Introducing Clustering and Care Packages

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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.     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)

Non-Psychotic Very Severe & Complex

    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)

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.    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)

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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                      Initial
    CPA            assessment            1st Session              Review
                                          Recovery
                                         Coordinator /           Recovery
    Yes          MWA Assessor            Psychiatrist           Coordinator
                                          Recovery               Recovery
     No          MWA Assessor            Coordinator            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:


                                                             Ind. Min   Ind. Max.
                                                                                     Cluster
                                                             Episode     Episode
 Cluster                  Cluster Description                                        Review
                                                              of care    of care
                                                                                      (wks)
                                                               (wks)      (wks)

              Common mental health problems (low
    1         severity)                                          8            12         8
    2         Common mental health problems                     12            15        12
    3         Non-Psychotic (Moderate Severity)                 16            24        16


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    4         Non-Psychotic (Severe)                               26          52          26
    5         Non-Psychotic (Very Severe)                          52         156          26
    6         Non-Psychotic Disorders of over valued ideas          0         156          26
              Enduring Non-Psychotic Disorders (High
    7         Disability)                                          0          156          52
              Non-Psychotic Chaotic and Challenging
     8        Disorders                                            0          156          52
     9        Blank Cluster
    10        First Episode in Psychosis                           0          156          52
              Ongoing Recurrent Psychosis (Low
    11        Symptoms)                                            0          156          52
              Ongoing or Recurrent Psychosis (High
    12        Disability)                                          0          156          52
              Ongoing or Recurrent Psychosis (High
    13        Symptoms and Disability)                             0          156          52
    14        Psychotic Crisis                                     8           12           4
    15        Severe Psychotic Depression                          8           12           4
    16        Dual Diagnosis                                       0          156          26
              Psychosis and Affective Disorder Difficult to
    17        Engage                                               0          156          26
    18        Cognitive Impairment (Low need)                      0          156          26
              Cogntive Impairment or Dementia
    19        Complicated (Moderate need)                          0          156          26
              Cognitive Impairment or Dementia
    20        Complicated (High need)                              0          156          26
              Cognitive Impairmentor Dementia (High
    21        Physical or engagement needs)                        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 3
 Mental Health Clustering Tool completed (HoNOS)                              Clinical
 Date/Time should be the date/time the clustering tool was                                                                  Author: Simon Polak,
                                                                            Assessment
 completed.                                                                                                                 Date: 19/4/11
 The Mental Health Clustering Tool Assessment Reason has
 several options. The following only should be used:                                                                        Reviewers:
                                                                                                                            Date:

       At referral - for use after initial assessment
       Planned Formal Review (CPA)                                       Mental Health
       During Therapy (Review) – at a review point or                    Clustering Tool
                                                                            completed
        change of plan / presentation at the discretion of the
        practitioner.




       The clinician will review the decision tree to
        highlight the likely cluster.
       The clinician will review the match in the                        Consideration of
        clustering handbook. This is for guidance to the                     Cluster
        clinical decision.



      Create a new MH Clustering Tool – Care Cluster
                       Allocation form.
                                                                       Record the Cluster
     The following approach should be taken:
                                                                       Decision on a new
                                                                         Care Cluster
      The Date/Time should be the date/time the
                                                                        Allocation Form
     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.
                                                                           Care Package                                 The MH Clustering Tool –
     This may be at a date after the assessment including
                                                                           (Clinical Care)                              Care Allocation should be
     post discussion or supervision.
      The Care Cluster is then selected from the menu.                                                                edited to show the end of the
     Cluster 1 – 21 should be chosen at this point based on                                                               cluster and end reason.
     clinical judgement and the support tools. If the                                                                   Enter the care cluster end
     presenting needs does not lead to any clear cluster then                                                          date – the date upon which the
     select ‘- None – ‘. This is equivalent to ‘Care Cluster 0 –                                                       current cluster ends.
     variance’ which indicates that the person is not                                                                   Enter the reason for the
     adequately described by any of the cluster descriptions.                                                          change of cluster – with error
                                                                                                  Edit current         or change in cluster.
                                                                                               Cluster Allocation
                                Clinical review needs to be                Clinical Review
                               undertaken when required or                (inc. 1st session)
                                not longer than indicated in
                               the Care Transition protocol.




                                                                           Discharge or
                                                                                                  Re-Cluster
                                                                            re-cluster


           Key
                                                                             Discharge
                     Clinical process


                        RiO Process                                                                        12. Discharge
                                                                             Discharge                   from the service
                                                                                                               date.
                        Care delivery




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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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