Care Pathways and Packages (Overview and history) Jon Painter Programme Director Northumberland Tyne and Wear NHS FT

Main elements of the CPP Model Individual patient needs Anxiety / Relationships / Hallucinations / Living conditions etc. Individual patient needs Anxiety / Relationships / Hallucinations / Living conditions etc. Mental Health Clustering Tool Standardised summary of individual needs Mental Health Clustering Tool Standardised summary of individual needs Cluster Global description of combination & severity of individual needs Cluster Global description of combination & severity of individual needs Care Packages Individually negotiated care plan informed by NICE Guidance Care Packages Individually negotiated care plan informed by NICE Guidance Quality and Outcome Metrics Triangulated measurement of process and effect Quality and Outcome Metrics Triangulated measurement of process and effect Local/national Tariff Derived from joint understanding of accurate costs Local/national Tariff Derived from joint understanding of accurate costs

Starting point Managers, psychiatrists, nurses, social workers, OTs, psychologists Acute inpatient services, community MH Teams & rehabilitation services Different parts of the service using different concepts to describe their casemix (functioning, risk, etc.) Often more reflective of service / service response than the patient (inpatient/outpatient, low/medium security) Clinicians recognised that patients weren’t getting what they needed, they got the best of what was available (idiosyncratic referral pathways and care packages)

Participatory action research questions: What information do professionals use to decide on care package to be offered? Is it possible to develop a shared language based on patient need? Is it possible to develop simple care packages to meet needs?

Needs identified as important to care planning: 1Overactive, aggressive, disruptive or agitated behaviour 2Non-accidental-self injury 3Problem drinking or drug taking 4Cognitive problems 5Physical illness or disability problems 6Problems associated with hallucinations and delusions 7Problems with depressed mood 8Other mental and behavioural problems 9Problems with relationships 10Problems with activities of daily living 11Problems with living conditions 12Problems with occupation and activities 13Strong unreasonable beliefs occurring in non-psychotic disorders only AAgitated behaviour / expansive mood BRepeat self-harm CSafeguarding children & vulnerable dependant adults DEngagement EVulnerability Mental Health Clustering Tool Standardised summary of individual needs Mental Health Clustering Tool Standardised summary of individual needs

Cluster analysis (example) A diagram summarising how cases group together at different levels of distance (distance is standardised onto a new scale) Used to identify the number of clusters to define in the 2nd stage of cluster analysis

Cluster Global description of combination & severity of individual needs Cluster Global description of combination & severity of individual needs MHCT Scales Score

Validation - clinical homogeneity Case presentations Score profiles Treatment aims Interventions Concurrent clinical data – CPA status – Diagnosis – Medication – Gender – MHA status – Time known to services Cluster Global description of combination & severity of individual needs Cluster Global description of combination & severity of individual needs

Initial results 13 statistically derived groups with good clinical face validity Balance between membership criteria and coverage 85% of patients allocated, remainder were not a homogeneous group but variations on existing clusters Cluster Global description of combination & severity of individual needs Cluster Global description of combination & severity of individual needs

Subsequent cluster developments: Disaggregation of low-end non-psychotic cluster Disaggregation of stable psychosis cluster Addition of organic clusters Removal of substance misuse cluster Refinements to some score profiles Improved coverage (90-95%) Cluster Global description of combination & severity of individual needs Cluster Global description of combination & severity of individual needs

Making profiles clinically useable (The mean is only half the story)

Relatively straightforward presentations, clusters progress primarily according to symptom severity Clusters progress primarily according to complexity Cluster dictated by virtue of first episode rather than symptom severity Clusters increase in terms of symptom severity & level of secondary disability Acuity Common features: complexity, chaos & engagement, distinguished by level of substance misuse Stage of dementia, level of cognitive impairment and frailty Cluster Global description of combination & severity of individual needs Cluster Global description of combination & severity of individual needs

Content of care packages should reflect NICE Guidance etc. BUT must also reflect local position (historic investment, previous organisational approaches to care pathways etc.) Must allow for innovation rather than locking in any particular practice As a result exact content and format will vary Any approach must provide clarity to all stakeholders (Patients, carers, staff, commissioners). Care Packages Individually negotiated care plan informed by NICE Care Packages Individually negotiated care plan informed by NICE

Care Packages Individually negotiated, NICE-informed care plan Care Packages Individually negotiated, NICE-informed care plan Initial cluster-specific expectation of care Refined by condition/diagnosis, evidence, guidance etc Final negotiations according to availability & patient choice

Quality and Outcome Metrics Triangulated measurement of process and effect Quality and Outcome Metrics Triangulated measurement of process and effect Payment for assumed quality Payment for demonstrable quality

Quality and Outcome Metrics Triangulated measurement of process and effect Quality and Outcome Metrics Triangulated measurement of process and effect Key: MHMDS: Mental Health Minimum Data Set MHCT: Mental Health Clustering Tool PREMS: Patient Reported Experience Measures PROMS: Patient Reported Outcome Measures CROMS: Clinician Reported Outcome Measures