Payment by Results
Clustering, Care Pathways
and Packages
July 2011
Devon Partnership
NHS Trust
Simon Polak & Kate Morris June 2011
1
Introduction and Background
Mental health PbR is now coming as a radical change to
funding mental health care in England.
It involves clustering people based on their needs using
an empirically derived process. Funding will be linked to
the clusters.
All teams will be clustering in the course of the next 3
months.
Devon Partnership
NHS Trust
Simon Polak & Kate Morris June 2011
2
What is PbR?
• Introduced into acute sector 2003/4
• Activity X Price = income
– e.g. 10 hip replacements X £1,000 = £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
Simon Polak & Kate Morris June 2011
Devon Partnership
NHS Trust
3
Clustering & Care Packages Approach
• The care clusters were developed as part of the Integrated
Packages Approach to Care (InPAC) programme in the Yorkshire
Partnership NHS Foundation Trust and tested across 6 MH Trusts
in the North East/ Yorkshire area. (Greene and Rigby, 2006)
• 21 Care Clusters were 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.
• It was the ability of the InPAC cluster methodology to classify
service users based on the similarity of their current needs, and
to describe the similarity of their care plans(Self, et al 2008), that
made care clusters attractive as a potential currency for mental
health.
Devon Partnership
NHS Trust
Simon Polak & Kate Morris June 2011
4
Payment 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 –
• All service users accessing mental health care (post GP or other referral)
that have traditionally been labelled working age (including early
intervention services from age 14) and older people’s services, should be
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. Negotiations for this start in
October 2011 – DPT needs as many people clustered by then as possible.
– • 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).
Devon Partnership
NHS Trust
Simon Polak & Kate Morris June 2011
5
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 recorded in the Clustering Assessment in
RiO.
Devon Partnership
NHS Trust
Simon Polak & Kate Morris June 2011
6
Referral
The process for determining
need through the allocation of
a care cluster is based on the
Clinical assessment.
The chosen cluster then leads
to an indicative care package
that will be individualised to
the person’s specific needs.
This will be reviewed which
may lead to a change of cluster
and care package.
Assessment
Clustering
Assessment
(HoNOS)
Review will lead to:
1. Re-clustering and the
need to complete the
clustering assessment
and allocate a new
cluster or,
2. To end a cluster because
the person has been
discharged or died.
Cluster
Care
Package
Review
Devon Partnership
NHS Trust
Simon Polak Feb 2011
7
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 forms simplify the process of capturing 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 indicate:
–
–
–
–
The therapeutic interventions
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.
Devon Partnership
NHS Trust
Simon Polak & Kate Morris June 2011
8
Care Packages
Care Cluster n
Care Packages
Evidenced
based
Intervention
Staff Member
Skills / Knowledge
Devon Partnership
NHS Trust
Simon Polak & Kate Morris June 2011
9
Cluster
Ind. Min Episode of Ind. Max. Episode Cluster Review
care (wks)
of care (wks)
(wks)
Cluster Description
1
Common mental health problems (low severity)
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 (High Disability)
0
156
52
8
Non-Psychotic Chaotic and Challenging Disorders
0
156
52
9
Blank Cluster
10
First Episode in Psychosis
0
156
52
11
Ongoing Recurrent Psychosis (Low Symptoms)
0
156
52
12
Ongoing or Recurrent Psychosis (High Disability)
0
156
52
13
Ongoing or Recurrent Psychosis (High Symptoms and Disability)
0
156
52
14
Psychotic Crisis
8
12
4
15
Severe Psychotic Depression
8
12
4
16
Dual Diagnosis
0
156
26
17
Psychosis and Affective Disorder Difficult to Engage
0
156
26
18
Cognitive Impairment (Low need)
0
156
26
19
Cogntive Impairment or Dementia Complicated (Moderate need)
0
156
26
20
Cognitive Impairment or Dementia Complicated (High need)
0
156
26
21
Cognitive Impairment or Dementia (High Physical or engagement needs)
0
156
26
Devon Partnership
NHS Trust
10
Simon Polak Feb 2011
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
– When the person’s presentation changes significantly
• 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.
Devon Partnership
NHS Trust
Simon Polak & Kate Morris June 2011
11
Rating Bias…
• Rating difference between raters – check with
colleagues
• Rating biased by emotional reaction of the rater –
review the evidence and the rating guide
• Rating biased by the assumptions made by the rater
– only use the available evidence
• Ratings biased by the future needs of the client –
focus on this decision not the consequences
• Ratings biased by misunderstanding the question –
carefully review the rating guide.
Devon Partnership
NHS Trust
Simon Polak & Kate Morris June 2011
12
Mental Health Clustering Tool
Revisiting HoNOS & SARN
HoNOS: In 1993 the UK Department of Health commissioned the Royal College of
Psychiatrists’ Research Unit (CRU) to develop scales to measure the health and social
functioning of people with severe mental illness.
Development and testing over three years resulted in an instrument with 12 items
measuring behaviour, impairment, symptoms and social functioning.1 The scales were
developed using stringent testing for acceptability, usability, sensitivity, reliability and
validity.
The scales also form part of the English Minimum Data Set for Mental Health.
HoNOS is the most widely used routine clinical outcome measure used by English mental
health services.
SARN: Summary of Assessments of Risk and Need. Was developed as part of the clinical
decision support tool which underpinned the care packages and clustering work.2
1Self
R; Rigby A; Leggett C and Paxton R (2008) Clinical Decision Support Tool: A rational needs-based approach to making clinical
decisions.
Journal of Mental Health, 17(1): 33-48.
2Wing, J. K., Curtis, R. H. & Beevor, A. S. (1999) Health of the Nation Outcome Scales (HoNOS). British Journal of Psychiatry, 174 (5),
432-434.
Devon Partnership
NHS Trust
Simon Polak & Kate Morris June 2011
13
Care Clusters – which level?
Devon Partnership
NHS Trust
Simon Polak & Kate Morris June 2011
14
Non-Psychotic
Mild /Mid / Severe
Non-Psychotic
Very Severe & Complex
Psychotic 1st Episode
Psychotic
Ongoing or recurrent
Psychotic Crisis
Psychotic
Very Severe Engagement
Organic
Cognitive Impairment
Devon Partnership
NHS Trust
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
Common Mental Health Problems (Low Severity)
Common Mental Health Problems (Low Severity with greater
need)
Non Psychotic (Moderate Severity)
Non-psychotic (Severe)
Non-psychotic Disorders (Very Severe)
Non-psychotic Disorder of Over-valued Ideas
Enduring Non-psychotic Disorders (High Disability)
Non-Psychotic Chaotic and Challenging Disorders
Blank Cluster (formally substance misuse)
First Episode Psychosis
Ongoing Recurrent Psychosis (Low Symptoms)
Ongoing or recurrent Psychosis (High Disability)
Ongoing or Recurrent Psychosis (High Symptom & Disability)
Psychotic Crisis.
Severe Psychotic Depression
Dual Diagnosis
Psychosis and Affective Disorder – Difficult to Engage
Cognitive Impairment (Low Need)
Cognitive Impairment or Dementia Complicated (Moderate
Need)
Cognitive Impairment or Dementia Complicated (High Need)
Cognitive Impairment or Dementia (High Physical or
Engagement)
Simon Polak & Kate Morris June 2011
15
Clustering
• Introduction to clustering booklet
• Once scoring is complete then:
– Use the decision tree to identify class
– Use the cluster shapes / descriptions / diagnoses to match
the cluster
– Reds must match for a cluster match
– Orange would be expected
– Yellow may score
– White unlikely to score
• Review the information in the blue tabs
(description, diagnosis etc).
• Record the result in RiO
Devon Partnership
NHS Trust
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 decision
HoNOS and clustering can be re-completed to reflect new
information and a possible change in cluster.
Devon Partnership
NHS Trust
Simon Polak & Kate Morris June 2011
17
Clustering – linking scores to allocation
• The Clustering Assessment (HoNOS) always
needs to be completed before clustering.
• The Clustering Allocation needs to be linked to
the completed Clustering Assessment.
• This shows that the care cluster allocation was
based on the scores in the Clustering
Assessment completed.
Devon Partnership
NHS Trust
Simon Polak & Kate Morris June 2011
18
The clustering assessment is found
in outcome measures together with
the clustering allocation screen
Devon Partnership
NHS Trust
Simon Polak & Kate Morris June 2011
19
Assessment
date in
here
Devon Partnership
NHS Trust
Search for the
relevant referral
here
Simon Polak & Kate Morris June 2011
20
Devon Partnership
NHS Trust
Simon Polak & Kate Morris June 2011
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Devon Partnership
NHS Trust
Simon Polak & Kate Morris June 2011
22
Link to Clustering
allocation form
Simon Polak & Kate Morris June 2011
Devon Partnership
NHS Trust
23
Date of assessment on
which the clustering is
based
Devon Partnership
NHS Trust
Simon Polak & Kate Morris June 2011
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Devon Partnership
NHS Trust
Simon Polak & Kate Morris June 2011
25
Devon Partnership
NHS Trust
Simon Polak & Kate Morris June 2011
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Devon Partnership
NHS Trust
Simon Polak & Kate Morris June 2011
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Devon Partnership
NHS Trust
Simon Polak & Kate Morris June 2011
28
Useful Information
• The RiO pages of the Intranet have a section
on PbR and can be accessed via the link
below.
• http://nww.devonpartnership.nhs.uk/default.
asp?a=11502&m=0
Devon Partnership
NHS Trust
Simon Polak & Kate Morris June 2011
29
Useful Documents
(Double click to open)
This booklet needs to
be read and available
to anyone undertaking
clustering.
Devon Partnership
NHS Trust
Simon Polak & Kate Morris June 2011
30
Further information?
Contact
Dpn-tr.pbr@nhs.net
Devon Partnership
NHS Trust
Simon Polak & Kate Morris June 2011
31