Rio Clustering and Care Packages April 11 v0 8

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Clustering, Care Packages & Pathways

Introduction

The development of the care pathways and packages approach was

developed by six Trusts in North East Yorkshire. This was a clinical projectdesigned to understand how care could be clustered to improve thequality and reliability of the care people received. They produced a matrixof 21 care clusters derived empirically from data from the initial clinicalmodel design which showed the relative agreement between clinicianswhen using the clustering tool. It showed that the clustering model andprocess had face validity, was clinically useful and could distinguishbetween groups of people referred to the service based on acomparatively simple model.

The approach leads to considering the commonalities and differences incare that people need in the different groups or clusters that they are

allocated to. It is clear that although care and therapies need to bedesigned with the individual in mind, interventions, therapies ormedications have clear evidence base to meet specific disorders,problems and needs. Equally as the evidence grows for specificapproaches these are chosen as a first line for many commonpresentations. These evidence based therapies and treatments can bepulled together into a care package around the presentation. As such for acluster of similar presentations a range of evidenced based treatments ortherapies can be pulled together to form a care package the clinician mayinitially draw from.

The Clusters

The clusters are outlined below. More details can be found in theclustering booklet. Each cluster contains a range of indicative or likelydiagnoses. However the use of diagnosis alone is not a way of clustering.

There are 21 clusters arranged in broad headings as described below.

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The clusters are listed below:

Non-Psychotic Mild /Mid / Severe

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)

Non-Psychotic Very Severe & Complex

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)

Psychotic 1st Episode

10.First Episode Psychosis

Psychotic Ongoing or recurrent

11.Ongoing Recurrent Psychosis (Low Symptoms)12.Ongoing or recurrent Psychosis (High Disability)13.Ongoing or Recurrent Psychosis (High Symptom & Disability)

Psychotic Crisis

14.Psychotic Crisis.15.Severe Psychotic Depression

Psychotic very severe Engagement

16.Dual Diagnosis17.Psychosis and Affective Disorder Difficult to Engage

Organic Cognitive Impairment

18.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)

The Clustering Process

The first task then is to assess the person referred to the service with aview to understanding them sufficiently to consider their needs andallocate them to a cluster that suggests a care package.

This involves: Completing an initial clinical assessment Completing the Clustering Tools

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RiO Clustering process and RiO Clustering tool.

After initial assessment has taken place the clinician needs to: Complete the Clustering Tool (HoNOS PbR)

Allocate the person to a cluster using the Clustering Tool carecluster allocation

HoNOS PbR

The Clustering tool can be found in the outcome measures folder of theRiO case record. The tool is a version of HoNOS but also includes questionsrelated to historical as well as current behaviours. Details for how to scorethe HoNOS are found in the Mental Health Clustering booklet.

The following approach should be taken:

The Date/Time should be the date/time the clustering tool wascompleted.

The Mental Health Clustering Tool Assessment Reason has severaloptions. The following only should be used:

o Assessment - for use after initial assessmento First Therapy Session: - for use at the outset of therapeutic /

care courseo During Therapy (Review) at a review point whether a care

programme review of review during therapy or where there isa change of plan.

(As the Trust develop the approach the additional choices may beimplemented)

HoNOS PbR Assessment

This consists of 13 questions based on the current two week history andfive additional questions based on historical information. Use the RiO toolin conjunction with the Mental Health Clustering Booklet (2010/11). Theratings should be completed in accordance with the guidance but allshould be scored between 0 and 4 with a score of 9 used to indicate thatthe area is unknown.

Cluster decision

The approach outlined in the Mental Health Clustering booklet should beadopted to identify the appropriate care cluster.

1. The decision tree should be used to identify the whether thepresenting needs are non-psychotic, psychotic or organic in origin

2. The most appropriate sub-headings should be selected.3. This will narrow the choice of clusters which should be selected

through the match of HoNOS reporting and the cluster descriptionsin the clustering handbook.

Allocation to a Cluster

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Allocation to a cluster is achieved using the MH Clustering Tool CareCluster Allocation. After creating a new a new form clustering is completedusing the options available.

The following approach should be taken:

The Date/Time should be the date/time the assessment tool wascompleted.

The Associated Mental Health Clustering Tool needs to be selected.The relevant clustering tool is denoted by the date and time that itwas completed remember over time there will be several.

The Care Cluster Identification Date needs to be completed to showwhen the care cluster was identified. This may be at a date after theassessment including post discussion or supervision.

The Care Cluster is then selected from the menu. Cluster 1 21should be chosen at this point based on clinical judgement and thesupport tools. If the presenting needs does not lead to any clearcluster then select - None . This is equivalent to Care Cluster 0 variance which indicates that the person is not adequatelydescribed by any of the cluster descriptions.

For more information about clustering see the Mental Health ClusteringBooklet (2010/11) [link below].

Changing or updating the cluster

This may occur at the First Therapy session or review of care. A new

Mental Health Clustering Tool (HoNOS) should be completed. The outcomeof the tool should be reviewed in the Mental Health Clustering ToolOverview Report. Where this leads to the clinician considering that theCluster needs to be changed then this is recorded in the MH Clustering

Tool Care Cluster Allocation screen.

Edit the current form with the following approach:

Enter the care cluster end date the date upon which the currentcluster ends.

Enter the reason for the change of cluster with error or change incluster.

To enter the new cluster, create a new allocation form.

A flow chart is available on the website.

Staff required to Cluster

This is clearly the responsibility of qualified staff designated to makeassessments and develop the care plan. The initial clustering is completedat the point of initial assessment following referral to DPT services.

Therefore virtually all initial clustering will initially take place in MentalWellbeing and Access services.

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However for many people a clearer picture emerges at the point ofengagement in a care / treatment course where new problems or issuesmay arise which puts the initial clustering in doubt. So people will also beclustered at the point of the beginning of an episode of care / treatment.

Finally after a period of care people will need to be reviewed which willinclude a new Mental Health Cluster Tool (HoNOS) being completed. Thismay give rise to a new cluster being identified and recorded.

This is summarised below:

CPAInitial

assessment 1st Session Review

Yes MWA Assessor

RecoveryCoordinator /Psychiatrist

RecoveryCoordinator

No MWA Assessor Recovery

CoordinatorRecovery

Coordinator

Note: A recovery coordinator is defined as a qualified clinician who holds acaseload or may be responsible for coordinating care from others thanthemselves. The psychologist or psychiatrist acts as the recoverycoordinator for people seen in psychological therapies or by medical staffwho do not have interventions offered by MWA, RIL or OPMH CRHT.

The role of the Recovery Coordinator

Many people will be involved in several services simultaneously. TheRecovery Coordinator will remain the individual responsible for the care

pathway dictated by the clustering. Others involved in care recognisingthe need to revise the clustering should liaise with the Recovery to reviewthe care and clustering through the use of the Clustering tool.

The Recovery Coordinator will need to:

Agree the package to be delivered

Monitor the delivery of the care package

Undertake a review process

Manage the transition between clusters and care packages usingthe Care Transition Protocol.

Care Transitions

The Mental Health Clustering Tool needs to be repeated at significantreview points where ever they occur but at a maximum time as indicatedin the table below. At these points the process may indicate that thepersons needs no longer fit the current allocated cluster and carepackage.

The clinician will need to consider whether the person should move to anew cluster based on the MHCT process and transition protocols in theCare Transition Protocol Booklet (2010/11). If this leads to a change in

cluster this should be achieved using the process outlined above.

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For more information see the Care Transition Protocol Booklet [link below].

Indicative episode lengths and review periods are outlined in the tablebelow:

Cluster Cluster Description

Ind. MinEpisodeof care(wks)

Ind. Max.Episodeof care(wks)

ClusterReview(wks)

1Common mental health problems (lowseverity) 8 12 8

2 Common mental health problems 12 15 12

3 Non-Psychotic (Moderate Severity) 16 24 16

4 Non-Psychotic (Severe) 26 52 26

5 Non-Psychotic (Very Severe) 52 156 26

6 Non-Psychotic Disorders of over valued ideas 0 156 26

7 Enduring Non-Psychotic Disorders (HighDisability) 0 156 52

8Non-Psychotic Chaotic and ChallengingDisorders 0 156 52

9 Blank Cluster

10 First Episode in Psychosis 0 156 52

11Ongoing Recurrent Psychosis (LowSymptoms) 0 156 52

12Ongoing or Recurrent Psychosis (HighDisability) 0 156 52

13Ongoing or Recurrent Psychosis (HighSymptoms and Disability) 0 156 52

14 Psychotic Crisis 8 12 4

15 Severe Psychotic Depression 8 12 4

16 Dual Diagnosis 0 156 26

17Psychosis and Affective Disorder Difficult toEngage 0 156 26

18 Cognitive Impairment (Low need) 0 156 26

19Cogntive Impairment or DementiaComplicated (Moderate need) 0 156 26

20Cognitive Impairment or DementiaComplicated (High need) 0 156 26

21Cognitive Impairmentor Dementia (HighPhysical or engagement needs) 0 156 26

Care Pathways and Packages

The clustering approach to needs assessment gives rise to thedevelopment of pathways and care packages that deliver care designed tomeet the needs of those in the cluster. These should be evidenced based,delivered by appropriately skilled workers in a time bound fashion.

The care package will broadly dictate:

The therapeutic intervention whether health or social care

The time required for the delivery of the intervention

The staff inputs to deliver the intervention including knowledge /skill requirements

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The care package can then be tailored to the individuals needs andcircumstances to ensure they receive an individualised care package.

The packages will be developed and be continually updated to reflect new

evidence.

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Clustering Flow Chart

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Further information.

Clustering

Mental Health Clustering Booklethttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_112282.pdf

Mental Health Care Transitions Booklethttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_113541.pdf

Integrated Packages Approach to Carehttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_086534

Mental Health Payment by Results

A simple guide to payment by resultshttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_120254.pdf

Practical guide to preparing for mental health payment by resultshttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_113541.pdf

Payment by Results slide packhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_112969.pdf

Payment by Results (section 9)http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_112970.pdf

What is the payment by results project?http://www.rcpsych.ac.uk/members/currentissues/ifqo/qa/qa-8.aspx

HoNOS

Health of The Nation Outcome Scores (HoNOS) Traininghttp://www.rcpsych.ac.uk/quality/honos.aspx

FAQs (HoNOS)http://www.rcpsych.ac.uk/quality/honos/generalinformation/faq.aspx

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http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_112282.pdfhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_112282.pdfhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_113541.pdfhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_113541.pdfhttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_086534http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_086534http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_120254.pdfhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_120254.pdfhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_113541.pdfhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_113541.pdfhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_112969.pdfhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_112969.pdfhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_112970.pdfhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_112970.pdfhttp://www.rcpsych.ac.uk/members/currentissues/ifqo/qa/qa-8.aspxhttp://www.rcpsych.ac.uk/quality/honos.aspxhttp://www.rcpsych.ac.uk/quality/honos/generalinformation/faq.aspxhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_112282.pdfhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_112282.pdfhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_113541.pdfhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_113541.pdfhttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_086534http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_086534http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_120254.pdfhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_120254.pdfhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_113541.pdfhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_113541.pdfhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_112969.pdfhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_112969.pdfhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_112970.pdfhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_112970.pdfhttp://www.rcpsych.ac.uk/members/currentissues/ifqo/qa/qa-8.aspxhttp://www.rcpsych.ac.uk/quality/honos.aspxhttp://www.rcpsych.ac.uk/quality/honos/generalinformation/faq.aspx

Documents

Rio Clustering and Care Packages April 11 v0 8