oxfordshire maximising recovery interventions & outcomes

Oxfordshire Maximising Recovery Interventions & Outcomes Group (MaRIO); Payment by Results (PbR)

Cluster Pathways.

CARE CLUSTERS AND PATHWAYS TO RECOVERY What is changing? The care and support that people with mental illness and mental health problems receive is not changing. The NHS will still provide the services that people need to get better. Some of the ways we describe support and the ways we think about it are changing. The NHS wants to make sure that everything we do focuses on recovery. We also want to make sure that the services and support people get are fair and that everyone knows what support and treatment people should get. We will do this by grouping people with the same needs into care clusters. The NHS in Oxfordshire has written a care pathway for each care cluster. What is recovery? Recovery is learning to live with a serious illness. Some people get fully better and don’t need support or treatment: other people need on-going support and treatment: some people need support and treatment sometimes and not at other times. Everyone’s experience is personal. What are Care Clusters? Care clusters are a way of grouping (“clustering”) people with similar support and treatment needs. Mental health workers will talk to you and your carers about your illness, your support needs, and your treatment and will use this information to identify which care cluster you are in. People will be reassessed regularly and your care cluster will change as your need for support and treatment changes. The NHS will use information from clusters to be sure that people with the same needs get a fair level of treatment, no matter where in the county they live and no matter what their social or cultural background. The NHS has done this by writing care pathways for each care cluster. What are Care Pathways? Care pathways describe the services and support people in a particular care cluster could receive. These pathways are based on the best available research evidence, on the views of people with lived experience of the conditions, their carers, and mental health professionals. The pathways are designed so that users of services and their families can work with health care professionals to make sure all their needs are taken into account. The aim is to try to explain what services will be available and how people, together with their families and health professionals, can choose the best types of care, support and interventions to meet their needs and to achieve their health goals.

What services can people expect to be able to access? Treatment and support will be provided by a range of local organisations. These may include services provided by Primary Care (from a GP practice), NHS mental health services, provided by other NHS funded organisations (such as voluntary organisations) or services bought with direct payments. The services they provide will be tailored to meet a person’s needs and enable them to achieve their goals.

Oxfordshire Clinical Commissioning Group Mental Health Cluster Pathways

1Understanding

the problemAgree the plan

Addressing

NeedsMove on

Common MH Problems

(Low Severity)

Gloomy or minor changes in mood or

minor anxiety etc. No risk of Self-harm. Criminal Justice System

Information

Care Clusters 2,3,or 18 Wellbeing Service Joining & EngagementCriteria for pathway no longer

met?

Who; Where and When?Consider input from other

agencies

GP

Most patients likely to be

successfully managed in

General Practice by Step 1

Interventions

Talking Space Needs & Risk AssessmentManage Risk & Contingency

planContingency planning Agree discharge date

PHQ9, GAD7, or HAD Acute care pathway need? MDS on discharge

Key ReferralPrimary Care Counselling

ServiceIAPT MDS

Commencement of care

planning

Psychological intervention or

therapy

Usual Range of ActivitiesUnlikely to require referral to

CMHTProvisional Dx Psychological interventions

Step 2 Interventions - Time

limited"Move on" to Clusters………

Psychiatric or Psychological Activities

After trial of Step 1

Interventions, may consider

referral to ------>

Signpost to other services

(external)Is Advocacy required ?

Consider with patient Drug

Therapy - but less likely in this

cluster

Consider Step 3 InterventionsCarer / Family involved in

move-on plan

Physical Health ActivitiesAssessment (includes carer

and relevant others)Recovery Services

Treatment Objectives and

TimescaleRelapse Prevention

Most likely to "No significant

Mental Health Problems"

Social, Financial, Housing, Employment &

Occupational Activities

Assessment of social,

housing, financial &

occupational need

Employment SupportPossibly to Clusters 2,3,4,5, or

8

Self-directed Activities - e.g. with

Personal Budgets

Factors influencing triage

outcomesAssessment of physical health

Baseline examination and

investigations

Ongoing monitoring

investigationsUnlikely to Cluster 18

Family, Carer & Dependants activities

Identification and

quantification of habitual

substance use

Intervention to reduce harmful

or dependent useConsider ongoing support

ServicesFamily Carers & Dependants

Assessment

Involve family, carer, &

dependants in planning

Consider need for support for

family, carer, dependants

Consider ongoing support for

Carer / Family as per Carer's

Pathway


housing, financial,

educational, employment &

occupational need

Agreed prioritisation of social,

housing, financial,


occupational need

Involve other agencies to

address specific needs

Identification of balance of self

help and professional help

Optimising opportunities for

employment, work, education

& training and meaningful

activity

Help in parenting and caring

roles

Optimising housing statusPatient Satisfaction survey -

IAPT & Counsellors

Optimising finances

Optimising social network

Detailed Social Care

assessment and calculation of

personal budget for social

care

Support Plan to address social

needs e.g.. Domiciliary, Day

Opportunity, Supported Living

& Residential

Social Care Support Plan

reviewed at CPA assessment

Service user offered

Brokerage Support

Repeat IAPT MDS at each

session

If MDS significantly unchanged

at end of plan consider

onward referral

Communicate with referrer /

GPCommunicate with GP Communicate with GP

TRIAGE or Identifying the nature of the problem and involving the right service

2011 Cluster 1 Page 0 of 23


2Understanding


Addressing

NeedsMove on

Common MH Problems

(Low Severity with

greater need)

Gloomy or minor changes in mood or

minor anxiety etc. No more than

fleeting thoughts of Self-harm.

Criminal Justice System

Information

Care Clusters 1,3,or 18 Wellbeing Service Joining & EngagementCriteria for pathway no longer

met?


agencies

GP



General Practice by Step 1

Interventions




Key ReferralPrimary Care Counselling

ServiceIAPT MDS


planning


therapy

Usual Range of ActivitiesUnlikely to require referral to







referral to ------>





cluster


move-on plan

Physical Health ActivitiesAssessment (includes carer






Social, Financial, Housing,

Employment & Occupational Activities



occupational need

Employment Support Possibly to Clusters 3,4,5, or 8


Personal Budgets

Factors influencing triage



investigations

Ongoing monitoring



Identification and


substance use



ServicesFamily Carers & Dependants

Assessment







Pathway


housing, financial,


occupational need


housing, financial,


occupational need








activity


roles


IAPT & Counsellors

Optimising finances





care




& Residential




Brokerage Support


session

If MDS significantly

unchanged at end of plan

consider onward referral






3Understanding


Addressing

NeedsMove on

Non Psychotic (moderate

severity)

Mild but definite depression (guilt &

low self-esteem) or mild anxiety. No

more than fleeting thoughts of Self-

harm.


Information

Care Clusters 1,2,4,18 Wellbeing Service Joining & EngagementCriteria for pathway no longer

met?


agencies

GP



Primary Care by Step 1

Interventions




ReferralPrimary Care Counselling

ServiceIAPT MDS


planning


therapy

Unlikely to require referral to




Key



referral to ------>





cluster


move-on plan

Usual Range of ActivitiesAssessment (includes carer









occupational need

Employment Support Possibly to Clusters 4,5, or 8

Physical Health ActivitiesFactors influencing triage



investigations

Ongoing monitoring




Identification and


substance use




Personal Budgets

Family Carers & Dependants

Assessment







Pathway



housing, financial,


occupational need


housing, financial,


occupational need



ServicesIdentification of balance of self





activity


roles


IAPT & Counsellors

Optimising finances





care




& Residential




Brokerage Support


session









4Understanding


Addressing

NeedsMove on

Non Psychotic

(Severe)

Depression with inappropriate self-

blame; preoccupied by guilt feelings.

Mild risk of self-harm; may include

recurrent non-hazardous self-harm (eg

wrist-scratching).

Wellbeing ServiceSingle assessment with

planned return to referrerFollow pathway as in Cluster 5

Information

Care Clusters 1,2,3,5,18

Some patients may be

managed in Primary Care

possibly with Psychiatric

advice

Accept to specialist mental

health serviceJoining & Engagement

Criteria for pathway no longer

met?


agencies

GP

Discussion between GP or

current care co-ordinator and

assessment team (CMHT in

hours or CRHT out of hours)



Referral PHQ9, GAD7, or HAD Acute care pathway need?Psychological intervention or

therapyMDS on discharge


May need to consider referral

to CMHT or Specialist

Psychiatric assessment

Primary Care Counselling

ServiceIAPT MDS


planning


limited



referral to ------>

Provisional Dx Psychological interventions Consider Step 3 Interventions "Move on" to Clusters………

Assessment (includes carer

and relevant others)




Therapy - more likely in this

cluster

Prescription and adverse

effect monitoring

Carer / Family involved in

move-on plan



occupational need

Recovery ServicesTreatment Objectives and




KeyFactors influencing triage

outcomesEmployment Support Possibly to Clusters 2,3,5, or 8

Usual Range of Activities Assessment of physical healthBaseline examination and

investigations

Ongoing monitoring



Identification and


substance use



Physical Health ActivitiesFamily Carers & Dependants

Assessment







Pathway




housing, financial,


occupational need


housing, financial,


occupational need



Self-directed Activities - eg with

Personal Budgets


help and profesional help




activity

Family, Carer & Dependants activitiesHelp in parenting and caring

roles

Services Optimising housing statusPatient Satisfaction survey -

IAPT & Counsellors

Optimising finances





care


needs eg. Domiciliary, Day

Opportuntiy, Supported Living

& Residential




Brokerage Support


session









5Understanding


Addressing

NeedsMove on

Non Psychotic

(Very Severe)

Single assessment with

planned return to referrer

Gathering of further or detailed

InformationInformation provision

Needs & Risk Assessment Joining & Engagement Contingency plan

HoNOS or PbR Care

Clustering Tool (CCT )

completed

Develop a shared care plan

with identified tasks for both

professionals and individual

Specific assistance towards

self directed support

CPA review & determine using

CCT if current care cluster is

appropriate

People moving on from previous

Care Cluster


health service


Timescale

Prescription and adverse effect

monitoring

CPA review with relapse

prevention plan

Agree Nature of Problem

(Provisional Dx) & Exclude

Organic Causes

Commencement of team care

planningCommunicate with carer

Consider input from other

agencies

GP / Other referral source





Consider need for MHA Communicate with GP Agree transfer date

Carers AssessmentCommunicate with referrer /

GP

Repeat HoNOS/PBR care

clustering tool at regular

intervals

CCT on discharge/transfer

Criminal Justice System Negotiate setting of care

Is more intensity needed to

support safety or treatment

concordance?


met?

Communicate with GP and

secondary care co-ordinator

Signpost to other service

relevant to different care

cluster

Is advocacy required?Co-morbid substance misuse

identified?

Intervention for co-morbid

substance misuse

KeyMaternal mental health needs

identified?

Maternal mental health

provision considered?

Movement to more appropriate

other care cluster or out of

care clustering


investigations

Ongoing monitoring

investigationsMost likely 6 or 8

Mental Health Activities -

Psychiatric or PsychologicalConsider ? Substance Misuse

Identification and quantification

of habitual substance use


or dependent use

Possible 5,6,7,8 or out of

clustering

Physical Health ActivitiesAssessment for psychiatric

intervention Establishing diagnosis

Monitoring of symptomatic

stateUnlikely 10,11,12,13,14,15, 18


Employment & Occupational

Activities

Selecting psychotropic drug

regime

Monitoring of potential adverse

effectsConsider ongoing support

Brokerage Activities - e.g. with

Personal Budgets

Prescribing psychotropic drug

regime

Adjustment of drug dosage

against response



Pathway

Family, Carer & Dependant

activities

Assessment of psychological

functioning

Matching of existing coping

strategies to formulated needs

Psychological therapy

(specified technique and

objectives )

Services

Identification of need for

additional psychological

technique




activity

Assessment of social, housing,

financial, occupational,

educational & employment

need


housing, financial,

occupational, educational &

employment need


roles


help and professional helpOptimising housing status

Optimising finances



Assessment







personal budget for social care

Support Plan put in place to

address social care needs

such as Domiciliary, Day


& Residential


Brokerage Support




Severely depressed and/or anxious and/or other. No distressing

hallucinations or delusions but may have some unreasonable beliefs. May

often be at high risk for Non-accidental self injury and may present

safeguarding issues. May have severe disruption to everyday living.



6Understanding


Addressing

NeedsMove on

Non Psychotic

Disorder of Over-

valued Ideas






HoNOS or PbR Care


completed






CPA review & determine

using CCT if current care

cluster is appropriate


Care Cluster


health serviceConsider ? Substance Misuse


Timescale


effect monitoring


prevention plan



Organic Causes




agencies








GP



intervals





concordance?


met?





cluster


identified?


substance misuse


identified?





care clustering


investigations

Ongoing monitoring

investigationsMost likely 8






or dependent use

Possible 5,7 or out of

clustering




state

Unlikely 10,11,12,13,14,15,

18



Activities


regime




Personal Budgets


regime


against response



Pathway

Family, Carer & Dependants

activities


functioning





objectives )

Services



technique




activity


housing, financial,


employment need


housing, financial,


employment need


roles



Optimising finances



Assessment












& Residential


Brokerage Support




Moderate to very severe disorders that are difficult to treat. This may

include treatment resistant eating disorder, OCD etc, where extreme

beliefs are strongly held, some personality disorders and enduring

depression.



7Understanding


Addressing

NeedsMove on

Enduring Non

Psychotic Disorders

(High Disability)



Gathering of further or

detailed InformationInformation provision


HoNOS or PbR Care


completed










Care Cluster




Timescale


effect monitoring


prevention plan



Organic Causes




agencies








GP



intervals





concordance?


met?





cluster


identified?


substance misuse


identified?



Movement to more

appropriate other care cluster

or out of care clustering


investigations

Ongoing monitoring

investigationsMost likely 6 or 8



Identification and


substance use


or dependent usePossible 5 or out of clustering




state

Unlikely 10,11,12,13,14,15,

18



Activities


regime

Monitoring of potential

adverse effectsConsider ongoing support


Personal Budgets


regime


against response



Pathway


activities


functioning





objectives )

Services



technique




activity


housing, financial,


employment need


housing, financial,


employment need


roles



Optimising finances


Family Carers & Dependant

Assessment








care





& Residential


Brokerage Support




This group suffers from moderate to severe disorders that are very

disabling. They will have received treatment for a number of years and

although they may have improvement in positive symptoms considerable

disability remains that is likely to affect role functioning in many ways.



8Understanding


Addressing

NeedsMove on

Non Psychotic

Chaotic and

Challenging Disorders






HoNOS or PbR Care


completed










Care Cluster




Timescale


effect monitoring


prevention plan



Organic Causes




agencies








GP



intervals





concordance?


met?





cluster


identified?


substance misuse


identified?





care clustering


investigations

Ongoing monitoring

investigationsMost likely 5






or dependent use

Possible 6,7, 10 or out of

clustering




stateUnlikely 11,12,13,14,15, 18



Activities


regime




Personal Budgets


regime


against response



Pathway


activities


functioning





objectives )

Services



technique




activity


housing, financial,


employment need


housing, financial,


employment need


roles



Optimising finances



Assessment












& Residential


Brokerage Support




This group will have a wide range of symptoms and chaotic and challenging

lifestyles. They are characterised by moderate to very severe repeat

deliberate self-harm and/or other impulsive behaviour and chaotic, over

dependent engagement and often hostile with services.



10Understanding


Addressing

NeedsMove on


Information


planned return to referrerNeeds & Risk Assessment Joining & Engagement Information provision

HoNOS or PbR Care


completed

Develop a shared car plan with

identified tasks for both


Contingency plan

Consider ? Substance Misuse Bio-psycho / social formulationSpecific assistance towards




appropriate


Care Cluster


health service



Organic Causes


Timescale


monitoring


prevention plan




agencies






Carers Assessment Consider need for MHA Communicate with GP Agree transfer date

Negotiate setting of careCommunicate with referrer /

GP



intervals

CCT on discharge / transfer

Criminal Justice System Is advocacy required?



concordance?


met?





cluster

Co-morbid substance misuse

identified?


substance misuse


identified?





care clustering


investigations

Ongoing monitoring

investigations

Most likely to 11,12,13 or out of

clustering


Psychiatric or Psychological




or dependent usePossibly to 14, 15, 16, 17




stateUnlikely to all other clusters



Activities


regime




Personal Budgets


regime


against response



Pathway


activities


functioning





objectives )

Services



technique




activity


financial, occupational &

employment need


housing, financial, occupational

& employment need


roles



Optimising finances


Family Carers & Dependant

Assessment












& Residential


Brokerage Support




First Episode Psychosis

This group will be presenting to the service

for the first time with mild to severe

psychotic phenomena. They may also have

depressed mood and/or anxiety or other

behaviours. Drinking or drug taking may be

present but will not be the only problem.



11Understanding


Addressing

NeedsMove on


Information



HoNOS or PbR Care


completed




Contingency plan





appropriate


Care Cluster


health service



Organic Causes


Timescale


monitoring


prevention plan




agencies








GP



intervals





concordance?


met?





cluster


identified?


substance misuse


identified?





care clustering


investigations

Ongoing monitoring

investigations

Most likely to 12, 13, 14 or out

of clustering






or dependent usePossibly to 5, 15, 16, 17







Activities


regime




Personal Budgets


regime


against response



Pathway


activities


functioning





objectives )

Services



technique




activity



employment need



& employment need


roles



Optimising finances



Assessment












& Residential


Brokerage Support




Ongoing Recurrent

Psychosis (Low Symptoms)

This group has a history of psychotic

symptoms that are currently controlled and

causing minor problems if any at all. They

are currently experiencing a period of

recovery where they are capable of full or

near functioning. However, there may be

impairment in self-esteem and efficacy and

vulnerability to life.



12Understanding


Addressing

NeedsMove on


Information



HoNOS or PbR Care


completed




Contingency plan





appropriate


Care Cluster


health service



Organic Causes


Timescale


monitoring


prevention plan




agencies








GP



intervals





concordance?


met?





cluster


identified?


substance misuse


identified?





care clustering


investigations

Ongoing monitoring

investigationsMost likely to 11, 13, 14






or dependent usePossibly to 15, 16, 17







Activities


regime




Personal Budgets


regime


against response



Pathway


activities


functioning





objectives )

Services



technique




activity



employment need



& employment need


roles



Optimising finances



Assessment












& Residential


Brokerage Support



History of psychotic symptoms with

significant disability and major impact on

role functioning. Likely to be vulnerable to

abuse or exploitation.


Psychosis ongoing &

recurrent with low symptoms

& disability



13Understanding


Addressing

NeedsMove on


Information



HoNOS or PbR Care


completed




Contingency plan





appropriate


Care Cluster


health service



Organic Causes


Timescale


monitoring


prevention plan




agencies








GP



intervals





concordance?


met?





cluster


identified?


substance misuse


identified?





care clustering


investigations

Ongoing monitoring

investigationsMost likely to 11, 12, 14






or dependent usePossibly to 15, 16, 17







Activities


regime




Personal Budgets


regime


against response



Pathway


activities


functioning





objectives )

Services



technique




activity



employment need



& employment need


roles



Optimising finances



Assessment












& Residential


Brokerage Support




Ongoing or Recurrent

Psychosis (High Symptoms &

Disability)

This group will have a history of psychotic

symptoms which are not controlled. They

will present with severe to very severe

psychotic symptoms and some anxiety or

depression. They have a significant disability

with major impact on role functioning.



14Understanding


Addressing

NeedsMove on

Psychotic Crisis

Setting up appointmentGathering of further or detailed

InformationProvision of information


care cluster or out of care

clustering


People moving on from previous Care

Cluster

Acceptance by specialist

mental health service (CMHT

or EIP)

HoNOS or PbR Care


completed








appropriate

Consider ? Substance MisusePrescription and adverse effect

monitoring


prevention plan

Awareness of problem and need for

mental health assessment raised by

family, friends, community agencies

usually through primary care GP

Referral by GP or other

professional



Organic Causes


TimescaleCommunicate with carer


agencies




planningCommunicate with GP Agree transfer date

Criminal Justice System Carers Assessment Consider need for MHA



intervals



GP


met?



Key Is advocacy required?



concordance?

Agree formal approach for self

directed support

Usual Range of ActivitiesSignpost to other services

(external)


identified?


substance misuse



care clustering

Mental Health Activities - Psychiatric

or Psychological

Maternal mental health needs

identified?



Likely to 11,12,13, 15 or out of

clustering

Physical Health Activities Assessment of physical healthBaseline examination and

investigations

Ongoing monitoring

investigationsPossibly to 5, 8, 10, 16, 17






or dependent useUnlikely all other clusters


Personal Budgets

Assessment for psychiatric



stateConsider ongoing support

Family, Carer & Dependants activitiesSelecting psychotropic drug

regime


effects



Pathway

ServicesPrescribing psychotropic drug

regime


against response


functioning





objectives )



technique


employment, work, education &

training and meaningful activity



employment need



& employment need


roles



Optimising finances



Assessment












& Residential

Service user offered Brokerage

Support



They will be experiencing an acute psychotic episode with severe symptoms

that cause severe disruption to role functioning. They may present as

vulnerable and a risk to others or themselves.








15Understanding


Addressing

NeedsMove on


Information



HoNOS or PbR Care


completed




Contingency plan





appropriate


Care Cluster


health service



Organic Causes


Timescale


monitoring


prevention plan




agencies








GP



intervals





concordance?


met?





cluster


identified?


substance misuse


identified?





care clustering


investigations

Ongoing monitoring

investigations

Likely to 5, 11, 12, 13 or out of

clustering






or dependent usePossibly 14, 16, 17




state

Unlikely 11, and all other

clusters



Activities


regime




Personal Budgets


regime


against response



Pathway


activities


functioning





objectives )

Services



technique




activity



employment need



& employment need


roles



Optimising finances


Family, Carers & Dependants

Assessment












& Residential


Brokerage Support




Severe Psychotic Depression

This group will be suffering from an acute

episode of moderate to severe depressive

symptoms. Hallucinations and delusions will

be present. It is likely that this group will

present a risk of non-accidental self injury

and have disruption in many areas of their

lives.



16Understanding


Addressing

NeedsMove on


Information



HoNOS or PbR Care


completed




Contingency plan





appropriate


Care Cluster


health service



Organic Causes


Timescale


monitoring


prevention plan




agencies








GP



intervals





concordance?


met?





cluster


identified?


substance misuse


identified?





care clustering


investigations

Ongoing monitoring

investigationsLikely to 8, 12, 13, 14






or dependent usePossibly to 11, 17




stateUnlikely all other clusters



Activities


regime




Personal Budgets


regime


against response



Pathway


activities


functioning





objectives )

Services



technique




activity



employment need



& employment need


roles



Optimising finances



Assessment












& Residential


Brokerage Support




Dual Diagnosis

This group has enduring, moderate to severe

psychotic or affective symptoms with

unstable, chaotic lifestyles and co-existing

problem drinking or drug taking. They may

present a risk to self and others and engage

poorly with services. Role functioning is

often globally impaired.



17Understanding


Addressing

NeedsMove on


Information



HoNOS or PbR Care


completed




Contingency plan





appropriate


Care Cluster


health service



Organic Causes


Timescale


monitoring


prevention plan




agencies








GP



intervals





concordance?


met?





cluster


identified?


substance misuse


identified?





care clustering


investigations

Ongoing monitoring

investigationsLikely to 11, 12, 13, 14






or dependent usePossibly to 16







Activities


regime




Personal Budgets


regime


against response



Pathway


activities


functioning





objectives )

Services



technique




activity



employment need



& employment need


roles



Optimising finances



Assessment












& Residential


Brokerage Support




Psychosis and Affective

Disorder - Difficult to Engage

This group has moderate to severe psychotic

symptoms with unstable, chaotic lifestyles.

There may be some problems with drugs or

alcohol not severe enough to warrant dual

diagnosis care. This group have a history of

non-concordance, are vulnerable & engage

poorly with services.



18Understanding


Addressing

NeedsMove on



Setting up a formal

assessment appointment


InformationTime limited intervention


met?

People who may be in the early

stages of dementia (or who may

have an organic brain disorder

affecting their cognitive function)

who have some memory

problems, or other low level

cognitive impairment but who are

still managing to cope reasonably

well. Underlying irreversible

physical causes have been ruled

out

Needs & Risk Assessment Joining & Engagement Contingency planningConsider input from other

agencies

GP or other referrer





Accept to secondary care

servicesMemory assessment service

HoNOS or PbR Care


completed

Care & treatment planning

meeting

Prescription & monitoring of

drug treatmentAgree discharge/transfer date

Initial assessment (includes

carer and relevant others)Consider ? Substance Misuse


Timescale

Repeat CCT at regular

intervals

CPA review with detailed care

plan

Moving on from previous Care

Cluster possibly 0, 1, 2, 3, 9



Organic Causes


planning

If CCT significantly unchanged

repeat treatment cycleHoNOS on discharge/transfer

Criminal Justice System CMHTCo-morbid substance misuse

identified?Communicate with GP



Carers Assessment ? Need for MHA / MCA

Key Negotiate setting of care



concordance?



care clustering

Usual Range of Activities Is advocacy required?Communicate with referrer /

GPLittle change stay in 18


Psychiatric or PsychologicalAssessment of physical health


investigations

Ongoing monitoring

investigations

Possibly step up to 19, 20 or

21

Physical Health Activities



cluster







Activities

Biophysical interventionsMonitoring of potential adverse



Personal BudgetsPsychological Therapies


functioning





objectives )



Pathway


activities



technique




activity

ServicesAssessment of social, housing,

financial & occupational need



occupational need


roles


help and professional helpOptimising Housing status

Optimising Finances

Carers support as appropriate Optimising social network


Assessment





Self directed support








& Residential


Brokerage Support




Cognitive Impairment (Low

Need)



19Understanding


Addressing

NeedsMove on



Setting up a formal





met?


agencies








HoNOS or PbR Care


completed


meeting






Timescale


intervals


plan


Cluster possibly 0, 1, 2, 3, 9, 18



Organic Causes


planning



CMHTCo-morbid substance misuse








concordance?



care clustering






investigations

Ongoing monitoring

investigationsPossibly step up to 20 or 21




cluster







Activities






functioning





objectives )



Pathway


activities



technique




activity





occupational need


roles



Optimising Finances



Assessment













& Residential


Brokerage Support




Cognitive Impairment or

Dementia Complicated

(Moderate Need)



20Understanding


Addressing

NeedsMove on



Setting up a formal





met?

People with dementia who are

having significant problems in

looking after themselves and

whose behaviour may challenge

their carers or services. They may

have high levels of anxiety or

depression, psychotic symptoms

or significant problems such as

aggression or agitation. They may

not be aware of their problems.

They are likely to be at high risk of

self neglect or harm to others, and

there may be a significant risk of

their care arrangements breaking

down.


agencies








HoNOS or PbR Care


completed


meeting






Timescale


intervals


plan


Cluster, probably 18 or 19



Organic Causes


planning











concordance?



care clustering






investigations

Ongoing monitoring

investigationsPossibly step up to 21




cluster







Activities






functioning





objectives )



Pathway


activities



technique


employment, work, education &

training and meaningful activity





occupational need


roles



Optimising Finances



Assessment













& Residential

Service user offered Brokerage

Support





Dementia Complicated (High

Need)



21Understanding


Addressing

NeedsMove on



Setting up a formal





met?

People with cognitive impairment

or dementia who are having

significant problems in looking

after themselves and whose

physical condition is becoming

increasingly frail. They may not be

aware of their problems and there

may be a significant risk of their

care arrangements breaking down


agencies








HoNOS or PbR Care


completed


meeting






Timescale


intervals


plan


Cluster probably 19 or 20



Organic Causes


planning











concordance?



care clustering






investigations

Ongoing monitoring

investigations

Possibly step across to 20

(unlikely)




cluster







Activities






functioning





objectives )



Pathway


activities



technique




activity





occupational need


roles



Optimising Finances



Assessment













& Residential


Brokerage Support





Dementia (High Physical or

Engagement)



Variance

Despite careful consideration of all the other clusters, this group of service users are not adequately

described by any of their descriptions. They do however require mental health care and will be offered

a service.

1 Non-PsychoticCommon Mental Health Problems (Low

Severity)

This group has definite but minor problems of depressed mood, anxiety or other disorder but they do

not present with any distressing psychotic symptoms.

2 Non-Psychotic Mild / Moderate / SevereCommon Mental Health Problems (Low

Severity with greater need)

This group has definite but minor problems of depressed mood, anxiety or other disorder but not with

any distressing psychotic symptoms. They may have already received care associated with cluster 1

and require more specific intervention or previously been successfully treated at a higher level but are

re-presenting with low level symptoms.

3 Non-Psychotic Mild / Moderate / Severe Non Psychotic (Moderate Severity) Moderate problems involving depressed mood, anxiety or other disorder (not including psychosis).

4 Non-Psychotic Mild / Moderate / Severe Non-psychotic (Severe)

This group is characterised by severe depression and/or anxiety and/or other increasing complexity of

needs. They may experience disruption to function in everyday life and there is an increasing likelihood

of significant risks.

5 Non-Psychotic Very Severe and Complex Non-psychotic Disorders (Very Severe)

This group will be severely depressed and/or anxious and/or other. They will not present with

distressing hallucinations or delusions but may have some unreasonable beliefs. They may often be at

high risk for Non-accidental self injury and they may present safeguarding issues and have severe

disruption to everyday living.

6 Non-Psychotic Very Severe and Complex Non-psychotic Disorder of Over-valued Ideas

Moderate to very severe disorders that are difficult to treat. This may include treatment resistant eating

disorder, OCD etc, where extreme beliefs are strongly held, some personality disorders and enduring

depression.

7 Non-Psychotic Very Severe and ComplexEnduring Non-psychotic Disorders (High

Disability)

This group suffers from moderate to severe disorders that are very disabling. They will have received

treatment for a number of years and although they may have improvement in positive symptoms

considerable disability remains that is likely to affect role functioning in many ways.

8 Non-Psychotic Very Severe and ComplexNon-Psychotic Chaotic and Challenging

Disorders

This group will have a wide range of symptoms and chaotic and challenging lifestyles. They are

characterised by moderate to very severe repeat deliberate self-harm and/or other impulsive behaviour

and chaotic, over dependent engagement and often hostile with services.

9 Non-Psychotic Blank Place Marker

10 Psychosis First Episode First Episode Psychosis

This group will be presenting to the service for the first time with mild to severe psychotic phenomena.

They may also have depressed mood and/or anxiety or other behaviours. Drinking or drug-taking may

be present but will not be the only problem.

11 Psychosis Ongoing or recurrentOngoing Recurrent Psychosis (Low

Symptoms)

This group has a history of psychotic symptoms that are currently controlled and causing minor

problems if any at all. They are currently experiencing a period of recovery where they are capable of

full or near functioning. However, there may be impairment in self-esteem and efficacy and

vulnerability to life.

12 Psychosis Ongoing or recurrentOngoing or recurrent Psychosis (High

Disability)

This group have a history of psychotic symptoms with a significant disability with major impact on role

functioning. They are likely to be vulnerable to abuse or exploitation.

13 Psychosis Ongoing or recurrentOngoing or Recurrent Psychosis (High

Symptom & Disability)

This group will have a history of psychotic symptoms which are not controlled. They will present with

severe to very severe psychotic symptoms and some anxiety or depression. They have a significant

disability with major impact on role functioning.

14 Psychosis Psychotic crisis Psychotic CrisisThey will be experiencing an acute psychotic episode with severe symptoms that cause severe

disruption to role functioning. They may present as vulnerable and a risk to others or themselves.

15 Psychosis Psychotic crisis Severe Psychotic Depression

This group will be suffering from an acute episode of moderate to severe depressive symptoms.

Hallucinations and delusions will be present. It is likely that this group will present a risk of Non-

accidental self injury and have disruption in many areas of their lives.

16 Psychosis Very Severe Engagement Dual Diagnosis

This group has enduring, moderate to severe psychotic or affective symptoms with unstable, chaotic

lifestyles and co-existing Problem drinking or drug taking. They may present a risk to self and others

and engage poorly with services. Role functioning is often globally impaired.

17 Psychosis Very Severe EngagementPsychosis and Affective Disorder – Difficult

to Engage

This group has moderate to severe psychotic symptoms with unstable, chaotic lifestyles. There may be

some problems with drugs or alcohol not severe enough to warrant dual diagnosis care. This group

have a history of non-concordance, are vulnerable & engage poorly with services.

18 Organic Cognitive Impairment Cognitive Impairment (Low Need)

People who may be in the early stages of dementia (or who may have an organic brain disorder

affecting their cognitive function) who have some memory problems, or other low level cognitive

impairment but who are still managing to cope reasonably well. Underlying reversible physical causes

have been rule out.

19 Organic Cognitive ImpairmentCognitive Impairment or Dementia

Complicated (Moderate Need)

People who have problems with their memory, and or other aspects of cognitive functioning resulting in

moderate problems looking after themselves and maintaining social relationships. Probable risk of self-

neglect or harm to others and may be experiencing some anxiety or depression.

20 Organic Cognitive ImpairmentCognitive Impairment or Dementia

Complicated (High Need)

People with dementia who are having significant problems in looking after themselves and whose

behaviour may challenge their carers or services. They may have high levels of anxiety or depression,

psychotic symptoms or significant problems such as aggression or agitation. The may not be aware of

their problems. They are likely to be at high risk of self-neglect or harm to others, and there may be a

significant risk of their care arrangements breaking down.

21 Organic Cognitive ImpairmentCognitive Impairment or Dementia (High

Physical or Engagement)

People with cognitive impairment or dementia who are having significant problems in looking after

themselves, and whose physical condition is becoming increasingly frail. They may not be aware of

their problems and there may be a significant risk of their care arrangements breaking down.2011 Cluster Definitions Page 0 of 23

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