Developing casemix classifications for rehabilitation in the UK

Background

The introduction of an episode-based reimbursement system within the UK NHS has led to the development of a new case-mix classification – Healthcare Resource Groups (HRGs), based on diagnostic and procedure codes. Diagnosis is a poor cost-determinator in rehabilitation. In the US and Australia, casemix classifications for rehabilitation have centred on function-related groups using physical dependency for on help for basic self-care as a surrogate for rehabilitation needs. These classifications may work reasonably well for many areas of general post-acute rehabilitation, but do not assess the need for inputs such as specialist nursing, therapy and medical care, which are important components of specialist rehabilitation programmes in the context of brain injury or progressive neurological conditions.

In the UK, rehabilitation services are arranged in networks which include local general (LGRS), district-based specialist rehabilitation (DSRS) and complex specialised services (CSRS) providing tertiary rehabilitation for the low-volume high-cost group of patients with particularly complex needs. A 'one-size-fits-all' fixed rate episode tariff set at the level for average service costs would lead to financial destabilisation of CSRS, and also those DSRS which manage a greater proportion of complex cases.

Methods

We have developed a set of validated tools to measure the complexity of rehabilitation need, offering direct assessment of rehabilitation inputs which may be used to provide patient level costing of rehabilitation service provision in a standardised format. The Rehabilitation Complexity Scale is a simple tool, which provides a valid and reliable, if somewhat crude, estimation of needs for rehabilitation input (see separate abstract). Feedback from service users suggests that it is practical to apply in time-pressed lower level services, but that it lacks sensitivity to distinguish higher levels of input at the more complex end of the scale. The Northwick Park nursing Dependency Scale (NPDS) and Therapy Dependency Assessment tool (NPTDA) have been developed to provide a more detailed breakdown of needs for nursing, therapy and medical interventions. From these, an algorithm is applied to provide a generic estimate the requirements for staff time in the relevant disciplines.

Discussion

The tools provide a standardised assessment of need for rehabilitation input, may also be used to estimate staffing requirements in relation to a given caseload. This presentation will describe the tools and their application to provide patient-level costing of rehabilitation inputs which may be used to inform the development of appropriate tariffs and commissioning currencies across the range of rehabilitation service provision.