How to do it: Assessment of Complexity and Dependency Prof Lynne Turner

The North West London Hospitals
NHS Trust
How
How to
to do
do it:
it:
Assessment
Assessment of
of
Complexity
Complexity and
and Dependency
Dependency
Prof Lynne Turner-Stokes
and the UKROC team
RRU, Northwick Park Hospital
Department of Palliative Care, Policy and Rehabilitation
King’s College London
Objectives
Familiarise clinicians
– with the key tools in the UKROC dataset?
Rehabilitation Complexity
– The RCS scale
– The RCS-E
Northwick Park Dependency scales
– Nursing – NPDS
– Therapy – NPTDA
Understanding the data
– Relationships between the scales
Freely available
On BSRM website
– Background papers
– Tools and publications
Summary of literature on validation
Full Reference list
From the UKROC team at Northwick Park
– Tools
Individual instruments
Information booklets
Rating manuals
– Software
Guide to computer entry
UKROC database
Funded by 5-year NIHR programme grant
Provides central collation of de-identified data
– Specialist in-patient neurorehabilitation episodes
For information and benchmarking
For tariff development under Payment by Results
Agreed national UKROC dataset
– NHS Information Centre - LTNC dataset
Inpatient rehab subset
– BSRM approved
Data Protection Act Compliant
UKROC dataset
Records 3 types of data:
– Complexity of rehabilitation needs
Individual requirements for rehabilitation
– Input - provided to meet those needs
Nursing, medical and therapy provision
– Identify unmet need
– Outcomes
The gains that are made during rehabilitation
– Functional independence
UKROC dataset – 30 items
Domain
Content
Demographics
Age, Gender, Ethnicity, PCT/SHA etc
Diagnostic group, HRG category
Process
Response times – referral to admission
Source of admission, interruption to treatment
Length of stay,
Discharge destination
Needs (Complexity)
Rehab Complexity Scale (Original / extended versions)
Inputs
Northwick Park Dependency Scales:
Nursing /care (NPDS/NPCNA); Therapy (NPTDA)
Outcomes
Barthel Index,
FIM or UK FIM+FAM (+ Neurological Impairment Set)
Goal attainment scaling (GAS)
Hierarchical dataset
Banding for different levels of complexity
Complexity
of need
(RCS)
Inputs
Banding
NPDS
NPTDA
Banding
RCS
Outcome
FIM±
FAM
BI
GAS
Tertiary Specialised Rehabilitation
(Level 1)
District Specialist Rehabilitation
(Level 2)
Local General Rehabilitation
(Level 3)
Data quality and consistency
Validated tools
– Ongoing evaluation of tools
In different contexts, populations and settings
Training
– Programme of training and updates
For clinicians providing the data
On-line accreditation
Data entry
– ‘Fool-proof’ data entry tools
Support validation at the point of data entry
Rehabilitation Complexity
Scales
Factors determining costs in rehab
Basic support and
nursing needs
Basic self care
Special nursing needs
Therapy Needs
No. of different disciplines
Intensity of input
Special facilities / equipment
Additional medical
needs
Medical support environment
Procedures / investigations
Length of
programme
Bed days
Rehabilitation Complexity Scale
Total score 0-15
C
N
T
M
Basic care needs
Special nursing needs
Therapy needs
0-3
0-3
No of disciplines
Intensity of treatment
0-3
0-3
Medical needs
E.g. RCS 8: (C2 N1 T4 M1)
Turner-Stokes et al: Clinical Medicine 2007; 7 :593-9
Turner-Stokes et al: JNNP 2010; 81: 146-153
0-3
RCS 8: (C2 N1 T4 M1)
C2
N1
Requires help from 2 people
for most basic care needs
Requires intervention from a qualified nurse
T4
Requires 2 therapy disciplines (TD=2)
For a daily 1:1 treatment programme (TI=2)
M1
Basic investigation / monitoring
RCS 8 Total RCS Score
16/10/2007
02/10/2007
18/09/2007
04/09/2007
21/08/2007
07/08/2007
24/07/2007
10/07/2007
26/06/2007
12/06/2007
29/05/2007
15/05/2007
RCS scores
16/10/2007
02/10/2007
18/09/2007
04/09/2007
21/08/2007
07/08/2007
24/07/2007
10/07/2007
26/06/2007
12/06/2007
29/05/2007
15/05/2007
Hours
Serial RCS scores: ceiling effect
60.00
50.00
40.00
30.00
20.00
10.00
0.00
therapy hours
nursing hours
7
6
5
4
3
2
1
0
RCS C+N+M
Care and nursing
needs may fall
over time.
Therapy needs
more constant
RCS follows the
same pattern
RCS T
Some ceiling
effect
The Extended RCS (RCS-E)
Developed to deal with ceiling effects
– Score levels are the same for 0-3
Expanded upper range (to 4) for:
– Care
– Therapy disciplines and intensity
Additional item
– Needs for equipment/ facilities
– Risk
offered as an alternative to ‘Care’
– For walking wounded patients
RCS versions compared
RCS
C
Basic care needs
RCS-E
0-3
Basic care needs
0-4
Or Risk ( walking wounded)
R
N
Special nursing needs
0-3
Special nursing needs
T
Therapy disciplines
Therapy intensity
0-3
0-3
Therapy disciplines
Therapy intensity
M
Medical needs
0-3
Medical needs
Total
0-15
0-4
0-4
Equipment / facilities
0-2
Total
0-20
Orientation to score sheet
RCS – note:
– Further instructions on the back
– Paper score sheet
For cross-sectional data collection
RCS –E:
– Opportunity for recording qualitative information
Basic care and support needs
RCS
C0
Largely independent in basic care activities
C1
Requires help from 1 person for most basic care needs
C2
Requires help from 2 people for most basic care needs
C3
Requires help from >2 people for basic care needs
OR Requires constant 1:1 supervision
RCS -E
C4
Requires constant 1:1 supervision
RISK
RCS-E
R0
No Risk – standard observations only
Able to go out unescorted
R1
Low Risk – standard observations only
But requires escorting outside the unit
R2
Medium Risk – above standard observations
Or managed under MHS section
R3
High Risk – above standard observations
And managed under MHS section
R4
Very High Risk
Requires constant 1:1 supervision
Skilled nursing needs
RCS
N0
No needs for skilled nursing
N1
Requires intervention from a qualified nurse
(Eg for wound dressing medication etc)
N2
Requires intervention from
trained rehabilitation nursing staff
N3
Requires highly specialist nursing care
(e.g. for tracheostomy, behavioural management etc)
RCS -E
-
-
Medical needs
RCS
M0
No active medical intervention
(Could be managed at home by GP)
M1
Basic investigation / monitoring / treatment
(Requires non-acute hospital setting – eg community hospital)
M2
Specialist medical intervention
(requires in-pt hospital care – DGH or specialist setting
Eg for specialist treatment, investigations, procedures etc)
M3
Acutely sick or potentially unstable medical condition
(Requiring 24 hour on-site acute medical or psychiatric cover)
RCS -E
-
-
Therapy - Disciplines
RCS
TD 0 No therapy intervention ( e.g. awaiting discharge)
TD 1 1 discipline only
TD 2 2-3 disciplines
TD 3 ≥4 disciplines
RCS -E
TD 4 ≥6 disciplines
Therapy Intensity
Group-based
programmes
RCS
TI 0
No therapy intervention (or < 1 hr per week)
TI 1
Low level - Less than daily intervention
Or
group therapy only
TI 2
Medium level
Daily intervention with mainly 1 to treat
Or very intensive
group therapy
>6 hrs per day)
TI 3
High level – (>25 hours total therapy staff time/week)
Daily intervention PLUS assistant
+/-Additional group
sessions
RCS -E
TD 4 Very intensive – eg 2 trained physios to treat
or total 1:1 therapy > 30 hours per week
Equipment / facilities
RCS-E
E0
No needs for special equipment
E1
Requires basic special equipment
(eg Wheelchair, standing frame, off the shelf orthotic)
E2
Requires highly specialist equipment
Eg Electronic assisted technology, ventilation, bespoke orthoses
or highly customised equipment
Rating
Rated by the MD Team
– Quick to use
Useful indicator of casemix
Informs caseload planning
Can be rated in two ways:
– Prospectively
To record rehabilitation needs
– Retrospectively
To record what they actually get
– Comparison of ‘Needs’ and ‘Gets’
Measure of unmet needs
So…
We can identify pts
– With complex needs
We accept those needs must be met
– But what additional resources are required?
Nursing
Medical
Therapy
Informs costing
– Differential costs of complex caseload
Care
Care Needs
Needs and
and Dependency
Dependency
Disability measures eg Barthel / FIM
Correlate with care needs
Do not indicate:
– How many help required from
– How long it takes
– What times of day
Cannot be used to assess care needs directly
Costing tools
Northwick Park Dependency Scales
– Nursing Dependency Scale (NPDS)
Dependency on nursing time
– Translates to hours of nursing time
– Therapy Dependency Assessment (NPTDA)
Therapy disciplines involved and intensity
– Translates into hours of therapy time
– Designed for neuro-rehabilitation settings
Inform patient-level costing
– Banding for more complex patients
Information about time spent in different activities
– Open the black box of rehabilitation
NPDS
Turner-Stokes et al: Clin Rehabil 1998; 12: 304-316
Ordinal scale of nursing dependency
– Basic Care Needs (0-65)
– Special Nursing Needs (0-35)
}
} 0-100
Dependency on nursing time
– For common tasks
No people required to help
Time taken
– Includes cognitive issues
Safety awareness, communication,
Behavioural management, psychological support
Developed 1996 - validated
– Increasingly widely used in UK and abroad
Therapy dependency (NPTDA)
Turner-Stokes et al: Clin Rehabil 2009; 23: 922-937
Ordinal scale of therapy dependency
– Total range 0-100
– 28 items – each rated on a scale of 0-4
Records all patient related activity:
–
–
Direct hands-on care
Indirect care – case conferences, report etc
Calculates therapy hours
– Hours for each discipline
– Total hours
Factors determining costs in rehab
Basic support and
nursing needs
Basic self care
Special nursing needs
NPDS
Therapy Needs
No. of different disciplines
Intensity of input
Special facilities / equipment
NPTDA
Additional medical
needs
Medical support environment
Procedures / investigations
Length of
programme
Bed days occupied
LOS
NPDS / NPTDA as casemix measures
Advantages over FIM
Translate directly into staff hours
– Principal costs of rehabilitation
Inform patient-level costing
Provide the tools to determine
– Staffing levels
– Skill mix
To suit the needs of the caseload
Especially for complex specialised services
Nursing dependency
and care needs
Nursing
Nursing dependency
dependency Scale:
Scale: NPDS
NPDS
Items
– Basic Care Needs
– Special Nursing Needs
Levels: cut-off points
– Number of people
– Time taken
5 additional items – community care needs
– To support conversion to the NPCNA
NPCNA
Northwick Park Care Needs Assessment
– Measure of care needs in the community
Estimates Total care hours per week
Timetable of care needs and when the occur
Type of care package required
– And its estimated weekly cost
– Useful for discharge planning
Derived from NPDS by computerised algorithm
Must use the UKROC software
– To get the conversion to NPCNA
Basic Care Needs Scale
12 items – Total range 0-65
– Each item: Ordinal scale 0-3 to 0-5
Dependency on nursing time
– For common care tasks
– Could be managed by trained HCA
No people required to help
Time taken
Basic Care Needs Scale
Item
Score range
1
Mobility
0-4
2
Transfers
0-3
3
Bladder – assistance and incontinence
0-4 + 0-3
4
Bowels – assistance and incontinence
0-5 + 0-3
5
Washing and grooming
0-5
6
Bathing/showering
0-5
7
Dressing
0-5
8
Eating / drinking /enteral feeding
9
Skin pressure
0-5
10
Safety awareness
0-3
11
Communication
0-5
12
Behaviour
0-5
TOTAL
0-65
0-3 + 0-3 + 0-4
Example - dressing
Level descriptor
Score
a)
Able to dress independently
0
b)
Needs help to set up only
1
c)
Needs only incidental help (eg just with shoes laces)
1
d)
Needs help from 1 person, takes <1/2 hour
2
e)
Needs help from 1 person, takes >1/2 hour
3
f)
Needs help from 2 people, takes <1/2 hour
4
g)
Needs help from 2 people, takes >1/2 hour
5
(eg laying out clothes)
Must record a), b) etc - NOT just numerical score
Special nursing needs
7 items – Total range 0-35
– Each item: Dichotomous score 0/5
Requirement for care
– From qualified nurse
Eg wound care, tracheostomy etc
Special nursing needs
Item
Score range
1
Tracheostomy
0-5
2
Open pressure sore / wound
0-3
3
>2 interventions required at night
0-5
4
Substantial psychological support (Pt or family)
0-5
5
Isolation for MRSA screening or infection
0-5
6
Intercurrent medical or surgical problem
0-5
7
Needs 1:1 ‘specialing’
0-5
TOTAL
0-65
Five Additional items
Essential for conversion to NPCNA
– Do they require help for
Stairs
– Do they require help
– If no, is that because (required for conversion to Barthel Index)
They can manage stairs independently
Unable to do stairs at all, so live on one level
Meal preparation
Medication
Skilled nurse or trained carer
Domestic duties
NPDS
Scale and score sheets
Background paper
– NPDS and NPCNA
NPDS tool
NPCNA outputs
Therapy dependency
NPTDA
3 versions
– Original NPTDA
Cognitive behavioural
Children’s
Reports
Therapy score
– Ordinal scale:
– Total score: 0-100
– 5 Subscales
Therapy hours
– Hours for each discipline
– Total hours
Direct and indirect activity
Structure of NPTDA
Domain
A
Range
Physical handing programme
0-20
Medical and risk management (Cog/behavioural NPTDA)
B
Basic functions
0-20
C
Activities of daily living
0-12
D
Cognitive/ psychosocial / family support
0-20
E
Discharge planning
0-20
F
Indirect interventions (meetings/reports)
Additional activities (groups)
0-8
G
Special facilities, investigations/procedures
Text
Total
100
General scale structure (A-E)
Score
Hrs/wk
Descriptor
Input
0
0
None
None planned at current time
1
<1
Low
Minimal intervention / review only
2
1-2
Medium
Basic intervention / assistant only
3
3-4
High
More intensive intervention by
qualified therapist ± assistant
3.5
<4
Interdisciplinary
Inter-disciplinary intervention
but for limited time (<4 hours total)
4
>4
Complex
Inter-disciplinary intervention
Or very high intensity input
Scale structure (F)
Indirect inputs
–
–
–
–
MD meetings
Report writing
Groups
Escorting to clinics / investigations etc
Score
Descriptor
Input
0
None
None
1
Low
Total staff time <1 hour per week
(or 1 group session only per week
2
Standard
Total staff time ≥1 hour per week
NPTDA
Scale and score sheets
Understanding the data
Relationships
between the scales
Relationship between scales
Correlations (Spearman rank)
RCS
C
N
T
M
NPDS
++
++
+/-
++
NPTDA
-
-
++
-
Barthel
++
++
+/-
-
FIM
++
++
+/-
-
16/10/2007
02/10/2007
18/09/2007
04/09/2007
21/08/2007
07/08/2007
24/07/2007
10/07/2007
26/06/2007
12/06/2007
29/05/2007
15/05/2007
RCS scores
16/10/2007
02/10/2007
18/09/2007
04/09/2007
21/08/2007
07/08/2007
24/07/2007
10/07/2007
26/06/2007
12/06/2007
29/05/2007
15/05/2007
Hours
RCS scores: nursing/ therapy hours
60.00
50.00
40.00
30.00
20.00
10.00
0.00
therapy hours
nursing hours
7
6
5
4
3
2
1
0
RCS C+N+M
Care and nursing
needs may fall
over time.
Therapy needs
more constant
RCS follows the
same pattern
RCS T
Some ceiling
effect
NPDS vs Nursing care hours
160
N =1736 ratings
Spearman rho 0.91
140
Nursing care hours (restricted)
120
100
80
60
40
20
0
0
20
Total NPDS Score
40
60
80
NPTDA vs therapy hours
100
N =1738 ratings
Spearman rho 0.85
80
Total therapy hours
60
40
20
0
0
10
20
NPTDA total score
30
40
50
60
Serial change: patient X
NPDS and nursing care hours
80
70
60
50
40
30
20
10
0
NPDS
Care Hours
1
3
5
7
9
11 13 15 17 19 21 23
Serial change: patient X
NPTDA and therapy hours
50
40
30
NPTDA
20
Therapy hours
10
0
1
3
5
7
9 11 13 15 17 19 21 23
NPDS and nursing care hours
80
70
60
50
40
30
20
10
0
NPDS
Care Hours
1
3
5
7
9
11 13 15 17 19 21 23
NPTDA and therapy hours
50
40
30
NPTDA
20
Therapy hours
10
0
1
3
5
7
9
11 13 15 17 19 21 23
Total staff hours per week
100
100
90
90
80
80
70
70
60
60
50
50
Nursing /care hours
Total therapy hours
by RCS group
40
30
20
10
0
-10
N=
59
322
559
262
4-6
7-9
10-12
13-15
RCS complexity group
Therapy
40
30
20
10
0
-10
N=
59
321
558
262
4-6
7-9
10-12
13-15
complexity group
Nursing care
3 important reasons
to use the UKROC software
Validated data entry
– Supports consistent data collection
Avoids missing data
Automatic collation
– With the other tools
De-identified data – difficult to trace back
Automatic conversion
– Staff hours – costs of care
NPDS - Nursing and care hours (via NPCNA)
NPTDA -Therapy hours
– Barthel Index
NPDS
FIM
UKROC software
demonstration
Making the case for
resources
Gaps in service
Needs
– Level of service required
Inputs
– Levels they actually get
Breakdown by discipline
– Record across service
Calculate total staffing hours required
– For each discipline
To provide for the given caseload
Problem
Referral pattern
– Increasing proportion of complex patients
20 bedded unit
– Staffed to manage 35-40% complex patients
Closed 3-4 beds
– To take higher proportion complex patients
16-17 beds – 75% high / v high complexity scores
Make case to increase staffing
– 20 beds – 75% heavy patients
Hierarchical dataset
Banding for different levels of complexity
Complexity
of need
(RCS)
Inputs
Banding
NPDS
NPTDA
Banding
RCS
Cost bands
£670
£520
£400
£280
Tertiary Specialised Rehabilitation
(Level 1)
District Specialist Rehabilitation
(Level 2)
Local General Rehabilitation
(Level 3)
Staff hours required
RCS
category
Proportion
Mean Nursing
hrs/ week
Mean Therapy hrs/
week
Very high
33%
60
31
High
45%
42
24
Medium
20%
28
20
Low
2%
10
19
Overall Mean hrs/wk
42 per patient
24 per patient
Total staff hours
required for 20 beds
840
480
Study Sample
Cases n=179
–
–
–
Mean age
M:F
LOS (days)
44.5 (SD 14.8)
110/69
78 (SD 64)
8%
PNS
11% SCI
1208 sets of rating
RCS
–
–
–
–
V high
High
Medium
Low
(13-15)
(10-12)
(7-9)
(4-6)
%
33%
45%
20%
2%
78% Brain injury
Staffing implications
Nursing
hours
Therapy
hours
24 WTE
19 WTE
Mean % time in
in-pt care
80%
66%
Hrs available
636
408
Hrs required
840
480
Total staff
33 WTE
24 WTE
Additional staff
required
9 WTE
5 WTE
Establishment
Within service – levels of complexity
Complexity of
rehabilitation
need
Rehabilitation
Complexity scale
Very High
£670
33%
High
£520
45%
Standard
£400
20%
Low
£280
2%
Within service – levels of complexity
Complexity of
rehabilitation
need
Rehabilitation
Complexity scale
Very High
£670
33%
High
£520
45%
Standard
£400
20%
Low
£280
2%
16 beds:
Income
£2.5m
20 beds:
Income
£3.1m
Difference
£630K
Funds extra
staff
Acknowledgement
This presentation presents independent research
commissioned by the National Institute for Health Research
(NIHR) under its Programme Grants for Applied Research
funding scheme (RP-PG-0407-10185).
The views expressed in this presentation are those of the
authors and not necessarily those of the NHS, the NIHR or
the Department of Health.
Financial support for the preparation of this presentation
was also provided by the Dunhill Medical Trust, the Luff
Foundation