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Clustering, Care Packages & Pathways
Introduction
The development of the care pathways and packages approach was developed by six Trusts
in North East Yorkshire. This was a clinical project designed to understand how care could be
clustered to improve the quality and reliability of the care people received. They produced a
matrix of 21 care clusters derived empirically from data from the initial clinical model design
which showed the relative agreement between clinicians when using the clustering tool. It
showed that the clustering model and process had face validity, was clinically useful and
could distinguish between groups of people referred to the service based on a comparatively
simple model.
The approach leads to considering the commonalities and differences in care that people
need in the different groups or clusters that they are allocated to. It is clear that although
care and therapies need to be designed with the individual in mind, interventions, therapies
or medications have clear evidence base to meet specific disorders, problems and needs.
Equally as the evidence grows for specific approaches these are chosen as a first line for
many common presentations. These evidence based therapies and treatments can be pulled
together into a care package around the presentation. As such for a cluster of similar
presentations a range of evidenced based treatments or therapies can be pulled together to
form a care package the clinician may initially draw from.
The Clusters
The clusters are outlined below. More details can be found in the clustering booklet. Each
cluster contains a range of indicative or likely diagnoses. However the use of diagnosis alone
is not a way of clustering.
There are 21 clusters arranged in broad headings as described below.
The clusters are listed below:
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Non-Psychotic Mild /Mid / Severe
1.
2.
3.
4.
Common Mental Health Problems (Low Severity)
Common Mental Health Problems (Low Severity with greater need)
Non Psychotic (Moderate Severity)
Non-psychotic (Severe)
Non-Psychotic Very Severe & Complex
5.
6.
7.
8.
9.
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)
Psychotic 1st Episode
10. First Episode Psychosis
Psychotic Ongoing or recurrent
11. Ongoing Recurrent Psychosis (Low Symptoms)
12. Ongoing or recurrent Psychosis (High Disability)
13. Ongoing or Recurrent Psychosis (High Symptom & Disability)
Psychotic Crisis
14. Psychotic Crisis.
15. Severe Psychotic Depression
Psychotic very severe Engagement
16. Dual Diagnosis
17. Psychosis and Affective Disorder – Difficult to Engage
Organic Cognitive Impairment
18.
19.
20.
21.
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)
The Clustering Process
The first task then is to assess the person referred to the service with a view to
understanding them sufficiently to consider their needs and allocate them to a cluster that
suggests a care package.
This involves:
 Completing an initial clinical assessment
 Completing the Clustering Tools
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RiO Clustering process and RiO Clustering tool.
After initial assessment has taken place the clinician needs to:
 Complete the Clustering Tool (HoNOS PbR)
 Allocate the person to a cluster using the Clustering Tool – care cluster allocation
HoNOS PbR
The Clustering tool can be found in the outcome measures folder of the RiO case record. The
tool is a version of HoNOS but also includes questions related to historical as well as current
behaviours. Details for how to score the HoNOS are found in the Mental Health Clustering
booklet.
The following approach should be taken:


The Date/Time should be the date/time the clustering tool was completed.
The Mental Health Clustering Tool Assessment Reason has several options. The
following only should be used:
o Assessment - for use after initial assessment
o First Therapy Session: - for use at the outset of therapeutic / care course
o During Therapy (Review) – at a review point whether a care programme
review of review during therapy or where there is a change of plan.
(As the Trust develop the approach the additional choices may be implemented)
HoNOS PbR Assessment
This consists of 13 questions based on the current two week history and five additional
questions based on historical information. Use the RiO tool in conjunction with the Mental
Health Clustering Booklet (2010/11). The ratings should be completed in accordance with
the guidance but all should be scored between 0 and 4 with a score of 9 used to indicate
that the area is unknown.
Cluster decision
The approach outlined in the Mental Health Clustering booklet should be adopted to identify
the appropriate care cluster.
1. The decision tree should be used to identify the whether the presenting needs are
non-psychotic, psychotic or organic in origin
2. The most appropriate sub-headings should be selected.
3. This will narrow the choice of clusters which should be selected through the match
of HoNOS reporting and the cluster descriptions in the clustering handbook.
Allocation to a Cluster
Allocation to a cluster is achieved using the MH Clustering Tool – Care Cluster Allocation.
After creating a new a new form clustering is completed using the options available.
The following approach should be taken:
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



The Date/Time should be the date/time the assessment tool was completed.
The Associated Mental Health Clustering Tool needs to be selected. The relevant
clustering tool is denoted by the date and time that it was completed – remember
over time there will be several.
The Care Cluster Identification Date needs to be completed to show when the care
cluster was identified. This may be at a date after the assessment including post
discussion or supervision.
The Care Cluster is then selected from the menu. Cluster 1 – 21 should be chosen at
this point based on clinical judgement and the support tools. If the presenting needs
does not lead to any clear cluster then select ‘- None – ‘. This is equivalent to ‘Care
Cluster 0 – variance’ which indicates that the person is not adequately described by
any of the cluster descriptions.
For more information about clustering see the Mental Health Clustering Booklet (2010/11)
[link below].
Changing or updating the cluster
This may occur at the First Therapy session or review of care. A new Mental Health
Clustering Tool (HoNOS) should be completed. The outcome of the tool should be reviewed
in the Mental Health Clustering Tool Overview Report. Where this leads to the clinician
considering that the Cluster needs to be changed then this is recorded in the MH Clustering
Tool – Care Cluster Allocation screen.
Edit the current form with the following approach:



Enter the care cluster end date – the date upon which the current cluster ends.
Enter the reason for the change of cluster – with error or change in cluster.
To enter the new cluster, create a new allocation form.
A flow chart is available on the website.
Staff required to Cluster
This is clearly the responsibility of qualified staff designated to make assessments and
develop the care plan. The initial clustering is completed at the point of initial assessment
following referral to DPT services. Therefore virtually all initial clustering will initially take
place in Mental Wellbeing and Access services.
However for many people a clearer picture emerges at the point of engagement in a care /
treatment course where new problems or issues may arise which puts the initial clustering in
doubt. So people will also be clustered at the point of the beginning of an episode of care /
treatment.
Finally after a period of care people will need to be reviewed which will include a new
Mental Health Cluster Tool (HoNOS) being completed. This may give rise to a new cluster
being identified and recorded.
This is summarised below:
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CPA
Initial
assessment
Yes
MWA Assessor
No
MWA Assessor
1st Session
Recovery
Coordinator /
Psychiatrist
Recovery
Coordinator
Review
Recovery
Coordinator
Recovery
Coordinator
Note: A recovery coordinator is defined as a qualified clinician who holds a caseload or may
be responsible for coordinating care from others than themselves. The psychologist or
psychiatrist acts as the recovery coordinator for people seen in psychological therapies or by
medical staff who do not have interventions offered by MWA, RIL or OPMH CRHT.
The role of the Recovery Coordinator
Many people will be involved in several services simultaneously. The Recovery Coordinator
will remain the individual responsible for the care pathway dictated by the clustering. Others
involved in care recognising the need to revise the clustering should liaise with the Recovery
to review the care and clustering through the use of the Clustering tool.
The Recovery Coordinator will need to:




Agree the package to be delivered
Monitor the delivery of the care package
Undertake a review process
Manage the transition between clusters and care packages using the Care Transition
Protocol.
Care Transitions
The Mental Health Clustering Tool needs to be repeated at significant review points where
ever they occur but at a maximum time as indicated in the table below. At these points the
process may indicate that the persons needs no longer fit the current allocated cluster and
care package.
The clinician will need to consider whether the person should move to a new cluster based
on the MHCT process and transition protocols in the Care Transition Protocol Booklet
(2010/11). If this leads to a change in cluster this should be achieved using the process
outlined above.
For more information see the Care Transition Protocol Booklet [link below].
Indicative episode lengths and review periods are outlined in the table below:
Cluster
1
2
3
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Cluster Description
Common mental health problems (low
severity)
Common mental health problems
Non-Psychotic (Moderate Severity)
5
Ind. Min
Episode
of care
(wks)
Ind. Max.
Episode
of care
(wks)
Cluster
Review
(wks)
8
12
16
12
15
24
8
12
16
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4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
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)
26
52
0
52
156
156
26
26
26
0
156
52
0
156
52
0
156
52
0
156
52
0
156
52
0
8
8
0
156
12
12
156
52
4
4
26
0
0
156
156
26
26
0
156
26
0
156
26
0
156
26
Care Pathways and Packages
The clustering approach to needs assessment gives rise to the development of pathways and
care packages that deliver care designed to meet the needs of those in the cluster. These
should be evidenced based, delivered by appropriately skilled workers in a time bound
fashion.
The care package will broadly dictate:



The therapeutic intervention whether health or social care
The time required for the delivery of the intervention
The staff inputs to deliver the intervention including knowledge / skill requirements
The care package can then be tailored to the individual’s needs and circumstances to ensure
they receive an individualised care package.
The packages will be developed and be continually updated to reflect new evidence.
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Clustering Flow Chart
Clustering Process
(Payment by Results)
Person will initially come
through MWA.
Referral to
services
Assessor could
be any qualified
worker.
Version 2
Mental Health Clustering Tool completed (HoNOS)
Date/Time should be the date/time the clustering tool was
completed.
The Mental Health Clustering Tool Assessment Reason has
several options. The following only should be used:





Clinical
Assessment
Author: Simon Polak,
Date: 5/12/11
Reviewers:
Date:
Assessment - for use after initial assessment
First Therapy Session: - for use at the outset of
therapeutic / care course
Mental Health
Clustering Tool
completed
During Therapy (Review) – at a review point
whether a care programme review of review during
therapy or where there is a change of plan.
The clinician will review the decision tree to
highlight the likely cluster.
The clinician will review the match in the
clustering handbook. This is for guidance to the
clinical decision.
Create a new MH Clustering Tool – Care Cluster
Allocation form.
The following approach should be taken:
 The Date/Time should be the date/time the
assessment tool was completed.
 The Associated Mental Health Clustering Tool needs to
be selected. The relevant clustering tool is denoted by
the date and time that it was completed – remember
over time there will be several.
 The Care Cluster identification Date needs to be
completed to show when the care cluster was identified.
This may be at a date after the assessment including
post discussion or supervision.
 The Care Cluster is then selected from the menu.
Cluster 1 – 21 should be chosen at this point based on
clinical judgement and the support tools. If the
presenting needs does not lead to any clear cluster then
select ‘- None – ‘. This is equivalent to ‘Care Cluster 0 –
variance’ which indicates that the person is not
adequately described by any of the cluster descriptions.
Consideration of
Cluster
Record the Cluster
Decision on a new
Care Cluster
Allocation Form
Care Package
(Clinical Care)
Edit current
Cluster Allocation
The MH Clustering Tool –
Care Allocation should be
edited to show the end of the
cluster and end reason.
 Enter the care cluster end
date – the date upon which the
current cluster ends.
 Enter the reason for the
change of cluster – with error
or change in cluster.
Clinical Review
(inc. 1st session)
Clinical review needs to be
undertaken when required or
not longer than indicated in
the Care Transition protocol.
Discharge or
re-cluster
Re-Cluster
Key
Discharge
Clinical process
RiO Process
Discharge
Care delivery
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12. Discharge
from the service
date.
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Further information.
Clustering
Mental Health Clustering Booklet
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/docume
nts/digitalasset/dh_112282.pdf
Mental Health Care Transitions Booklet
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/docume
nts/digitalasset/dh_113541.pdf
Integrated Packages Approach to Care
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuid
ance/DH_086534
Mental Health Payment by Results
A simple guide to payment by results
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/docume
nts/digitalasset/dh_120254.pdf
Practical guide to preparing for mental health payment by results
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/docume
nts/digitalasset/dh_113541.pdf
Payment by Results slide pack
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/docume
nts/digitalasset/dh_112969.pdf
Payment by Results (section 9)
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/docume
nts/digitalasset/dh_112970.pdf
What is the payment by results project?
http://www.rcpsych.ac.uk/members/currentissues/ifqo/qa/qa-8.aspx
HoNOS
Health of The Nation Outcome Scores (HoNOS) Training
http://www.rcpsych.ac.uk/quality/honos.aspx
FAQs (HoNOS)
http://www.rcpsych.ac.uk/quality/honos/generalinformation/faq.aspx
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