Download Dementia CQUIN template for medication prescribing

Standard template for CQUIN schemes in national contracts
Coordinating Commissioner
NA
Associate Commissioners
NA
Expected financial value of Scheme
£
Goals and Indicators
Goal
no.
Description of goal
Quality
Domain(s)
Indicator
number
Indicator name
National or
Regional
indicator
Indicator
weighting
(within
Goal)
Guarantee appropriate
prescribing of antipsychotic
medication for people with
dementia & Behavioural and
Psychological Symptoms of
Dementia (BPSD) through
the development and
implementation of best
practice prescribing
guidance
Safety,
effectiveness
and patient
experience.
1
Prescribing
guidance
Regionally
Suggested
25%
Embed good practice in the
discharge of patients with
dementia & BPSD who are
prescribed antipsychotic
medication through the
development and
implementation of discharge
processes that lead to
routine / timely review of
antipsychotic medications.
Safety,
effectiveness
and patient
experience.
2
Discharge Planning
Regionally
Suggested
25%
Review all current
prescribing of antipsychotic
medications in patients with
dementia & BPSD
Safety,
effectiveness
and patient
experience.
3
Prescribing review.
Regionally
Suggested
12.5%
Undertake a baseline audit
of the use of antipsychotic
medications for people with
dementia & BPSD
Safety,
effectiveness
and patient
experience.
4
Baseline Audit
Regionally
Suggested
12.5%
Work with the wider health
and social care economy to
promote good practice
around the treatment of
Behavioural and
Psychological Symptoms of
dementia
Safety,
effectiveness
and patient
experience.
5
Supporting Good
Practice
Regionally
Suggested
25%
Detail of Indicator (Prescribing Guidance)
Description of indicator
The Trust should develop prescribing guidance
that informs the decision of clinicians to
commence with the prescription of antipsychotic
medication licensed for people with dementia &
BPSD. This guidance should be in line with both
NICE and MHRA definitions of good practice.
The guidance should emphasise the
requirement that antipsychotic medication
should not be a first line intervention. Guidance
should look at alternative ways of working with
BPSDs and should detail those symptoms that
the prescription aims to address. This guidance
should then be used to inform all prescribing
practise across the Trust in the form of a
prescribing checklist that will be completed for
new antipsychotic scripts.
Numerator
N/A (see below)
Denominator
N/A (see below)
Rationale for inclusion
The need to reduce the use of antipsychotic
medications for people with dementia is detailed
in the work of Sube Banerjee *(Time for Action
2009). This message is included in the NHS
operating framework for 2012-2013.
Data source and frequency of collection
Trusts
Organisation responsible for data collection
PCTs
Frequency of reporting to commissioner
Quarterly
Baseline period / date
April 2012
Baseline value
See milestones below
Final indicator period / date (on which payment is based)
End of Q4
Final indicator value (payment threshold)
See milestones below
Final indicator reporting date
End of Q4
Rules for partial achievement of indicator at year-end
See milestones below
Rules for any agreed in-year milestones that result in payment
Q1 – The completion of Q1 is defined by the
publication of a set of prescribing guidelines that
have been developed by an appropriate group
of clinicians from across the health economy
(the guidelines should be accepted by clinicians
in primary care and the acute sector as well as
within the Trust). These guidelines should meet
the requirements described above. As a culture
shift is needed across an entire pathway,
success will be more likely if a whole system
approach is adopted. Involvement of Social
Care, Care Homes, Intermediate Care (if
applicable), service users and carers is highly
desirable at this stage. This whole systems
approach will produce guidelines that should be
disseminated to all prescribers.
At this stage the Trust should be able to
evidence that reducing the inappropriate use of
antipsychotics is considered to be a clinical
governance priority, for example through
meeting notes or standing agenda items at
relevant meetings.
Q2 – 50% of all new antipsychotic prescribing
within the trust should be done with reference to
stated guidelines and following the completion
of the prescribing checklist. Evidence will be via
audit of new prescribing cases.
Q3 - 75% of all new antipsychotic prescribing
within the trust should be done with reference to
stated guidelines and following the completion
of the prescribing checklist. Evidence will be via
audit of new prescribing cases.
Q4 - 100% of all new antipsychotic prescribing
within the trust should be done with reference to
stated guidelines and following the completion
of the prescribing checklist. Evidence will be via
audit of new prescribing cases.
Rules for delayed achievement against final indicator period/date and/or
in-year milestones
If the provider is unable to achieve the
milestones then they will receive the percentage
of the overall value that corresponds to their
achievement (for example, if the three month
indicator target of 75% is reached by the end of
the year then they will receive 75% of the target
value).
Detail of Indicator (Discharge Planning)
Description of indicator
Audit evidence suggests that between 50% and
80% of antipsychotic initiation takes place in
secondary mental health settings. Primary care
practitioners are often loathed to change
prescribing patterns once they are established.
Clinicians in secondary care should make sure
that their discharge processes do everything
they can to make sure that prescriptions are
reviewed within the 6 week period suggested by
MHRA guidance (search MHRA PL10622/0285)
- 12 weeks should be considered an absolute
maximum for a review to have taken place. As a
minimum the need for a review should be
communicated to the patient’s GP in writing and
to one other person as deemed appropriate (the
patient themselves, or a primary carer, care
home manager etc). In addition to this we would
expect to see at least one further mechanism
(local innovation, for example text message
reminder) put in place to make sure that the
review takes place.
Discharge procedures should also make it very
clear the nature of the diagnosis – dementia and
type – as a prompt for primary care to update
their dementia registers.
Numerator
Recipients of antipsychotic medication requiring
a medication review.
Denominator
All recipients of antipsychotic medications with
dementia & BPSD
Rationale for inclusion
The need to reduce the use of antipsychotic
medications for people with dementia is detailed
in the work of Sube Banerjee *(Time for Action
2009). This message is included in the NHS
operating framework for 2012-2013.
Data source and frequency of collection
Trusts, quarterly.
Organisation responsible for data collection
PCT
Frequency of reporting to commissioner
Quarterly
Baseline period / date
April 2012
Baseline value
Anecdotal evidence suggests that there is a
wide variety of practice in this area,
commissioners will want to set their baseline
values to make sure that targets stretch current
discharge practises.
Final indicator period / date (on which payment is based)
Q4
Final indicator value (payment threshold)
See milestones below
Final indicator reporting date
Q4
Rules for partial achievement of indicator at year-end
See milestones below.
Rules for any agreed in-year milestones that result in payment
See milestones below
Rules for delayed achievement against final indicator period/date and/or
in-year milestones
Q1 – Develop a discharge process that
maximises the likelihood of a review of
antipsychotic medication taking place in a timely
fashion. A task and finish group to establish this
process should include clinicians from primary
care, the acute trust, intermediate care (if
appropriate), medicines management, social
care and commissioning. Audit will be via
scrutiny of meeting to notes and evidence that a
rigorous process has been developed. The
process should, as a minimum, establish the
prescribing as time limited, establish the
symptoms for which the prescribing was
initiated and have mechanisms to prompt the
review to take place (see above).
Q2 – 50% of all patients discharged with an
antipsychotic medication follow the discharge
guidance.
Q3 – 75% of all patients discharged with an
antipsychotic medication follow the discharge
guidance.
Q2 – 100% of all patients discharged with an
antipsychotic medication follow the discharge
guidance.
Detail of Indicator (Review Current Prescribing)
Description of indicator
New practises around discharge will not deal
with ongoing prescribing. There is some debate
amongst clinicians as to what constitutes a
medication review. This indicator demands that
clinicians decide on a robust review process. A
review will then be undertaken on all patients
with a diagnosis of dementia who are being
prescribed antipsychotic medication.
Numerator
Reviews undertaken of patients with dementia &
BPSD on antipsychotic medication who have
not been reviewed in the last 12 weeks.
Denominator
All patients with dementia & BPSD receiving
antipsychotic medication.
Rationale for inclusion
The need to reduce the use of antipsychotic
medications for people with dementia is detailed
in the work of Sube Banerjee *(Time for Action
2009). This message is included in the NHS
operating framework for 2011-2012. The need
for timely review is central in the Banerjee
report.
Data source and frequency of collection
Trust, Quarterly.
Organisation responsible for data collection
PCT
Frequency of reporting to commissioner
Quarterly
Baseline period / date
April 2012
Baseline value
Practise varies between trusts. This indicator
should be modified to make sure that the
indicator stretches current Trust practise. For
example if a robust review process is already in
place and 50% of patients are routinely
reviewed within 12 weeks then the baseline
value should be set at 50% and indicator targets
should be set as quarterly increments from 50%
to 100%.
Final indicator period / date (on which payment is based)
Q4
Final indicator value (payment threshold)
12.5%
Final indicator reporting date
Q4
Rules for partial achievement of indicator at year-end
See milestones below.
Rules for any agreed in-year milestones that result in payment
See milestones below
Rules for delayed achievement against final indicator period/date and/or
in-year milestones
As mentioned above milestones should be set
based on the local context. If no review
processes exist then the indicator for Q1 will be
the development of a review process. The
subsequent three quarters will then challenge
the trust to review an increasing proportion of all
patients on antipsychotic medications.
Detail of Indicator (Audit of Antipsychotic use for people with Dementia)
Many Trusts will have already undertaken an audit of their prescribing
practices. For those that have not a baseline audit is an important
starting point. There are a number of sample audit tools available that
cover all of the relevant areas. These are available here;
Description of indicator
https://groups.itsservices.org.uk/display/Events/Reducing+Antipsychotic+Prescribing++Resource+Library
The specifics of the audit process should be agreed in advance with
the commissioner.
Numerator
Audit of patients with dementia & BPSD receiving antipsychotic
medications
Denominator
All patients with dementia & BPSD receiving antipsychotic
medications
Rationale for inclusion
The need to reduce the use of antipsychotic medications for people
with dementia is detailed in the work of Sube Banerjee *(Time for
Action 2009). This message is included in the NHS operating
framework for 2012-2013. Baseline audit is a key recommendation in
the Banerjee report.
Data source and frequency of collection
The antipsychotic audit should take place over a fixed duration, and
the audit results should be a one-off submission.
Organisation responsible for data
collection
Trust
Frequency of reporting to commissioner
One off
Baseline period / date
To be agreed with commissioner
Baseline value
This indicator assumes that no audit has taken place in the previous
12 months.
Final indicator period / date (on which
payment is based)
N/A
Final indicator value (payment threshold)
Audit Complete
Final indicator reporting date
Q4
Rules for partial achievement of indicator
at year-end
None
Rules for any agreed in-year milestones
that result in payment
Payment can be received early if the audit is completed to the
required standard.
Rules for delayed achievement against final
indicator period/date and/or in-year milestones
None
Detail of Indicator (Work with the wider health and social care economy )
Mental Health Trusts employ experts in the treatment
of the Behavioural and Psychological Symptoms of
Dementia. It is important for the whole health economy
that these skills are shared outside of the secondary
mental health setting.
The aspiration of this CQUIN is that the knowledge
and expertise that reside with practitioners in
secondary care services have the maximum possible
impact on the wider health and social care system.
The Trust should develop a local plan in collaboration
with the commissioner and primary care and care
home representatives that facilitates the sharing of
expertise. This plan may include elements such as ;

Nominating a champion within the Trust to
become a Single Point of Contact for all BPSD
and prescribing queries

Providing training to GPs

Providing training to care home staff

Information bulletins and case studies shared
with networks

Conference / Events to showcase alternative
interventions

Local Innovation
Description of indicator
The local plan should contain benchmarks that are
solely under the control of the Trust in line with CQUIN
guidance. For example, a benchmark for training to
GPs might say that training materials have been
identified, an offer of training has been extended to all
surgeries and 100% of requests for training have been
fulfilled.
Training might also be extended to Acute Hospital
Teams, Care Homes and Social Care teams. Training
should emphasise a pathway approach, where the
service user and their carer are at the heart of the
pathway. This multidisciplinary, team based training
should also promote;
1) Early intervention, including an early assistive
technology assessment.
2) None pharmacological interventions
3) Outcome measures of person centred care,
e.g. VIPS tool and dementia care mapping.
Numerator
Percentage of actions completed
Denominator
Total actions in locally agreed plan
Rationale for inclusion
The need to reduce the use of antipsychotic
medications for people with dementia is detailed in the
work of Sube Banerjee *(Time for Action 2009). This
message is included in the NHS operating framework
for 2011-2012
Data source and frequency of collection
Trust, quarterly
Organisation responsible for data collection
PCT
Frequency of reporting to commissioner
Quarterly
Baseline period / date
Content of plan must be in addition to both current
activity and to any training and development roles
identified in existing contractual arrangements.
Baseline value
Final indicator period / date (on which payment is based)
Q4
Final indicator value (payment threshold)
Final indicator reporting date
Rules for partial achievement of indicator at year-end
See below
Rules for any agreed in-year milestones that result in
payment
Q1 – Development of an action plan that defines
training and development activity within primary care
and care home settings. Likely content is described
above. The plan needs to make a contribution to the
sector that is commensurate with the value of the
CQUIN; it should be aspirational and attempt to find
innovative ways to work with partners.
Rules for delayed achievement against final indicator
period/date and/or in-year milestones
CQUIN Definitions:
“Scheme”
The agreed package of goals and indicators, which in total, if achieved, enables the provider to earn 1.5%
of its contract value. Where the provider has multiple contracts, the scheme should be reflected within all
contracts, (exceptions specified within guidance).
“Goal”
A description of the intended objective which is being incentivised by the CQUIN scheme eg. “to improve
patient satisfaction within maternity clinics”, or “to improve the health of the population by delivering
effective stop smoking advice to smokers and ensuring referral pathways to the local NHS Stop Smoking
Services” . A goal may be measured using several indicators (see below).
“Indicator”
A measure which determines whether the goal or an element of the goal has been achieved, and on the
basis of which payment is made. The achievement of one indicator should not be dependent on the
achievement of a separate indicator within the scheme.
“Payment threshold”
The level of performance against the indicator which must be achieved to earn payment. This should be
informed by available evidence, (eg. a NICE Quality Standard, a National Service Framework or
benchmarking) and by the provider’s own baseline. Where a baseline needs to be set in-year, the
payment threshold may also need to be confirmed in-year.
In addition to the final indicator value, it may also be appropriate to agree payment thresholds for a)
partial achievement of the indicator and/or b) in-year milestones. However any locally agreed rules should
comply with the national policy on rewarding measurement through CQUIN schemes; acute schemes
cannot reward measurement in 2010/11, hence any payments for in-year milestones should reward real
process or outcome improvements only.