CPPP
Care Pathways and Packages Project
Developing currencies for mental health payment by results
Forensic Mental Health, Learning
Disability and ASD Pilot
Train the Trainer Workshop
Mick James
Jon Painter
Tracy Whitelock
Dewi Williams
CPPP
Care Pathways and Packages Project
Developing currencies for mental health payment by results
Agenda
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09.30
10.00
10.10
11.00
11.15
11:45
12.30
13.15
13.50
14.20
15:00
15.15
15.30
15.45
Registration + refreshments
Introductions
MHCT scales
Morning Refreshments
Draft additional forensic and LD scales
Group Work – Using the scales in practice
LUNCH
Cluster allocation
Draft forensic additional clusters and forensic pathways
Group Work - Cluster allocation
Afternoon Refreshments
Transitions
Next steps – analysis and plans
Finish/feedback
CPPP
Care Pathways and Packages Project
Aims
Developing currencies for mental health payment by results
• 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.
CPPP
Care Pathways and Packages Project
Developing currencies for mental health payment by results
Ideal Clusters
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CPPP
Care Pathways and Packages Project
Developing currencies for mental health payment by results
Clustering of non-forensic population
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CPPP
Care Pathways and Packages Project
Developing currencies for mental health payment by results
Extending the scope of clusters
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CPPP
Care Pathways and Packages Project
Developing currencies for mental health payment by results
Combining clusters and pathways
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CPPP
Care Pathways and Packages Project
Developing currencies for mental health payment by results
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. 8
© Royal College of Psychiatrists
CPPP
Care Pathways and Packages Project
Developing currencies for mental health payment by results
The Forensic MH, LD and ASD Pilot tool is…..
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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.
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© Royal College of Psychiatrists
CPPP
What does the Tool provide?
Care Pathways and Packages Project
Developing currencies for mental health payment by results
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’
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© Royal College of Psychiatrists
CPPP
Care Pathways and Packages Project
Using the tool
Developing currencies for mental health payment by results
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The tool itself is not a clinical assessment but a clinical assessment is a prerequisite for rating the tool
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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
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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
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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.
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© Royal College of Psychiatrists
CPPP
Care Pathways and Packages Project
Some Cautions!
Developing currencies for mental health payment by results
• 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.
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© Royal College of Psychiatrists
CPPP
The Scale Structure
Care Pathways and Packages Project
Developing currencies for mental health payment by results
Each scale uses the same 5-point severity scales (0-4)
0 - no problem
1 = 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)
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The glossary provides further information on each SCALE and examples of each
point in the severity scale.
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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.
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CPPP
Care Pathways and Packages Project
Scoring
Developing currencies for mental health payment by results
• 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).
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© Royal College of Psychiatrists
CPPP
Points of Assessment
Care Pathways and Packages Project
Developing currencies for mental health payment by results
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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.
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Clustering is not required at discharge from Trust services since no care package will
be provided, but clinical outcome measurement is required at discharge.
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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.
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© Royal College of Psychiatrists
CPPP
General Guidelines
Care Pathways and Packages Project
Developing currencies for mental health payment by results
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There is no absolutely ‘correct’ rating.
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Rating is the clinical judgement of the rater.
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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.
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For the current scales, each mental health/social problem is rated only once.
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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.
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For the Part 1 scales, do not include information rated in an earlier scale except for
scale 10 which is an overall rating.
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Rate the most severe problem that occurred during the period – both current and
historical.
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© Royal College of Psychiatrists
CPPP
Care Pathways and Packages Project
The tool is not…..
Developing currencies for mental health payment by results
• 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.
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© Royal College of Psychiatrists
CPPP
Care Pathways and Packages Project
Features of the tool
Developing currencies for mental health payment by results
• 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).
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© Royal College of Psychiatrists
CPPP
Care Pathways and Packages Project
How do I cluster someone?
Developing currencies for mental health payment by results
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.
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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.
© Royal College of Psychiatrists
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CPPP
Care Pathways and Packages Project
Developing currencies for mental health payment by results
CPPP
Care Pathways and Packages Project
How do I cluster someone?
Developing currencies for mental health payment by results
• 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.
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© Royal College of Psychiatrists
CPPP
Care Pathways and Packages Project
How do I cluster someone?
Developing currencies for mental health payment by results
• 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.
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© Royal College of Psychiatrists
CPPP When should I cluster someone?
Care Pathways and Packages Project
Developing currencies for mental health payment by results
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:
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The end of the initial assessment (typically within 2 contacts).
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All planned CPA or other formal care reviews.
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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.
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CPPP
Care Transition Protocols
Care Pathways and Packages Project
Developing currencies for mental health payment by results
• 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
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© Royal College of Psychiatrists
CPPP
Care Transition Protocols
Care Pathways and Packages Project
Developing currencies for mental health payment by results
• 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:
© Royal College of Psychiatrists
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CPPP
Care Transition Protocols
Care Pathways and Packages Project
Developing currencies for mental health payment by results
• 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.
© Royal College of Psychiatrists
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CPPP
Care Pathways and Packages Project
Care Transition Protocols
Developing currencies for mental health payment by results
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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.
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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.
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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.
© Royal College of Psychiatrists
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