restricted external are we worth it? exploring the economic value of specialist nursing in practice...

restricted externalrestricted external

Are we worth it?Are we worth it?Exploring the economic value of Exploring the economic value of

specialist nursing in practicespecialist nursing in practice

Jill NichollsJill Nicholls

Heart Failure Specialist NurseHeart Failure Specialist Nursesupported by supported by

Royal College of Nursing and Royal College of Nursing and

Office for Public ManagementOffice for Public Management


Project backgroundProject background

Collaborative project between The Royal College of Nursing (RCN) Collaborative project between The Royal College of Nursing (RCN) andand

the Office for Public Management (OPM), funded by the Burdett Trustthe Office for Public Management (OPM), funded by the Burdett Trustfor Nursing to for Nursing to

Equip senior nursing staff with the skills to understand and Equip senior nursing staff with the skills to understand and evidence the economic value of servicesevidence the economic value of services

To ensure that nursing innovations are To ensure that nursing innovations are ‘‘fit for purposefit for purpose’’

To support service review / redesignTo support service review / redesign

First nurses recruited April 2012, training commenced May with First nurses recruited April 2012, training commenced May with submission of economic assessments for verification and submission of economic assessments for verification and publication by Oct 2012publication by Oct 2012


Project aimProject aim

To monetise data regarding the acute heart failure admissions To monetise data regarding the acute heart failure admissions with differing managementwith differing management

To explore length of stay associated with differing managementTo explore length of stay associated with differing management

To monetise the cost of SIGN CHF recommended management for To monetise the cost of SIGN CHF recommended management for HFNLS patients in the communityHFNLS patients in the community

To explore patient symptom assessment within the HFNLSTo explore patient symptom assessment within the HFNLS

To identify potential improvements to maximise quality of both To identify potential improvements to maximise quality of both patient care and service delivery across NHS Taysidepatient care and service delivery across NHS Tayside


Costs of HF to the UK NHS (2000)Costs of HF to the UK NHS (2000)

Hospital inpatient care

60.5%

Outpatientcare

8%Outpatient investigations

6%

Drugs9%

Primary care

16.5%

Cost elementCost element £ £ millionmillion

Primary carePrimary care 103.8103.8

Hospital inpatient Hospital inpatient carecare 378.6378.6

Day case careDay case care 0.450.45

Outpatient careOutpatient care 51.2551.25

Outpatient Outpatient investigationsinvestigations 37.4437.44

DrugsDrugs 54.0854.08

TotalTotal 625.62625.62

Coronary heart disease statistics: heart failure supplement., BHF 2002, http://www.heartstats.org, accessed 25.02.04.


Heart failure therapiesHeart failure therapies

Mortality by 24%(cumulative by 57%)

B-Blockers Mortality by 32 %

(cumulative by 44%)

ACEIs 12 month

mortality by 17 %

Aldosterone antagonists 12 month

mortality by 32%

Mann DL et al. Circulation 2005;111: 2837-2849


The Glasgow experienceThe Glasgow experience

Lynda Blue et al 2001Lynda Blue et al 2001 Randomised controlled trial of specialist nurse intervention in Randomised controlled trial of specialist nurse intervention in

heart failureheart failure 165 participants – 75 pts usual care & 82 pts HFNLS (6 withdrew)165 participants – 75 pts usual care & 82 pts HFNLS (6 withdrew) Decompensating heart failure admissions due to Left Ventricular Decompensating heart failure admissions due to Left Ventricular

Systolic Dysfunction (LVSD)Systolic Dysfunction (LVSD) Intervention – home visiting programme, education and ongoing Intervention – home visiting programme, education and ongoing

specialist support by telephonespecialist support by telephone ResultsResults

Reduction in death or readmission due to heart failureReduction in death or readmission due to heart failure Reduction in death or readmission from all causesReduction in death or readmission from all causes If admitted, reduced length of stay If admitted, reduced length of stay


•Home visiting model•Individual management plan•Expert symptom & clinical assessment•Optimise medication management•Investigations•Multi-disciplinary team working across all sectors of care•Patient & Carer education •Self monitoring•Rapid response service•Palliative care•Patient discharge if stable > 6mths & optimal medication

•Home visiting model•Individual management plan•Expert symptom & clinical assessment•Optimise medication management•Investigations•Multi-disciplinary team working across all sectors of care•Patient & Carer education •Self monitoring•Rapid response service•Palliative care•Patient discharge if stable > 6mths & optimal medication

Direct•3x WTE Band 7 Heart Failure Specialist Nurses•1x.5 WTE Band 7 Physiotherapist•1x.8 WTE Band 3 Administrative support •NHS Tayside budget•Office space (within NHS Tayside property)•Training •Clinical supplies & equipment•Office supplies & equipment

Direct•3x WTE Band 7 Heart Failure Specialist Nurses•1x.5 WTE Band 7 Physiotherapist•1x.8 WTE Band 3 Administrative support •NHS Tayside budget•Office space (within NHS Tayside property)•Training •Clinical supplies & equipment•Office supplies & equipment

Heart Failure Nurse Liaison Service – ‘Pathway to outcomes’Heart Failure Nurse Liaison Service – ‘Pathway to outcomes’

Staff outcomes•Expert knowledge / confidence in heart failure management•Staff satisfaction due to autonomy of role

Patient outcomes•Improved symptom control results in improved clinical stability•Reduced frequency of hospital admissions•Ongoing support from an expert clinical service•Patient-centred model of care

Organisational outcomes•Reduced costs attached to managing this patient group within a general practice setting•Reduced financial burden associated with an unstable patient group due to reduced bed days and reduced length of stay

Staff outcomes•Expert knowledge / confidence in heart failure management•Staff satisfaction due to autonomy of role

Patient outcomes•Improved symptom control results in improved clinical stability•Reduced frequency of hospital admissions•Ongoing support from an expert clinical service•Patient-centred model of care

Organisational outcomes•Reduced costs attached to managing this patient group within a general practice setting•Reduced financial burden associated with an unstable patient group due to reduced bed days and reduced length of stay

‘A’ grade recommendation from SIGN 95 Management of Chronic Heart Failure 2007 identifies :• Comprehensive discharge planning should ensure links with post-discharge services are in place for all those with symptomatic heart failure. A nurse-led, home based element should be included.

‘A’ grade recommendation from SIGN 95 Management of Chronic Heart Failure 2007 identifies :• Comprehensive discharge planning should ensure links with post-discharge services are in place for all those with symptomatic heart failure. A nurse-led, home based element should be included.

InputInput

Indirect•Travel costs•Non-medical prescribing

Indirect•Travel costs•Non-medical prescribing

Activities & outputsActivities & outputs Groups targetedGroups targeted

For intervention•Patients with Heart Failure due to Left Ventricular Systolic Dysfunction (LVSD), either post admission or remain symptomatic / complex at out-patient clinic assessment

For partnership•Patients•Carers•Acute cardiology services•NHS Tayside Heart Failure Working Group•GP / Practice & District Nursing services •Allied Health Professionals •Social Care services

For delivery•Heart Failure Specialist Nursing Team

For intervention•Patients with Heart Failure due to Left Ventricular Systolic Dysfunction (LVSD), either post admission or remain symptomatic / complex at out-patient clinic assessment

For partnership•Patients•Carers•Acute cardiology services•NHS Tayside Heart Failure Working Group•GP / Practice & District Nursing services •Allied Health Professionals •Social Care services

For delivery•Heart Failure Specialist Nursing Team

OutcomesOutcomes


Methods (1)Methods (1)

Clinical audit Clinical audit

Data sourceData source NHS Tayside Information Service Division (ISD)NHS Tayside Information Service Division (ISD)

• Hospital admissions for CHF (Hospital admissions for CHF (primary coding diagnosis of Heart primary coding diagnosis of Heart Failure, Left Ventricular Failure, Non Specific HF and Congestive Failure, Left Ventricular Failure, Non Specific HF and Congestive Cardiac Failure)Cardiac Failure)

To assess the impact of NHS Tayside HFNLSTo assess the impact of NHS Tayside HFNLS Comparison of 2 cohorts of CHF admissions Comparison of 2 cohorts of CHF admissions

• Pre and post service introduction Pre and post service introduction

Jan 2003-04 & Jan 2011-12 Jan 2003-04 & Jan 2011-12



MeasurementsMeasurements

Site of admissionsSite of admissions• To allocate accurate costing for each locationTo allocate accurate costing for each location

Clinical data review via Clinical Portal, SCI & EDDClinical data review via Clinical Portal, SCI & EDD• To verify primary diagnosis codingTo verify primary diagnosis coding

Patient activityPatient activity• Number of Re-admissionsNumber of Re-admissions• Length of stayLength of stay

Quality valueQuality value• NYHA improvement (2011)NYHA improvement (2011)• Patient satisfaction questionnaire (2011 cohort)Patient satisfaction questionnaire (2011 cohort)



Economic costingEconomic costing

Cost per admissionCost per admission• Type of wardType of ward• LocationLocation• Length of stayLength of stay• Inflation adjustment of 2.5% per year to provide actual costingInflation adjustment of 2.5% per year to provide actual costing

Cost per primary care type of contact (mid costs taken)Cost per primary care type of contact (mid costs taken)

Annual running cost of HFNLSAnnual running cost of HFNLS


Economic approachesEconomic approaches

A number of economic options are available as guided by H.M.A number of economic options are available as guided by H.M.

Treasury depending on the information available and purpose for Treasury depending on the information available and purpose for studystudy

such as:-such as:-

Cost-benefit analysis - inputs & outputs quantified and monetisedCost-benefit analysis - inputs & outputs quantified and monetised Cost-effectiveness analysis - alternative interventions comparedCost-effectiveness analysis - alternative interventions compared Cost-minimisation analysis - different approaches for same Cost-minimisation analysis - different approaches for same

outcome outcome Cost-consequence analysis - range of benefits from differing Cost-consequence analysis - range of benefits from differing

activitiesactivities Social return on investment - information not normally given cost Social return on investment - information not normally given cost

valuevalue Cost-avoidance analysisCost-avoidance analysis ref OPM Handout 1, 2012ref OPM Handout 1, 2012


Initial resultsInitial results

0

10

20

30

40

50

60

70

80

90

100

£370,000

£380,000

£390,000

£400,000

£410,000

£420,000

£430,000

£440,000

£450,000

£460,000

£470,000

£480,000

Total pts re-admitEpisodes of re-admitTotal bed days(10s)Av LOS per admit

RIP re-admits

Cost

Total pts re-admit 41 41

Episodes of re-admit 53 48

Total bed days (10s) 82.7 94.1

Av LOS per admit 15.6 19.6

RIP re-admits 1.00 8.00

Cost £407,848 £471,121

2003-04 2011-12


DiscussionDiscussion

Heart Failure admission costs appear increased however this may Heart Failure admission costs appear increased however this may be related to increased number of episodes ending in death be related to increased number of episodes ending in death 2003/04=1 (24 days) v2003/04=1 (24 days) v’’s 2011/12=8 (259 days)s 2011/12=8 (259 days)

Slightly less episodes of re-admission but overall length of stay Slightly less episodes of re-admission but overall length of stay has increased has increased

Average age in 2003/04 was 75yrs, 2011/12 was 79yrs Average age in 2003/04 was 75yrs, 2011/12 was 79yrs

When scrutinised further, data from 2011 / 12 indicates clear When scrutinised further, data from 2011 / 12 indicates clear differences in activity depending on post discharge management – differences in activity depending on post discharge management –

• 132 patients (54%) were referred to the HFNLS132 patients (54%) were referred to the HFNLS• 112 patients (46%) were not referred112 patients (46%) were not referred


Activity non ref vActivity non ref v’’s ref patientss ref patients

0

20

40

60

80

100

120

140

£0

£50,000

£100,000

£150,000

£200,000

£250,000

£300,000

Total LVSDadmitsTotal pts re-admit

Episodes of re-admitTotal bed days(10s)Av LOS per admit

Cost

Total LVSD admits 112 132

Total pts re-admit 30 11

Episodes of re-admit 32 16

Total bed days (10s) 66.4 27.7

Av LOS per admit 22.1 17.3

Cost £276,528 £194,593

Not referred Referred


Discussion (2)Discussion (2)

Patient location Patient location Referred group NW n87 / PRI n39 / Comm. Hosp n6Referred group NW n87 / PRI n39 / Comm. Hosp n6 Non referred group:- NW n49 / PRI n40 / Comm. Hosp n23Non referred group:- NW n49 / PRI n40 / Comm. Hosp n23

AgeAge Average age of referred group 78yrsAverage age of referred group 78yrs Average age of non referred group 80yrsAverage age of non referred group 80yrs

Co-morbidities Co-morbidities Difficult to establish without full individual review but from HFNLS Difficult to establish without full individual review but from HFNLS

records, patients have between 2-13 documented co-morbiditiesrecords, patients have between 2-13 documented co-morbidities

Palliative Care / End of life – acknowledged this is difficult to predictPalliative Care / End of life – acknowledged this is difficult to predict

but should not preclude patients from specialist inputbut should not preclude patients from specialist input


Avoided admission costAvoided admission cost

Comparison between the two groups explores potential efficiencies Comparison between the two groups explores potential efficiencies fromfrom

re-admission ratesre-admission rates

8.3% (n11) of referred pt group re-admitted = 8.3% (n11) of referred pt group re-admitted = £194,593£194,593 26.7% (n30) of non referred pt group re-admitted = 26.7% (n30) of non referred pt group re-admitted = £276,528£276,528

If HFNLS were not in place, it can be assumed that the referred groupIf HFNLS were not in place, it can be assumed that the referred groupwould have resembled non-referred patterns, thereforewould have resembled non-referred patterns, therefore

26.7% of 132 patients (n35) assuming each patient had26.7% of 132 patients (n35) assuming each patient had1.45 admits each @ £9,815 av NHST Cardiac admit = 1.45 admits each @ £9,815 av NHST Cardiac admit = £498,111£498,111

Indicates approx reduced care costs ofIndicates approx reduced care costs of £303,518£303,518


CHP associated costsCHP associated costs

Total face to face contacts 2011/12 Total face to face contacts 2011/12 34933493 Total blood tests during same periodTotal blood tests during same period 37313731

515 patients managed within HFNLS during this period515 patients managed within HFNLS during this period Average 7 visits & 7 bloods tests per pt/per yearAverage 7 visits & 7 bloods tests per pt/per year

The CHP cost for equivalent review process:-The CHP cost for equivalent review process:-

£10-12 per Practice Nurse apt (£11 av cost used)£10-12 per Practice Nurse apt (£11 av cost used) £28-35 per GP review (£31 av cost used) £28-35 per GP review (£31 av cost used) ref RCGP Scotland, 2011. A Manifesto for Scotlandref RCGP Scotland, 2011. A Manifesto for Scotland

£294 X 515 patients = avoided costs of£294 X 515 patients = avoided costs of £151,410£151,410


Cost commitment for HFNLSCost commitment for HFNLS

HF Specialist Nurse x 3HF Specialist Nurse x 3 1x .8 Administrative Support1x .8 Administrative Support 1x .5 Physiotherapist1x .5 Physiotherapist Supplies - clinicalSupplies - clinical Training BudgetTraining Budget Physical resources eg office furniturePhysical resources eg office furniture Service equipmentService equipment StationeryStationery Travel costsTravel costs

TotalTotal £202,604£202,604


Room for improvement?

Total HF admission costs from 2011/12Total HF admission costs from 2011/12 £471,121£471,121

8.3% of HFNLS group re-admit = 8.3% of HFNLS group re-admit = 11 pts with 16 episodes (av adm/pt is 1.45)11 pts with 16 episodes (av adm/pt is 1.45) £194,593£194,593

If non-referred group were under HFNLS model If non-referred group were under HFNLS model assuming 8.3% of 112 pts continue would be 9 pts assuming 8.3% of 112 pts continue would be 9 pts between 1.06between 1.06 & 1.45 adm/pt (9.54 /13 episodes) & 1.45 adm/pt (9.54 /13 episodes) @ NHST HF@ NHST HF average admission cost of £9,815average admission cost of £9,815

Potential range acute cost Potential range acute cost £288,228 - £322,188£288,228 - £322,188

Indicated cost efficiency rangeIndicated cost efficiency range £93,635 -£93,635 - £148,933£148,933


Financial SummaryFinancial Summary

Evidenced efficiencies from avoided admissionsEvidenced efficiencies from avoided admissions ££303,518303,518 HFNLS activity resulting in CHP cost avoidanceHFNLS activity resulting in CHP cost avoidance ££151,410151,410 SubtotalSubtotal ££454,928454,928

Cost of HFNLSCost of HFNLS - - ££202,604202,604 SubtotalSubtotal ££252,324252,324

Average return on investment (ROI) per pt/per yearAverage return on investment (ROI) per pt/per year ££489489

If estimated £93,635 -148,933 added from improved If estimated £93,635 -148,933 added from improved referral and reduced rates of re-admission referral and reduced rates of re-admission £345,959- 401,257£345,959- 401,257

Potential ROI range per pt/per yrPotential ROI range per pt/per yr £671 - £779 £671 - £779


Further patient related valueFurther patient related value

The New York Heart Association (NYHA) classification tool is The New York Heart Association (NYHA) classification tool is internationally recognised for the purpose of clinical assessmentinternationally recognised for the purpose of clinical assessment

Total 515 patients in service 2011/12. To gauge trend, two Total 515 patients in service 2011/12. To gauge trend, two recordings of NYHA Class required for each patient resulting in 430 recordings of NYHA Class required for each patient resulting in 430 records providing data illustrating the patient journey within the records providing data illustrating the patient journey within the HFNLS model of careHFNLS model of care

Outcomes:-Outcomes:- 56% report stable symptom control56% report stable symptom control 30% report improved symptom control 30% report improved symptom control 14% report decline in symptom control, of those 8% were end of 14% report decline in symptom control, of those 8% were end of

lifelife

Given low percentage of decline control, this supports data Given low percentage of decline control, this supports data regarding reduced admit rates from HFNLSregarding reduced admit rates from HFNLS


Assessment of patient symptom Assessment of patient symptom burdenburden

Improve13130%

Decline - End of life

338%

Stable 24156%

Decline - Non-end of life

256%

Decline58

14%

Total:n430


Patient Feedback MeasurePatient Feedback Measure

This year NHS TaysideThis year NHS Tayside’’s Specialist Nurses commissioned patients Specialist Nurses commissioned patient

feedback project regarding service value to patient experience usingfeedback project regarding service value to patient experience using

validated CARE measure tool (University of Glasgow) validated CARE measure tool (University of Glasgow)

50 questionnaires per service50 questionnaires per service

45 replies to date – 90% response rate 45 replies to date – 90% response rate

100% of patients reporting very good or excellent satisfaction in 100% of patients reporting very good or excellent satisfaction in areas such as listening, understanding concerns, positivity, care areas such as listening, understanding concerns, positivity, care and compassion, helping patients to take control and encouraging and compassion, helping patients to take control and encouraging partnership working.partnership working.


Scottish Heart Failure Nurse Forum (SHFNF)

Established 7 years ago

Over 50 members representing all health boards in Scotland

Bi annual educational meetings

Support network, communicate good practice, representative of HF members


Scottish Heart Failure Nurse Posts


National caseload levels


Key messagesKey messages

Heart Failure services appear to contribute in the avoidance Heart Failure services appear to contribute in the avoidance of admissions by improving management and by provision of admissions by improving management and by provision of rapid response facilityof rapid response facility

There are clear financial efficiencies for NHS Tayside There are clear financial efficiencies for NHS Tayside attached to this improvement from reduced re-admission attached to this improvement from reduced re-admission rates and LOSrates and LOS

Further benefits can be achieved from improving referral Further benefits can be achieved from improving referral strategiesstrategies

Community Health Partnerships benefit from avoided costs Community Health Partnerships benefit from avoided costs as evidenced in this work as evidenced in this work


many thanksmany thanks

restricted external are we worth it? exploring the economic value of specialist nursing in practice...

Documents

heart failure supplement

acute heart failure

heart failurereduction

heart failure165 participants

nursing innovations

ongoing specialist support

month mortality

burdett trustfor nursing