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Mental Health Payment by Results (PbR)

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Outline• Why move to PbR?• What is the mental health currency?• Care clusters• How does clustering work• Assessment• Transition protocols• Care packages• Pricing• Implementation timeline• Local commissioner update• Local trust update

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Why does MH commissioning need to change?

• Quality, efficiency and the cost of MH care have been variable across the country, and with little flexibility or patient choice.

• Economic context makes it all the more important to ensure we get the best value for every single pound of tax payer money we spend. We need a framework that will enable us to do just that.

• Providers in MH are fed up with acute providers taking all the money and being left as a soft target.

• Commissioners need to demonstrate more value from substantial MH investment.

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Why move to PbR?

• Facilitate patient choice

• Enable diversity of provision

• Introduce some of the benefits of a market without having to negotiate the cost. Reward quality more!

• Promote efficiency at higher cost trusts (because they have to reduce costs to a national tariff level) and there is more standardisation of pathways

• Refocus discussions between commissioner and provider

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The Mental Health Currency

• The mental currency is care clusters – the tariff is based on the packages of care and interventions that go with it.

• A key issue for mental health and PbR is that in many cases diagnosis and severity of the illness do not predict resource use accurately.

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What is in the currency?

• All mental health care should be covered by the clusters.

• The clusters are designed to be setting independent, on the premise that people should be treated in the least restrictive care setting possible.

• They should cover care provided by social care staff of integrated services (Section 75 agreements).

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Care clusters – some characteristics

• The care clusters are based primarily on the needs and characteristics of a service user.

• Expected diagnoses are given for each cluster, but the same diagnosis can appear in multiple clusters.

• The clusters are mutually exclusive in that a service user can only be allocated to one cluster at a time.

• Clinicians allocate patients to clusters using the Mental Health Clustering Tool (MHCT)

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Description of clusters

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Decision tree for clustering

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MH PbR vs acute PbR• Care clusters are needs based but clinically relevant (Acute

PbR uses HRGs, based on diagnosis (ICD-10)* and procedures (OPCS-4)**

• Clusters are different from Acute HRGs– Currently only 21 clusters (c/f approx. 1,500 HRGs)– Clusters cover extended periods of time (HRGs cover short

term, completed episodes of care)– Clusters are determined at the beginning of the process

(HRGs are determined at the end of treatment – finished consultant episodes)

– Clusters embody a review / transition process (HRGs have no equivalent)

– Nobody has yet successfully implemented an MH PbR process (Acute PbR has been working since 2003/4)

* International Statistical Classification of Diseases and Related Health Problems 10th Revision

** Office of Population Censuses and Surveys Classification of Surgical Operations and Procedures (4th revision)

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How will PbR work?

• MH providers will be paid for actual patients they see and treat (X patients x £Y for each cluster)

• Payment initially based on a local tariff (possibility of moving to a national tariff)

• Tariff will use 20 clusters to reflect patient complexity

• This will expand over time as the system becomes more refined– PbR initially encompasses Adult and Older Adult services

only– Projects are underway to extend MH PbR to CAMHS, LD,

Forensics, IAPT, Alcohol services, Quality and Outcomes

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How does clustering work?

• Part1 – 11 HoNOS items and 1 SARN item related to severity of problems during 2 weeks prior to assessment (HoNOS scale 1 is not used for clustering)

• Part2 – 5 SARN items consider problems from a ‘historical’ perspective: these may not have been experienced during the two weeks prior to assessment

• This then also gives a baselines from which to measure outcomes later at transition points agreed nationally

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How does clustering work? (cont’d)

• Step 1 - Routine screening assessment process to score the patient’s needs using MHCT (will suggest the closest fit – maybe more than one possible cluster); or

• Step 2 - Decision tree - to decide if the presenting needs are “A,B,C” (“super clusters)This will then narrow down the list of possible clusters.

• Step 3 - Look at the grids - which one is the most appropriate?– red: level of need which must score– orange: expected scores -– yellow : may score

• Final clustering decision is based on clinical judgement applying the guidance

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What is the Initial Assessment• It relates to new referrals and ‘one-off’ assessment

services, rather than to re-assessments of existing service users

• The initial assessment can be triggered in a number of ways– E.g. GP referral or self referral and others

• These initial assessments can be classified in three ways

a) Assessed not clustered

b) Assessed, clustered

c) Assessment ‘service’N.B: Great potential to print money – so prior approval rules important to be developed, particularly if GPs want telephone advice with Consultants etc.

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Duration of Initial Assessment

• The assessment is completed when the individual is either allocated to a cluster, not allocated, or the provision of the one-off service has concluded.

• An initial assessment will take no more than two community or outpatient sessions or two inpatient days

NB: The Initial Assessment is not necessarily a full diagnostic assessment – it is principally for the purpose of clustering the patient.

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Transition Protocols

• Use of the MHCT is appropriate only on initial assessment

• At review, Transition Protocols must be used

• These describe different criteria to be used to determine whether a patient should change clusters or notNB: a change of cluster will mean a change of care package

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Concepts included in the Care Transition Protocols

• Indicative episode of care– The length of time service users typically need to be

in receipt of a specific package of care– Indicative episode refers to current understanding of

reasonable practice– Variations will occur around this duration

• Cluster review interval– Review interval refers to the maximum time that

should elapse between scheduled clinical reviews– Review intervals are appropriate to the cluster rather

than being a universal standard

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Care packages

• The clusters do not define the appropriate interventions and treatments to meet an individual’s characteristics

• Exact format of care packages to be decided locally

• Providers have the flexibility to develop innovative approaches to care

• Care packages can be tailored to an individual’s requirements (support the personalisation agenda)

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Care packages (cont’d)

• Content of care packages should reflect NICE guidance

• Content and format will vary due to location

• Guidance on care packages content www.mednetconsult.co.uk/imhsec

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Care packages (cont’d)

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Pricing issues

• Local vs regional vs national• Cost per day per cluster• Cost per cluster episode• Cost for assessments• Top-ups/additional payments• How cost becomes price• Payment for outcomes

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Main critical risks and issues

• Volatility of expenditure• Savings required at a time of major change• Data collection requirements• Variation in the accuracy of clustering and the

quality of clustering data• Clarity around costing• New standard contract• Both commissioners and providers must work

on this together

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2010/11

Mental health currencies (clusters & clustering tool) made available for use

2011/12

All eligible patients to have been clustered

2012/13

Transition protocols to be implemented

Algorithm to become available for use

Care packages to be developed for each cluster

Local prices to be developed (average cluster cost per day)

2013/14

Care packages to form the basis of contract service specifications

Local tariffs to be implemented

2015/16

Earliest date for national tariffs to be introduced (and only if sufficiently robust data available)

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Expanding the scope

• Current scope WAA & OP (50-75%)• Forensic MH (1% NHS spend)• IAPT• CAMHS• Alcohol and Drugs• Learning Disability

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Lots more to do

• Develop the guidance further – 3 year plan• Improve communications• Improve data quality• Social care, PHB’s, SDS• Outcomes• Competing priorities & economic

pressures

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Benefits

• Greater focus on the individual and their needs

• Transparency – common language• Developing benchmarking• Increased knowledge and awareness of

what is offered/provided – choice• Opportunity to establish an outcomes

focus

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Add local commissioner update here:

• PbR technical group• Development of service specs• Data schedules and collection• Engagement with CCGs

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Add local trust update here:

Clustering• progress so far• next steps

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Add local trust update here

Care packages development• progress so far• next steps

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Add local trust update here

Costing• progress so far• next steps

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Issues to consider

• Governance structure• Rebasing – ‘price per cluster per

organisation’• Care packages• Non-PbR activity

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Next steps

• How do you want to move forward from here?