The Care Review Approach

1
The Care Review Approach

• Using clinical information systems in the
  community to support quality care

2
Bridget Riches

• Ravensbourne NHS Trust Chief Executive

3
Contents

• Introductory comments
• Key concepts and origins of the approach
• Community Implementation Progress and Issues
• Coffee
• Learning Disability Service Implementation
  Progress and Issues
• Lunch
• Group work
• Tea
• Our Vision
• Questions

4
Introduction

• Why we wanted a new approach
• Context of need for change
• Why contacts alone dont deliver
• What have been the benefits

5
Why we wanted a new approach

• Breaking the perceived managerial bias
• Morale ! And the need to value staff and be seen
  to value staff
• Avoiding perverse incentives
• Conducting the cost benefit analysis in a world
  where paper records are still a reality
• Establishing clinical responsibility for
  electronic data capture/ use
• Eliminating duplication of effort by staff
• Establishing an information culture
• Focusing on the primary objective

6
Context of need for change
Soft performance view Quality of relationships,
whole economy working
Clinical Governance Agenda
Reflective Practice A habit of challenge and
improvement
Whole System Benefits
HImP Priorities
Hard performance view Caseload, casemix,
contacts, throughput (outcome)
7
Why contacts alone dont deliver

• Uni-dimensional, with
• No diagnostic analysis
• No casemix analysis
• No throughput analysis
• No outcome analysis
• Tendency to produce perverse incentives
• Unjustified use of time
• Value added by recording the information must be
  greater than the effort needed to record it
• Duplication of effort paper records a reality
• Difficulties with event linkage to demonstrate
  HImP progress
• Variable unlinkable concepts

8
What did the HA agree to ?

• Sampling of contacts using 1 in 13 weeks as a
  basis
• Continue to collect child health surveillance and
  immunisation data
• The implementation of Care Reviews using Care
  Aims and Categories of Care as a basis

9
What are the benefits ?

• Able to answer questions about
• what we do,
• who we treat,
• why, and
• to what end
• Useful locally and for others who may ask, such
  as CHI, to prove
• Good clinical performance
• Fair access to appropriate good quality care

10
First Assessment recommendations this has helped
with

• Define the objectives and role of the service
• Systematic and regular caseload profiling
• Identify poor clinical performance
• Support the idea of self-managing teams
• Providing a performance management system
• Influence and manage demand by improving referral
  process
• Potentially
• agree with local social services how social care
  needs will be met

11
Geoff Broome

• Director GDB Limited
• Healthcare Management Consultancy (IMT
  Specialism)

12
The origins of the approach and its key concepts

• Local and national project influences
• Key concepts
• The Performance Management Framework
• A multi-dimensional approach

13
Local and national project influences

• Local
• Categories of Care - dependency model
• Mental Health minimum data set
• Review based approach
• Community minimum data set
• Care aims
• EPPIC
• CRISP
• Reasons for care
• Diagnosis
• Learning disability Type of Care Method of Care
• Prospective approach

14
Other key influences

• Using the information
• Continual feedback and analysis
• Experiential approach not waiting for
  perfection
• Effort in recording justified against value
  gained from information by patients and staff
• No more feeding the beast
• Must be intuitive for clinicians the process of
  information recording and the process of care
  must be aligned MUST BE SIMPLE
• Integration into other initiatives and used to
  respond to national reports
• Clinical governance HImP First Assessment

15
How we implemented our approach

• Sample week for contacts (1 in 13)
• Collect Care Reviews as the outcome of a
  reflection on the care being provided, looking
  forward and recording
• Diagnosis
• Care Aim
• Category of Care (Dependency)
• Reason for Care (Discipline specific reason for
  involvement)
• Revise Care Review details on clinical/ care
  changes
• Saves 20 minutes per practitioner day

16
Project Organisation
17
High level chronology
New Paper Systems Introduced Final system
configuration completed
Project initiation December 1998
Need for radical change highlighted
Proposal prepared for BHA/ Region
Agreement reached! Approach refined, data
detailed briefings and system training conducted
Initial Go Live
January 99
Feb/ Mar 99
April/ May 99
Implementation Project
June 1999
18
How we use it A New Performance Management
Framework
Understanding a change in one area by looking at
another. Making changes where necessary, working
with partners.
Caseload/ Casemix
Expected levels

• Raising and
• tackling issues
• Team leaders
• Service managers
• HAs/ PCGs
• Acute/ Social care

Contacts
Throughput
Expected levels
Expected levels
19
Things that have slowed us down

• TOTALCARE functionality
• Especially reporting, necessitating off-loads and
  resulting in delays in caseload profiling
• IT and Information skills of clinical, managerial
  and administrative staff
• Resulting in slow uptake of ideas and inability
  to realise potential benefits in some areas
• Unlearning problems
• A minority had problems with concepts (esp.
  prospective nature of the information and that it
  is not contact/ activity based)
• Understanding their responsibilities
• Information is for managers culture
• Mixed workforce data

20
Things we would do differently or more rigorously

• Even greater emphasis on reporting and use
• Training
• Technical arrangements for offloading data
• Middle Management training and education
• Integration into Board processes
• Even greater emphasis on the link between the
  Care Review Approach and good practice in care
• Greater emphasis on early primary care use
• More detailed post Go Live planning in general
• More proactive support
• Allocate more staff time

21
Andrew Hardman

• Clinical Governance Information Officer
• Adult Speech and Language Therapy Service Manager

22
Implementing our vision of an information cycle
Review and refine
Data collection
Change Management
An Organisation's Information Culture
Data input
Information Analysis
Reporting
23
The Care Review in context
Registration
Referral Discharge
Care Reviews
Routine collection
Contact details
Sample collection clinical choice
24
What is a Care Review and who records it ?

• A Care Review is a point when a caseholder
  reflects on the care delivered its direction,
  success, and whether there are any changes in the
  patients condition and/or the approach to care
  delivery
• A caseholder records the review - a caseholder is
  the person deciding on the care to be provided
  for a patient/ client by a service eg. a
  therapist, a nurse, HV, a dentist or a doctor.
• In case of district nursing the senior nurse
  would record the review after consulting with
  colleagues

25
What is the result of a Care Review ?

• The result of a Care Review is the Review Status
  Record
• A Care Review is recorded for each discipline
• The Care Review describes the next period (ie. is
  Prospective) of care and contains
• The primary Care Aim
• The dominant Category of Care
• The main Reason for Care
• The relevant Diagnosis

26
How does this information fit together ?
Care Aim
Why service offered
Level of input/ need/ priority
Category of Care
High level reason for discipline involvement
Medical Diagnosis
Reason for Care
Specific details of client contact (sample)
Care Activities, Interventions, Treatments
27
What are the benefits ?

• Reinforces review process and encourages
  reflective practice
• supporting the Trusts approach to clinical
  governance
• Used within Clinical Supervision Appraisal
• Reduces duplication and unnecessary data
  collection
• note, clinicians can still record contacts if
  necessary for the care they are delivering
• saves approximately 20 minutes of individual
  staff time daily - waiting lists falling
• Improves the collection, recording and reporting
  of data

28
Clinical Ownership Of The Data

• Prior to go live all professions consulted on
  definitions,diagnosis and their reasons for care
• Ongoing validation work
• An ongoing process of evolution whereby
  clinicians can continue to influence the data
  collected
• Regular feedback to clinicians

29
Examples Adult Speech Language Therapy - CVA
Ass
Cur
Ass
Reh
A
A
B
B
Dysphagia CVA
Dysarthria CVA
Dysarthria CVA
Dysphagia CVA
Acute admission and swallowing problems
Patient stable, swallowing therapy started
Assessing communication problems
Therapy begins, still inpatient
Mai
Discharged continuing care in community setting
C
Dysarthria CVA
30
Examples Health Visiting - Well Child
Hospital Birth
Ass
Ant
Category C
Category C
NAD Core Programme
NAD Core Programme
Visits baby Awaiting birth details, hand over
from midwife and GP Visit
No problems found Child on Core Programme
31
How does this all fit with referral and discharge
information ?
First Contact Registration
Discharge
Referral
Contacts
32
District Nurses

• Janet Ettridge
• Lead District Nurse
• Nicki Creasey
• Associate Director of Nursing

33
The New PMF How it works District Nursing
GP Practice Profile January
20 new referrals 12 from GP 3 from other DNs 3
from hospitals 1 self referral 1 from a carer
140 cases (up 2), dependency 12 High 57
Moderate 31 Low Care aims 50 Maintenance 30
Curative 10 Assessment
14 Diabetes 11 Genito urinary problems 7
Cancers 7 Frail elderly 6 CHD
Caseload/ Casemix
Staffing 1 wte G grade 1 wte D grade Help from 9
others Patients 67 female 80 median age
250 face to face Contacts (sample)
Contacts
Throughput
18 discharges 8 with care aim achieved/ healed
wound 5 with care otherwise completed 2 Died 2
Referred on 1 Moved out of area
34
The PMF Positive local use District Nursing
management in a single base
High Level of Inappropriate referrals

• Background
• Poor clinical outcomes
• Eg. Healing wounds
• Trust average 51
• This base 28
• High total caseload/
• low throughput
• Poor team working
• Inflexible working
• patterns

6 Teams Similarly staffed
43 cases 2 complex
2 teams 108 cases 11 complex
57 cases 8 complex
85 cases 15 complex
30 cases 2 complex
GP Practices With low 75 List size
Actions Monthly caseload reviews
reallocations between teams to develop practice
and ensure even workload. Outcomes monitored.
35
District Nursing Perspective A front line view

• Getting away from numbers appreciated/ motivating
  staff
• More meaningful information
• Caseload comparisons across the Trust
• Profiling caseload to allocate resources and
  skill equally/ fairly for patients and staff
• Easy and regular caseload review (First
  Assessment)
• Not long winded trawling thru paper notes (often
  still with an incomplete picture)
• Able to examine caseload/ casemix at a summary
  level
• Able to review appropriateness of caseload at
  different levels

36
Problems experienced

• Unlearning contacts approach, some found it hard
  to come to terms with new ideas/ concepts
  especially
• Review basis not contacts
• Prospective recording approach

37
Things we would improve on

• Service specific training on concepts
• Enhance induction process earlier
• More pro-active support and feedback
• Focus Reason for Care codes on problems/
  conditions not nursing interventions
• Simplify sample week codes (activity)
• Separate training for middle managers/ team
  leaders
• Especially on use of the information and data
  quality issues

38
Health Visiting

• Barbara Castle
• Assistant Director of Nursing

39
Health Visiting Perspective Following a Review

• Using the information as a framework for the
  development of Care Packages/ Profiles
• Needs led approach with resources and skills
  applied according to localised need
• Using the information to target training

40
HV data analysis

• Core of HV work is Anticipatory, Category C, Core
  Programme for mother and baby
• Analysis is focused on the percentage that are in
  this group and an analysis of the rest
• This can then be used as a basis for assessing
  resource allocations, skill mix requirements and
  training needs
• Can produce this monthly, previously a major
  annual paper exercise

41
Health Visiting Caseload PCG Analysis

• Caseload
• Penge 5618
• Bromley 5813
• Orpington 6459
• Child protection/ at risk of neglect/ abuse
• Penge 1.1
• Bromley 0.8
• Orpington 1.1

42
Health Visiting Validation, service and care
profiling

• Validation vignettes
• 5 scenarios used
• 98 response
• 88 accuracy on Categories
• Follow-up planned
• Service profiling
• Care profiling
• Using combinations of Care Aims/ Reasons for
  Care
• Currently working on structure of a Care Profile
  ideas include problems/ conditions,
  interventions/ treatments, expected outcomes
  (quality standards)

43
Dietetics The use of Care Reviews in a service
development bid

• Susan Kostrzewska
• Head of Community Dietetics

44
Current Paediatric service

• 1.0 wte Paediatric dietician
• Paediatric service established Nov.1997
• 55 of caseload is category A B
• 28 (Cat. A) have complex needs and high level of
  dependency
• 14 Gastrostomy feeds (Nov. 1997)
• 29 Gastrostomy feeds (March 2000)
• 5 Naso-gastric feeds
• Large caseload clinical risk

45
Summary of Service Care Reviews - Category of
Care

• Trust-wide current caseload casemix
• Category A
• 18
• Category B
• 25
• Category C
• 57
• Total caseload 481

• Paediatric current caseload casemix
• Category A
• 28
• Category B
• 27
• Category C
• 45
• Total caseload 123

46
Summary of Paediatric Service Care Reviews Care
Aims

• Assessment 2
• Curative 32
• Maintenance 9
• Rehabilitation 47
• Supportive 10
• Rehab Supportive are Cat. A B
• Curative cases predominantly Cat. C

47
Summary of Care Reviews Reasons for Care
Diagnosis

• Paediatric current caseload reasons for care
• 29 Gastrostomy feeds
• 25 category A gastrostomy feeds
• 5 Naso-gastric feeds

• Paediatric current caseload main diagnosis
• Other Neurological 14
• Cerebral Palsy 11
• Chromosome Abnormalities 6.5
• Obesity 13
• Other Medical 10

48
Service Development Bid

• Based on only 1.0 wte paediatric dietician (1
  member of staff)
• No holiday cover
• Complex caseload
• High Need/Input caseload
• Data available monthly to support bid
• If bid not agreed data will help identify areas
  to be cut from service

49
Colin Lambert

• Learning Disability Psychology Service Manager

50
The Care Review Approach in Learning Disability

• Psychology, Psychiatry, IBIS, CATS, Community
  Nursing, OT, Physiotherapy, Speech and Language
  Therapy

51
History

• Information system as the beast to feed
• Emphasis on contacts and contract currency
• Little clinical relevance
• Were down on contacts how can we get them
  up?
• Were up on contacts how can we get them down?

52
Small pilot project

• Each discipline scored Care Review categories for
  a small sample of actual cases
• Two professionals from each discipline scored
  Case Scenarios
• Feedback forms and inter-rater comparisons led to
  adaptations from community approach

53
What is the result of a LD Care Review ?

• A Care Review will be recorded for each
  discipline
• The Care View describes the next period of care
  and contains
• The primary Care Aim
• The Category of Care
• The Resource/ time allocation (7 bandings)
• The main Reason for Care (upto 3)
• The relevant Diagnosis (upto 3)
• Method/ Type of Care (upto 3)

54
How does this information fit together ?
Care Aim
Why service offered
Level of input/ need/ complexity
Category of Care
Resource/ Time
High level reason for discipline involvement
Medical Diagnosis (upto 3)
Reason for Care (upto 3)
Specific details of settings In which care is
provided
Method/ Type of Care (upto3)
55
Scenario Psychology - Male, 29
Road Traffic Accident
Cur
Ass
Discharged with care aim achieved
3-6 Hours/ month
6-10 Hours/ month
B
B
Moderate Learning Disability
Moderate Learning Disability
Fears/ phobias
Fears/ phobias
Advice/ support assessment and training/
teaching of client
Care implemented via carers and training/
teaching client
Also referred to Physiotherapy and Nursing
56
What the system can tell us client numbers (1)

• At end of March there were 891 Care Review
  records involving care for 537 clients
• 132 clients were being cared for in one of the
  Trust residences and 405 were based in the
  community
• Those clients in residences involved more
  services - each client being seen by 2.4
  different services (on average) compared to 1.4
  in the community

57
What the system can tell us care aims (2)

• Residential caseload
• Maintenance (69)
• Enabling (12)
• Assessment (11.5)
• Curative (6)
• Supportive (1.3)

• Community caseload
• Maintenance (49)
• Assessment (21.5)
• Enabling (12.5)
• Supportive (6.5)
• Curative (5.5)
• Anticipatory (4)
• Rehabilitation (.7)
• Palliative (.3)

58
Positive aspects (1)

• It feels relevant and appropriate and easy to do
  most staff like it
• Encourages clinical review of cases makes staff
  review what theyre doing
• Meaningful and rich source of information for
• Monitoring caseloads eg epilepsy
• Describing care/ service activity
• Monitoring needs/ trends
• Links to consumer feedback
• Links to outcomes

59
Positive aspects (2)

• Flexibility downloads to Excel and Access give
  professionals the power to analyse and present
  information
• Reduces inputting time compared to contact
  recording

60
Things to resolve

• Information overload so many possibilities,
  its hard to decide what to look at
• For LD having 3 Reasons for care, diagnosis,
  types of care makes analysis complex
• Need to have system for ensuring staff update the
  information
• What to make available to commissioners to avoid
  Were down on cases, how do we get them up?
• Managers/ professionals training needs in
  Access/ Excel

61
Mimi Morris-Cotterrill

• Service Development Director

62
Summary of benefits achieved

• Able to manage workload across PCG areas, within
  a PCG and at a local base level reallocating
  resources where necessary
• Commissioning framework revised for 2000/01
• High level outcomes are accessible
• Information recording supports and encourages
  reflective practice
• Information is used to review caseloads and
  allocate work appropriately
• Public Health information available
• Diagnosis
• Fair/ need based access is assessable by GP/ PCG

63
Summary of wider benefits achievable

• Able to manage workload across HA or sector areas
  and on a wider basis reallocating resources where
  necessary
• easing pressures elsewhere in the healthcare
  system
• Benchmarking and performance management across
  the region
• Broader Public Health information available
• Staff time saving available to oil the wheels of
  change and improve quality
• Response to First Assessment, Clinical
  Governance, CHI and PAF
• Basis of monitoring NSF implementation as they
  emerge
• Able to group data to produce HRG analysis

64
Group work focus

• Andrew Hardman
• Using the data for Operational Service Management
• Mimi Morris-Cotterrill
• Using the data for Service Development
• Geoff Broome
• Using the data as a Commissioning Framework

65
Bridget and Geoff
66
Our Vision

• Information for Health
• Primary/ Community Care EHR/EPR, piloting
  implementation in EMIS
• Systematic Caseload Review
• Operational skill mix/ workforce management
• Refining Care Review data
• Possible Outcome field looking at results of
  last Care Review
• Using the PMF in all aspects and at all levels of
  service management and commissioning
• Community Service Management Application (COSMA)
• Sharing information with patients (esp. Care Aim)

67
The New PMF How it works District Nursing
example 1
Lower total Caseload Higher Curative and
Category A Casemix
Caseload/ Casemix
Acute shift Younger mix of patients seen for
shorter time, larger use of high grade nurses.
Contacts
Throughput
Fall in Contacts
More discharges
68
The PMF How it works District Nursing example
2
Increased Caseload and level of Maintenance and
Category C in the Casemix
Caseload/ Casemix
Chronic shift Increase in long-term and elderly
larger use of staff and auxiliary nurses.
Contacts
Throughput
Rise in contacts
Less discharges
69
The PMF and Service Management
Aim Adjusting resource allocations away from
historical norms to a needs based
approach. Must answer the question What
sort of service do we want or need?
Need
Continuing debate based on knowledge of the
actual position.
Provision
Demand
70
Improving the whole system?
Can we do more/ are we performing well in all
areas? Are our resources deployed fairly and to
best effect - with an appropriate balance
between continuity of care, practice
development and flexibility? Is everybodys
role clear? Are our service models/ objectives
clear and owned by all? Are we working
together as best we can? Are we thinking
imaginatively about how technology can help?
Acute Care
Primary/ Community Care
Specialist Care
Social Care
71
Conclusions

• Not for the feint hearted or those happy with the
  status quo
• Will show up under performance, inappropriate use
  of skills/ resources and poor clinical quality if
  it exists
• Will result in changes in most service areas
• Will lead to whole system improvements, a happier
  workforce and better patient care
• Relatively straight forward to implement
• Intuitive, simple concepts
• Minimises use of staff time
• All GP and Community systems can collect it (EMIS
  trial pending)
• Consistent with IfH goals and standards

72
Functionality of COSMA

• Configuring the Care Review content and discharge
  information including setting service
  expectations in
• Caseload, casemix, throughput and contact terms
• Importing extracted data from operational
  (including GP) and workforce systems
• Highlighting variances from expectations, poor
  clinical performance and volatile data
• Modeling, using historic data as a knowledge
  base, especially
• developments in the pathology and age/ gender mix
  of patients or the impact of service changes in
  our own or other organisations e.g. referral
  patterns, eligibility criteria, care/ service
  aims/ protocols

73
Characteristics of COSMA

• Browser style available via NHSnet
• Secure
• available to all in different layers of
  aggregation and anonymity
• Routinely used by service managers,
  commissioners, team leaders and other staff to
  review care provided

74
Schema of COSMA Interfaces
TOTALCARE
EMIS
EMIS
EMIS
EMIS
Child Health And Therapy data
DN/HV and other attached service data
Community Service Management Application
75
Wider Implementation?
Seminars inviting stakeholders
Templates for proposals
Contributors to new seminars
Refinements to seminar briefings
Proposals developed by Trusts/ HA on
implementation
Revision requests
Proposals
Care Reviews and Sampled Contacts
Report back
Scrutiny at Regional Level
Implementation of Project Locally
Accepted Proposals