By Eileen Burns and Amit Arora
Payment by results (PbR) never fully addressed the management of long term conditions, and the importance of timely and seamless transition to and from the community for patients who live with them.
Year of Care (YoC) was suggested as a possible solution in 2011 by Richard Murray, Chief Economist at the Department of Health in his document, “Payment reform in the NHS”. The long-term conditions YoC tariff is designed to allow health and social care to be provided based on a person’s overall needs as opposed to what specific diseases they have. It fits with the work being undertaken across the NHS to make care better integrated. If it works as intended, it will allow funding to be moved around as needed to provide the most effective ‘package’ of care for the person over a 12-month period. The underpinning philosophy is that money should be present in the parts of the healthcare system best-suited to provide patient care. The financial model is based upon an annual risk-adjusted ‘capitation’ budget, based on levels of health care need.
The work was transferred from the Department of Health to National Health Service Improving Quality (NHSIQ) in 2012 and is currently being carried out in seven “early implementer” health and social care communities. Each of the implementer sites received £95k in funding to support the development of the project. If it is successful, it is envisaged that the model will be rolled out across England.
The model requires variation to commissioning contracts and service provision, to include greater capacity to provide long-term conditions services closer to home, with providers jointly committed to delivering a year’s worth of care. Integral to the model is the RRR tariff – that is recovery, rehabilitation, reablement – which is designed to promote early transition from acute hospital to community-based services. RRR requires a split-point to be determined at which patients’ needs change from acute to RRR (fig 1). As part of the YoC work, a team at NHSIQ are analysing hospital tariffs for various presentations associated with long-term conditions and determining where they might be split, so that RRR funding might be used to help pull patients into appropriate community-based services sooner.
The ambition of YoC as a whole is to prevent unnecessary hospital admissions, shorten hospital stays and to channel funding towards the care facility best-suited to meet a patient’s needs.
In the first year of the pilot, a cohort of people with long-term health conditions who were at risk of having escalating needs in the following twelve months were identified in each of the implementer sites. Different levels of need were identified, and a detailed analysis was carried out to determine what services were being provided for each person and how much that cost.
Year two of the pilot started at the end of the first quarter of 2013. Work continued with the group of patients who had been identified in the first audit phase, to build up a longer-term picture of their care.
Put simply, the approach involves comparing the current way one provides and pays for support with what things would theoretically be like under a new, more flexible system. Year two of the project also examines new ways of commissioning and contracting for services, for people with long-term conditions who are eligible for the YOC tariff. A workshop has been held to look at new types of contracting and discuss options. As this work progresses the aim is to start trialling a new way of contracting in year 3.
Some early implementer teams are using computer simulation software and other methods to safely test out ‘what if ’ scenarios, such as making changes that could improve care pathways for patients between various organisations.
A comprehensive audit undertaken by the North Staffordshire early-implementer site under the leadership of Dr Amit Arora, identified two key issues that have been fed into the national process. The first of these was the important confounding effect of co-morbidity – for any given admission with a long-term condition, the time to the beginning of the RRR phase increased with comorbidity. It also increased with age. The second issue was a latent phase between the point that safe discharge to RRR could be anticipated – the “R” point – and the point at which it actually became medically safe for the patient to leave hospital – the liberation or “L” pojnt. These findings are important, as they highlight the need to acknowledge medical complexity and multimorbidity in the modeling work being undertaken through NHSIQ and the fact that discharge to RRR can be anticipated in advance of the date it can safely be realized. Geriatricianly skill may well be required to negotiate both of these issues in practice.
As YoC and RRR progress, they are likely to have significant implications for the work that geriatricians do. We’ll keep you updated through the newsletter.