Care Pathways and Packages(Overview and history)

Jon PainterProgramme Director

Northumberland Tyne and Wear NHS FT

Main elements of the CPP ModelIndividual patient needs

Anxiety / Relationships / Hallucinations / Living conditions etc.

Mental Health Clustering ToolStandardised summary of individual needs

ClusterGlobal description of combination & severity of individual needs

Care PackagesIndividually negotiated care plan informed by NICE Guidance

Quality and Outcome MetricsTriangulated measurement of process and effect

Local/national TariffDerived from joint understanding of accurate costs

Starting point• Managers, psychiatrists, nurses, social workers, OTs, psychologists

• Acute inpatient services, community MH Teams & rehabilitation services

• Different parts of the service using different concepts to describe their casemix (functioning, risk, etc.)

• Often more reflective of service / service response than the patient (inpatient/outpatient, low/medium security)

• Clinicians recognised that patients weren’t getting what they needed, they got the best of what was available (idiosyncratic referral pathways and care packages)

Participatory action research questions:

• What information do professionals use to decide on care package to be offered?

• Is it possible to develop a shared language based on patient need?

• Is it possible to develop simple care packages to meet needs?

Needs identified as important to care planning:

1 Overactive, aggressive, disruptive or agitated behaviour2 Non-accidental-self injury3 Problem drinking or drug taking4 Cognitive problems5 Physical illness or disability problems6 Problems associated with hallucinations and delusions7 Problems with depressed mood8 Other mental and behavioural problems9 Problems with relationships

10 Problems with activities of daily living11 Problems with living conditions12 Problems with occupation and activities13 Strong unreasonable beliefs occurring in non-psychotic disorders onlyA Agitated behaviour / expansive moodB Repeat self-harmC Safeguarding children & vulnerable dependant adultsD EngagementE Vulnerability

Mental Health Clustering ToolStandardised summary of individual needs

Cluster analysis (example)A diagram summarising how cases group together at different levels of distance (distance is standardised onto a new scale)Used to identify the number of clusters to define in the 2nd stage of cluster analysis

ClusterGlobal description of combination & severity of individual needs

MHCT Scales

Scor

e

Validation - clinical homogeneity• Case presentations• Score profiles• Treatment aims• Interventions• Concurrent clinical data

– CPA status– Diagnosis– Medication– Gender– MHA status– Time known to services

ClusterGlobal description of combination & severity of individual needs

Initial results

• 13 statistically derived groups with good clinical face validity

• Balance between membership criteria and coverage

• 85% of patients allocated, remainder were not a homogeneous group but variations on existing clusters

ClusterGlobal description of combination & severity of individual needs

Subsequent cluster developments:

• Disaggregation of low-end non-psychotic cluster

• Disaggregation of stable psychosis cluster• Addition of organic clusters• Removal of substance misuse cluster• Refinements to some score profiles• Improved coverage (90-95%)

ClusterGlobal description of combination & severity of individual needs

Making profiles clinically useable (The mean is only half the story)

Relatively straightforward presentations,

clusters progress primarily according

to symptom severity

Clusters progress primarily

according to complexity

Cluster dictated by virtue of first episode rather than symptom

severity

Clusters increase in

terms of symptom

severity & level of secondary

disability

Acuity

Common features:

complexity, chaos & engagement, distinguished by

level of substance misuse

Stage of dementia, level

of cognitive impairment and frailty

ClusterGlobal description of combination & severity of individual needs

• Content of care packages should reflect NICE Guidance etc.

• BUT must also reflect local position (historic investment, previous organisational approaches to care pathways etc.)

• Must allow for innovation rather than locking in any particular practice

• As a result exact content and format will vary• Any approach must provide clarity to all stakeholders

(Patients, carers, staff, commissioners).

Care PackagesIndividually negotiated care plan informed by NICE

Care PackagesIndividually negotiated, NICE-informed care plan

Initial cluster-specific expectation of care

Refined by condition/diagnosis,

evidence, guidance etc

Final negotiations according to availability & patient

choice

Quality and Outcome MetricsTriangulated measurement of process and effect

Payment for assumed quality

Payment for demonstrable

quality

MHCT & Cluster metricsMHMDS Metrics

Locally gen-erated met-rics and data

set

Source of Q&O Measures

PROMS

CROMS

PREMS

Type of Q&O Measures

Quality and Outcome MetricsTriangulated measurement of process and effect

Key: MHMDS: Mental Health Minimum Data SetMHCT: Mental Health Clustering ToolPREMS: Patient Reported Experience MeasuresPROMS: Patient Reported Outcome MeasuresCROMS: Clinician Reported Outcome Measures