Hx & setting the scene

1. - Use of the International Classification of Functioning, Disability and Health (ICF) as a framework for capturing Allied Health Indicators for Intervention (IFI) - Amy Mayer, Mary Haire, Jan Erven

2. Hx & setting the scene • NAHCC Formed in 1990’s • Achievements: • Allied Health Minimum Dataset • Health Activity Hierarchy Model (HAH) • Indicator for Intervention (conceptual framework) • NAHCC as a Standing Committee of AHPA in 2012 • Active participants in IHPA working groups

3. AHPA’s definition of Allied Health & Allied Health Professionals http://www.ahpa.com.au

4. An allied health profession is one which has: a direct patient care role and may have application to broader public health outcomes a national professional organisation with a code of ethics/conduct and clearly defined membership requirements university health sciences courses (not medical, dental or nursing) at AQF Level 7 or higher, accredited by their relevant national accreditation body clearly articulated national entry level competency standards and assessment procedures a professionally defined and a publicly recognised core scope of practice robust and enforceable regulatory mechanisms

5. and has allied health professionals who: are autonomous practitioners practice in an evidence based paradigm using an internationally recognised body of knowledge to protect, restore and maintain optimal physical, sensory, psychological, cognitive, social and cultural function may utilise or supervise assistants, technicians and support workers.

6. The workforce • Similar % of total workforce as medicine • http://www.ahpa.com.au/Portals/0/Representation/AHPA_Policy_Paper-Workforce-March_2013.pdf

7. Health Activity Hierarchy • Widely used by allied health clinicians and nursing services in some settings, could be utilised by all clinicians in all settings • Allows all activities to be assigned to a category • Allows time to be collected per category • Provides high quality ‘product’ information when combined with relevant classifier eg AR-DRG. Extensively used in Health Round Table allied health activities, CHIME environments etc • Allows the calculation of an average, median and range resource consumption by classifier so is a powerful tool for calculating cost and informing funding

8. Health Activity Hierarchy

9. http://www.nahcc.org.au/hierarchy.htm

10. Allied Health Minimum Dataset • 20 data elements defined to describe allied health activities: • Patient demographics • Provider details – profession • Interventions provided • Method for collecting data agreed and in wide use (time-based) • An undefined data element was the reason the clinician provided for intervention – the Indicator for intervention - (the professional diagnosis, complementary to the medical diagnosis). • The IFI would provide a ‘grouper’ specific to each profession which could be more predictive of resource consumption and useful for funding mechanisms

11. What is an IFI? • A service provider description of the characteristics of the individual or population which indicate need for intervention: • ‘Why am I providing a service?’ EXAMPLE: Stroke: Dietician: treating underlying conditions: malnutrition, diabetes Speech Pathologist: aphasia, dysphagia Psychologist: Memory strategies Social Worker: interpersonal/family issues, guardianship issues, placement in care facility

12. Drivers for IFI Development • Need for a patient descriptor that better predicts clinicians involvement, resource consumption and cost than DRG or ICD-10. • DRG is a poor predictor of AH resources (as per sub-acute which is why we have other classifications). • A mechanism to group together like activity for funding, planning and research. • The developing passion for outcome measures. • Medical diagnosis does not set a basis for outcomes. • A behavioural descriptor that better explained reason for AH intervening also set a basis for measuring change

13. History of the IFI Project • 1998 Commonwealth Department of Health (Casemix Branch) Funded development of IFI in stages • 2000 First report published containing broad set of ‘high level’ IFIs and Performance Indicators. No further funding • 2005 Again identified that IFI was missing for data collected from Australian Outpatients Departments Funded two further stages Phase 1 Development of IFI data set (2006) Phase 2 Pilot of IFI data set (2006 –2008)

14. Use of the ICF • ICF chosen for classifying IFIs rather than continuing former codeset • ICF: • Internationally validated • Biopsychosocial model • Known cost driver • Function vs dysfunction Emphasises that health care as more than the removal of problems but about “supporting the individual to regain the capacity or restore a life worth living” (Felton, 2006) neutral language > intervention > opportunity > positivity

15. Participants • Prosthetics and Orthotics (P&O) (15) • Psychology (49) • Social Work (35) • Speech Pathology (34) TOTAL = 341 clinicians across 11 disciplines • Audiology (14) • Dietetics (24) • Exercise Physiology (EP) (11) • Occupational Therapy (64) • Orthoptics (10) • Physiotherapy (70) • Podiatry (15)

17. Methodology Decision to use ICF vs another code set e.g., SNOMED CT: -  Internationally validated - Biopsychosocial -  Known cost driver Coding Infrastructure: • Web based system and optimally accessible • Participants received an icon shortcut to the on-line data collection system • Option to enter codes directly or use a standardised process to guide choices • Other options to complete hard copies and enter data later or send to project team for data entry • Each supplied with a manual including a short list of common codes for all professions.

18. http://www.nahcc.org.au/ifiproject.htm

19. Frequently Used Codes Examples

20. Reliability Study • Objective: to assess whether clinicians within a profession used the IFI codes in a consistent way • Invited 220 participants across professions (all regular coders) • 132 participants completed the reliability study • Average 65.2% participation rate across professions • Presented with 20 on-line cases - developed by a working group from that profession - a variety of settings, client types, complexities - responses compared against a list allocated by working group • Asked to allocate up to two IFI codes to each case using the same system used in daily coding

21. Tool evaluation USEFUL • 74.1% of participants thought the IFI would be ‘moderately’ to ‘extremely’ useful to collect as standard allied health data. USEABLE AND SIMPLE • ~ 80% were at least ‘moderately’ confident of the accuracy of their coding EFFICIENT • Took most participants less than an average of 2 minutes to allocate and enter the IFI data

22. Results • The IFI found to be a useful indicator of why allied health is involved in patient care in the public health system. • Most Allied Health Professions (AHPs) were able to use the IFI codes in a consistent way. • 80.3% participants coded 80% or more cases appropriately • 7/11 professions coded at or above 80% of cases correct • 3 of the 4 professions below the benchmark had very small numbers (4-9 participants)

23. IFI and Sub-acute care definitions: a future together? Robust classifications are the basis for activity based funding (ABF). Under the National Health Reform Act 2011, IHPA was tasked with developing and specifying the classification systems used to classify health care and other services provided by public hospitals for ABF purposes. IHPA website www.ipha.gov.au

24. Sub-acute care types Sub-acute care type definitions necessary as: DRG/medical diagnosis not sufficient grouper for clinical intervention and cost prediction in sub-acute care These definitions align with ICF framework on which allied health IFIs are based. Why am I intervening? To improve functioning, activity, participation, quality of life. This is the question and answer for both allied health care and for sub-acute care

25. ICF Components Body Functions & Structures Activities & Participation Environmental Factors Functions Structures Capacity Performance Barriers Facilitators

26. New definitions of sub-acute care (AIHW/IHPA 2013) • Subacute care is specialised multidisciplinary care in which the primary need for care is optimisation of the patient’s functioning and quality of life. A person’s functioning may relate to their whole body or a body part, the whole person, or the whole person in a social context, and to impairment of a body function or structure, activity limitation and/or participation restriction. • Subacute care comprises the defined care types of rehabilitation, palliative care, geriatric evaluation and management (GEM) and psychogeriatric care.

27. New definitions of sub-acute care (IHPA 2013) cont.. • A multidisciplinary management plan comprises a series of documented and agreed initiatives or treatments (specifying program goals, actions and timeframes) which has been established through multidisciplinary consultation and consultation with the patient and/or carers.

28. Sub-acute Care Type definitions cont…(IHPA 2013) 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 care 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.

29. Sub-acute Care Type definitions (IHPA 2013) • Palliative care is care in which the primary clinical purpose or treatment goal is optimisation of the quality of life of a patient with an active and advanced life-limiting illness. The patient will have complex physical, psychosocial and/or spiritual needs.

30. ICF and Assessment Tools The ICF is extensively used as a framework to compare different assessment tools across settings and health conditions. IHPA engaged the University of Sydney to identify instruments for assessment of sub-acute care patients, which address deficiencies in existing tools for each care type and options. The ICF is considered a framework and classification system on which assessment or measurement tools may be based and to which they can be mapped The project addresses IHPA’s work plan for the development and implementation of nationally consistent data standards, data collection, classification and reporting of sub-acute and non-acute care required for Activity Based Funding (ABF) purposes

31. Further defining Model of Care in Sub-acute care types and predicting resource use Allied Health an essential component in care of complex patients with multiple problems restricting functioning, activity, participation and quality of life. IFIs based on ICF framework may be useful to further define model of care for staff in non-designated units (where Sub-acute care types are assigned on physical acute units or staff in smaller facilities work across acute and sub-acute). Although designed by allied health the IFI framework is not allied health specific. Enables tighter definition of “multidisciplinary care plan” to explain model of care and more accurately predict resource use

32. Potential for IFI classification: resource measurement and funding • Basis for predicting and measuring resource use and cost for Allied Health services in all settings (‘Allied Health’s DRGs’) • Extended classification framework for multidisciplinary sub-acute work which is based on ICF • Assessment of service scope in non-admitted settings

33. Potential for IFI classification: performance indicators and outcomes • IFIs originally developed as part of a system of performance indicators to assist with clinical outcome measurement • Application of ICF qualifiers for specificity (‘no problem’ ranging to ‘complete or total problem’) could provide national outcome measures for Allied Health similar to AusTOMS (also based on ICF)

34. Potential for IFI classification cont.. • Provision of National Health Data Dictionary elements (AIHW) for allied health • Provision of data elements for Allied Health Data Set Specification (National eHealth strategy) currently in development, progressing integration with eHealth development

35. Future directions & recommendations for subacute care • Allied health practitioners work in both non designated and designated units. IFI as a conceptual framework can help to define this work further, particularly in non designated units. • Further classification of reasons why allied health intervene will assist the refining of subacute care types in non- admitted settings • Performance indicators driven by IFIs would enable relationship between funding, efficiency and quality to be measured for allied health in sub-acute care

36. References available The Australian Psychological Society Report to Department of Health and Ageing Indicator for Intervention (IFI) Project Final Report March 2008 World Health Organization (WHO, 2001). International Classification of functioning, disability and health. Geneva: World Health Organization. National Allied Health Casemix Committee Health Activity Hierarchy Version 1.1; An Australian standard describing the range of activities provided by health professionals 2001 NAHCC Report on the Development of Allied Health Indicators for Intervention and Performance Indicators; and Revision of Allied Health-sensitive ICD-10-AM Codes for Inclusion in ICD-10-AM Edition Two January 2000 NAHCC Indicators for Intervention Version 1; a service provider description of the characteristics of the individual which indicate need for attention August 1999

37. References available cont.. Felton, K. (2006) Quality of Life: Conceptualising measurement for client outcomes in hospital social work.PhD thesis, University of Qld2006 AIHW (2013)Development of nationally consistent subacute and non-acute admitted patient care data definitions and guidelines Perry A, Morris M, Unsworth C, Duckett S, et al. (2004). Therapy outcome measures for allied health practitioners in Australia: the AusTOMs. International Journal for Quality in Health Care 16(4):285-91