SUS Release 11 Best Practice & Readmissions

1. SUS Release 11Best Practice & Readmissions Training Presentation SUS PbR Policy - Best Practice & Readmissions 1

2. Agenda Purpose of today’s session Best Practice Readmissions

3. APC Best Practice 2012/13

4. APC Best Practice Introduction The Department of Health introduced Best Practice in Tariffs 2010/11 with the aim of reimbursing providers for improving the quality of care. The aim is to incentivise Providers to provide High Quality and Cost Effective care. The incentive is a National Best Practice Tariff. Best Practice initially addressed four high volume areas; cataracts, fragility hip fracture, gall bladder and acute stroke, chosen due to the significant and unexplained variation in practice and clear consensus of what clinical best practice constituted. In 2011/12 Best Practice was extended to cover a further five clinical areas and to cover the use of Daycase admissions.

5. APC Best Practice • APC Best Practice – Adjustment to Tariff • Best Practice Tariff (BPT) in SUS is treated as an adjustment to tariff and not a separate National Best Practice tariff • The Adjustment may take the National Tariff down to a ‘Base Tariff’ which is then used locally as a base to uplift to an increased Tariff once local data has been reviewed e.g. fragility hip fracture and stroke • Other BP adjustments are negative with no local uplift as the Best Practice tariff for relevant activity is set at a level lower than the standard elective (or non-elective) APC tariff – DH policy

6. APC Best Practice • APC Best Practice has been extended again in 2012/13 with the • following effects: • There are now approximately 40 service areas that are assigned BPT flags that may be eligible for Best Practice Tariff adjustment • Best Practice Tariff (BPT) adjustments applied to APC Spells only

7. APC Best Practice

8. APC Best Practice • Specialised Service Codes and Best Practice Flags • This year the Grouping process will output separate Specialised Service Codes (SSC) and Best Practice flags • The format of these flags is the same between the Local Payment grouper and the SUS Grouper • The Grouper formats are: • Specialised Service Code (SSC) = SSnn e.g. SS08 • Best Practice = BPnn e.g. BP36 • Note: Making this change ensures that the difference between BPT and SSC flags is much clearer for users from a processing and output perspective.

9. APC Best Practice • Flags from the Grouper for Best Practice are produced at Spell level • Flags from the Grouper for Best Practice are DISTINCT i.e. only one distinct value per Spell. However you can have multiple flags per Spell (but not the same flag multiple times) • Local Grouper outputs the SSC and BPT flags into a file ‘xxx_File_rel’ (where xxx is the filename provided at run time) Example output from Local/SUS Grouper

10. APC Best Practice • BPT Action Indicators • BPT Indicator 1 • BPT Indicator 1 Action • BPT Indicator 2 • BPT Indicator 2 Action • BPT Indicator 3 • BPT Indicator 3 Action • BPT Indicator 4 • BPT Indicator 4 Action • BPT Indicator 5 • BPT Indicator 5 Action • All Best Practice Flags whether they are SUS or Grouper • derived will be ordered from the Lowest to Highest • e.g. (BP01 to BP47) • The five Best Practice Indicators will be populated by the first five flags from the ordered Best Practice flags

11. APC Best Practice Invalid Combinations

12. APC Best Practice • New BPT Action Indicator attribute displays status of BPT flag • Values are:- • Invalid (Failed Combination Check) • Adj Tariff (The BPT has a National BPT Adjustment) • Opt Tariff (The BPT has an Optional Adjustment) • Multi (The BPT has an Optional and National Adjustment) • No Tariff (the BPT has no adjustments) • BPT Indicators where the ACTION Indicator is NULL will be used to derive a Best Practice Tariff adjustment • BPT Indicators where the ACTION Indicator is Invalid will NOT be used to derive a Best Practice Tariff adjustment • Note: The BP Combination Indicator(APC Spell extract) contains “Null” as this attribute is no longer used.

13. APC Best Practice • Short Stay Emergency (SSEM) • To apply Best Practice for Spells that have an HRG and Length of Stay that qualifies for a Short Stay Emergency Tariff SUS will apply the following rules. • Record the HRG Short Stay Emergency Tariff on the Spell • Record the HRG National Non Elective Emergency Tariff on the Spell • Using the Spell attributes that contribute to a BPT adjustment check if the Spell is qualified for an adjustment • There are two outcomes possible: (see next slide)

14. APC Best Practice • Short Stay Emergency (SSEM) • Outcome 1: Tariff adjustment is qualified and will: • Apply the National Non Elective Emergency Tariff as the Initial Tariff • Apply the adjustment to the Initial Tariff • Record ‘Adj Tariff’ in the BPT Action attribute • Remove the recorded Short Stay Tariff as it is no longer relevant.

15. Best Practice Short Stay Emergency (SSEM) Outcome 2: NO BPT adjustment is qualified and will:  Apply the Short Stay Emergency Tariff as the Initial Tariff Record ‘No Tariff’ in the BPT Action attribute Remove the recorded National Non Elective Emergency Tariff as it is no longer relevant.

16. APC Best Practice Apply BPT Adjustments In SUS PbR 2012/13 the following attributes from the Spell will be used to match against reference data to derive if an adjustment for BPT is qualified.

17. APC Best Practice Apply BPT Adjustments In SUS PbR 2012/13 the following attributes are retrieved from the reference data table when a BPT adjustment is qualified. • Note: SUS will apply each of the BPT Indicators together with the required attributes. If a match is found the Tariff Adjustment will be recorded and the appropriate BPT Indicator Action will be populated with the value taken from BPT ACTION INDICATOR in the reference data. • Note: An Optional Tariff is output for information & local purposes and does not contribute to the Final PbR Tariff or any Market Forces Factor calculations.

18. APC Best Practice Row 1 Row 2 Row 3 Row 4

19. APC Best Practice • APC Spell Extract attributes • BPT Flags • SSC Flags • BPT Indicator • BPT Action Indicator • Tariff Adjustment • Optional Tariff Adjustment

20. APC Best Practice • Number of BPT Indicators • Number of distinct Best Practice Tariff Indicators (BPTs) - count regardless of a BPT Adjustment being applied or BPT Invalid Combinations. This reflects the number of BPT that have been allocated by the Grouper or SUS • Count does not include phantom Spells or Spells where all episodes have been deleted. Where this occurs count will be NULL

21. APC Best Practice • Number of Specialised Service Code Indicators • The Number of distinct Specialised Service Codes (SSCs) based on Grouper output - count for PbR Included activity only. • Whether the SSC is eligible for a top-up is not considered for • this count • Count does not include phantom Spells (Spells where all episodes have been deleted). Where this occurs count will always be NULL

22. APC Best Practice • Optional APC BPT Adjustment • While the field may contain a £s value, it is for information only and does not contribute to the Final Tariff. The adjustment may be applied locally but will not attract Market Forces Factor (MFF) • Note: The BPT Action Indicator will contain “Multi” if both Tariff Adjustment £ (+/- value in £) which is added to the total payment for the Spell and Optional Tariff Adjustment £ are populated within APC extracts

23. APC Best Practice • Length of Stay (LOS) • A new length of stay check (LOS) check has been introduced for all APC Spells with a BPT flag when applying adjustment • Spells are checked to ensure that the length of time that a patient spends in hospital is BETWEEN a maximum and minimum • Spells which fall outside of the maximum or minimum length of stay for that procedure will not qualify for appropriate adjustments. The BPT Action will be ‘No Tariff’

24. Readmissions

25. Readmissions • Readmissions in 2011/12 – High Level Detail • Readmissions policy was introduced in April 2011. This meant that Commissioners could retain funds for Spells that are deemed a readmission in order to make investments in other areas in an attempt to reduce the number of readmissions. • To support this policy, readmission activity in SUS for 2011/12 was processed using readmission pathway logic with details output in a Managed Service “Readmissions” extract available to Commissioners only.

26. Readmissions • High Level Detail • For 2012/13 SUS Readmissions logic will cover: • Multiple Years – covers 2011/12 and 2012/13 • SUS will flag Spells in a pathway that are: ‘Parent’ (First Admission), ‘Child’ (Follow-on Admission) or ‘Both’ • Validation results will now be shown at a Spell level as opposed to at a Pathway level

27. Readmissions • How a Readmissions Pathway is created: • Child Spells Identified • Child Spells Validated • Readmissions Path Created • Parent & Child Spells identified in Pathway • Parent & Child Spells Validated

28. Readmissions Step 1 – Identifying Eligible Child Spells SUS will look at incoming APC Spells to find eligible child Spells using the criteria shown below. Where it finds a match RAP Spell Type and RAP Eligible Child will be populated. Only Spell that are Admission Sub Type = EMR - The admission must be an emergency Spell In PbR/Not in PbR = 0 - The PbR qualified indicator must be zero, telling SUS that the Spell is to be tariffed Total National Tariff > = 0 – the Tariff Total National must be greater than or equal to ZERO If all are passed then RAP Eligible Child = ‘Y’ and RAP Spell Type = ‘Child’ If a Spell passes (a) but fails on either (b) or (c) then RAP Eligible Child = ‘N’and RAP Spell Type = ‘Child’

29. Readmissions • Step 2 - Validate Child Spells • Only Spells which are marked as RAP Eligible Child = Y are picked up by SUS for validation against the Reference Data. • Once a Spell is validated against the reference data: • A Spell that passes (no hits) then DH TARIFF ADJ CHILD = ‘Y’ • A Spell that fails (has a hit) then DH TARIFF ADJ CHILD = ‘N’

30. Readmissions Attributes used in Child Validations

31. Readmissions • Step 3 – Create Readmissions Pathway • Once child Spells have been identified and validated SUS will link the Spells that fall within the interval (30 days) from child Spell admission date to parent Spell discharge date into a readmissions pathway • To ensure that same day readmissions are included the gap between the Discharge Date and Readmission date is calculated from the actual discharge date • The data used to find potential parents of the identified child Spells is all held in the post reconciliation marts

32. Readmissions • Step 4 - Identify Parent & Child Spells within the Readmissions Pathway • SUS will now identify Parent from Child Spells with the Readmissions pathway always working from the last Child back in time. • Step 5 – Apply Validations • SUS will perform Parent validation checks on pairs of eligible Spells.

33. Readmissions New Readmission Attributes in 2012/13

34. Readmissions Processing Outcomes Using the matching criteria and processing steps this is the simplest pathway with just two Spells. Spell 1 - This Spell has been identified as an elective admission, is a Parent Spell with a PQI of zero and is eligible for adjustment. Spell 2 - This Spell has been identified as an emergency admission and is Child Spell only with a PQI of zero and is eligible for adjustment. Both Spells have passed validation tests as the DH ADJ Parent and DH ADJ Child are both set to ‘Y’ and the Validation Parent and Validation Child are both NULL.

35. Readmissions Processing Outcomes Using the matching criteria and processing steps here are some of the possible outcomes Spell 1 - This Spell has been identified as an elective admission, is a Parent Spell with a PQI of zero and is eligible for adjustment. Spell 2 - This Spell has been identified as an emergency admission and is both a Parent and Child Spell with a PQI of zero and is eligible for adjustment on both Spells before further validations. Spell 3 - This Spell has been identified as an emergency admission and is Child Spell only with a PQI of zero and is eligible for adjustment.

36. Readmissions Further Validations Spell 2 - This Spell has been identified as an emergency admission with a PQI of zero and is both a Parent and Child Spell. When further validations on pairs of Parent and Child Spells are carried out , Spell 2 - Spell Type - Both, has VC4 populated in the Validation Child column causing the DH_ADJ_Child. To be set to ‘N’ S2 is not a Valid Child therefore it does not need a Parent, however S2 is a valid Parent to spell S3.

37. Readmissions Errors Spell S2 is considered as an ERROR since the Admission date (10th April) is before the previous Discharge date (15th April). A Spell that is considered as ‘ERROR’ is not used in any processing in readmissions.

38. Readmissions Same Day Transfers SUS will flag same day transfers between providers in a Readmissions pathway using reference data from 2012/13. Only Spells which fall within this financial year are can be identified as a same day transfer and can be seen in the Readmissions extract in the attributes Transfer Out and Transfer In.