Care Pathways and Packages
(Overview and history)
Jon Painter
Programme Director
Northumberland Tyne and Wear NHS FT
Main elements of the CPP Model
Individual patient needs
Anxiety / Relationships / Hallucinations / Living conditions etc.
Mental Health Clustering Tool
Standardised summary of individual needs
Cluster
Global description of combination & severity of individual needs
Care Packages
Individually negotiated care plan informed by NICE Guidance
Quality and Outcome Metrics
Triangulated measurement of process and effect
Local/national Tariff
Derived from joint understanding of accurate costs
Starting point
• Managers, psychiatrists, nurses, social workers, OTs, psychologists
• Acute inpatient services, community MH Teams & rehabilitation
services
• Different parts of the service using different concepts to describe
their casemix (functioning, risk, etc.)
• Often more reflective of service / service response than the
patient (inpatient/outpatient, low/medium security)
• Clinicians recognised that patients weren’t getting what they
needed, they got the best of what was available (idiosyncratic
referral pathways and care packages)
Participatory action research questions:
• What information do professionals use to decide on
care package to be offered?
• Is it possible to develop a shared language based on
patient need?
• Is it possible to develop simple care packages to
meet needs?
MentalasHealth
Clustering
Tool planning:
Needs identified
important
to care
Standardised summary of individual needs
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 and behavioural problems
9
Problems with relationships
10
Problems with activities of daily living
11
Problems with living conditions
12
Problems with occupation and activities
13
Strong unreasonable beliefs occurring in non-psychotic disorders only
A
Agitated behaviour / expansive mood
B
Repeat self-harm
C
Safeguarding children & vulnerable dependant adults
D
Engagement
E
Vulnerability
Cluster analysis (example)
A diagram summarising how
cases group together at
different levels of distance
(distance is standardised onto
a new scale)
Used to identify the number
of clusters to define in the 2nd
stage of cluster analysis
Cluster
Score
Global description of combination & severity of individual needs
MHCT Scales
Cluster
Global description of combination & severity of individual needs
Validation - clinical homogeneity
•
•
•
•
•
Case presentations
Score profiles
Treatment aims
Interventions
Concurrent clinical data
–
–
–
–
–
–
CPA status
Diagnosis
Medication
Gender
MHA status
Time known to services
Cluster
Global description of combination & severity of individual needs
Initial results
• 13 statistically derived groups with good
clinical face validity
• Balance between membership criteria and
coverage
• 85% of patients allocated, remainder were not
a homogeneous group but variations on
existing clusters
Cluster
Global description of combination & severity of individual needs
Subsequent cluster developments:
• Disaggregation of low-end non-psychotic
cluster
• Disaggregation of stable psychosis cluster
• Addition of organic clusters
• Removal of substance misuse cluster
• Refinements to some score profiles
• Improved coverage (90-95%)
Making profiles clinically useable
(The mean is only half the story)
Cluster
Global description of combination & severity of individual needs
Relatively
straightforward
presentations,
clusters progress
primarily according
to symptom
severity
Clusters
progress
primarily
according to
complexity
Cluster dictated
by virtue of first
episode rather
than symptom
severity
Clusters
increase in
terms of
symptom
severity & level
of secondary
disability
Acuity
Common
features:
complexity, chaos
& engagement,
distinguished by
level of substance
misuse
Stage of
dementia, level
of cognitive
impairment
and frailty
Care Packages
Individually negotiated care plan informed by NICE
• Content of care packages should reflect NICE
Guidance etc.
• BUT must also reflect local position (historic
investment, previous organisational approaches to
care pathways etc.)
• Must allow for innovation rather than locking in any
particular practice
• As a result exact content and format will vary
• Any approach must provide clarity to all stakeholders
(Patients, carers, staff, commissioners).
Care Packages
Individually negotiated, NICE-informed care plan
Initial cluster-specific expectation of care
Refined by
condition/diagnosis,
evidence, guidance etc
Final
negotiations
according to
availability
& patient
choice
Quality and Outcome Metrics
Triangulated measurement of process and effect
Payment for
demonstrable
quality
Payment for
assumed quality
Quality and Outcome Metrics
Triangulated measurement of process and effect
Type of Q&O Measures
PROMS
PREMS
CROMS
Key:
MHMDS: Mental Health Minimum Data Set
MHCT: Mental Health Clustering Tool
PREMS: Patient Reported Experience Measures
PROMS: Patient Reported Outcome Measures
CROMS: Clinician Reported Outcome Measures
Source of Q&O Measures
Locally
generated
metrics
and data
set
MHCT &
Cluster
metrics
MHMDS
Metrics