Care Pathways and Packages
Development
Data items within the Mental Health Clustering Tool
HoNOS
1
OVERACTIVE, AGGRESSIVE, DISRUPTIVE OR AGITATED BEHAVIOUR*
2
NON ACCIDENTAL SELF-INJURY
3
PROBLEM DRINKING OR DRUG-TAKING
4
COGNITIVE PROBLEMS
5
PHYSICAL ILLNESS OR DISABILITY PROBLEMS
6
PROBLEMS ASSOCIATED WITH HALLUCINATIONS AND DELUSIONS
7
PROBLEMS WITH DEPRESSED MOOD
8
OTHER MENTAL HEALTH AND BEHAVIOURAL DISORDERS
9
PROBLEMS WITH RELATIONSHIPS
10
ACTIVITIES OF DAILY LIVING
11
LIVING CONDITIONS
12
PROBLEMS WITH OCCUPATION AND ACTIVITIES
Summary Assessment of Characteristics (SAC)
13
STRONG UNREASONABLE BELIEFS
A
AGITATED BEHAVIOUR / EXPANSIVE MOOD (H)
B
REPEAT SELF HARM (H)
C
SAFEGUARDING CHILDREN & VULNERABLE ADULTS (H)
D
ENGAGEMENT (H)
E
VULNERABILITY (H)
2
Mental Health PbR Development
Mental Health Care Clusters
Working-aged Adults and Older People with Mental Health Problems
A
B
C
Non-Psychotic
Psychosis
Organic
a
b
a
b
c
d
a
Mild/
Very
Severe
and
complex
First
Episode
Ongoing
or
recurrent
Psychotic
crisis
Very Severe
engagement
Cognitive
impairment
Moderate/
Severe
01
02
03
04
05
06
07
08
10
11
12
13
14
15
16
17
18
19
20
21
There are two additional codes if it is not possible to allocate to a Cluster or Super Class:
Z - Unable to assign patient to Mental
Health Care Cluster Super Class
0 (Variance)
3
Cluster payment periods
•
•
•
•
•
•
•
•
•
•
•
1 Common mental health problems (low severity)-12 weeks
2 Common mental health problems-15 weeks
3 Non-psychotic (moderate severity)-6 months
4 Non-psychotic (severe)-6 months
5 Non-psychotic (very severe)-6 months
6 Non-psychotic disorders of overvalued Ideas-6 months
7 Enduring non-psychotic disorders (high disability)-Annual
8 Non-psychotic chaotic and challenging disorders-Annual
9 Blank cluster-Not applicable
10 First episode in psychosis-Annual
11 Ongoing recurrent psychosis (low symptoms)-Annual
Payment Periods Cont’d
• 12 Ongoing or recurrent psychosis (high disability)-Annual
• 13 Ongoing or recurrent psychosis (high symptom and
disability)-Annual
• 14 Psychotic crisis-4 weeks
• 15 Severe psychotic depression-4 weeks
• 16 Dual diagnosis (substance abuse and mental illness)-6
months
• 17 Psychosis and affective disorder difficult to engage-6
months
• 18 Cognitive impairment (low need)-6 months
• 19 Cognitive impairment or dementia (moderate need)-6
months
• 20 Cognitive impairment or dementia (high need-6 months
• 21 Cognitive impairment or dementia (high physical or
engagement)-6 months
Relationship between mandated and proposed forensic, LD & alcohol
misuse clusters
Main elements of the CPP Model
Individual service user needs
Anxiety / Accommodation / Hallucinations / Living conditions etc.
Mental Health Clustering Tool
Standardised summary of individual needs
Cluster
Global description of combination & severity of individual needs
Care Packages
Negotiated care plan
Quality and Outcome Metrics
Triangulated measurement of process and effect
Local Tariff
Derived from joint understanding of accurate costs
Person
One Big
Conversation
Outputs
Outcomes
Mental Health
PbR
CPA
Non CPA
Support Plan
Social Care
FACs
Financial Assessment
Personal Budget
Physical Health
Long terms condition
Personal Health Budget
Care Coordinator
Covering elements of
Mental Health Care
Programme
Social Care
Activities/support
Health
Activities/Support
Next Steps
• DOH acknowledge project slippage
• New Cluster booklet
• New 2013-14 Guidance for Commissioners
and Providers
• Commissioners considering Care Planning
CQUIN
• Major emphasis on accurate data collection
MH PbR Project summary
Working Age Adults / Older People
Implementation
Finance / Costing
Algorithm /
Transitions
Quality and
Outcomes
Extending the Scope
Forensic
Learning Disabilities
Psychological
Medicine
IAPT
CAMHS
Alcohol
IC supporting
requirements for all
work streams
Finance
Work plan Priorities for Development for 2014/15
Objectives
Develop stable and transactionally simple payment mechanism for 2014/15, building on 2013/14 guidance, which maintains overall
financial stability but increases relationship between payment and caseload, and builds in incentives and penalties for delivering on
quality standards and outcomes
Deliverables
•Develop business rules which increase link between payment and active caseload at a cluster level
•Develop incentives and penalties framework for the contract to support:
•Improvement in outcomes for patients and defined through the quality and outcomes work stream
•Delivery against standards for care delivery (review periods, transitions, etc)
•Data quality
•Develop pricing and costing guidance on initial assessment-single assessment price or cluster dependent
•Develop cluster pricing and costing model for inpatients to include review of period durations for in-patient stay, in-patient usage by
bed type by cluster, develop data set of interventions in an in-patient setting to understand variation by cluster.
•Review options for standardising cluster period considering current national standards, lower as well as outer limits, average, mean
and bets practice, in conjunction with quality and outcomes work stream
•Develop standardised data set to support PBR, linked to MHMDS deliverables and work plan, identifying nationally available solutions
and local requirements through 2014/15
•Ensure business rules support required developments in Choice agenda for 2014/15
•Ensure alignment and consistency in development of payment mechanism across all areas of mental health and LD
•Develop understanding of variation in price associated with variation in provider landscape
Timescales
Outline business rules framework to be developed by May 2013 and agreed by Monitor and NHS England
Draft Guidance to be produced by Sep 2013,
Ongoing benchmarking and shared learning through the year.
Approach
Outline business rules framework to be developed by May 2013
Publication of indicative prices May 2013
Quarterly Review of lessons learned
Integration with quality and outcomes work stream to develop incentives and penalties framework
Integration with all work streams and IC to develop standardised data set
Development of national template for data collection of prices, activity and quality metrics in October 2013
Selected deep dives on a cluster specific basis to understand variation in provider landscape
IC Requirements
NOT FUNDED: Analysis to support inpatients work, cluster periods and transitions, work on business rules, work on variation, work on benchmarking,
work on other national data collections; reporting warehouse at Exeter for fast reports to commissioners on PbR activity.
FUNDED: MHMDS maintenance to take changes through approval process.
Risks
Future
developments
Q&O
Objectives
To develop a fit for purpose Quality and Outcomes Framework for use in Mental Health Payment by Results
(PbR).
Deliverables
To test whether SWEMWBS proves sensitive to change over time and whether it can be used as the generic
PROM for the MH PBR Framework.
To identify and recommend a range of patient experience measures which will inform and support mental
health PbR.
To establish how the HoNOS measure can be practically implemented within the PbR framework.
To put in place a set of quality indicators that are ready for use as part of the MH PbR Framework
Scope
Timescales
Signal key proposals June, publish September
WEMWBS pilot - at least 15 months.
Friends and Family tested through 13/14. Other experience questions developed in 13/14.
HoNOS – final testing in early 13/14. Baseline data being collected nationally from April 2013.
Approach
IC Requirements
NOT FUNDED: taking any of the 12/13 work and producing routinely; further investigation work for 13/14;
work on indicator development and production. Inexpensive developments – CROMS analysis, clustering
quality indicators, urban/rural splits, DUP.
FUNDED: limited reporting in monthly MHMDS file at organisation level, selected numerator and denominator
measures.
Risks
Inconsistent approaches to gathering data nationally across the project.
Future
Developments
AlgorithmTransitions
Objectives
Ensure that the algorithm is fit for purpose as a decision support tool at the initial cluster assessment.
Review the transitions and cluster tool rules to ensure that they reflect current practice.
Assess the potential for an algorithm to be used at a review assessment.
Deliverables
An agreed methodology for collecting feedback from providers on their use of the algorithm in practice, and for
identifying aspects of the algorithm requiring further modification
A programme of further development of the algorithms as required
A process for signing off the algorithm for application for an ISN
Recommendations for any changes to transitions and cluster rules
Improved cluster booklet guidance
Scope
Timescales
Develop questionnaire for methodology for collecting qualitative algorithm feedback April/May 2013
Develop approach for assessing use of transitions and rules in practice April to August 2013
Write out to providers June 2013 to get numbers of user organisations and agreement to provide qualitative
feedback on algorithm and use of transitions and cluster tool rules in practice
September 2013 collect feedback. Review feedback October 2013
Recommendations for changes to transition and cluster rules November 2013
Develop methodology for developing quantitative analysis on algorithm October/November 2013
Write to providers for quantitative feedback December 2013. Collect feedback January 2014. Amend algorithm
February 2014. Publish revised algorithm March 2014
Approach
IC
Requirements
Risks
Future
Developments
NO WORK FUNDED.
Key milestones
•
•
•
•
Readiness review completed
PbR CQUIN agreed
Joint action plan developed for 2013-14
MOU signed and cluster monitoring with
commissioners started
• Stronger links between PbR and operations
• Pre cluster tariff (P) developed for PCL
• Local tariff to be agreed by year end
2013-14 CQUIN
• PbR PREM . Tied into national patient surveyTop 4-6 questions
• PROM- Short version of the WEMHWS
• Family and Friends Test
• All of the above on one simple questionnaire
• Still keeping a watching brief on clustering
Training Programme
Quantitative
Qualitative
RiO/CAST
Assessment
Formulation
HoNOS/Cluster (CAST)
Cluster transitions
Knowledge Centre
Problem List
Care Plan Problems (categories)
Care Plan Interventions (categories)
RiO Text fields
Assessment
Formulation writing
HoNOS/Cluster
Cluster transitions
Knowledge Centre
Problem List
Care Plan Problems (text)
Care Plan Interventions (text)
Clinical Dashboard/Reporting
HoNOS/Cluster completion
Cluster accuracy (Red Rules)
Care Plan completion
HoNOS/Care Plan problems (Red R)
Problem/Intervention guidelines
Caseload profile
Outcomes (HoNOS)
Resources
Supervision
HoNOS/Cluster completion
Cluster accuracy
Care Plan completion
HoNOS/Care Plan problems
Problem/Intervention guidelines
Caseload profile
Outcomes (HoNOS)
Resources
Forensic
Objectives
To develop a currency model for testing in 14/15 that meets the agreed criteria.
Deliverables
Reports on the qualitative and quantitative analysis of the current data collection – July 13
Proposals for currency model testing in 14/15 – September 13
Proposals for the quality and outcomes to be used within the currency model – December 13
Proposals for the costing methodology to support 14/15 testing – December 13
Scope
High, medium and low secure mental health and learning disability services
Timescales
Report and recommendations for future developments September 13
Model testing during 14/15
Approach
Data collection required through contracts
Secure PRG sub group leading the project work
IC Requirements
No analysis work funded.
Risks
Model not workable across all levels of security
Data quality inadequate for purpose
Future
Developments
Learning
Disabilities
Objectives
•To consider potential expansion of the current MH clusters by creating a seamless continuation for patients
requiring input from NHS funded specialist adult Learning Disabilities health services .
•To undertake a pilot project to develop a new Learning Disabilities clustering process.
Deliverables
•Integrated Mental Health and Learning Disability Clustering Tool.
•Additional guidance specific to Learning Disability.
•New set of Learning Disability Clusters.
•Final report outlining proposed clustering tool, new clusters and next steps.
Scope
Inpatient and community specialist adult Learning Disability health services.
Timescales
Submission and analysis of pilot site data – Oct-Dec 2012
Service User/Family carer consultation events – Oct 2012
Learning Disability cluster development workshops with stakeholders – Jan-Feb 2013
Initial validation of new Learning Disability clusters with pilots sites – Apr-May 2013
New Learning Disability clustering process within report to National PbR group – June 2013
Approach
Analysis of clustering data from pilot sites, service user/clinician consultation across the participating pilot sites
and validation of a new set of Learning Disability clusters with participating sites.
IC Requirements
Funded – expanding the scope of MHMDS to include LD (phase 1).
Risks
Uncertain mandate within NHS Commissioning and DH Learning Disability policy
Future
Developments
To be determined following the above report findings
Psychological
Medicine
Objectives
To develop recommendations for an incentivised payment mechanism based on integration that discourages
the separation of physical and mental health, that improves patient outcomes, reduces costs, and improves
system functioning. Proposals to be developed in 2013/14 followed by further development and testing in
subsequent years.
Deliverables
•T o develop a proposals for system enabling services.
• To develop proposals for a payment mechanism for clinical care that incentivises improved outcomes.
An initial piece of analysis will be undertaken with the following remit:
• Breakdown of the amount of investment in liaison
• Summary of how it is commissioned and who commissions the work.
• Overview of good practice models of where it is working well.
• Summary of outcome measures that are in place.
• Cover acute, community and mental health settings.
• Considers the next generation, training and expansion.
• Would examine whether enabling services could be funded centrally or locally.
Scope
Hospital and community.
Peri-natal and neuro-psychiatry are within scope.
Full scope of project will be agreed following delivery of initial analysis.
Timescales
June/July for delivery of initial report.
Approach
TBC following initial scoping work.
IC Requirements
No work funded.
Risks
TBC
IAPT
Objectives
To develop an outcomes based currency for IAPT services
Deliverables
A software package to calculate currencies for commissioned services at monthly intervals
Data completeness and data quality higher than 90%
A method of incorporating MH Cluster in the model, determined by way of an extended pilot
Evidence the model is appropriate across a wide range of providers, provided by way of an extended pilot
Scope
Any IAPT service in England will be eligible to take part in the extended pilot, all the 23 commissioned services
that took part in the feasibility pilot will be encouraged to continue. The MDS and the PbR Data set will be
submitted centrally and analysed. The currency model will be applied to the model and the results reported
Timescales
The extended pilot will run for 12 months, 2013/14. Data will be analysed to support a decision about a
possible full road test for 2014/15 and further analysed for a decision about 2015/16 in line with the new PbR
planning cycle.
Approach
The approach is an extended pilot, with associated statistical and economic analysis running in parallel with
software development
IC Requirements
The HSCIC will need to continue to make data available via the data depot for each of the extended pilot
commissioned services. The HSCIC will also support changes to the MDS and changes to clinical systems. They
will need to support the development/integration of the software, it may be case-mix write this software, or
commission it.
Risks
No funding exists for this development, thus it is likely to start late, meaning decisions will be made with less
data, thus making those decisions prone to error
Future
Developments
Once the currency has been sufficiently developed a national road test will be used to establish baseline
performance of every commissioned services over a full financial year, this will enable the currency to be
deployed with local prices in the following financial year
CAMHS
Objectives
To develop national currencies that can be used as the basis for contracting and paying for child and adolescent
mental health services in England .
To produce a more transparent funding system for child and adolescent mental health services, with clarity as
to what care is being provided, how it is paid for and by whom, and what outcomes are being delivered
To ensure that funding reforms support child and adolescent mental health services policy objectives
Deliverables
Allocation tool
Clusters
Algorithm
Associated guidance material
Approach to care package development
Scope
Tiers 2-4
Will exclude non mental health LD services
Timescales
Pilot of allocation tool underway.
Draft clusters - Autumn 2013
Finalised clusters, algorithm and associated guidance September 2014
Approach
Identification of assessment factors that are associated with resource use through analysis of existing data sets
and collection of prospective data.
Collection of outcome
IC Requirements
CAMHS minimum data set mandated from April 2013
IC notified of changes required for PbR (and CYPIAPT implementation) for 2015/6
Risks
Technical difficulties with prospective data collection
Data not conclusive
Objections from clinicians/commissioners
Future
Developments
Alcohol
Objectives
Local authorities take over the responsibility to commission alcohol treatment services from April 2013. Local
authorities are not mandated to implement Mental Health PbR. Nevertheless, the range of products developed
to support alcohol treatment PbR can be used as a programme of systems improvement and on an elective
basis, be used as currencies for payment within contracts between local authorities and mental health trusts or
voluntary sector agencies delivering alcohol treatment.
Deliverables
To provide cluster/currencies that identify the range of complexity of patients seeking alcohol treatment.
These clusters will:
• Be based on - The Mental Health Clustering Tool PLUS
- Appropriate alcohol dependency measures
• Segment the alcohol treatment seeking population into complexity groups
To specify the appropriate packages of care, based on NICE guidance, to address the treatment needs of
patients in each cluster
To make available the range of Outcome measures found to be effective in the 4 pilot sites
To make available the methods used in the 4 pilot sites to determine the cost of delivering appropriate
packages of care to patients in each of the clusters
Scope
Hospital and community specialist alcohol treatment services.
Timescales
April/May for delivery of clusters/currencies
May/June for refined packages of care
September for Outcome measures
September/October for costing examples
Approach
Analysis of clustering data, treatment journey data and in consultation with the 4 pilot areas
IC Requirements
No work funded.
Risks
Limited available time for analysis
Pilot site continued participation in light of their busy schedules
Future
Developments