1. 15 th November 2013 Steve Byng- PbR Implementation Lead DWMH Trust- Facilitator of Regional Quality and Outcome Group Mike Jones- Project Manager, South Staffordshire and Shropshire NHS Foundation Trust 1

2. 2 Aims of Presentation Update on current position of the Quality and Outcome Agenda Role of the Regional Quality and Outcome Group What are Quality and Outcome Measures? 14/15 Guidance – Next Steps

3. 3 Regional Quality and Outcome Group Sub Group of Regional PbR Steering Group Attended by regional Trusts:- Dudley Walsall Mental Health Partnership NHS Trust North Staffordshire Combined Healthcare NHS Trust South Staffordshire and Shropshire NHS Foundation Trust Birmingham Solihull Mental Health NHS Foundation Trust Black Country Partnership NHS Foundation Trust Worcester Health and Care NHS Trust Coventry and Warwick Partnership NHS Trust Clinical Representation Links into Finance & Informatic Sub Group Recent links with West Midlands Strategic Clinical Network- Neurological conditions, Dementia & Mental Health. New Links to National Group and Work streams

4. 4 ‘Quality and Outcome measures are particularly important for mental health, because of the longer term nature of an individuals interaction with providers and the need to understand whether people are getting good quality care, are recovering, and for commissioners to be able to compare one provider with another’- Monitor Oct 13

5. 5 Quality and Outcomes- Background and Context PbR currencies - Quality and Outcome Measures fundamental part of the new currency Quality and Outcome Measures to be mandated for all 21 Care Clusters Long term vision of Quality and Outcome Measures – intrinsically linked to the construction of national care cluster tariffs and PbR currencies. Payment of full cluster Tariff on delivery and demonstration of the 4 measures by Trusts Quality and Outcome agenda driven by National Quality and Outcome Group – Development of appropriate measures has been and remains problematic Regional Quality and Outcome Group - support Trusts in developing their awareness and understanding around this agenda

6. Quality and Outcome Measures – What are they and what do they mean? 6 Patient Rated Experience Measures (PREM) Patient Rated Outcome Measure (PROM) The Clinician Rated Outcome measure (CROM) A set of quality indicators, reported via MHMDS have been analysed with 10 recommended for use

7. PREM- Patient Reported Experience Measure There is no universally or agreed way to assess and report Patient Experience. Commissioners and Providers should agree local activity to assess patient experience. Consideration should also be given to the appropriate use of the ‘friends and family’ question. The scale below should be used to answer the ‘friends and family’ question: 1.Extremely Likely 2.Likely 3.Neither likely or unlikely 4.unlikely 5.Extremely unlikely 6.Don’t know PREM’s should be collected in line with the Care Cluster Allocation Tool: At initial assessment, routine review, significant change in presenting needs and at discharge. It is not expected that either Proms or Patient Experience data will be linked to payment during 14/15, but commissioners and providers should consider how this could be used in the future. 7

8. PREM- Patient Reported Experience Measure It is recommended providers ask follow up questions at the time of the family and friends question. The number and wording of these questions should be determined locally. Consideration should be given to the top 12 questions rated by service users form the CQC community survey: 1. Did you feel carefully listened to the last time you seen your NHS health care worker? 2. Did this person take your views into account? 3. Did you have trust and confidence in this person? 4. Do you understand what is in your NHS care plan? 5. Do you have a telephone number to contact your mental health service out of hours? 6. In the last 12 months have you received any sort of talking therapy from NHS mental health services? 7. In the last 12 months have you had a care review meeting to discuss your care? 8. Do you think your views were taken into account when deciding what was in you NHS care plan? 9. Do you think your views were taken into account when deciding which medication to take? 10. Overall rating of the service you have received? 11. In the last 12 months has your NHS worker checked how you are getting on with your medication? 12. Time period for last seeing someone form mental health services 8

9. Use of PROM- Patient Reported Outcome Measure National Q&O Group acknowledge it has not been possible to identify a single PROM that adequately reflects the priorities for all of the clusters. It is suggested that where no PROM is currently being used within an organisation, WEMWEBS should be the PROM of choice. Additional or different PROMs may also be used Commissioners and Providers should ensure a PROM is being used for all of the clusters Use of PROM should be tied in with Cluster reviews. A quarterly review of the data relating to this should be undertaken. 9

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11. Quality Indicators Recommended IndicatorsAdditional Indicators 1.The proportion of users with a Crisis Plan in place, limited to those on CPA 2.The accommodation status of all users (as measured by an indicator of settled status and an indicator of accommodation problems) 3.The completeness of ethnicity recording 4. The proportion of users on CPA who have had a review in the last 12 mths 5. The proportion of users who have a valid ICD 10 diagnosis code recorded 6.The intensity of care (Bed days as a proportion of care days) 7.The intensity of care (OBD) 8.Proportion of in scope patients assigned to a cluster 9.Proportion of initial cluster allocations adhering to red rules 10. Proportion of patients within cluster review periods 1.Distribution of Actual Cluster Review Periods 2.Distribution of Actual Cluster Episode Period Duration 3.Distribution of Actual MH Cluster Review Period Duration 4.Re-referral Rate (to any in scope services 5.Proportion of Reviews (CPA) with a corresponding Clustering review 6.Indicator of accommodation problems 7.Cluster Profile 8.Step Up/ Step Down/ Little change/ Discharge The Recommended Indicators will be reported nationally from MHMDS submissions during14/15. Additional indicators can be used locally to inform service improvement. Providers and commissioners may wish to assess how they could be used as part of a local payment. 11

12. Use of CROM- Clinical Reported Outcome Measure The HONOS four Factor Model is the mandated generic clinician rated outcome measure which will be one of the methods used to demonstrate outcome for PbR The model allows reliable change to be reported across total and factor scores showing clinical significance. The four factors are derived from the HoNOS ratings extracted from the cluster tool. The 4 factors are: 1. Personal Well Being 2. Emotional Well Being 3. Social Well Being 4. Severe Disturbance Further information is expected regarding the methodology used to analyse and report on outcome data using the four factor model including total score and clinical significance. HONOS scores to be completed at: Initial assessment routine review significant change in presenting needs Discharge. 12

13. 13 01234 No problemMinor problem require no action Mild problem but Definitely present Moderately severe problem Severe to very severe problem FACTOR 1 Personal Well Being FACTOR 2 Emotional Well Being FACTOR 3 Social Well Being FACTOR 4 Severe Disturbance Item 4: Cognitive Problems Item 2: Non-accidental Injury Item 3: Problem-drinking or drug taking Item 1: Overactive, aggressive, disruptive or agitated behaviour Item 5: Physical Illness or disability or disability problems Item 7: Problems with depressed mood Item 9: Problems with relationships Item 6: Problems associated with hallucinations & delusions Item 10: Problems with activities of daily living Item 8: Other mental and behavioural problems Item 11: Problems with living conditions Item 12: Problems with occupation and activities Item 12: Problems with occupation and activities 4 Factor Model (Speak et al 2013) - Based on the Health of the Nation Outcome Scales (HoNOS 12 Questions)

14. HoNOS ScaleFactor CARE CLUSTER 12345678 10101 1212 1313 1414 1515 1616 1717 18 1919 2020 2121 Cognitive Problems4 Personal Well-Being SSSSSSMMSSMMSSMMSMMM Physical Illness5SSSSSSMMSSMMSSMMSMMM Activities of daily living10SSSSSSMMSSSSSSMMSMMM Occupation & Activities12SSSSSSSSSSSSSSSSSSVV Non-accidental self injury2 Emotional Well-Being MMMMSSSSSSSSSSSSSSVV Depressed mood *7SSSSSSMMSSMMSSMMMVVV Other mental & behavioural problems 8SSSSSSMMSSMMSSMMMVVV Problem drinking or drug taking 3 Social Well-Being MMMMSSSSSSSSSSSSSSVV Relationships9SSSSSSMMSSSSSSMMSMMM Living conditions11SSSSSSMMSSSSSSMMSMMM Occupation & Activities12SSSSSSSSSSSSSSSSSSSV Overactive, aggressive, disruptive or agitated behaviour 1 Severe Disturbance MMMMSSSSSSSSSSSSSSVV Hallucinations and Delusions 6SSSSSSMMSSMMSSMMMVVV LEGEND SExpected Improvement/Significant Change MMinimum Improvement/No change in presentation VWorsening of Symptoms/Deterioration in Condition 4 Factor Model (Speak et al 2013) Care Clusters & Weighted Domains 14

15. HoNOS ScaleFactor Accumulated Score Individual Score Weighted Domains 4Cognitive Problems Personal Well-Being6 (16) 1M 5Physical Illness1M 10Activities of daily living3S 12Occupation & Activities3S 2Non-accidental self injury Emotional Well Being5 (12) 0S 7Depressed mood *2M 8Other mental & behavioural problems: Sleep3M 3Problem drinking or drug taking Social Well-Being4 (16) 0S 9Relationships2S 11Living conditions1S 12Occupation & Activities3S 1 Overactive, aggressive, disruptive or agitated behaviour Severe Disturbance6 (8) 3S 6Hallucinations and Delusions4M Care Cluster 14 Psychotic Crisis TOTALS21 (48)26 15

16. Acute Care Plan - Multi Disciplinary - Focus -Severe Disturbance -Emotional Well-being - Home Treatment or Inpatient Care Plan - Diagnose - Treat acute symptoms - Manage and reduce risk/behaviours - Liaise with & support family/carers Expected Outcomes with Clinical Significance - Reduction/management of symptoms - Medication compliance - Reduction in risk/behaviours 16

17. THE EFFECTIVENESS OF CARE PACKAGES: FACTOR SPECIFIC OUTCOME EVALUATION 17

18. 18 14/15 Guidance- Next Steps National Guidance mandates the use of one outcome measure. Pilot sites have been selected to start collecting PROM/PREM information to understand how they are to be used, interpreted and be linked to full tariff payment. Updates are expected out during 2014 to inform 15/16 contracting agreements Opportunity for local development of PREMs and PROMs As PREMs and PROMs remain in development, HONOS, reported through MHMDS extracts would be the natural Outcome choice for Trusts. One of the quality indicators is to be reported per cluster and mandated within contracts ( Reported through MHMDS) 14/15 guidance is suggesting that for next year, adherence to review periods will be a quality measure - not mandated within 14/15 contracts. For more detail on Quality and Outcome Measures, please see Draft guidance on mental health currencies and payment- 3 rd October 2013.

19. Any Questions? 19