOS

% Discharged within Pathway

LOS

% Discharged within Day X

Total Hip Replacement Post-Op 49 49 84 56.59 90% 98%

Total Hip Replacement Pre-Op 108 108 28 12.83 99% 100%

Total Knee Replacement Post-Op 15 15 84 44.00 93% 100%

Grand Total 172 172 28.02 96% 99%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Total Hip ReplacementPost-Op

Total Hip ReplacementPre-Op

Total Knee ReplacementPost-Op

% o

f Pat

hway

s

Discharge Dispositions Proportions



Only those pathways whose “Day X” was prior to May 15th, 2013 are included Pathways may be either discharged or still active For pathways that are discharged, all pathway discharge dispositions are included

Service Utilization Introduction

• The following slides examine information related to service utilization for discharged pathways; however, given that POC has been 6 months, the following data criteria applied for Length of Stay analysis: • Only those pathways whose “Day X” was prior to May

15th, 2013 are included • Only Discharged Pathways are included • All pathway discharge dispositions are included

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Service Utilization: Single Service

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Pathway # Discharged Pathways

% that were single service

Arterial Leg Ulcer 19 68% Assessment 1371 72%

Diabetic Foot Ulcer 80 66% Pilonidal Sinus 153 92%

Surgical Wound 973 81% Total Hip Replacement

Post-Op 49 27%

Total Hip Replacement Pre-Op 108 94%

Total Knee Replacement Post-Op 15 40%

Traumatic Wound 391 72% Venous Leg Ulcer 61 67%

Grand Total 3220 75%

0%10%20%30%40%50%60%70%80%90%

100%

% o

f Sin

gle

Serv

ice

Path

way

s

For pathways that were discharged with single service, what single service did they receive?

Other

SW

PT

OT

SLP

Nutrition

PSW

Nursing

Only those pathways whose “Day X” was prior to May 15th, 2013 are included Only Discharged Pathways are included All pathway discharge dispositions are included

Service Utilization: All discharged Pathways

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Pathway # Discharged

Pathways Visit

Nursing Primary Care Nursing Clinic Nutrition OT PSW PT SLP SW Other

Arterial Leg Ulcer 19 24.8 0.2 0.0 0.4 7.4 0.5 0.0 0.2 0.1 Assessment 1371 2.8 0.5 0.0 0.1 2.0 0.0 0.0 0.0 0.0

Diabetic Foot Ulcer 80 21.8 3.0 0.0 0.3 5.5 0.4 0.0 0.0 0.1 Pilonidal Sinus 153 11.2 8.5 0.0 0.0 0.2 0.0 0.0 0.0 0.0

Surgical Wound 973 13.4 3.9 0.0 0.1 2.0 0.1 0.0 0.0 0.0 Total Hip Replacement Post-Op 49 3.6 0.0 0.0 0.0 0.7 5.7 0.0 0.0 0.0 Total Hip Replacement Pre-Op 108 0.0 0.0 0.0 0.0 0.0 0.9 0.0 0.0 0.0

Total Knee Replacement Post-Op 15 3.1 0.0 0.0 0.0 0.0 5.3 0.0 0.0 0.0 Traumatic Wound 391 12.2 2.6 0.0 0.1 5.8 0.2 0.0 0.0 0.0 Venous Leg Ulcer 61 17.4 2.0 0.0 0.2 9.5 0.1 0.0 0.0 0.0

Grand Total 3220 8.3 2.2 0.0 0.1 2.5 0.2 0.0 0.0 0.0

Only those pathways whose “Day X” was prior to May 15th, 2013 are included Only Discharged Pathways are included All pathway discharge dispositions are included

Pathway Outcomes Introduction

• The following slides examine the current state of POC outcomes to date; this includes the following:

• All Wound and Orthopedic OBP categorized using the CHRIS functionality from November 28th, 2012 to June 3, 2013

• All non-cancelled OBPs • Both Discharged and Active Pathways • Data from 5 CCACs are included • Percentage indicates proportion of outcomes met by

interval due date

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Pathway Outcomes Wounds: Interval 1 and 2 % Met on Time

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N=482 N=460 n=764 n=2763 n=1155 n=476 Interval 1 DFU Pilonidal Sinus Pressure Ulcer Surgical Traumatic VLU

Client Discharge Planning Initiated for Client Independence and Prevention 93% 98% 92% 96% 95% 89%

Compression Therapy Initiated N/A N/A N/A N/A N/A 66% Correct outcome-based pathway confirmed 93% 98% 94% 96% 95% 91%

Holistic client and wound assessment completed 94% 98% 94% 97% 96% 91% Lower limb assessment completed 82% N/A N/A N/A N/A 83%

Pressure redistribution measures initiated 88% N/A 92% N/A N/A N/A Root cause of trauma identified and addressed N/A N/A N/A N/A 95% N/A

Wound Measurement Completed 95% 98% 96% 97% 96% 91% Wound Therapy Initiated 94% 98% 93% 97% 96% 90%

n=390 n=405 n=605 n=2420 n=996 n=401 Interval 2 DFU Pilonidal Sinus Pressure Ulcer Surgical Traumatic VLU

Chronic disease self-management plan initiated 73% N/A 82% N/A N/A N/A Referral initiated for long-term compression system N/A N/A N/A N/A N/A 68%

Referral Initiated for Long-Term Pressure Redistribution System 68% N/A N/A N/A N/A N/A

Wound Healing Percentage >=20% 54% 80% 70% 78% 74% 65%

• Outcomes in Bold are Payment-Linked Outcomes • All Wound and Orthopedic OBP categorized using the CHRIS functionality from November 28th, 2012 to June 3, 2013 included • All non-cancelled OBPs and Both Discharged and Active Pathways included

Pathway Outcomes Wounds: Interval 3 and 4 % Met on Time

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Client has obtained and is adhering to pressure redistribution system 66% N/A N/A N/A N/A N/A

Wound Healing Percentage = 100% OR Wound Healing Percentage >=70% for Pressure Ulcer 44% 61% 78% 71% 73% 53%


Client is independent with long-term compression system by week 14 N/A N/A N/A N/A N/A 62%

Wound Healing Percentage = 100% N/A N/A 78% N/A N/A N/A

• Outcomes in Bold are Payment-Linked Outcomes • All Wound and Orthopedic OBP categorized using the CHRIS functionality from November 28th, 2012 to June 3, 2013 included • All non-cancelled OBPs and Both Discharged and Active Pathways included

Pathway Outcomes Ortho – All Intervals - % Met on Time

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• All Wound and Orthopedic OBP categorized using the CHRIS functionality from November 28th, 2012 to June 3, 2013 included • All non-cancelled OBPs and Both Discharged and Active Pathways included

n=385 n=143 n=310

Interval 1 Total Hip Replacement Post Op

Total Hip Replacement Pre-Op

Total Knee Replacement Post-Op

Client demonstrates safe mobility using mobility and ambulation equipment maintaining prescribed surgical hip precautions 98% N/A N/A

Client demonstrates safe mobility using mobility and ambulation equipment maintaining prescribed surgical knee precautions N/A N/A 98%

Client/family/caregiver demonstrates knowledge of equipment needed post-operatively N/A 100% N/A Completed Physiotherapy assessment 99% N/A 98%

Pre-Operative Assessment N/A 97% N/A

n=253 n=287



Client demonstrates 90 degrees or greater knee flexion N/A 79% Client demonstrates a functional level of safe mobility with or without gait aid 98% N/A

Client demonstrates independence in activities of daily living with or without assistive devices 97% N/A Client is connected to additional services/resources to address ongoing or unmet needs 91% N/A

Surgical wound is healed 93% N/A

n=0 n=253



Client demonstrates a functional level of safe mobility with or without gait aid N/A 98% Client demonstrates independence in activities of daily living with or without assistive devices N/A 91%

Client is connected to additional services/resources to address ongoing or unmet needs N/A 94% Surgical wound is healed N/A 78%

• Early days for data analysis • System solution is not yet fully supporting

solution • Local variation in business processes

continues to impact data • Must be cautious with any definitive

statements • Data is supporting some of our expectations

Conclusions

outcome-based pathways & outcome-based...

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