1. Devon Partnership NHS Trust Simon Polak Jan 2011 v3 1 Payment by Results Clustering, Care Pathways and Packages Jan 2011

2. Devon Partnership NHS Trust Simon Polak Jan 2011 v3 2 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.

3. Devon Partnership NHS Trust Simon Polak Jan 2011 v3 3 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

4. Devon Partnership NHS Trust Simon Polak Jan 2011 v3 4 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.

5. Devon Partnership NHS Trust Simon Polak Jan 2011 v3 5 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.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).

6. Devon Partnership NHS Trust Simon Polak Jan 2011 v3 6 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.

7. Devon Partnership NHS Trust Simon Polak Jan 2011 v3 7 Referral Assessment MHCT (HoNOS) Cluster Care Package Review 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. 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.

8. Devon Partnership NHS Trust Simon Polak Jan 2011 v3 8 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.

9. Devon Partnership NHS Trust Simon Polak Jan 2011 v3 9 Care Packages Care Cluster n Care Packages Evidenced based Intervention Evidenced based Intervention Staff Member Skills / Knowledge

10. Devon Partnership NHS Trust Simon Polak Jan 2011 v3 10 Care Clusters

11. Devon Partnership NHS Trust Simon Polak Jan 2011 v3 11 Non-Psychotic Mild /Mid / Severe Non-Psychotic Very Severe & Complex Psychotic 1 st Episode Psychotic Ongoing or recurrent Psychotic Crisis Psychotic Very Severe Engagement Organic Cognitive Impairment 1.Common Mental Health Problems (Low Severity) 2.Common Mental Health Problems (Low Severity with greater need) 3.Non Psychotic (Moderate Severity) 4.Non-psychotic (Severe) 5.Non-psychotic Disorders (Very Severe) 6.Non-psychotic Disorder of Over-valued Ideas 7.Enduring Non-psychotic Disorders (High Disability) 8.Non-Psychotic Chaotic and Challenging Disorders 9.Blank Cluster (formally substance misuse) 10.First Episode Psychosis 11.Ongoing Recurrent Psychosis (Low Symptoms) 12.Ongoing or recurrent Psychosis (High Disability) 13.Ongoing or Recurrent Psychosis (High Symptom & Disability) 14.Psychotic Crisis. 15.Severe Psychotic Depression 16.Dual Diagnosis 17.Psychosis and Affective Disorder – Difficult to Engage 18.Cognitive Impairment (Low Need) 19.Cognitive Impairment or Dementia Complicated (Moderate Need) 20.Cognitive Impairment or Dementia Complicated (High Need) 21.Cognitive Impairment or Dementia (High Physical or Engagement)

12. Devon Partnership NHS Trust Simon Polak Jan 2011 v3 12 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.

13. Devon Partnership NHS Trust Simon Polak Jan 2011 v3 13 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.

14. Devon Partnership NHS Trust Simon Polak Jan 2011 v3 14 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.

15. Devon Partnership NHS Trust Simon Polak Jan 2011 v3 15 Mental Health Clustering Tool (based on HoNOS) 1.Agitated behaviour 2.Non-accidental self-injury 3.Problem drinking or drug taking 4.Cognitive problems 5.Physical illness or disability problems 6.Hallucinations or delusions 7.Depressed mood 8.Other mental and behavioural disorders 9.Problems with relationships 10.Problems with activities of daily living 11.Problems with living conditions 12.Problems with occupation and activities 13.Unreasonable beliefs in non-psychotic disorders A.Agitated behaviour / expansive mood B.Repeated self harm C.Safeguarding children or vulnerable adults D.Engagement E.Vulnerability

16. Devon Partnership NHS Trust Simon Polak Jan 2011 v3 16 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.

17. Devon Partnership NHS Trust Simon Polak Jan 2011 v3 17 The clustering tool is found in outcome measures together with the results and recording screen Help will be available by clicking here

18. Devon Partnership NHS Trust Simon Polak Jan 2011 v3 18 HoNOS is scored in the tool with the scores copied across. The additional assessment questions refer to historical rather than present problems. Help will be available by clicking here

19. Devon Partnership NHS Trust Simon Polak Jan 2011 v3 19 The clinician uses this form to allocate the cluster. Although guided by the report the final decision lies with the clinician. Help will be available by clicking here This allocation needs to be linked to the Clustering tool (HoNOS) that was completed following assessment

20. Devon Partnership NHS Trust Simon Polak Jan 2011 v3 20 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.

21. Devon Partnership NHS Trust Simon Polak Jan 2011 v3 21 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.

22. Devon Partnership NHS Trust Simon Polak Jan 2011 v3 22 Care Package indicative length and review periods

23. Devon Partnership NHS Trust Simon Polak Jan 2011 v3 23 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.

24. Devon Partnership NHS Trust Simon Polak Jan 2011 v3 24

25. Devon Partnership NHS Trust Simon Polak Jan 2011 v3 25

26. Devon Partnership NHS Trust Simon Polak Jan 2011 v3 26 Clustercluster Attended Cont acts Duration (hrs) Average contactAverage Time (hrs)Admissions 0Variance17014014.17121 1Non-Psych. Low Severity13140.9310 2Non-Psych. L.Sev greater need24202.1820 3Non-Psych. Moderate Severity1481398.7181 4Non-psychotic (Sev)55435.5040 5Non-psychotic (V Sev)24268.0091 7End Non_psy (H Dis)000.0000 8Non-psychotic (Chaotic & CH)562.5060 9Substance Misuse28253.1130 101st Episode Psychosis15214119.00181 11Ong Rec Psy (L Sym)574828.50240 12Ong Rec Psy (H Dis)747318.50180 14Psychotic Crisis8128.00120 15Sev Psychotic Dep210238210.002381 16Dual Diagnosis242124.00210 17Psy&Aff. Disorder222322.00230 18Cog Impair (L Need)111411.00140 21Cog Impair/Dem (H Phy666.0060

27. Devon Partnership NHS Trust Simon Polak Jan 2011 v3 27 Development Requirements

28. Devon Partnership NHS Trust Simon Polak Jan 2011 v3 28 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

29. Devon Partnership NHS Trust Simon Polak Jan 2011 v3 29 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.

30. Devon Partnership NHS Trust Simon Polak Jan 2011 v3 30 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

31. Devon Partnership NHS Trust Simon Polak Jan 2011 v3 31 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.

32. Devon Partnership NHS Trust Simon Polak Jan 2011 v3 32 Useful Documents (Double click to open) This booklet needs to be read and available to anyone undertaking clustering.

33. Devon Partnership NHS Trust Simon Polak Jan 2011 v3 33 Further information? Contact Dpn-tr.pbr@nhs.net