Forensic Mental Health, Learning Disability and ASD Pilot Train the Trainer Workshop Mick James Jon Painter Tracy Whitelock Dewi Williams C P P P Care

Forensic Mental Health, Learning Disability and ASD Pilot

Train the Trainer Workshop

Mick JamesJon Painter

Tracy WhitelockDewi Williams

C PPPCare Pathways and Packages Project

Developing currencies for mental health payment by results

Agenda• 09.30 Registration + refreshments • 10.00 Introductions• 10.10 MHCT scales • 11.00 Morning Refreshments • 11.15 Draft additional forensic and LD scales • 11:45 Group Work – Using the scales in practice• 12.30 LUNCH• 13.15 Cluster allocation • 13.50 Draft forensic additional clusters and forensic pathways• 14.20 Group Work - Cluster allocation• 15:00 Afternoon Refreshments • 15.15 Transitions• 15.30 Next steps – analysis and plans• 15.45 Finish/feedback



Aims

• To share the work that has been undertaken to develop an Integrated Mental Health and Learning Disability Forensic Clustering Toolkit with those sites that have agreed to be pilot sites for the Forensic MH, LD & ASD Clustering Toolkit.

• The focus of the training is to share the updated toolkit to enable sites to 'Train the Trainer' within their organisation, enabling them to cascade the toolkit and data submission requirements to their teams.



Ideal Clusters

A B C D

G F E

H I J K



Clustering of non-forensic population

A B C D

G F E

J

H

I K



Extending the scope of clusters

A B C D

G F E

J

H

I K

M

L



Combining clusters and pathways

Ai Bii Ciii Div

Gv Fi Eii

Jv

Hiii

Iiv Ki

Miii

Lii



Background to the development of the MHCT

The Department of Health, NHS England and Monitor:Are driving the development of a national system for currencies and payment for Mental Health and Learning Disability services. This will enable commissioners to understand the needs of people who use these services and set tariffs for reimbursing providers for the work that they do. It builds on work done by the Care Pathways and Packages Project in developing an assessment tool that allows allocation of clients to Care Clusters. It has the advantage that it retains intact HoNOS, an internationally recognised outcome measure developed by the Royal College of Psychiatrists (collection of which is mandatory), thus avoiding the need for two separate data collections.

© Royal College of Psychiatrists

8



The Forensic MH, LD and ASD Pilot tool is…..• The HoNOS with the addition of a further 6 scales, comprised of 3 additional

current scales and 6 historic scales• PART 1 contains 13 scales to record problems experienced during the 2 week

period prior to your assessment (the current rating period). This includes the HoNOS, a set of 12 scales with a 5-point rating scale. The version to be used in these trials also contain an additional 3 current items.

• PART 2 contains another five scales (A-E) that consider problems from a ‘historical’ perspective. These will be problems that occur in episodic or unpredictable ways. While they may not have been experienced by the individual during the 2 week current rating period, clinical judgement would suggest there is still a cause for concern that cannot be disregarded (i.e. no evidence to suggest that the person has changed since the last occurrence either as a result of time, therapy, medication or environment etc.) In these circumstances any event that remains relevant to the cluster allocation (and hence the interventions offered) should be included. The version used in these trials contain an additional 6 historical items

• PART 3 contains 5 forensic pathways that allow the patient’s presenting needs to be set in a forensic context

• The tool will allow you to allocate a client to a Care Cluster and a pathway. © Royal College of Psychiatrists

9



What does the Tool provide?

A single ‘rating’ is completion of the scales

A single rating provides:A profile of the individual client and measure of severity of mental health problems. This provides the evidence to allocate to a cluster.

Two HoNOS ratings provide:• Measure of health outcomes when two or more ratings are

compared

Three or more HoNOS ratings provide:• A means of examining trends over time; for individuals or

groups when three or more ratings are compared• HoNOS ratings cannot be compared if any of the items are

scored at ‘9’


10



Using the tool

• The tool itself is not a clinical assessment but a clinical assessment is a pre-requisite for rating the tool

• A rating of HoNOS is a rating of the client’s current problems in terms of impact on the client of the problem. Rating the tool shows both current and historical problems in terms of impact on the client of the problem

• Not included in making a rating for HoNOS is:The diagnosis, the cause of the problem, the intervention or the risk to others or the effect on others of the problem

• HOWEVER: The tool as a whole brings some of these into consideration when making a rating. This includes the issues of risk which are clearly so important in forensic settings. It is important to read the glossary for each scale and rate what is asked.


11



Some Cautions!

• The tool was not constructed to measure mental health problems in the general population or in general practice.

• HoNOS cannot be used to compare wards, districts, treatment regimes etc, unless context/background information is also collected (e.g. MDS) and like is compared with like.

• A brief one-off training course is not sufficient to guarantee comparability between individual raters or between groups of raters. Practice is required to maintain reliability and efficiency.


12



The Scale Structure

Each scale uses the same 5-point severity scales (0-4)

0 - no problem1 = minor problem requiring no action (sub-clinical)2 = mild problems but definitely present (mild)3 = problem of moderate severity (moderate)4 = severe to very severe problem (severe/very severe)

• The glossary provides further information on each SCALE and examples of each point in the severity scale.

• When no information is available to score a SCALE, the figure ‘9’ is used to indicate ‘not known’. The ‘9’ is not added to the 0-4 scores. Further information should be collected again and a 0-4 score given – without a full set of scores the rating cannot be used to measure outcome or cluster a client.


13



Scoring

• The following guidance is offered to separate the rating period for ‘current’ and ‘historical’ problems:

– The rating period for the ‘current’ scales is the 2 week period prior to your current assessment.

– The rating period for the historic scales is any point in the past, including the current rating period i.e. the 2 week period prior to your current assessment (where this is deemed to remain relevant for current care planning and cluster allocation).


14



Points of Assessment

• In practice, the required points of assessment are much the same for both Care Clustering and for routine clinical outcome measurement. These are at the point of Referral, at any formal Review, at any time of Crisis and at Transfer from a team or from the service i.e. at any point where a significant change in need occurs.

• Clustering is not required at discharge from Trust services since no care package will be provided, but clinical outcome measurement is required at discharge.

• Only the first 12 original HoNOS scales are used to measure health outcome and these scales can be used at any other time clinical staff deem appropriate to monitor the impact of specific clinical interventions.


15



General Guidelines

• There is no absolutely ‘correct’ rating.

• Rating is the clinical judgement of the rater.

• Serial ratings should be made by the same rater wherever possible and where this is not possible the use of multidisciplinary team ratings should be encouraged.

• For the current scales, each mental health/social problem is rated only once.

• Rate each scale in order from 1 to 13, 30, 31 & 40 (Part 1) followed by scales A to E, I, J, K, P, Q & R (Part 2). Then complete Part 3.

• For the Part 1 scales, do not include information rated in an earlier scale except for scale 10 which is an overall rating.

• Rate the most severe problem that occurred during the period – both current and historical.


16



The tool is not…..

• A structured clinical assessment tool or interview guide.

• An assessment of future risk.

• A measure of health care outcomes or clinical effectiveness (e.g. interventions).

• A substitute for more specific standardised assessment tools/rating scales.

• But the tool is used to summarise your full clinical assessment.


17



Features of the tool

• Are short, simple, acceptable and useful to professionals.

• Provide an overview of clinical and social problems.

• Have a variety of uses for clinicians, administrators and researchers.

• Are sensitive to improvement, deterioration or lack of change.

• HoNOS has a known relationship to more established scales such as BPRS, role functioning scales.

• HoNOS is a simple indicator for local and national use of health outcome if like is compared with like using context information (e.g. MDS).


18



How do I cluster someone?

To Cluster a client follow these steps:

1) Assess your client and record the scores.

2) Use the Decision Tree to drill down to the most appropriate clusters by a process of elimination.

3) Consider your client’s profile of scores in relation to the reported range for each cluster as shown in the Integrated Clustering Booklet.

4) On the basis of your client’s scores decide which cluster best describes their current needs and accurately allocate to a cluster, bearing in mind that client scores will usually fit best at the point of referral or when needs change significantly.

56© Royal College of Psychiatrists






• As organisations use different IT systems, the exact procedures will vary from provider to provider. However all providers will follow these basic steps:

• Step 1: Based on the information you have gathered during your routine screening/assessment process, rate the individual’s identified needs using the Integrated Clustering Tool (Appendix 1).

• Step 2: : Use the Decision Tree (Appendix 2) to decide if the presenting needs are non-psychotic, psychotic or organic in origin. Then decide which of the next level of headings is most accurate. This will have narrowed down the list of clusters that are likely to describe the person’s needs.


21




• Step 3: Look at the rating grids (Appendix 3) to decide which one is the most appropriate by using the colour-coded key.

• Start with the Red ratings. These indicate the type and level of need which must be rated. If the ratings do not match, try another cluster.

• Next, consider the Orange ratings. These represent expected ratings. You may allocate a person to a cluster if the orange ratings do not exactly match the coloured grids. However, this reflects a “weaker fit” to that cluster.

• Finally review the Yellow ratings. These represent ratings that may occur. These scales have significantly less bearing on cluster allocation but may indicate the need for additional care plan interventions.


22



When should I cluster someone?

People’s needs change over time, and over the course of their treatment. A payment system for mental healthcare must reflect the differing levels of input that are provided throughout changing and unpredictable episodes of care. In order to achieve this, it is essential that people are not only assessed and clustered at the point of referral, but also re-assessed and re-clustered periodically. In practice this will equate to assessing and clustering people at:

• The end of the initial assessment (typically within 2 contacts).• All planned CPA or other formal care reviews.• Any other point where a significant change in planned care is deemed necessary (e.g. unplanned reviews, urgent admissions etc.)

Organisations should ensure there is clarity about who is responsible for clustering, particularly when more than one professional is involved.


23



Care Transition Protocols

• Indicative episode of care for clusters

• Align to CPA and needs of client/pace of treatment

• Cluster review intervals

• Cluster Transition protocols

• Step up criteria

• Step down criteria

• Discharge criteria and required MHCT severity scores on key scales


24




• The points at which the appropriateness of the current cluster allocation is reconsidered should not be arbitrary. It should occur at natural and appropriate points in the individual’s care pathway. Typically these are termed as reviews but, it is important to note that reviews can be relatively informal as well as formal, and can be in response to unforeseen changes in need i.e. unplanned as well as pre-planned.

• Consider the following clinical scenarios:





• Some months after treatment from an assertive outreach team begins, improvements in presentation (particularly patterns of engagement) are not uncommon. These are unlikely to trigger a significant reduction in the overall level of intervention provided until the improvements have been maintained for some time. Thus the cluster allocation that originally triggered an assertive and intensive service response remains valid as it is still seen as a truer reflection of the individual’s overall needs.

• Service users diagnosed with borderline personality disorder are well known to exhibit erratic patterns of behaviour, with fluctuations in distress and risk commonplace. Despite increases in risk, decisions are often made to take therapeutic risks rather than immediately increasing the overall level of intervention in response to what may turn out to be transient and self-limiting increases in perceived need.





• From these examples it is clear that individuals only fit the needs profiles for the appropriate cluster at certain key points in their journey (i.e. the start of a period of care) and that, at clinical reviews additional factors must also be taken into account before a different cluster allocation is made and care is changed significantly.

• These factors are described in the Care Transition Protocol booklet as care transition

protocols and include the step-up and step-down criteria for each cluster. Only when a set of criteria have been met should the allocated cluster be changed to that suggested by the clustering tool scores. The protocols also include examples of local discharge criteria which outline the circumstances when service users could be discharged from mental health services completely.

• The remaining pages in the Care Transition Protocol booklet describe, for each cluster:

the length of time service users are likely to be allocated to a particular cluster; a frequency for re-assessing the appropriateness of the cluster; and the likelihood of each possible cluster transition. It also attempts to visually represent the relationship between each cluster in terms of intensity, acuity and complexity etc.




Documents

Forensic Mental Health, Learning Disability and ASD Pilot Train the Trainer Workshop Mick James Jon Painter Tracy Whitelock Dewi Williams C P P P Care