care pathways and packages (overview and history)
DESCRIPTION
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. Mental Health Clustering Tool - PowerPoint PPT PresentationTRANSCRIPT
Care Pathways and Packages(Overview and history)
Jon PainterProgramme Director
Northumberland Tyne and Wear NHS FT
Main elements of the CPP ModelIndividual patient needs
Anxiety / Relationships / Hallucinations / Living conditions etc.
Mental Health Clustering ToolStandardised summary of individual needs
ClusterGlobal description of combination & severity of individual needs
Care PackagesIndividually negotiated care plan informed by NICE Guidance
Quality and Outcome MetricsTriangulated measurement of process and effect
Local/national TariffDerived 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:
1 Overactive, aggressive, disruptive or agitated behaviour2 Non-accidental-self injury3 Problem drinking or drug taking4 Cognitive problems5 Physical illness or disability problems6 Problems associated with hallucinations and delusions7 Problems with depressed mood8 Other mental and behavioural problems9 Problems with relationships
10 Problems with activities of daily living11 Problems with living conditions12 Problems with occupation and activities13 Strong unreasonable beliefs occurring in non-psychotic disorders onlyA Agitated behaviour / expansive moodB Repeat self-harmC Safeguarding children & vulnerable dependant adultsD EngagementE Vulnerability
Mental Health Clustering ToolStandardised 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
ClusterGlobal description of combination & severity of individual needs
MHCT Scales
Scor
e
Validation - clinical homogeneity• Case presentations• Score profiles• Treatment aims• Interventions• Concurrent clinical data
– CPA status– Diagnosis– Medication– Gender– MHA status– Time known to services
ClusterGlobal 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
ClusterGlobal 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%)
ClusterGlobal 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
ClusterGlobal 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 PackagesIndividually negotiated care plan informed by NICE
Care PackagesIndividually 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 MetricsTriangulated measurement of process and effect
Payment for assumed quality
Payment for demonstrable
quality
MHCT & Cluster metricsMHMDS Metrics
Locally gen-erated met-rics and data
set
Source of Q&O Measures
PROMS
CROMS
PREMS
Type of Q&O Measures
Quality and Outcome MetricsTriangulated measurement of process and effect
Key: MHMDS: Mental Health Minimum Data SetMHCT: Mental Health Clustering ToolPREMS: Patient Reported Experience MeasuresPROMS: Patient Reported Outcome MeasuresCROMS: Clinician Reported Outcome Measures