Devon Partnership NHS Trust Simon Polak Jan 2011 v3 1 Payment by Results Clustering, Care Pathways and Packages Jan 2011

Simon Polak Jan 2011 v3 1Devon PartnershipNHS Trust

Payment by ResultsPayment by Results

Clustering,Clustering, Care Pathways Care Pathways and Packagesand Packages

Jan 2011


Introduction and Background

Mental health PbR is now coming as a radical change to funding mental health care.

Based on empirical work it is used to aid the funding of care packages based on clustering

peoples’ needs.


What is PbR?What is PbR?

• Introduced into acute sector 2003/4• Price X activity = income

– e.g. £1000 X 10 hip replacements = £10,000• But for mental health, what’s the unit of

activity? – currency unit in mental health is a ‘Cluster’

• The price or tariff is yet to be set


Clustering & Care Packages ApproachClustering & Care Packages Approach

• Care Pathways and Packages approach was developed by 6 Trusts in the North East and Yorkshire

• 21 Care Clusters were empirically derived.• Patients were assigned to the care clusters

based on their presentation as assessed by the clinician and using a clustering tool based on HoNOS.


Payment by results PbR timescalesPayment by results PbR timescales• Clarifying the timescales in the Operating Framework 2010-11

by proposing the following: – • 2010/11 – The clusters are available for use. Reference costs are

returned on a cluster basis. – • • 2011/12 – 2011/12 –

• All service users accessing mental health care (post GP or other referral) All service users accessing mental health care (post GP or other referral) that have traditionally been labelled working age (including early that have traditionally been labelled working age (including early intervention services from age 14) and older people’s services, should be intervention services from age 14) and older people’s services, should be allocated to a cluster by 31 December 2011.allocated to a cluster by 31 December 2011.

• Local prices should be agreed for use in 2012/13 and this will require understanding of local costs per cluster

– • 2012/13 – The clusters (with local prices) become mandatory for contracting and payment purposes.

– • 2013/2014 – The earliest possible date for a national tariff for mental health (if evidence from the use of a national currency presents a compelling case for a national price).


Care Clusters & Packages

Clustering is a process developed to match needs to eventual evidence based care packages developed and delivered by clinical staff.

This is supported by the Mental Health Clustering Tool (MHCT) in RiO.


ReferralReferral

AssessmentAssessment

MHCT (HoNOS)MHCT

(HoNOS)

ClusterCluster

Care Package

Care Package

ReviewReview

The process for determiningneed through the allocation of a care cluster is based on theClinical assessment.

The chosen cluster then leadsto the a care package individualised to the persons specific needs.

This will be reviewed which may lead to a change of clusterand care package.

The process for determiningneed through the allocation of a care cluster is based on theClinical assessment.

The chosen cluster then leadsto the a care package individualised to the persons specific needs.

This will be reviewed which may lead to a change of clusterand care package.


Care Clusters and Packages• Primarily clustering is based on the use of HoNOS PbR and

clinical judgement• It enables us to distinguish between clinical groupings based

on need as reflected in the clustering process.• The RiO tool simplifies the process for staff to cluster and

capture the results.• It enables us to develop a discreet range of evidence based

interventions to meet those needs. These are the Care Packages.

• The care packages will broadly dictate:– The therapeutic intervention– The time required based on the cluster– The staff inputs– The skills and knowledge base required for the intervention

• The individual will require a tailored package within the broad framework.


Care PackagesCare PackagesCare Cluster Care Cluster nnCare Cluster Care Cluster nn

Care PackagesCare PackagesCare PackagesCare Packages

Evidenced based

Intervention

Evidenced based

InterventionStaff MemberStaff Member

Skills / Knowledge Skills / Knowledge


Care ClustersCare Clusters


Non-PsychoticMild /Mid / Severe

Non-PsychoticVery Severe & Complex

Psychotic 1st EpisodePsychoticOngoing or recurrent

Psychotic Crisis

PsychoticVery Severe Engagement

OrganicCognitive Impairment

1. Common Mental Health Problems (Low Severity)2. Common Mental Health Problems (Low Severity with greater

need)3. Non Psychotic (Moderate Severity)4. Non-psychotic (Severe)5. Non-psychotic Disorders (Very Severe)6. Non-psychotic Disorder of Over-valued Ideas7. Enduring Non-psychotic Disorders (High Disability)8. Non-Psychotic Chaotic and Challenging Disorders9. Blank Cluster (formally substance misuse)10. First Episode Psychosis11. Ongoing Recurrent Psychosis (Low Symptoms)12. Ongoing or recurrent Psychosis (High Disability)13. Ongoing or Recurrent Psychosis (High Symptom & Disability)14. Psychotic Crisis.15. Severe Psychotic Depression16. Dual Diagnosis17. Psychosis and Affective Disorder – Difficult to Engage18. Cognitive Impairment (Low Need)19. Cognitive Impairment or Dementia Complicated (Moderate

Need)20. Cognitive Impairment or Dementia Complicated (High Need)21. Cognitive Impairment or Dementia (High Physical or

Engagement)


Clustering & Care Packages

Staff responsibilitiesAll trained staff will have a role in clustering at

some point in the persons involvement with DPT.Some staff will have a great deal of their work

focussed on assessment and clustering.


Clustering – when, who?• Clustering will be required

– At new presentation to the service, i.e. initial assessment– At key review points including CPA review, or at the end of

a defined Care Package intervention• Staff required to cluster:

– Assessors (completing initial assessment)– Recovery coordinators & Care Coordinators– Consultant psychiatrists

• A recovery coordinator:– Has a defined caseload– Is responsible for directly delivering care and/or managing

the gateway into care delivered by others.


RiO & Clustering

• RiO includes a three step process to aid clustering and recording.

• The tool is:– Mental Health Clustering tool (MHCT) provides for

the HoNOS (working age adults) recording– The Mental Health Clustering tool – Care Cluster

Allocation form records the clustering decision.– This is supported by an overview report that gives

a % indication of match to care cluster but leaves the judgement to the clinician.


Mental Health Clustering Tool(based on HoNOS)

1. Agitated behaviour2. Non-accidental self-injury3. Problem drinking or drug taking4. Cognitive problems5. Physical illness or disability problems6. Hallucinations or delusions7. Depressed mood8. Other mental and behavioural disorders9. Problems with relationships10. Problems with activities of daily living11. Problems with living conditions12. Problems with occupation and activities13. Unreasonable beliefs in non-psychotic disorders

A. Agitated behaviour / expansive moodB. Repeated self harmC. Safeguarding children or vulnerable adultsD. EngagementE. Vulnerability


Clustering with RiO

The following slides take you through the RiO process.The final clustering decision always lies with the clinician –

RiO is designed to aid the decisionHoNOS and clustering can be re-completed to reflect new

information and a possible change in cluster.


The clustering tool is found in outcome measures together with the results and recording screen

The clustering tool is found in outcome measures together with the results and recording screen

Help will be available by clicking here


HoNOS is scored in the tool with the scores copied across. The additional assessment questions refer to historical rather than present problems.

HoNOS is scored in the tool with the scores copied across. The additional assessment questions refer to historical rather than present problems.



The clinician uses this form to allocate the cluster. Although guided by the report the final decision lies with the clinician.

The clinician uses this form to allocate the cluster. Although guided by the report the final decision lies with the clinician.


This allocation needs to be linked to the

Clustering tool (HoNOS) that was completed

following assessment


Care Packages

Staff ResponsibilitiesThe Care packages will be designed to respond the clustered need.

They will be based on evidence and tailored to the individual.These will then need to be reviewed for progress and to consider any change to cluster. The review period differs for each cluster.


Care Packages & the role of the recovery coordinator

• The Care packages will be developed by the Directorates in relation to clusters

• The Recovery coordinator will need to:– agree the care package to be delivered and

monitor its delivery.– undertake the review process.– manage movement between clusters (step up or

down) using the Care Transition Protocol.


Care Package indicative length and review periods

Cluster Cluster Description

Ind. Min Episode of care (wks)

Ind. Max. Episode of care (wks)

Cluster Review (wks)

1 Common mental health problems (low severity) 8 12 82 Common mental health problems 12 15 123 Non-Psychotic (Moderate Severity) 16 24 164 Non-Psychotic (Severe) 26 52 265 Non-Psychotic (Very Severe) 52 156 266 Non-Psychotic Disorders of over valued ideas 0 156 267 Enduring Non-Psychotic Disorders (High Disability) 0 156 528 Non-Psychotic Chaotic and Challenging Disorders 0 156 529 Blank Cluster10 First Episode in Psychosis 0 156 5211 Ongoing Recurrent Psychosis (Low Symptoms) 0 156 5212 Ongoing or Recurrent Psychosis (High Disability) 0 156 5213 Ongoing or Recurrent Psychosis (High Symptoms and Disability) 0 156 5214 Psychotic Crisis 8 12 415 Severe Psychotic Depression 8 12 416 Dual Diagnosis 0 156 2617 Psychosis and Affective Disorder Difficult to Engage 0 156 2618 Cognitive Impairment (Low need) 0 156 2619 Cogntive Impairment or Dementia Complicated (Moderate need) 0 156 2620 Cognitive Impairment or Dementia Complicated (High need) 0 156 2621 Cognitive Impairmentor Dementia (High Physical or engagement needs) 0 156 26


North Devon Pilot

• A small pilot was run with epex to cluster and collect information

• The WBA staff were prepared through two, half day workshops based on use of HoNOS and clustering to develop rating reliability.

• They clustered 99 patients seen for the first time in the service.

• Staff valued the workshop experience.


Attendance by Cluster

0

50

100

150

200

250V

ari

an

ce

No

n-P

sych

. Lo

w S

eve

rity

No

n-P

sych

. L.S

ev

gre

ate

r n

ee

d

No

n-P

sych

. Mo

de

rate

Se

veri

ty

No

n-p

sych

otic

(S

ev)

No

n-p

sych

otic

(V

Se

v)

En

d N

on

_p

sy (

H D

is)

No

n-p

sych

otic

(C

ha

otic

& C

H)

Su

bst

an

ce M

isu

se

1st

Ep

iso

de

Psy

cho

sis

On

g R

ec

Psy

(L

Sym

)

On

g R

ec

Psy

(H

Dis

)

Psy

cho

tic C

risi

s

Se

v P

sych

otic

De

p

Du

al D

iag

no

sis

Psy

&A

ff. D

iso

rde

r

Co

g Im

pa

ir (

L N

ee

d)

Co

g Im

pa

ir/D

em

(H

Ph

y

0 1 2 3 4 5 7 8 9 10 11 12 14 15 16 17 18 21

Cluster

No

. Attended Contacts

Duration (hrs)


Average Attendance by Cluster

14.170.93 2.18 8.71 5.50 8.00 2.50 3.11

19.0028.50

18.508.00

210.00

24.00 22.0011.00 6.000.00

50.00

100.00

150.00

200.00

250.00V

ari

an

ce

No

n-P

sych

. Lo

w S

eve

rity

No

n-P

sych

. L.S

ev

gre

ate

r n

ee

d

No

n-P

sych

. Mo

de

rate

Se

veri

ty

No

n-p

sych

otic

(S

ev)

No

n-p

sych

otic

(V

Se

v)

En

d N

on

_p

sy (

H D

is)

No

n-p

sych

otic

(C

ha

otic

& C

H)

Su

bst

an

ce M

isu

se

1st

Ep

iso

de

Psy

cho

sis

On

g R

ec

Psy

(L

Sym

)

On

g R

ec

Psy

(H

Dis

)

Psy

cho

tic C

risi

s

Se

v P

sych

otic

De

p

Du

al D

iag

no

sis

Psy

&A

ff. D

iso

rde

r

Co

g Im

pa

ir (

L N

ee

d)

Co

g Im

pa

ir/D

em

(H

Ph

y

0 1 2 3 4 5 7 8 9 10 11 12 14 15 16 17 18 21

Cluster

No

. Average contact

Average Time (hrs)


Cluster clusterAttended

Contacts

Duration (hrs) Average contact Average Time (hrs) Admissions

0 Variance 170 140 14.17 12 1

1 Non-Psych. Low Severity 13 14 0.93 1 0

2 Non-Psych. L.Sev greater need 24 20 2.18 2 0

3 Non-Psych. Moderate Severity 148 139 8.71 8 1

4 Non-psychotic (Sev) 55 43 5.50 4 0

5 Non-psychotic (V Sev) 24 26 8.00 9 1

7 End Non_psy (H Dis) 0 0 0.00 0 0

8 Non-psychotic (Chaotic & CH) 5 6 2.50 6 0

9 Substance Misuse 28 25 3.11 3 0

10 1st Episode Psychosis 152 141 19.00 18 1

11 Ong Rec Psy (L Sym) 57 48 28.50 24 0

12 Ong Rec Psy (H Dis) 74 73 18.50 18 0

14 Psychotic Crisis 8 12 8.00 12 0

15 Sev Psychotic Dep 210 238 210.00 238 1

16 Dual Diagnosis 24 21 24.00 21 0

17 Psy&Aff. Disorder 22 23 22.00 23 0

18 Cog Impair (L Need) 11 14 11.00 14 0

21 Cog Impair/Dem (H Phy 6 6 6.00 6 0


Development Requirements


Key ActivitiesKey Activities1. Use the clustering tool in RiO to begin to derive clusters for

all those in the service– Role out assessment training to all staff (in CQC / RiO training)– All reviews / clusters will be completed– Specific training will need to take place for some staff groups.

2. Care pathways and packages - to develop evidenced based Care Packages in response.

3. Develop workforce capacity to meet the care packages.4. Implementation of Clustering / Care Package Approach to

care5. Information collection and analysis6. Commissioning & contracting7. Costing


Clustering Training

• Training workshops are taking place between March 2011 and August 2011 to offer training to all staff involved in clustering.

• This will initially cover all Mental Wellbeing and Access teams for all new referrals

• And rolled out to all Recovery and Independent Living teams and specialist services to cluster the current caseloads.


Care Quality Development Programme

• The programme includes raising awareness of staff in clustering using the RiO tool.

• The programme in 2011 is:– North Devon– Forensic– Exeter, Mid & East– South Devon


Developing Workforce capacity

• This is clearly a long term aim for the Trust• The workforce group will need to complete a

Training needs analysis against the Care Packages

• Develop / recruit appropriate staff• Effect current training SLAs.


Useful Documents (Double click to open)

This booklet needs to be read and available to anyone undertaking clustering.


Further information?Further information?

[email protected]