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Gaming. Sub-acute patients. RIC AND LINDY DRG Workshop Belgrade, 18-22.November 2013. Generating additional data counts for more funding • “Paper cases” administrative discharges and readmission in Hungary • Change of care type in NSW. • “Empty cases” in Slovenia • Admitting cases in Emergency Departments and Outpatients – • ?can these be legitimate? DRG Workshop Belgrade, 18-22.November 2013. DEFINITIONS AND RULES PRIVATE AND DISCRETIONARY ELECTIVE?? ED PATIENTS DRG INPATIENTS BUNDLED OUTPATIENTS FFS AMB PATIENTS TRAUMA AND ACUTE ILLNESS AGED CARE AND MENTAL HEALTH PROGRAMS CHRONIC CARE PROGRAMS SAME DAY INPATIENTS DRG Workshop Belgrade, 18-22.November 2013. Admitting outpatients as short stay inpatients • Rapid growth in Victoria of same day episodes • Clear evidence of admitting cases that can be treated in ambulatory setting • Cases that can be treated either way becoming all inpatient – eg – dialysis and chemotherapy • REMOVE PAYMENT INCENTIVE - CAPS DRG Workshop Belgrade, 18-22.November 2013. UPCODING CA$EMAX 1000 500 100 0 70% ACCURACY 30% CREATIVITY – SUBECT TO EDITS DRG Workshop Belgrade, 18-22.November 2013. DRG creep in Hungary DRG Manipulations: (I) report higher severity, (ii) shift outpatient to inpatient 1994-1995 7000 1994 1995 6272 6000 5313 5000 cases 4139 4000 3000 3596 2839 2000 1000 52 0 218 P (complications) 6 Workshop 442 P (other minor surgery) 219 P (withoutDRG complications) Belgrade, 18-22.November 2013. Source: Nagy, J., 1999 Change of care type or discharge and readmission for rehabilitation • How many times per stay? • How many times per day? • Can we pay for them both together? • What is the right time? DRG Workshop Belgrade, 18-22.November 2013. How to detect and control gaming „The only way to pay doctors is to change the system every three years, because by then they will have found ways to get round it to their own advantage” Bob Evans • All casemix systems adjust the system every year • New cost weights and recalibrated price • Potential to cap or reweight overprovision. DRG Workshop Belgrade, 18-22.November 2013. Fine tuning of the system: addressing negative effects • Upcoding (creep), “paper” (readmitted) cases – Monitor and control provider reporting of cases – Continuous cost weight revision • Efficiency and quality – Addressing undertreatment (quality/effectiveness): • creating new groups • *DRGs for sophisticated care, but only selected providers – Quicker-sicker problem: readmission before maximum day limit does not pay extra DRG Workshop 9 Belgrade, 18-22.November 2013. The difference between gaming and fraud • Fraud is repeated offences with intention • Fraud is knowing violation of reporting rules • Fraud is materially profiting from systematic ‘mistakes’ • Fraud is attempting to hide payments claimed that do not relate to a real service DRG Workshop Belgrade, 18-22.November 2013. QUESTIONS • How can these issues be addressed in Serbia? • What is done now about professional review? • How is fraud detected and controlled? DRG Workshop Belgrade, 18-22.November 2013. PART 2 SUB ACUTE CASEMIX DRG Workshop Belgrade, 18-22.November 2013. “SUB ACUTE CARE” • REHABILITATION • PALLIATIVE CARE • GERIATRIC EVALUATION AND MANAGEMENT • PSYCHOGERIATRIC • ??MAINTENANCE (OR NURSING HOME TYPE)? DRG Workshop Belgrade, 18-22.November 2013. SNAP – SUB ACUTE INPATIENT DRG Workshop Belgrade, 18-22.November 2013. SNAP – SUB ACUTE AMBULATORY DRG Workshop Belgrade, 18-22.November 2013. CARE TYPE CHANGE OF CARE TYPE ‘ACUTE SERVICES’ ‘REHABILITATION SERVICES’ DAY OF EPISODE OF CARE OR SPEL DRG Workshop Belgrade, 18-22.November 2013. CARE PATHS AND CLASSIFICATIONS For a clinical pathway you must FOR DRG’s you must have: have: • an episode of care. • an episode of care. • diagnoses. • diagnoses. • a care planning process. • know what was done to the patient - at least in general terms. • a team approach to patient management. • discretion in choice of the most cost effective care. • decisions made before the treatment is undertaken. • decisions made after the treatment is completed. DRG Workshop Belgrade, 18-22.November 2013. REHABILITATION CASEMIX DRG Workshop Belgrade, 18-22.November 2013. REHAB CAN BE ACCESSED • As part of an acute episode (DRG) (usually?) • As a separate “ACUTE” DRG episode • As a separate admission type (where substantial) – Different care type – ‘SUBACUTE’ • As a series of one off referrals from a community provider for eg • PHYSIO, OT, PSYCHOLOGY, SPEECH THERAPY, POD ETC • As a planned package/program of care on an ambulatory basis or combination. DRG Workshop Belgrade, 18-22.November 2013. The Oz classification smorgasbord DRG Workshop Belgrade, 18-22.November 2013. TWO EXAMPLE REHAB CLASSIFICATIONS DRG Workshop Belgrade, 18-22.November 2013. MEASURES OF FUNCTION AVAILABLE FOR CLASSIFICATIONS • ICF – International classification of function – WHO • FIM • Barthels • RUGs DRG Workshop Belgrade, 18-22.November 2013. Rehabilitation Patient Groups – Ontario 2008 • 83 RPG in the new classification system • Relies on the following data elements where applicable: – 1. Rehabilitation Client Code – 2. Admit Motor Functional Independence Measure (FIM) score – 3. Admit Cognitive FIM score – 4. Patient Age DRG Workshop Belgrade, 18-22.November 2013. Rehabilitation Patient Groups – Ontario 2008 –1 of 2 1. Stroke 2. Traumatic Brain Injury 3. Non-Traumatic Brain Injury 4. Neurological 1100. M=12-38 and Age<=68 1110. M=12-38 and Age>=69 1120. M=39-50 1130. M=51-84 and C=5-25 1140. M=51-84 and C=26-29 1150. M=51-69 and C=30-35 1160. M=69-84 and C=30-35 1200. M-12-13 and C-5-21 1210. M=14-47 and C=5-21 1220. M=48-84 and C=5-21 1230. M=12-44 and C=22-28 1240. M=45-84 and C=22-28 1250. M=12-84 and C=29-35 1300. C-5-21 1310. C=22-32 and Age <= 61 1320. C=22-32 and Age>=62 1330. C=33-35 1400. M-12-32 1410. M=33-55 5. Traumatic Spinal Cord Injury 6. Non-Traumatic Spinal Cord Injury 7. Amputation, NonLower Extremity 8. Amputation, Lower Extremity 9. Osteoarthritis 10. Rheumatoid Arthritis and Other Arthritis DRG Workshop 1420. M=56-74 Belgrade, 18-22.November 2013. 1430. M=75-84 1500. M-12-16 1510. M=17-41 and Age <= 30 1520. M=17-41 and Age >= 31 1530. M=42-84 1600. M-12-28 1610. M=29-54 and Age >=51 1620. M=29-54 and Age<=50 1630. M=55-72 1640. M=73-84 1700. M-12-63 1710. M=64-84 1800. M-12-41 1810. M=42-64 1820. M=65-84 and C=5-31 1830. M=65-84 and C=32-35 1900. M-12-59 1910. M=60-84 2000. M-12-68 2010. M=69-84 (M = motor FIM score; C=cognitive FIM score Rehabilitation Patient Groups – Ontario 2008 –2 of 2 11. Pain 2100. M-12-68 2110. M=69-84 12. Fracture of Lower Extremity 2200. M-12-47 and Age >- 84 2210. M=12-30 and Age <= 83 2220. M=31-47 and Age <=83 13. Replacement of Lower Extremity 2230. M=48-51 2240. M=52-84 and Age >= 79 2250. M=52-84 and Age <= 78 2300. M-12-53 and C-5-33 2310. M=12-53 and C=34-35 2320. M=54-68 and C=5-33 2330. M=54-60 and C=34-35 2340. M=61-68 and C=34-35 2350. M=69-84 14. Other Orthopedic 2400. M=12-51 and C-5-33 2410. M=12-51 and C=34-35 2420. M=52-64 and C=5-33 2430. M=52-64 and C=34-35 16. Pulmonary 17. Burns 18. Major Multiple Trauma, Other Multiple Trauma and Major Multiple Fracture 19. Major Multiple Trauma, with Brain or Spinal Cord Injury 20. Ventilator Dependent Respiratory Disorders 21. Other Disabilities 2440. M=65-84 15. Cardiac 2500. M-12-49 and C-5-30 2510. M=12-49 and C=31-35 DRG Workshop 2520. M=50-67 andBelgrade, Age <= 82 18-22.November 2013. 2530. M=68-84 and Age <= 82 2540. M=50-84 and Age >= 83 2600. M-12-36 and Age >- 80 2610. M=37-84 and Age >= 80 2620. C=5-33 and Age <= 79 2630. C=34-35 and Age <= 79 2700. M-12-84 and C-5-35 2800. M-12-24 2810. M=25-55 and Age <= 24 2820. M=25-48 and Age >= 25 2830. M=49-55 and Age >= 25 2840. M=56-84 2900. M-12-34 2910. M=35-59 2920. M=60-84 3000. M-12-84 and C-5-35 3100. M-12-46 3110. M=47-58 3120. M=59-84 and Age <= 58 3130. M=59-84 and C=5-33 and Age >= 59 3140. M=59-84 and C=34-35 and Age >= 59 Victorian Rehabilitation • •Designated Rehabilitation Units – –Agencies are designated for Rehabilitation Units • –10 beds or more and must meet designation criteria • –Paid by per diem grants (or for CRAFT agencies a mix of episode & per diem since 1999) • •Non-Designated – –Payment through Casemix AN-DRG system by WIES DRG Workshop Belgrade, 18-22.November 2013. CRAFT Development • Objective to develop a casemix classification system for Rehabilitation patients which could be effectively adopted as a casemix funding method • Important therefore that the model meet the following criteria: – – – – –Clinical similarity –Resource homogeneity –Administrative ease –Suitable for funding agencies DRG Workshop Belgrade, 18-22.November 2013. Functional Status Issues • Functional status is not used in other DRGs, but • Functional status is basic to rehabilitation practice, assessment and theory – – so important to consider in a classification • Main issues with regard to functional status: – Choice of standard measure instrument • Barthel • FIM • Barthel was chosen originally by Clinical Panel of advisers for collection in Victoria. • It can also be mapped to FIM DRG Workshop Belgrade, 18-22.November 2013. Craft Categories • • • • • • • • • • • • • • • • • . 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Short Stay (overnight stay 1-3 days) Stroke/NeurologicalAdmission Barthel score <60 Stroke/NeurologicalAdmission Barthel score ≥ 60 Orthopaedic Fracture Admission Barthel score < 60 Orthopaedic Fracture Admission Barthel score ≥ 60 Orthopaedic Replace Hip/Knee Admission Barthel score < 60 Orthopaedic Replace Hip/Knee Admission Barthel score 60 – 79 Orthopaedic Replace Hip/Knee Admission Barthel score ≥ 80 Other Orthopaedic Admission Barthel score < 60 Other Orthopaedic Admission Barthel score ≥ 60 Cardio/Pulmonary Amputation Head Injury/Major Multiple Trauma Spinal Burns DRG Workshop Other Rehabilitation Admission Barthel score < 60 Belgrade, 18-22.November 2013. Other Rehabilitation Admission Barthel score ≥ 60 Casemix Rehabilitation and Funding Tree (CRAFT) DRG Workshop Belgrade, 18-22.November 2013. Options for Funding • Episode Costs -Payment for an episode of care – Advantages: • Promotes and rewards efficiencies and standard practice across agencies • Provides a clearer benchmark for units for planning, funding and the evaluation of services– – Disadvantages: • Variability in LOS (“Quicker And Sicker” risk) • Per Diem Costs -Payment based on a day rate– – Advantages:– • More closely approximates existing care • May better reflect service differences– – Disadvantages:– • Does not encourage efficiencies or standard practice across agencies • Consultations with field –episode preference DRG Workshop Belgrade, 18-22.November 2013. NON-ADMITTED DIFFERENCES • Lower? cost structures (usually , not necessarily): – Can be a substitute program for admitted or – A separate different care model (eg voc placement) . – Community can be an essential part of the rehab. • Goals can be staged – series of sub programs. • Function dependent goals and decision points. • Combinations of services can change depending on progress. – Dx can change – certainly needs can. DRG Workshop Belgrade, 18-22.November 2013. PAYING FOR NON-ADMITTED REHAB Minimum requirements Oz • Criterion 1 Rehabilitation care provided by a specialist rehabilitation team on an admitted or non-admitted basis in a specialist rehabilitation unit (a separate physical space.) – and • Criterion 2 Rehabilitation care provided by a multi-disciplinary team which is under the Clinical management of a consultant in rehabilitation medicine or equivalent. – and • Criterion 3 Rehabilitation care provided for a person with an impairment and a disability and for whom there is reasonable expectation of functional gain. – and • Criterion 4 Rehabilitation care for whom the primary treatment goal is improvement in functional status. – and • Criterion 5 Rehabilitation care which is evidenced in the medical record by: – an individualised and documented initial and periodic assessment of functional ability by use of a recognised functional assessment measure. – an individualised multidisciplinary rehabilitation plan which includes negotiated rehabilitation goals and indicative time frames. DRG Workshop MORE DETAIL Belgrade, 18-22.November 2013. MENTAL HEALTH CARE AND CASEMIX DRG Workshop Belgrade, 18-22.November 2013. Mental Health Services as a Part of Health Care? (1/2) • We spend between 7 and 13% of recurrent health expenditure on mental health as the primary condition. • Compared with cardiovascular diseases (10.9%), nervous system disorders (9.9%), musculoskeletal diseases (9.2%), injuries (8.0%), respiratory diseases (7.5%) and oral health (6.9%). AIHW (Mental health services in Australia 2004–05). • The big growth factor in the last decade has been increased expenditure on drugs for depression. • DEPRESSION has highest burden of disease disease where Quality of Life is factored in (rather than mortality). DRG Workshop Belgrade, 18-22.November 2013. Mental Health Services as a Part of Health Care? (2/2) • Acute hospitals – MH alone 3% of separations, 9.7% of bed-days – MH+D&A 3.7% of separations, 10.7% of bed-days. • Special inpatient facilites – Mental health is one of the few clinical specialties where a proportion is done in specialised inpatient and outpatient treatment services. – These are operated both on a voluntary and compulsory basis – and they may involve legal incarceration. – $534AUD million pa in Australia • Private sector hospitals / clinics – Mental health is one of their biggest products – Both as direct care and as a comorbidity with other DRG Workshop conditions – liaison Belgrade, psychiatry 18-22.November–2013. major issue. What is the scope of mental health services? (1/2) • Drug and alcohol services are grouped together as the same service statistics? • Community support services – even such things as housing assistance can be included in mental health care. • Rehabilitation and social independence programs • Cognitive diseases often associated with aging – Alzheimers, Senile dementias etc – may be here or in Aged care. – “Psychogeriatric” can be siloed as a completely different care stream. DRG Workshop Belgrade, 18-22.November 2013. What is the scope of mental health services? (2/2) • “Developmental” disorders – Autistic disorders – Severe learning disorders – Hyperactivity • What about mental health as a CC of other conditions? – Mental health diagnoses and their related treatments are one of the most common comorbidity factors in the treatment of physical conditions. – Generally these costs are not taken into account in the estimates on mental health expenditure. – Some patients can be treated for mental health problems when DRG Workshop actually not eligible from health Belgrade,their 18-22.November 2013.insurance status – by being admitted for a less urgent physical condition. Casemix classifications of mental health? (1/2) • DRG type Classifications – – – – AR-DRGs CMS DRGs HRGs etc • Ambulatory and community classifications – APCs?? – DBGs • Care path based classifications – Care packages – Care programs – DSM 4 Procedure axis DRG Workshop Belgrade, 18-22.November 2013. Casemix classifications of mental health? (2/2) • Mental health status classifications - eg – – – – HoNOS - http://www.crufad.com/phc/honosglossary.htm - http://pb.rcpsych.org/cgi/content/full/29/11/419/TBL1?ck=nck CIDI – DIS http://www.crufad.unsw.edu.au/cidi/cidi.htm BDI – HAS – etc. etc. http://www.swin.edu.au/victims/resources/assessment/affect/bdi.ht ml – General assessment tools – mental status components. • Sf36, SF12 - http://www.crufad.com/phc/sf-12.htm • FIM - http://www.tbims.org/combi/FIM/index.html • ICF - http://www.who.int/classifications/icf/site/onlinebrowser/icf.cfm • Mixed classifications – Combination of inputs relating to patient characteristics and Px’s – DSM DRG Workshop Belgrade, 18-22.November 2013. The World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) • The CIDI is a comprehensive, fully-structured interview designed to be used by trained lay interviewers for the assessment of mental disorders according to the definitions and criteria of ICD-10 and DSMIV. • The CIDI allows the investigator to: - Measure the prevalence of mental disorders - Measure the severity of these disorders - Determine the burden of these disorders - Assess service use - Assess the use of medications in treating these disorders - Assess who is treated, • http://www.hcp.med.harvard.edu/wmhcidi/ DRG Workshop Belgrade, 18-22.November 2013. Is Mental Health so different from other health services? COST RISK FACTORS Legal status MENTAL HEALTH OTHER SPECIALTIES ++ - +++ + ++++ + High level of discretionary treatments +++ ++ High variability in proven efficacy for most treatments +++? -?+? Social support differentiation High level of “talking therapies” DRG Workshop Belgrade, 18-22.November 2013. SOME PRACTICAL PROBLEMS • Discrete funding silos – Continuity gaps – Availability versus suitability • Information barriers – Privacy – Professional territoriality – Patient disempowerment – stigma - chronicity • Accessible/current best practice protocols DRG Workshop Belgrade, 18-22.November 2013. Why do some insurers want to limit access to MH care? • Differential eligibility restrictions – eg – Longer wait for coverage for mental health as a pre-existing condition. – Exclusion of mental health coverage. • USA’s parity legislation – THE OBAMA REFORMS • Expenditure caps – lifetime hospital admission cap. DRG Workshop Belgrade, 18-22.November 2013. USA CMS – INPATIENTS Episode and per-diem mixture DRG Workshop Belgrade, 18-22.November 2013. AUSTRALIAN CASE STUDY “YOU CAN KEEP SOME OF THE PEOPLE HAPPY SOME OF THE TIME….” DRG Workshop Belgrade, 18-22.November 2013. DRG Workshop Belgrade, 18-22.November 2013. DRG Workshop Belgrade, 18-22.November 2013. http://www.health.gov.au/internet/main/publishing.nsf/Content/mental-pubs-d-casemix-toc~mental-pubs-d-casemix-mh AR-DRG CATEGORIES U40Z Mental Health Treatment, Sameday, W ECT U60Z Mental Health Treatment, Sameday, W/O ECT U61ASchizophrenia Disorders W Mental Health Legal Status U61B Schizophrenia Disorders W/O Mental Health Legal Status U62A Paranoia & Acute Psych Disorder W Cat/Sev CC or W Mental Health Legal Status U62B Paranoia & Acute Psych Disorder W/O Cat/Sev CC W/O Mental Health Legal Status U63A Major Affective Disorders Age >69 or W (Catastrophic or Severe CC) U63B Major Affective Disorders Age <70 W/O Catastrophic or Severe CC U64Z Other Affective and Somatoform Disorders U65Z Anxiety Disorders U66Z Eating and Obsessive-Compulsive Disorders DRG Workshop U67Z Personality Disorders andBelgrade, Acute Reactions 18-22.November 2013. U68Z Childhood Mental Disorders • 12 CATEGORIES • • • • DX BASED ICD LEGAL NO D & A LARGE DATABASE FOR GROUPER CALIBRATION • INPATIENT ONLY DRGs/HRGs and Mental Health • Politically rejected for payment because “poor predictor of individual service cost” – Are other specialities so sensitive?? • Not usually considered for use with other variables – Facility – level – availability support. – Extended care programs – capitation – add on DRG Workshop Belgrade, 18-22.November 2013. MH-CASC .. CONTINUING STORY OR GRAND FAILURE?? • Scoped to fund MH by outcomes – or even outputs – across all settings • How can you get a setting independent input independent grouping of ‘products’ – – – – – Diagnosis Severity measures Comorbidities Chronicity – Acuity Social constraints – eg supports, legal risk DRG Workshop Belgrade, 18-22.November 2013. UK CASE STUDY RESOURCE HOMOGENEITY VS CLINICAL MEANINGFULNESS REVISITED DRG Workshop Belgrade, 18-22.November 2013. HRG v3.5 MH CATEGORIES • T01 - Senile Dementia • T03 - Schizophreniform • DX BASED DSM4? Psychoses without Section • T07 - Depression without Section • BROAD SCOPE • T08 - Presenile Dementia – Eg A&D INCLUDED • T09 - Anxiety Syndromes • IP / OP ? • T10 - Alcohol or Drugs NonDependent Use >18 • SMALL DATASET • T11 - Alcohol or Drugs NonFOR GROUPER Dependent Use <19 NORM • T12 - Alcohol or Drugs Dependency • INCLUDES A & D • T13 - Eating Disorders or Obsessive Compulsive Disorders • T14 - Acute Reactions or Workshop Personality Disorders Belgrade,DRG 18-22.November 2013. UK PbR STUDY SETTING DEPENDENT CATEGORIES • • • • • • • • • • • • • • • • • Cty No or std CPA Low prob daily act HONOS10 Cty No or std CPA High prob daily act HONOS10 Cty Std CPA Low prob daily act HONOS10 Cty Std CPA High prob daily act HONOS10 Cty Enh CPA Low prob daily act HONOS10 Cty Enh CPA High prob occ act HONOS12 Cty Enh CPA High prob occ act HONOS12 Cty Enh CPA Low prob occ act HONOS12 IP/OP no or std CPA working age IP/OP no or std CPA above working age IP/OP enh CPA Low cog prob HONOS4 no section ord IP/OP enh CPA Low cog prob HONOS4 section ord IP/OP enh CPA High cog prob HONOS4 0-2 phys prob IP/OP enh CPA High cog prob HONOS4 >2 phys prob IP Low social prob HoNOS social IP Med social prob HoNOS social IP High social prob HoNOS social CPA=Care Programme Approach 17 CATEGORIES SETTING/ PROBLEM / FN BASED CARE APPROACH SMALL DATASET COSTING? DRG Workshop RELIES ON Belgrade, 18-22.November 2013. http://www.gpsa.org.au/media/docs/mentalhealth/honos_information.pdf HONOS UK PbR STUDY SETTING INDEPENDENT CATEGORIES ;W/o Section;No or std CPA;Dx= F0, F2, F5, F6, F7;;; ;W/o Section;No or std CPA;Dx=F1, F3, F4 ,F9;No or low prob daily activities (HoNOS 10);; ONLY WORKING AGE + LEGAL, DX AND HoNOS 78% RECORDS EDIT REJECTED N=11,364 ;W/o Section;No or std CPA;Dx=F1, F3, F4 ,F9;High prob daily activities (HoNOS 10); Wkg age; ;W/o Section;No or std CPA;Dx=F1, F3, F4 ,F9;High prob daily activities (HoNOS 10); Above wkg age;>3 HoNOS psych ;W/o Section;No or std CPA;Dx=F1, F3, F4 ,F9;High prob daily activities (HoNOS 10); Above wkg age;1-3 HoNOS psych ;W/o Section;Enh CPA;Dx=None, F1, F7, F8;No or low prob daily activities (HoNOS 10);; ;W/o Section;Enh CPA;Dx=None, F1, F7, F8;High prob daily activities (HoNOS 10);; ;W/o Section;Enh CPA;Dx=F0, F2, F3, F4, F5, F6, F9;Med or hi CRU complexity;Low or no cognitive prob HoNOS4; ;W/o Section;Enh CPA;Dx=F0, F2, F3, F4, F5, F6, F9;Med or hi CRU complexity;High cognitive prob HoNOS4; ;W/o Section;Enh CPA;Dx=F0, F2, F3, F4, F5, F6, F9;Low CRU complexity;; ;W Section;>2 HoNOSpsych;Enh CPA;Dx= None, F1, F3, F4;; ;W Section;>2 HoNOSpsych;Enh CPA;Dx=F0, F2, F5, F6, F9;; ;W Section;>2 HoNOSpsych;No or std CPA;;; ;W Section;0-2 HoNOSpsych;;;; DRG Workshop Belgrade, 18-22.November 2013. pat Categories Suggested by the Care Path Study • • • • • • • • • • • • • Acute non-psychotic low Acute non-psychotic med Acute non-psychotic high Non-psychot overval idea Non-psychot chaotic & challenging Drug & alcohol First episode psychosis Chronic severe low sympt Chronic severe high sympt Severe psychot episode Severe depression Dual diag Assertive outreach DRG Workshop Belgrade, 18-22.November 2013. • CARE PATH DEFINITIONS • CLINICIAN GROUPING VS ALGORITHM GROUPING • COST VARIANCE ANALYSIS • N=2,287 PATIENTS Ideas on classification dimensions from the forensic MH study. • • • • • • Socio demo Offence Clinical IP/cty Medico-legal Seclusion • DEMOGRAPHIC STUDY • DISTRIBUTION OF ACCESS AND SERVICE PROVISION • SECLUSION AS MANAGEMENT TOOL • COSTS DRG Workshop Belgrade, 18-22.November 2013. DEFINITIONS AND RULES AGED CARE ED PATIENTS AND MENTAL BUNDLED OUTPATIENTS FFS OUTPATIENTS TRAUMA AND ACUTE ILLNESS HEALTH PROGRAMS INPATIENTS PRIVATE AND CHRONIC DISCRETIONARY SAME DAY INPATIENTS CARE ELECTIVE?? PROGRAMS DRG Workshop Belgrade, 18-22.November 2013. DRG Workshop Belgrade, 18-22.November 2013. Patient Classification Systems • “There is no such thing as a bad classification – only people who are more or less happy with the category to which their case is assigned” • Ric Marshall, PCSI Summer School, 17 June, 2010 DRG Workshop Belgrade, 18-22.November 2013. Patient Classification Systems • “There is also the validity of the classification categories for particular uses. • And then there is the reliability of the data” Anon DRG Workshop Belgrade, 18-22.November 2013.