Payment by Results
Clustering, Care Pathways
and Packages
Jan 2011
Devon Partnership
NHS Trust
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Introduction and Background
Mental health PbR is now coming as a radical
change to funding mental health care.
Based on empirical work it is used to aid the
funding of care packages based on clustering
peoples’ needs.
Devon Partnership
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What is PbR?
• Introduced into acute sector 2003/4
• Price X activity = income
– e.g. £1000 X 10 hip replacements = £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
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Clustering & Care Packages Approach
• Care Pathways and Packages approach was
developed by 6 Trusts in the North East and
Yorkshire
• 21 Care Clusters were empirically 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.
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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
– • 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
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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 supported by the Mental Health Clustering
Tool (MHCT) in RiO.
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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 the a care package
individualised to the persons
specific needs.
This will be reviewed which
may lead to a change of cluster
and care package.
Assessment
MHCT
(HoNOS)
Cluster
Care
Package
Review
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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 tool simplifies the process for staff to cluster and
capture 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 dictate:
–
–
–
–
The therapeutic intervention
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.
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Care Packages
Care Cluster n
Care Packages
Evidenced
based
Intervention
Staff Member
Skills / Knowledge
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Care Clusters
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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)
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Clustering & Care Packages
Staff responsibilities
All trained staff will have a role in clustering at
some point in the persons involvement with DPT.
Some staff will have a great deal of their work
focussed on assessment and clustering.
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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
• 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
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RiO & Clustering
• RiO includes a three step process to aid
clustering and recording.
• The tool is:
– Mental Health Clustering tool (MHCT) provides for
the HoNOS (working age adults) recording
– The Mental Health Clustering tool – Care Cluster
Allocation form records the clustering decision.
– This is supported by an overview report that gives
a % indication of match to care cluster but leaves
the judgement to the clinician.
Devon Partnership
NHS Trust
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Mental Health Clustering Tool
(based on HoNOS)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Agitated behaviour
Non-accidental self-injury
Problem drinking or drug taking
Cognitive problems
Physical illness or disability problems
Hallucinations or delusions
Depressed mood
Other mental and behavioural disorders
Problems with relationships
Problems with activities of daily living
Problems with living conditions
Problems with occupation and activities
Unreasonable beliefs in non-psychotic disorders
A.
B.
C.
D.
E.
Agitated behaviour / expansive mood
Repeated self harm
Safeguarding children or vulnerable adults
Engagement
Vulnerability
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NHS Trust
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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.
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Help will be available by
clicking here
The clustering tool is found in
outcome measures together with
the results and recording screen
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Help will be available by
clicking here
HoNOS is scored in the tool with the
scores copied across. The additional
assessment questions refer to
historical rather than present
Devon
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problems.
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Help will be available by
clicking here
This allocation needs to
be linked to the
Clustering tool (HoNOS)
that was completed
following assessment
The clinician uses this form to
allocate the cluster. Although
guided by the report the final
decision lies with the clinician.
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NHS Trust
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Care Packages
Staff Responsibilities
The Care packages will be designed to respond the clustered need.
They will be based on evidence and tailored to the individual.
These will then need to be reviewed for progress and to consider
any change to cluster. The review period differs for each cluster.
Devon Partnership
NHS Trust
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Care Packages & the role of the
recovery coordinator
• The Care packages will be developed by the
Directorates in relation to clusters
• The Recovery coordinator will need to:
– agree the care package to be delivered and
monitor its delivery.
– undertake the review process.
– manage movement between clusters (step up or
down) using the Care Transition Protocol.
Devon Partnership
NHS Trust
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Care Package indicative length and
review periods
Cluster
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
Cluster Description
Common mental health problems (low severity)
Common mental health problems
Non-Psychotic (Moderate Severity)
Non-Psychotic (Severe)
Non-Psychotic (Very Severe)
Non-Psychotic Disorders of over valued ideas
Enduring Non-Psychotic Disorders (High Disability)
Non-Psychotic Chaotic and Challenging Disorders
Blank Cluster
First Episode in Psychosis
Ongoing Recurrent Psychosis (Low Symptoms)
Ongoing or Recurrent Psychosis (High Disability)
Ongoing or Recurrent Psychosis (High Symptoms and Disability)
Psychotic Crisis
Severe Psychotic Depression
Dual Diagnosis
Psychosis and Affective Disorder Difficult to Engage
Cognitive Impairment (Low need)
Cogntive Impairment or Dementia Complicated (Moderate need)
Cognitive Impairment or Dementia Complicated (High need)
Cognitive Impairmentor Dementia (High Physical or engagement needs)
Devon Partnership
NHS Trust
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Ind.
Ind. Min Max.
Episode Episode Cluster
of care of care Review
(wks)
(wks)
(wks)
8
12
8
12
15
12
16
24
16
26
52
26
52
156
26
0
156
26
0
156
52
0
156
52
0
0
0
0
8
8
0
0
0
0
0
0
156
156
156
156
12
12
156
156
156
156
156
156
52
52
52
52
4
4
26
26
26
26
26
26
22
North Devon Pilot
• A small pilot was run with epex to cluster and
collect information
• The WBA staff were prepared through two,
half day workshops based on use of HoNOS
and clustering to develop rating reliability.
• They clustered 99 patients seen for the first
time in the service.
• Staff valued the workshop experience.
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NHS Trust
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Non-Psych. Low Severity
Non-Psych. L.Sev greater need
Non-Psych. Moderate Severity
Non-psychotic (Sev)
Non-psychotic (V Sev)
End Non_psy (H Dis)
Non-psychotic (Chaotic & CH)
Substance Misuse
1st Episode Psychosis
Ong Rec Psy (L Sym)
Ong Rec Psy (H Dis)
Psychotic Crisis
Sev Psychotic Dep
Dual Diagnosis
Psy&Aff. Disorder
Cog Impair (L Need)
Cog Impair/Dem (H Phy
0
Variance
No.
Attendance by Cluster
250
200
150
Attended Contacts
Duration (hrs)
100
50
0
1
2
3
4
5
7
8
9
10
11
12
14
15
16
17
18
21
Cluster
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NHS Trust
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Non-Psych. Low Severity
0.00
Variance
0
1
Non-Psych. Moderate Severity
Non-psychotic (Sev)
Non-psychotic (V Sev)
End Non_psy (H Dis)
Non-psychotic (Chaotic & CH)
Substance Misuse
1st Episode Psychosis
Ong Rec Psy (L Sym)
Ong Rec Psy (H Dis)
Psychotic Crisis
Sev Psychotic Dep
Dual Diagnosis
Psy&Aff. Disorder
Cog Impair (L Need)
Cog Impair/Dem (H Phy
0.93
Non-Psych. L.Sev greater need
No.
Average Attendance by Cluster
250.00
200.00
210.00
150.00
Average contact
Average Time (hrs)
100.00
50.00
14.17
2.18
Devon Partnership
NHS Trust
8.71
5.50
8.00
19.00
2.50
28.50
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18.50
3.11
8.00
24.00 22.00
11.00 6.00
2
3
4
5
7
8
9
10
11
12
14
15
16
17
18
21
Cluster
25
Cluster
cluster
Attended
Cont
acts
Duration
(hrs)
Average contact
Average Time (hrs)
Admissions
0
Variance
170
140
14.17
12
1
1
Non-Psych. Low Severity
13
14
0.93
1
0
2
Non-Psych. L.Sev greater need
24
20
2.18
2
0
3
Non-Psych. Moderate Severity
148
139
8.71
8
1
4
Non-psychotic (Sev)
55
43
5.50
4
0
5
Non-psychotic (V Sev)
24
26
8.00
9
1
7
End Non_psy (H Dis)
0
0
0.00
0
0
8
Non-psychotic (Chaotic & CH)
5
6
2.50
6
0
9
Substance Misuse
28
25
3.11
3
0
10
1st Episode Psychosis
152
141
19.00
18
1
11
Ong Rec Psy (L Sym)
57
48
28.50
24
0
12
Ong Rec Psy (H Dis)
74
73
18.50
18
0
14
Psychotic Crisis
8
12
8.00
12
0
15
Sev Psychotic Dep
210
238
210.00
238
1
16
Dual Diagnosis
24
21
24.00
21
0
17
Psy&Aff. Disorder
22
23
22.00
23
0
18
Cog Impair (L Need)
11
14
11.00
14
0
21
Cog Impair/Dem (H Phy
6
6
6.00
6
0
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NHS Trust
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Development Requirements
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Key Activities
1. Use the clustering tool in RiO to begin to derive clusters for all
those in the service
– Role out assessment training to all staff (in CQC / RiO training)
– All reviews / clusters will be completed
– Specific training will need to take place for some staff groups.
2. Care pathways and packages - to develop evidenced based
Care Packages in response.
3. Develop workforce capacity to meet the care packages.
4. Implementation of Clustering / Care Package Approach to
care
5. Information collection and analysis
6. Commissioning & contracting
7. Costing
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Clustering Training
• Training workshops are taking place between
March 2011 and August 2011 to offer training
to all staff involved in clustering.
• This will initially cover all Mental Wellbeing
and Access teams for all new referrals
• And rolled out to all Recovery and
Independent Living teams and specialist
services to cluster the current caseloads.
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NHS Trust
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Care Quality Development Programme
• The programme includes raising awareness of
staff in clustering using the RiO tool.
• The programme in 2011 is:
–
–
–
–
North Devon
Forensic
Exeter, Mid & East
South Devon
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NHS Trust
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Developing Workforce capacity
• This is clearly a long term aim for the Trust
• The workforce group will need to complete a
Training needs analysis against the Care
Packages
• Develop / recruit appropriate staff
• Effect current training SLAs.
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Useful Documents
(Double click to open)
This booklet needs to
be read and available
to anyone undertaking
clustering.
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NHS Trust
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Further information?
Contact
Dpn-tr.pbr@nhs.net
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