1. Integrated Mental Health & Learning Disabilities Cluster Training Second Phase 2014-15

2. Objectives By the end of the session you should have an understanding of: The rationale behind the updated MH & LD Clustering Tool (MHLDCT) Who is responsible for clustering and when Each item within the tool and additional guidance to accompany it The content of the clusters The decision tree for cluster allocation How to score and cluster a case Movement between clusters

3. History of Care Pathways & Packages Developed originally to increase use of evidence based practice and reduce inconsistent treatment. A number of Trusts as part of the Care Pathways & Packages Project Consortium have led this development nationally. The Mental Health Clustering Tool is now a recognised and mandated tool for all Working Age and Older Peoples Services. A list of relevant care packages and a quality & outcomes framework have been developed for Working Age Adult and Older Peoples Services.

4. Using the Integrated MHLDCT It is a summary of need not a clinical assessment. It rates current problems in terms of impact on client. It also rates historical problems. The tool should be completed within two contacts. It is seeks to identify the most significant presenting need. The cause of the problem and the interventions used are NOT included in making a rating. The more the MHLDCT is used the more reliable and efficient it will be for users.

5. Responsibility for Clustering Lead Professional, Care Coordinator OR Delegated Professional are responsible for clustering. BUT at any given time a significant change may occur with a client’s presentation where the person normally responsible for clustering may not be available. E.g. if a client was admitted to an inpatient unit under Mental Health Act section or from out of area then professionals within that inpatient unit would cluster.

6. MHLDCT – Overview The first section in the tool contains a number of items to rate. There are Two Parts (Current and Historical) to this section:  Part 1 Problems in the past two weeks  Items 1-13 are taken from the original MHCT  Items 30-31 are LD specific  Part 2 Historical Issues (including the past two weeks)  Items A-E are taken from the original MHCT  Items I-K are LD specific

7. MHLDCT – Overview Part 1 Problems in the past two weeks 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 30 Non accidental Self Injury (associated with cognitive impairment 31Physical problems with eating and drinking LD specific items

8. AAgitated behaviour / expansive mood BRepeat self-harm CSafeguarding children & vulnerable dependant adults DEngagement EVulnerability ISocial Communication and interaction difficulties JProblems with communication KSeizures LD specific items MHLDCT – Overview Part 2 Historical issues

9. MHLDCT – General scoring guidance Rate every item using the 0- 4 scale where 0-1 = sub clinical requiring ‘no action’ 2 = mild problem but definitely present 3 = moderately severe problem 4= severe to very severe problem Also, Check Score Guide for examples and anchor points. Score each item in turn and don’t rate an aspect of a client’s presentation twice For Item 8 – choose and rate the most severe problem if relevant.

10. A. Agitated behaviour/ expansive mood (historical)  Rate agitation and overactive behaviour causing disruption to social role functioning. Behaviour causing concern or harm to others. Elevated mood that is out of proportion to circumstances.  Include such behaviour due to any cause (e.g. drugs, alcohol, dementia, psychosis, depression etc).  Excessive irritability, restlessness, intimidation, obscene behaviour and aggression to people animals or property.  Do not include odd or bizarre behaviour to be rated at Scale 6. 2 Makes verbal/gestural threats. Pushes/pesters but no evidence of intent to cause serious harm. Causes minor damage to property (e.g. glass or crockery). Is obviously over-active or agitated. 3 Agitation or threatening manner causing fear in others. Physical aggression to people or animals. Property destruction. Serious levels of elevated mood, agitation, restlessness causing significant disruption to functioning. 4 Serious physical harm caused to persons/animals. Major destruction of property. Seriously intimidating others or exhibiting highly obscene behaviour. Elevated mood, agitation, restlessness causing complete disruption. Rate 9 if not known Example of Need for Accurate Rating:

11. MHLDCT - Additional Guidance -Additional guidance has been put together to provide clarity on certain items and to explain how some of the Mental Health examples apply in Learning Disabilities - Guidance was derived from the first pilot with clinicians

12. Eg. Scale 4: Cognitive Problems Please be aware that the anchor points in this question may not be helpful for learning disabilities clients, it may be easier to revert to the generic scale for this item. In this context, 0 = no learning disabilities; 1= borderline learning disabilities; 2= mild learning disabilities; 3=moderate learning disabilities; 4=severe to profound learning disabilities. Where the person is experiencing dementia or other additional difficulties that may impact on cognitive impairment, score the most severe impairment for the person.

13. MHLDCT – Using the Decision Tree The Decision Tree helps to reduce the range of potential clusters for allocation. To do this: 1.Firstly you need to identify the ‘super class’ (Non-psychosis, Psychosis or Organic) that the client may fit best with. 2.Then consider the particular need/level of complexity/severity relevant to the client within that super class. 3.You should then be able to reduce the list of potential clusters for allocation.

14. DECISON TREE (RELATIONSHIP OF CLUSTERS TO EACH OTHER) Acuity

15. New Learning Disability Specific Clusters 9A Maintenance, engagement and minor support needs, complicated by LD 9B Risk to self, complicated by LD 9C Risk to others complicated by LD 9D Risk to others, complicated by mild LD & ASD 9E Risk to others, complicated by moderate - profound LD & ASD 9F Risk to others & self, complicated by moderate - profound LD & ASD 22 Physical health complicated by mild LD 23 Physical health complicated by moderate - profound LD 24 Physical health with dysphagia complicated by moderate - profound LD

16. Example Cluster Profile

17. Using the scoring profile Make sure the scoring fits in with the Must Scores (‘Red rules’) If they don’t fit but the cluster profile is a good match then go back and check your scoring to see if you under/overscored. Use the Expected to score (orange) and May score (yellow) to help decide between different clusters, check that you’ve got a reasonable match with the profile and check you’re not under/overscoring.

18. Using the Variance Cluster There may be times when the client’s needs do not readily fit an existing cluster profile. On these occasions the Variance Cluster may be used (Cluster 0). However, this is likely to happen less than 10% of the time and it’s important that the Variance Cluster is only used as a last resort. It is much more helpful in terms of understanding needs to have a cluster profile allocated but with concerns noted in ‘Additional Information’.

19. Retrospective clustering The current scores might not reflect the patient’s needs at the point of assessment if the care package is working. SO… Choose a superclass that best fits the patient’s needs over their time in the service. Consider the long term presentation of the patient and complexity rather than changes in severity. Consider the patient’s needs at their worst. Record appropriate cluster according to this and place a comment in the free text box confirming “this is a retrospective cluster”.

20. You allocate to a Cluster by using your Decision Tree Choices & the MHLDCT scores identify the most appropriate ‘Cluster Profile’

21. Care clusters identify needs of clients at a particular ‘moment in time’ Clusters allow for a certain amount of fluctuation in condition But a significant change in condition will often lead to a change in cluster allocation. So a client’s journey may involve them moving through a range of clusters as their condition changes over time How do we re-allocate clusters? We use Cluster Reviews to help understand this. These happen on a significant change (e.g. admission to inpatient services) or at planned reviews (typically six monthly).

22. Examples of when not to cluster No allocation to cluster on discharge but you will do a new set of scores on discharge No MHLDCT if only a one-off assessment or the client does not require services and it is identified that no interventions/treatment is required

23. Begin using the Clustering Process now for all new assessments (by second contact) that lead to further assessment or treatment all Reviews Planned/Unplanned Any other significant change of circumstance.

24. Give it a go (Using real cases or vignettes as a practice)

25. Cluster Profiles for Information

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