CQUINS

Commissioning for Quality and Innovation (CQUIN)

The CQUIN payment framework aims to support a cultural shift by embedding quality improvement and innovation as part of the commissioner-provider discussion everywhere. It was introduced from April 2009, requiring a proportion of provider contract value to be linked to the achievement of locally agreed ambitious quality improvement goals (or, in the first year, a simpler quality improvement plan for non-acute providers). Locally agreed CQUIN schemes are required to include goals in the three domains of quality: safety, effectiveness and patient experience; and to reflect innovation.

The  CQUINS for 2010 - 11 written by NHS West Midlands that are most relevant to Mental Health are:

Assessing patients accommodation and employment status:

This indicator helps address the requirements of PSA 16 which aims to ensure that the most socially excluded adults are offered the chance to get to a more successful life by increasing the number of individuals in settled accommodation and employment, education or training.
Additionally this indicator may influence earlier action within a patients care plan that helps manage their accommodation and employments circumstances during the period of their treatment, thus providing a more "intact" life upon their recovery and discharge and a reduction of "lengths of stay" due to accommodation issues.

Minimising Broken Engagement by Assertive Outreach Teams

Policy guidance and best practice examples clearly describe the role of Assertive Outreach teams to include the active engagement of people who have severe and enduring mental illness with potential acute periods and are at risk of disengaging with mental health services.
This measure is included to demonstrate, and where necessary improve, the active engagement practice of Assertive Outreach teams to demonstrate effective risk management practices and to support positive outcomes for their patients.

CRHT Gatekeeping

When mental health hospital admissions are assessed ("gate kept") by their local Crisis Resolution Home Treatment team patients have the opportunity to be treated in their own home .
To maximise the potential of investment in home treatment to reduce hospital admission rates and there for bed occupancy.
By using an actual sample of inpatient admission as the denominator, cross referred to the CRHT assessment data as the denominator, provides an accurate Gatekeeping rate. This reflects the fact the Gatekeeping is an "inter team" measure which requires data from both sources to be compared.

CRHT Facilitated Discharge from hospital Response Time:

A function of CRHT is to support "early discharge" from mental health hospital, that is, where a patient can be discharged home earlier than may have otherwise been clinically advisable, because of the provision of intensive domiciliary acute care by the CRHT.
In order to offer home treatment to those patients whose CRHT "gatekeeping" assessments led to admission rather than home treatment, those patients can be offered home treatment to facilitate early discharge and shorten their in-patient appropriately.
However, it is NOT appropriate to use a CRHT to provide non-intensive domiciliary support; therefore, any patient who does not clinically requires a "face to face" follow-up within 48 hours of discharge should not be referred to the CRHT for that function.
Any inappropriate use of the CRHT, including that as outlined here, depletes their capacity to provide effective assessment, "gatekeeping" and home treatment, therefore this indicator is set at 48 hours to indicate appropriate use of the service.
Excessive use of this function of the CRHT to achieve a "seven day" follow up target for all discharges from hospital, as required by national policy, is not appropriate, as this similarly depletes the CRHT capacity.
Best practice advice form the West Midlands Regional Development Centre suggests that in an effective CRHT approximately 10% of all assessments would result in admission to hospital. Therefore, whilst the local referral rate to CRHT for facilitating early discharge can be agreed with commissioners we recommend the indicative range of 5% to 15% in order to ensure this patients admitted do get the opportunity for Home Treatment (albeit at the end of the inpatient admission period) and to avoid risk of depleting the CRHT capacity for carry out home treatment and gatekeeping of admissions.

Effective EI DUP:

Early Intervention in Psychosis focuses on the early treatment of psychosis during the formative years of the illness. The first three to five years are believed to be a critical period. The duration of untreated psychosis (DUP) has been shown as an indicator of more positive prognoses, with a longer DUP associated with increased likelihood of long term disability. EIS aims to reduce delays to treatment for those in their first episode of psychosis.

Birchwood M; Tood P; Jackson C (1988). "Early intervention in psychosis: the critical period hypothesis". British Journal of Psychiatry

Guidance from the Early Intervention in Psychosis Network, hosted by The National Mental Health Development Unit, supports the use of the DUP Calculation as outlined as an alternative to  the "PANSS" criteria used in the original Department of Health guidance.

Managing leave as a part of Hospital Admission

Recently developed service specifications for inpatient services aim towards a maximum leave period of 7 days being acceptable before a discharge date is established.

This indicator aims to encourage that leave is used as part of discharge planning from hospital and is supported appropriately by community based care as a transition from inpatient to community care.

This is consistent with the role of CRHT supporting early discharge from Hospital and the aim of promoting effective and risk managed use of hospital beds as service resources.

Understanding and Improving the experience of Service users

This indicator helps ensure that all service activities and improvements are oriented towards improving the experience of patients. The audit questions included in the CQUIN are based upon the patient's experience questions set by the Care Quality Commission and have been extended to add a further "stretch" in terms of service development and improvement.
Service users were consulted in the original drafting of these questions and it is understood that the questions included in these audits are an important part of the experience of people using services and indicate the experiential effect of organisations working to service and quality standards.
This CQUIN also promotes the capture and use of information on patients experience as a part of ongoing service improvements.