Rehabilitation
Activity Based Funding and
Activity Based Management
ACI- Rehabilitation Network July 2014
Sharon Smith- Manager of Sub Acute
and Mental Health Workstreams
Aim
For participants to understand how ABF
principles apply to rehabilitation care
For participants to understand how ABM can
assist in managing services in an ABF
environment
Where we are: How is rehab being funded in NSW?
What is likely to happen in the future?
What has changed?
Purchasing Principles
$
Beds
G&S
Staff
Traditional approaches to funding health care
involve providing $ for inputs for example:
ABF Purchasing Principles
ED
Acute
SNAP
• Funding now linked to outputs or activity
NAP
$
• LHD determines the
inputs
• Activity is measured
(counted) in National
Weighted Activity
Units (NWAU)
The ABF Formula
A method by which health services are funded for what they do, not who they are (output funding instead of input)
Price
Price
weight
(NWAU)
Volume
Funding Under ABF =
NSW ABF – The main components
Agreed Target Level of activity or services
Weight Activity – relative resource intensity of
treatment for patients.
State price at which each activity will be paid
Transition payments to keep the system safe and
operating
Price
$4,583
Price
weight
(NWAU)
Volume
Activity targets
Target Setting
Negotiation between MoH and
LHD’s regarding the level of activity
to be “purchased” in the upcoming
year
Targets set by “stream” i.e. Acute,
ED, SNAP, NAP, Mental Health
Targets set at LHD level
Targets set in NWAU
Targets based on historical activity
(trends) and any agreed variations-
growth,
capacity changes,
model of care changes
Targets for 14/15 based on activity in
10/11, 11/12, 12/13 and first 6
months of 13/14
Target Setting
Schedule C Part 1
A B C D E F* G H I
NSW
Target
Volume
(NWAU13)
Volume(Admissions
& Attendances)
Indicative
only
State
Price per
NWAU13
Projected
Average
Cost per
NWAU13
Initial Budget
2013/14
($ '000)
2012/13
Annualised
Budget ($ '000) #
Variance
Initial
Budget and
Annualised
($ '000)
Variance
(%)
Volume
Forecast
2012/13
(NWAU13)
Acute 834,728 861,372 $3,883,936 $3,718,027 $165,909 4.5% 816,159 Incl. Provision for additional Acute, PICU, NICU & ICU capacity
ED 152,374 1,309,595 $709,201 $652,728 $56,473 8.7% 148,996
Non Admitted Patients (Outpatient Services)^ 218,119 4,521,254 $770,583 $742,411 $28,172 3.8% 215,018
A Total 1,205,221 6,692,221 $5,363,720 $5,113,166 $250,554 4.9% 1,180,173
Sub-Acute Services - Admitted 67,807 35,015 $315,582 $265,792 $49,790 18.7% 64,335 Incl. Provision for Palliative Care Services & additional Subacute capacity (Schedule D)
Sub-Acute Services - Non Admitted^ 20,485 503,852 $77,932 $75,083 $2,849 3.8% 20,349
B Total 88,291 538,867 $393,514 $340,874 $52,640 15.4% 84,684
Mental Health - ABF Hospitals 89,600 161,951 4,671$ 4,836 $417,244 $391,952 $25,292 6.5% 85,864 Incl. Provision for additional MH Acute & Subacute capacity (Schedule D)
Mental Health - Block Funded Hospitals $11,539 $11,322 $217 1.9%
Mental Health - Non Admitted (Block) $254,415 $249,633 $4,782 1.9%
Mental Health - Transition Grant $50,900 $49,944 $957 1.9%
C Total 89,600 161,951 $734,097 $702,850 $31,247 4.4% 85,864
Block Funding Allocation
Block Funded Hospitals (Small Hospitals) $572,872 $562,104 $10,768 1.9%
Block Funded Services In-Scope
- Teaching, Training and Research $205,645 $201,780 $3,865 1.9%
- Other Non Admitted Patient Services $104,715 $102,747 $1,968 1.9%
D Total $883,232 $866,631 $16,601 1.9%
State Only Block Funded Services
E Total $948,001 $930,182 $17,819 1.9%
F Transition Grant (excluding Mental Health) $203,576 $199,749 $3,826 1.9%
G Gross-Up (Private Patient Service Adjustments) $219,769 $215,638 $4,131 1.9%
Provision for Specific Initiatives (not included above)
Operating Costs of Radiotherapy $6,362
Nurses - Additional CNS $6,218
H Total $12,580 $12,580
I SP&T Expenses $121,839 $121,839 $
J Depreciation (General Funds only) $298,035 $298,035 $
K Total Expenses (K=A+B+C+D+E+F+G+H+I+J) $9,178,362 $8,788,964 $389,397 4.4%
L Other - Gain/Loss on disposal of assets etc $7,022 $7,022 $
M LHD Revenue -$8,938,723 -$8,808,605 -$130,118
N Net Result (N=K+L+M) $246,660 -$12,619
Sch
edu
le C
Par
t 1
xxx LHD - Budget 2013/142013/14 BUDGET Comparative Data
4,671$ 4,836$
Weighted activity step 1-
Classification
Classifications used in ABF
Activity is grouped using classifications
– Clinically meaningful
– Resource use homogenous
Acute admitted – Separations (AR-DRG)
Emergency department – Presentations
(URG/UDG)
Non-admitted – Service Events (Tier 2)
Sub and non-acute – Episodes / Phases
(AN-SNAP)
AN-SNAP
Rehabilitation
Impairment
FIM
Age
Palliative Care
Phase
RUG
Age
GEM
FIM
Age
Maintenance
Maintenance Type
RUG
Psychogeriatric
HoNOS
NWAU Example: Stroke
Class Description
3204 Stroke, motor 63-91, cognition 20-35
3205 Stroke, motor 63-91, cognition 5-19
3206 Stroke, motor 47-62, cognition 16-35
3207 Stroke, motor 47-62, cognition 5-15
3208 Stroke, motor 14-46, age >=75
3209 Stroke, motor 14-46, age <=74
Weighted Activity Step 1-
calculate NWAU
What is an NWAU
(National Weighted Activity Unit)?
Ave=1 NWAU
DRG A01Z
Insertion of Ventricular
Assist Device (VAD)
= 68.5150 NWAU
Tier 2:
20.22 Cardiology = 0.0652
NWAU
The NWAU is the ‘currency’ used to express the price
weights for all services funded on an activity basis.
Adjustments for: paediatrics 196%, regionality (7-21%),
Indigenous patients (17%) , private patients (varies by
care type)
NWAU
NWAU are determined annually
based on the patient level costing
data submitted to IHPA
The better the cost data the more
accurate the NWAU
NWAU Calculation Rehabilitation
NWAU Calculation for Rehab is a
combination of class and LOS
NWAU Calculation Rehabilitation:
LOS
Lower Bound Upper Bound
Short Stay outliers
Inlier Inlier
Long Stay Outliers
NWAU Example: Stroke
Class Description ALOS Lower
Bound
Upper
Bound
3204 Stroke, motor 63-91, cognition 20-35 16 6 29
3205 Stroke, motor 63-91, cognition 5-19 17 8 33
3206 Stroke, motor 47-62, cognition 16-35 25 13 38
3207 Stroke, motor 47-62, cognition 5-15 29 13 38
3208 Stroke, motor 14-46, age >=75 36 16 41
3209 Stroke, motor 14-46, age <=74 48 28 53
NWAU Calculation: AN-SNAP
Short Stay Outlier
LOS x Outlier Per Diem
LOS 6:
6 x 0.2225
Inlier
LOS x Inlier Per Diem
1 Episode Weight
LOS 15:
(15 x 0.1367) + 1.7894
Long Stay Outlier
Inlier Per Diem x Upper
Bound
1 Episode Weight
Outlier Per Diem x No.
days above Upper Bound
LOS: 40
(33 x 0.1367) + (7 x 0.2225) + 1.7894
3-205 Stroke, motor 63-91, cognition 5-19
Lower Bound 8- Upper Bound 33
NWAU Example: Stroke classes 28 day
LOS
Class Description NWAU 14 Funding
3204 Stroke, motor 63-91, cognition 20-35 5.6170 $25,743
3205
Stroke, motor 63-91, cognition 5-19
4.8606 $22,276
3206 Stroke, motor 47-62, cognition 16-35 5.1366 $23,541
3207
Stroke, motor 47-62, cognition 5-15
5.6411 $25,853
3208 Stroke, motor 14-46, age >=75 5.8391 $26,761
3209 Stroke, motor 14-46, age <=74 7.1353 $32,701
What about activity without a SNAP
class?
NWAU calculated on basis of care
type and LOS
IHPA purchasing framework states no
NWAU for episodes without SNAP data
from 2015/16 onward
NWAU Example: Stroke classes 28 day
LOS
Class Description NWAU 14 Funding
3204 Stroke, motor 63-91, cognition 20-35 5.6170 $25,743
3205
Stroke, motor 63-91, cognition 5-19
4.8606 $22,276
3206 Stroke, motor 47-62, cognition 16-35 5.1366 $23,541
3207
Stroke, motor 47-62, cognition 5-15
5.6411 $25,853
3208 Stroke, motor 14-46, age >=75 5.8391 $26,761
3209 Stroke, motor 14-46, age <=74 7.1353 $32,701
NA No SNAP data has been collected 4.3876 $20,108
NWAU Example- Brain Injury
ED
URG 3,
Admitted
Triage 1,
Injury
NWAU
0.4334;
$1,986
SNAP
AN-SNAP
3210
Brain
Dysfunction
FIM Motor
56-91 FIM
Cog 32-35,
LOS 20
NWAU 3.8008
$ 17,419
Acute
DRG B78A
Intracranial
Injury + CSCC
NWAU 2.7283
$ 12,503
Non
Admitted
40.12
Rehabilitation
Allied Health
10 visits
NWAU 0.468
$2,145
Adjustments for: paediatrics, regionality,
aboriginality, private patients
Caretype Definitions
New National Definitions
Rehabilitation Care
Rehabilitation care is care in which the primary clinical
purpose or treatment goal is improvement in the functioning
of a patient with an impairment, activity limitation or
participation restriction due to a health condition. The
patient will be capable of actively participating.
Rehabilitation is always:
Delivered under the management of or informed by a clinician
with specialised expertise in rehabilitation, and
Evidenced by an individualised multidisciplinary management
plan, which is documented in the patient’s medical record
that includes negotiated goals within specified time frames
and formal assessment of functional ability.
New National Definitions
Maintenance Care
Maintenance (or non acute) care is care in which the
primary clinical purpose or treatment goal is support for a
patient with impairment, activity limitation or participation
restriction due to a health condition. Following assessment
or treatment the patient does not require further complex
assessment or stabilisation. Patients with a care type of
maintenance care often require care over an indefinite
period.
Includes care provided to a patient, who would normally
not require hospital treatment and would be more
appropriately treated in another setting, which is
unavailable in the short term or where there are factors in
the home environment making it inappropriate to
discharge the patient in the short term.
New National Definitions
Geriatric Evaluation and Management (GEM)
Geriatric Evaluation and Management care is care in which the primary clinical
purpose or treatment goal is improvement in the functioning of a patient with multi-
dimensional needs associated with medical conditions related to ageing, such a
tendency to fall, incontinence, reduced mobility and cognitive impairment. The
patient may also have complex psychosocial problems.
Geriatric Evaluation and Management is always:
• delivered under the management of or informed by a clinician with specialised
expertise in geriatric Evaluation and Management, and
• evidenced by an individualised multidisciplinary management plan, which is
documented in the patient’s medical record that covers the physical, psychological,
emotional and social needs of the patient and includes negotiated goals within
indicative time frames and formal assessment of functional ability
National Care Type Change Rules
Only one care type at a time
Care type should reflect the primary clinical purpose of
care currently provided- not intended at some point in
the future
If more there is more than one primary clinical purpose
chose the care type that best describes/reflects care
Independent of location
National Care Type Change Rules
If care is transferred, the care type is assigned by the
receiving clinician
If care is not transferred a change in the clinical purpose of
care must be evident in record
(Linked to $ so assume will be audited)
“Unlikely that more than one change in care type will occur
in a 24 hr period”
“Unlikely that a care type change to/from sub acute will
occur on the day of formal separation/discharge”
NSW Policy also states….
When an acute patient is waiting for Rehabilitation, but Rehabilitation
care has not yet commenced, a care type change to Rehabilitation cannot
occur. The patient must remain in an acute care type until rehabilitation
care begins. In some instances a care type change to maintenance may
be warranted.
If Rehabilitation is occurring on an acute ward, the Rehabilitation care
type should be used, as care type is independent of patient location.
The period of recovery at the end of an acute episode prior to separation
(for example, the final 1-2 days after a joint replacement) is not
necessarily a separate episode and should not trigger a care type change
to rehabilitation. Even though the care has lower resource intensity and
the patient may receive some allied health involvement, unless the
definition of Rehabilitation (as stated above) is met, the care type
remains acute.
A multidisciplinary management plan comprises a series
of documented and agreed initiatives or treatments
(specifying program goals, actions and timeframes)
which have been established through multidisciplinary
consultation and consultation with the patient and/or
carers.
Patients who receive acute same day interventions, such
as dialysis, during the course of a Rehabilitation episode
of care do not change care type. Instead, procedure
codes for the acute same day intervention(s) and an
additional diagnosis (if relevant) should be added to the
record of the Rehabilitation episode of care.
Interventions such as radiotherapy, chemotherapy, and
surgery are considered part of the palliative episode if
they are undertaken specifically to provide symptom
relief.
NSW Policy also states….
NSW SNAP data collection
How we collect Data?
SYNAPTIX
What system will be next?
Known Issues for SYNAPTIX
Psycho geriatrics (fixed)
Same Day activity
No ability to import data
Linking SNAP data to admitted
patient data
SNAP Monthly LHD NWAU
Reports
Began in Sept. 13
Purpose:
To provide a linked patient level data set (APDC and
SNAP) for local analysis
To provide YTD NWAU data for all sub acute activity
To provide feedback regarding key issues such as level
of activity, SNAP data coverage and data errors
Provided to LHD’s by the 10th of each month
Data Sources: Monthly NWAU
Reports
NWAU
Report
HIE
SYNAPTIX
SNAPshot
Summaries
Activity Summary by Episode of Care Type,
LHD total excluding mental health
Episode Care Type No. of Episodes# Occupied Bed Days NWAU13s Ave NWAU13s per Day
2-Rehabilitation 512 6473 1044 0.16
3-Palliative Care 232 1092 194 0.18
4-Maintenance 1081 11584 1524 0.13
7-GEM 869 15529 2412 0.16
8-Psychogeriatri 11 127 26 0.21
Total 2705 34805 5199 0.15
# Including episodes that have not been ended in the reporting period
Provided at a facility
level also
SNAP data collection status
Episodes Occupied Bed Days NWAU13s
Ave NWAU13s per
Day
ABF in
Scope Facility G UG %G G UG %G G UG %G G UG
Y A 72 1232 6.00% 519 9702 5.00% 56 1356 4.00% 0.11 0.14
B 161 211 43.00% 4788 4521 51.00% 719 669 52.00% 0.15 0.15
C . 92 . . 2346 . . 329 . . 0.14
D 374 562 40.00% 7419 5491 57.00% 1214 853 59.00% 0.16 0.16
Sub Total 607 2097 22.00% 12726 22060 37.00% 1989 3207 38.00% 0.16 0.15
N E . 1 . . 19 . . 3 . . 0.18
Sub-total . 1 . . 19 . . 3 . . 0.18
Total 607 2098 22.00% 12726 22079 37.00% 1989 3210 38.00% 0.16 0.15
# Includes episodes that have not ended in the reporting period
Table 4: Activity by AN-SNAP Data Collection Status and Facility
Data Errors
Error Type
Episode
is Acute
in PAS
No Episode
recorded in
PAS
Different
Care Type in
PAS
1 PAS Episode
matches 2 or
more SNAP
Episodes
1 PAS Episode
matched 2 or
more SNAP
Episodes
Start
Date
mismatch
End date
mismatch Total
Facility
A 4 . . . 91 2 3 100
B . 1 11 2 . 48 29 91
C 2 . 29 10 . 60 61 162
Total 6 1 40 12 91 110 93 353
Note: Some episodes/phases may be counted more than once if more than one type of error is recorded
Table 7: Error Episodes / Phases by Facility and Error Type
Ungrouped Activity
Ward Facility
Care Type
Total
Rehabilitation Palliative Care Maintenance GEM
AAA A 6 17 235 81 339
BBB A 123 30 104 30 287
CCC A 17 106 19 142
DDD A 55 18 40 15 128
EEE A 22 1 54 29 106
FFF B 1 66 30 97
GGG A 30 1 40 16 87
HHH D 1 81 82
III B 4 3 14 60 81
JJJ B 2 34 35 4 75
Note “ungrouped cases” sheet now includes
Medical Officer (MO) code
Table 10: Hospital wards that had the largest number of ungrouped
episodes
Ungrouped Activity
Facility Specialty Unit Specialty Name
Care Type
Total
Rehabilitation Palliative Care Maintenance GEM
A GER Medical 34 25 278 132 469
NEU Medical 137 31 112 3 283
ORT Orthopaedic 29 1 74 34 138
RES Medical 34 5 22 7 68
RHU Medical 7 3 36 15 61
REM Renal Dialysis 4 8 42 1 55
B GP Medical 1 66 32 99
GER Medical 2 1 2 66 71
C GP Medical 1 82 83
D GER Medical 1 8 124 93 226
MED Medical 6 91 77 5 179
REH Medical 11 16 6 33
RES Medical 1 8 8 1 18
NEU Medical 2 13 1 16
SUR General Surgery 1 4 9 14
E GP Medical 1 1
Table 11: Specialty units that had the largest number of ungrouped
episodes
Data Monitoring- Would you
expect?
Ungrouped subacute episodes by specialty
Specialty Unit
Episode of Care Type
2-Rehabilitation 3-Palliative Care 4-Maintenance 7-GEM Total
GER 134 . 8 2 144
NEU 31 1 23 . 55
RES 16 15 21 1 53
REH 23 . . . 23
GAS 16 2 26 . 44
PAL . 21 . . 21
HAE 1 43 2 . 46
ACG 107 59 43 67 276
GM 6 1 19 1 27
MDO 6 4 1 . 11
RNL 9 3 3 1 16
GS 29 1 5 . 35
GNC 25 1 19 . 45
OBS 15 1 10 . 26
ED 14 . 1 . 15
ABM
Activity Based Management
ABM
Using information to attain strategic
and operational objectives
Analysis of Variation – Clinical and
Financial
The ABM Portal provides:
Comparisons of activity, costs and prices
for
The ability to benchmark costs and LOS
LHDs
Facilities
ABF
Workstreams
Patients
Eg. ED, acute, non-
admitted
Patient
level costing
LHD/SHN
GL Data
LHD/SHN
Patient
Data
Where does the data come from?
CE
sign off
Submit to
Ministry of
Health
ABM
Portal Updated every 6
months
Maturity in costing practice
No patient level
data available;
Total cost / total
activity;
Cost modelling
Some patient level
data;
All cost centres
point to an
outpatient area;
Total cost / total
activity
Cost modelling
Mostly patient
level data;
All cost centres
point to an
outpatient area;
Service activity
data used to
allocate S&W;
Average cost
allocated to
patients for:
- Pharmacy
- Imaging
- Pathology
- etc.
A combination of
both Level 5 and
Level 3 scenarios
is implemented
Some feeder
system data
Some average
cost allocation
Full patient level
data;
Cost centres are
identified for each
service unit
Duration / charge
data used to
allocate S&W;
Feeder system
data used to
allocate:
- Prosthesis
- Pharmacy
- Imaging
- Pathology
- etc.
Level
1
Level
2
Level
3
Level
4
Level
5
ABM Portal
ABM Portal
ABM Portal
SNAP App
Outcome data
Benchmarking
Ability to produce ad hoc reports
Activity against target
Goal
Provide the tools for world class
healthcare
Sustainability