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8 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.

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The clusters are listed below: 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.Cognitive 19.Cognitive 20.Cognitive 21.Cognitive Impairment Impairment Impairment Impairment (Low Need) or Dementia Complicated (Moderate Need) or Dementia Complicated (High Need) 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

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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: 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.

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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:
CPA Yes No Initial assessment MWA Assessor 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.

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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 Episode of care (wks) 8 12 16 26 52 0 0 0 0 0 0 0 8 8 0 0 0 0 0 0 Ind. Max. Episode of care (wks) 12 15 24 52 156 156 156 156 156 156 156 156 12 12 156 156 156 156 156 156

Cluster

Cluster Description

Cluster Review (wks)

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 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)

8 12 16 26 26 26 52 52 52 52 52 52 4 4 26 26 26 26 26 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

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The care package can then be tailored to the individuals 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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April 11 v0.8 Clustering Flow Chart

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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/documents/digitalasset/dh_112282.pdf Mental Health Care Transitions Booklet http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/ @ps/documents/digitalasset/dh_113541.pdf Integrated Packages Approach to Care http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publication sPolicyAndGuidance/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/documents/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/documents/digitalasset/dh_113541.pdf Payment by Results slide pack http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/ @ps/documents/digitalasset/dh_112969.pdf Payment by Results (section 9) http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/ @ps/documents/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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