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Section A - Policy
4. VicRehab for Designated Rehabilitation Units - Acute Health & Aged Care
4.1 Introduction
Since 1993 and the introduction of casemix in Victoria, the single DRG category "rehabilitation" has been recognised as inadequate for casemix based funding. Funding for rehabilitation in Victoria, therefore, has been made primarily through a per diem block grant to designated rehabilitation units. For those hospital services not designated, payment has been made through a single AN-DRG payment. Agencies are designated based on Departmental criteria, the type of rehabilitation carried out and a site evaluation by a rehabilitation accreditation team. Funding has been provided across the Acute Health Program and Aged Care Program in recognition of the similarity across services. Payment was based on a per diem rate at two levels reflecting the rehabilitation type;
- Level 1, spinal, amputation and head injury (where the rehabilitation episode follows the acute care episode in which the injury is the principal diagnosis);
- Level 2, stroke, orthopaedic, neurological, and other rehabilitation services.
In July 1999 a new system for funding rehabilitation in-patients in major designated units will be introduced for the Acute Health (111) and Aged Care (113) Programs. The new system, Victorian Rehabilitation Classification and Funding System (VicRehab) will also provide new opportunities for transforming services to expand community and ambulatory services within service planning guidelines consistent with the directions outlined in Rehabilitation into the 21st Century - A Vision for Victoria.
Given that the new system represents a marked change from historical funding, and to ensure service planning occurs within a structured environment there will be a two year implementation period with guaranteed compensation grants. This will effectively quarantine rehabilitation funding for two years at Network and rural regional level. Furthermore, services with atypical profiles will be reviewed in 1999 - 2000. A Monitoring and Review Committee with industry representation will oversee the implementation period. This Committee will advise on the implementation of the model; evaluate agency performance and assist in the establishment of new flexible funding arrangements to promote new service opportunities for outpatient, community and home-based rehabilitation care.
A number of studies have been undertaken in Australia incorporating recommendations for funding mechanisms for rehabilitation and other sub-acute areas. In Victoria there has been a long process of development, from the introduction of designation in November 1993; first Pilot Study 1994; introduction of the VIMD data set 1995; first analysis of all services and development of CRAFT in 1996.
The VicRehab funding model is based on the Casemix Rehabilitation and Funding Tree (CRAFT) classification. This CRAFT Classification has been designed to ensure:
- Clinical similarity within groups;
- Resource homogeneity within groups;
- Administrative ease (in the collection and integrity of data); and
- Suitability for funding agencies, i.e. ease of implementation and application.
Clinical appropriateness has been of fundamental importance in the design of the model and clinical consultation has occurred at each stage.
Casemix Rehabilitation and Funding Tree (CRAFT)
Source: VIMD 1997 - 98 (overnight stays 4 days or more, excludes same days).
The tree based on 1997 - 98 data shows the primary split into major clinical groups and sub-splits show the sub clinical groups, totalling 16 classes in all. The final 16 categories are highlighted in bold (e.g. orthopaedic fractures with high admission Barthel scores, all persons with spinal injuries undergoing rehabilitation).
It should be noted that sixty-six percent of cases (7,234) are found in the groupings for stroke/neurological (two groups) and orthopaedic (seven groups). A relatively small number of cases are found within burns, head injury and spinal classifications.
4.3 Consultation with the field
There has been extensive industry discussion over the long development period. In September 1998, VicRehab - Rehabilitation Classification and Funding System: Options Paper was circulated to the industry. Subsequently, workshops were held across Victoria and the Rehabilitation Funding Model Industry Consultative Group was established to advise on details of development and implementation.
Implementation of the new Vic Rehab system for all major designated rehabilitation units includes those services with 20 beds or more, notably:
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In the first year, all budgets for designated units of 20 beds or more will be modelled for Level 2 patients using the new classification. Level 1 and Level 2 clinical categories covering amputee, spinal, head injury cases and burns cases will continue as a per diem based block grant. Level 1 rates will be reviewed in 1999 - 2000.
Designated units with less than 20 beds will continue to receive the per diem based block grant.
In 1999 - 2000 all units will continue to receive their funding in the form of a grant for the year with a budget/activity cap.
Table 3 in Chapter 14 Modelled Budgets outlines the budgets for the 17 designated units and for each Network and rural region.
4.4.1 Cost Weights
Clinical costing systems that provide accurate and reliable patient costing are yet to be fully implemented for rehabilitation care in all services. Some rehabilitation cost data are available and has been collected from a small number of acute hospital rehabilitation units as part of the 1999 Victorian Cost Weight Study. Cost weights have been developed from the study and the relativities (i.e. not the actual prices) applied to the total existing budget. The cost weights based on episode costs, are shown in Section C.
4.4.2 Short Stays
A separate short-stay weight is provided for overnight stays of less than four days which are treated as a separate group.
It is generally accepted in rehabilitation literature and supported in previous Australian studies that these episodes are not likely to be true rehabilitation episodes. These short stays usually represent a variety of patient episodes including interruption to the introduction of rehabilitation by return to acute care.
4.4.3 Same-Day Rates
A same day patient is a patient who is admitted and separated on the same day. The PRS/2 manual issued by the Department identifies the criteria for admission for a same day patient for rehabilitation treatment as: ‘Patients attending a rehabilitation facility approved by the Health Benefits Council and receiving two or more therapy interventions requiring four or more hours treatment in total in a single day."
In 1999 - 2000, a discounted notional same day payment rate has been introduced to reflect the resource intensity compared to a bed stay. This will be reviewed in 1999 - 2000.
4.4.4 Length of Stay and Outliers
Recorded rehabilitation practice varies for Level 2 patients across Victoria, for a number of reasons including the availability of community-based practices; the proportion of aged persons within the service; different patient complexities; service inefficiencies and/or genuine differences in clinical practice.
Rehabilitation treatment also can be undertaken in a number of settings over an extended period of time. It is for this reason that the method used in acute settings to determine the inlier range is inappropriate. While an extended inlier range would include the experience of a larger number of agencies, it could also lead to higher rates of re-admissions. For these reasons, episode payment has been set as a relatively narrow band of +/- 4 days of the average length of stay.
The new system is based on the average practice of the major rehabilitation units. While these reflect current industry benchmarks, there will be opportunities over the next two years, to modify benchmarks and refine the system for particular patient groupings.
Baseline data and prior practice will be circulated to the field, and the expectation is that changes should be consistent to the individual agencies. Atypical agencies will be reviewed during 1999 - 2000.
4.4.5 Targets
In 1999 - 2000, targets for Rehabilitation will include, weighted units, beddays for specified grants and veterans’ targets. These targets, with the exception of veterans’, are capped for the next two years at Network and rural regional level. The targets for each Designated Unit, Network and rural region are given in Table 4 in Chapter 15.
4.4.6 Veterans
Eligible veteran rehabilitation bed days will be block funded on a per diem basis for 1999-2000. Veterans bed day targets have been deducted from existing DHS funded bed day targets. Substitution of beddays, (i.e. Veterans bed days for DHS bed days) is not available. Failure to reach the estimated Veterans targets will result in funds being recalled for unutilised days.
Bed day rates for eligible veterans’ rehabilitation for 1999-2000 are:
- ?Level 1 per diem??$424
- ?Level 2 per diem??$352
Designated rehabilitation services will now become part of those services subject to the Coding Audits, Patient Satisfaction Surveys and other quality initiatives undertaken in the public hospital and related services. Furthermore, over 1999 - 2001 a special Monitoring and Review Committee will advise on changes to patient type and throughput and changes to services.
Baseline data will be produced and circulated to all agencies by October 1999 with details regarding the possible movement to non-inpatient and community-based services.
The accuracy, completeness of the patient record, and timeliness of the data submitted are of crucial importance for the new funding system. If data are "missing" then cases cannot be classified within the new system and agencies cannot be appropriately funded.
The current definitions and regulations specified in Circular 15/1998 (issued in August 1998) regarding the treatment of leave should be followed. It should be noted that penalties will be introduced for data that is not transmitted within the timelines specified in Section B.
Hospital patient data as recorded in the VAED will be assessed by the Monitoring and Review Committee to ensure that transfer and re-admission policies continue to be appropriate.
During 1999-2000, possible coding changes will be discussed with the field within the usual processes for implementation 1 July 2000. Clearly, if any particular changes or anomalies occur, coding regulations will be introduced prior to 1 July 2000.