Care Cluster Standard Operating Procedures (Clinical)

Clinical Care Cluster Standard Operating Procedures (Clinical) Document Control Summary Status: Amended. Version: v1.2 Date: 16 November 2017 Mike Jones Author: MH Payments & Care Cluster Programme Project Manager Approved by: Policy and Procedures Committee Date: 19/11/2015 Ratified: Policy and Procedures Committee Date: 19/11/2015 Related Trust Strategy and/or Strategic Aims Implementation Date: Review Date: Key Words: Associated Policy or Standard Operating Procedures Care Clusters Clinical, Quality, Information & Finance. Strategic Plan 2015-2017 December 2015 November 2018 Care Cluster, HoNOS, Outcome Measure, Clinical Significance, Four Factor Model Care Cluster Policy

Contents 1. Introduction...2 2. Purpose...3 3. Scope...3 4. Care Clusters...3 4.1. Care Clusters Specific to Service areas..4 4.2. Care Cluster Profiles & Clinical Significance 5 4.3. Using HoNOS as an Outcome Measure....7 4.4 Weighted Domains..8 4.5. Initial Care Cluster Allocation Tool.......9 4.6. Care Cluster Review Tool 9 4.7. When Should Care Clusters be Allocated and Reviewed....9 4.8. Care Cluster Procedures, Responsibilities and Standards.. 13 4.9. Key Performance Indicators.....16 5. Process For Monitoring Compliance And Effectiveness.....17 6. References... 137 Appendix 1... Care Cluster Descriptions Appendix 2... Care Cluster Scoring Profiles Appendix 3 Clinical Significance & Weighted Domains Change Control Amendment History Version Dates Amendments V1.0 24/11/2015 Additional Guidance given in the Review Transition Guidance Section. - Table 2 slightly amended. - Additions made to Comments Section in Table 12 v1.1 01/11/2017 - Title change to Care Cluster Standard Operating Procedures (Clinical) - Deletions to Table 3 - Changes to Care Cluster Allocation Tool guidance Para 4.5 - Addition of Care Cluster Review Tool guidance Para 4.6 - Additions to Transition Protocols. Table 12 - Deletion of Table 13 and associated text - Updated References

1. Introduction The Department of Health (DoH) requires that all Service Users must be assessed and allocated to a Care Cluster by their Mental Health provider. Care Clusters are applicable to Service Users receiving services from; Primary and Secondary Care Mental Health Services (Including Dementia), Eating Disorders and Perinatal Services. The DoH and Monitor have also mandated that all providers should evaluate and report Service and Patient Outcomes via a Clinician Rated Outcome Measure (CROM), a Patient Rated Outcome Measure (PROM) and a Patient Reported Experience Measure (PREM). To be able to measure outcomes effectively it will be necessary to benchmark need and any expected outcomes at the Initial Assessment phase of the patient journey by the use of CROM s and PROM s. In short utilise assessment information/scores through the formulation, Care Planning, review and discharge phases of the patient journey The framework for Care Planning and the evaluation of interventions and outcomes for Clinicians and Service Users is demonstrated in flow chart below. The chart gives an indication of the points within the clinical process that the Outcome measures are to be used: Table 1 Outcome Measures and the Clinical Pathway Measurement of Levels of Recovery and/or deterioration Requirement of new or continuation of current interventions Measurement of Levels of Recovery and Experience Assessment Care Cluster Formulation Care Plan Review Discharge PROM Generic & Specialist including either: SWMWEBS ReQual Benchmark Scores CROM HoNOS 4 Factor Model Benchmark Scores User & Carer Perspective Benchmark Scores Service User Goals Access to associated interventions based upon relevant Care Package CROM HoNOS 4 Factor Model PROM CORE SWMWEBS ReQual Service User Goals CROM HoNOS 4 Factor Model PROM CORE SWMWEBS ReQual Service User Goals GAS/MEO GAS/MEO *(GAS) Goal Attainment Scale (MEO) My Expected Outcomes PREM Note: Other Outcome Measures specific to diagnosis/symptoms may be used The assessment process is the starting point for identifying people s strengths and needs. The assessment for allocation to Care Clusters requires a thorough understanding of an individual s circumstances in order that the Mental Health Cluster Allocation Tool can be completed with scores accurately reflecting the presenting symptoms and needs. Philosophy of Care: The focus of these interventions is to provide holistic care that works with people s needs, concerns, perceptions and strengths and that inspires hopes in them. All care should be formulation based, focussed on recovery and maximising living well and optimise opportunities for personalisation *Mednet Consult Care Pathways

This fits with a model of providing safe and effective services using evidenced based interventions that work to improve the mental health, well-being and recovery of Service Users 2. Purpose The purpose of making a plan and putting it into action is to try and achieve the improvements, changes, or outcomes agreed with the service user at the assessment and information gathering stages This SOP will: *Fundamentals of Mental Health Nursing Edited by: Victoria Clarke & Andrew Walsh Provide information/guidance on Care Clusters Set out Care Clusters Specific to Service Areas Provide information/guidance on Care Cluster Scoring Profiles and Clinical Significance Provide guidance on the use of HoNOS as a Clinically Related Outcome Measure (CROM) HoNOS 4 Factor Model Provide guidance on the use of the Care Cluster Initial Assessment Tool Provide Guidance on the use of the Care Cluster Review Tool Set out Care Cluster Assessment and Review Standards Set out Care Cluster Transitions for Community & Inpatient Services Set out Care Cluster Procedures, Clinical Responsibilities and Standards o Role of the Care Coordinator/Lead Professional in the allocation and review of Care Clusters o Role of CRHT and Inpatient staff in the allocation/review of Care Clusters This SOP should be read in association with all other Trust Policies and Procedures, in particular the Care Cluster Policy and the Care Programme Approach Policy. 3. Scope This Procedure includes all clinical and administrative staff of South Staffordshire & Shropshire Healthcare NHS Foundation Trust. This SOP applies to all service users who access in-scope mental health services, e.g. Secondary Mental Health, Eating Disorders, Perinatal. The policy may also apply to other services as the Mental Health Currency & Payment Mechanism is rolled out to Learning Disability, Children & Adolescent Mental Health Services and Forensic Services This SOP applies to all staff involved in the provision of the above services

4. CARE CLUSTERS There are 21 Care Clusters, each of which describes groups of service users with similar needs and characteristics. These groups/care Clusters can be compared to each other in a variety of ways including: severity of need; complexity of need; acuity; intensity of likely treatment response; anticipated course of illness etc. that helps standardise what care is offered to service users with similar problems. See Appendix 1: Care Cluster Descriptions etc A Care Cluster is a marker which identifies the level of need and the intensity of interventions and the anticipated duration of service provision. For example the anticipated course of treatment for a Care Cluster 4 is 6 to 12 months, Care Cluster 5 is 1 to 3 years, and Care Clusters 14 & 15 is 4 to 8 weeks. The Care Cluster allocated to an individual must be a representation of their assessed need(s) as it will be used in several ways: Treatment: Care Pathways will be aligned to each Care Cluster. They describe the activities that underpin the Care Cluster and provide a process of managed care. They consist of NICE Guidelines and evidenced based interventions. It is likely that there will be CORE (minimum) interventions and SUPPLEMENTARY interventions to be offered as appropriate/required. Outcomes: Each Care Clusters is associated with Well-being & Recovery and positive outcomes. These will be measured by the use of Patient Reported Outcome Measures (PROMS), Clinician Reported Outcome Measure (CROM) and Patient Reported Experience Measure (PREM). HoNOS 4 Factor Model (Speak et al 2013) is the designated CROM and SWEMEB the designated general PROM. Payment/Income: The income the Trust will receive from Commissioners will be based on the numbers of patients allocated to the Care Clusters. The payments will be related to complexity of need, interventions provided and outcomes achieved 4.1 CARE CLUSTERS SPECIFIC TO SERVICE AREAS The tables below identify which Care Clusters are specific to Inpatient and Community Services. Table 2. Mental Health - Inpatient Care Clusters Team Care Cluster Super Cluster Comment 0, 5, 6, 7, 8, Non Psychosis CC4 - low numbers into Inpatient Services Inpatients 10, 13, 14, 15, 16, 17 Psychosis CC12 - low numbers into Inpatient Services 20, 21 Organic

Table 3. Mental Health - Community Services Team Care Cluster Super Cluster Non Psychosis Pathway 0, 4, 5, 6, 7, 8 Non Psychosis Psychosis Pathway 10, 11, 12, 13, 14, 15, 16, 17 Psychosis Memory & Dementia Home Treatment Service CRHT 18, 19, 20, 21 Organic 0, 4, 5, 6, 7, 8 Non Psychosis 10, 12, 13, 14, 15, 16, 17 Psychosis 4.2 CARE CLUSTER SCORING PROFILES & CLINICAL SIGNIFICANCE HoNOS scores have a direct relationship to the allocation of each Care Cluster with colour coding of the scoring ranges indicating the importance of each scale to the membership of each Care Cluster. See Table 4 Table 4.. HoNOS Scoring Importance of Colour Coding Must Score May Score Expected to Score Unlikely to Score The HoNOS Scales (questions) which are scored 0 4 should be seen in the context of clinical significance. Clinical Significance is a way of understanding the HoNOS Scores and relating them to a requirement for interventions in specific need areas. The clinical significance of the scores can be identified by the score descriptions. Scores of zero and one have no or little clinical significance as they represent No Problem and Minor Problem Requiring No Action. Therefore there is an expectation that the service user would not require specific interventions in these areas. Scores of three and four are clearly clinically significant and therefore interventions in these areas would be expected. A score of two is on the cusp; they may or may not be clinically significant in relation to requiring a specific intervention. Problems are definitely present but may be aligned to other areas of need such as hallucinations & delusions and/or overactive behaviour affecting sleep or other behaviours. Clinicians will need to decide if specific interventions for these needs are required in their own right or if they could/may be addressed as part of the interventions for other clinically significant areas of need. Note: Individual Patients may have needs identified and scored which would usually fall within the Unlikely to Score category. In these cases the score should be viewed within the context of Clinical Significance and interventions provided as necessary and appropriate. Table 5 below demonstrates the clinical significance of the HoNOS Scoring profiles. See Appendix 2: Care Cluster 1 21 Scoring Profiles Table 5. HoNOS Scoring/Clinical Significance No Clinical Significance Clinical Significance 0 1 2 3 4 No Problem Minor Problem Requires No Action Mild Problem But Definitely Present Moderate To Severe Problem Severe To Very Severe Problem In the example below (Table 6), HoNOS Scores from an assessment (represented by O) have been overlaid on the Care Cluster 4 Scoring Profile. Clinical Significance of the scoring has been added via a dashed line through rating score 2. Scores falling to the right of this line indicate a Mild to Very Severe problem. The concept facilitates the clear identification of specific need areas from the assessment process and captured during the Care Cluster allocation process. Clinicians should utilise these scores when developing a care plan which should focus on need, specific evidenced based interventions and outcome focussed.

In this example, the identified needs are related to depressed mood and a mild sleep problem - Interventions may be biological or psychological or mixture of both. There is also a history of mild agitated behaviour and repeat self-harm which should be recognised and managed throughout the spell of care with services. The Care Plan should also include timescales and be detailed enough to allow for Outcomes to be measured. In short the Care Plan would be SMART Specific, Measurable, Achievable, Realistic and Timed. Table 6 Example: Care Cluster 4 Scoring Profile & Clinical Significance (Initial Assessment) Care Cluster 4 Rating The 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. 0 1 2 3 4 HoNOS No Clinical Clinical Item Description Scale Significance significance 1 Overactive, aggressive, disruptive or agitated behaviour O 2 Non-accidental self-injury O 3 Problem drinking or drug taking O 4 Cognitive Problems O 5 Physical Illness O 6 Hallucinations and Delusions O 7 Depressed mood * O 8 Other mental & behavioural problems * SLEEP O 9 Relationships O 10 Activities of daily living O 11 Living conditions O 12 Occupation & Activities O 13 Strong Unreasonable Beliefs O A Agitated behaviour / expansive mood O B Repeat Self-Harm O C Safeguarding other children & vulnerable dependant adults O D Engagement O E Vulnerability O At Review the HoNOS Scales are re-assessed and any improvement, deterioration or maintenance of symptoms and circumstances can be identified and reported on. Table 7 demonstrates the improvements in Depressed Mood, Sleep, Activities of Daily Living and Occupation and Activities. (O represents improved Score) Table 7. Example: Care Cluster 4 Scoring Profile & Clinical Significance (Review) Care Cluster 4 Rating The 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. 0 1 2 3 4 HoNOS No Clinical Clinical Item Description Scale Significance significance 1 Overactive, aggressive, disruptive or agitated behaviour O 2 Non-accidental self-injury O 3 Problem drinking or drug taking O 4 Cognitive Problems O 5 Physical Illness O 6 Hallucinations and Delusions O 7 Depressed mood * O O 8 Other mental & behavioural problems * SLEEP O O 9 Relationships O 10 Activities of daily living O O 11 Living conditions O 12 Occupation & Activities O O 13 Strong Unreasonable Beliefs O A Agitated behaviour / expansive mood O B Repeat Self-Harm O C Safeguarding other children & vulnerable dependant adults O D Engagement O E Vulnerability O

Note: Even though scores demonstrate an improvement, there is a need to continue the treatment regime on the same Cluster to maintain improvement/stability 4.3 USING HoNOS AS AN OUTCOME MEASURE - 4 Factor Model (Speak et al. 2012) The 12 Scales of HoNOS translates a clinical encounter into a numerical score, allowing changes to be easily tracked and analysed. - At Initial assessment the assessed HoNOS scores are a benchmark of current need - At Review they are summaries of where improvements and deterioration have taken place, where positive outcomes have been achieved and where interventions may be ongoing or further interventions are required to maintain/increase the levels of recovery achieved. Outcomes can be evaluated on 4 Factors/Dimensions or negative well- being indicators (i.e. Personal Well-Being, Emotional Well-Being, Social Well-Being and Severe Disturbance), which summarise and describe the original HoNOS items in a meaningful way without losing any of the original data contained within the HoNOS. The Factors are used as overarching summaries for the HoNOS items they represent and allow clinicians to see high level summaries of where improvements and deterioration have taken place. This will form the basis of understanding for where positive outcomes have been achieved and where further improvements may be required. The model can also assist clinicians to focus the Care Plan and identify a need for appropriate professionals or services to be involved in the delivery of care and positive outcomes Table 8 below shows the 4 Factors within the Factor Model of HoNOS with each Factor representing a summary of individual items or scales that make up that Factor. Item 12 (problems with occupations and activities) appears in both the personal and social well-being factors. This is because this item contributes equally to both factors. Table 8: Speak et al. 4 Factor Model of the HoNOS 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

In Table 9 below the individual and accumulated HoNOS Scores from the example in Table 6 (Initial Assessment) and Table 7 (Review) are reflected in the 4 Factors of Personal, Emotional & Social Well-Being and Severe Disturbance. Table 9: 4 Factor Model Scoring Matrix HoNOS Scale Factor Individual Score (Initial Assessment) Accumulated Score Individual Scores (Review) Accumulated Score 4 Cognitive Problems 0 0 5 Physical Illness 0 0 Personal 2 (16) Well-Being 10 Activities of daily living 1 0 0 (16) 12 Occupation & Activities 1 0 2 Non-accidental self-injury 0 0 7 Depressed mood * Emotional Well-Being 3 5 (12) 2 8 Other mental & behavioural problems: Sleep 2 1 3 (12) 3 Problem drinking or drug taking 0 0 9 Relationships 1 1 Social 3 (16) Well-Being 11 Living conditions 1 1 2 (16) 12 Occupation & Activities 1 0 1 Overactive, aggressive, disruptive or agitated behaviour 0 0 Severe 0 (8) Disturbance 6 Hallucinations and Delusions 0 0 0 (8) TOTALS 10 10 (48) 5 5 (48) *Figures in Brackets = Max Score for each Factor To establish just how effective the interventions/packages of care are at meeting the needs of Service Users within each of the Factors there will need to be a reduction shown in the HoNOS scores at Review. The key thing to remember is that in the majority of people, the HoNOS scores will not generally change significantly in the short term. However, when a person is acutely unwell there may be significant changes in the short-term as symptoms/behaviours etc are treated and managed. 4.4 WEIGHTED DOMAINS As well as identifying areas of need the HoNOS Scoring and Clinical Significance of the scoring is used for an Outcome Framework of Weighted Domains. The aim of which is to provide clinicians, managers and commissioners with an overview of expected recovery levels for the population of each individual Care Cluster. Table 10 below gives a high level view of expected areas of interventions and outcome levels across the 4 Factor Model and Recovery Domains. Appendix 3 provides further information. The weighted domain concept shows that the following high level outcomes could be expected from interventions provided under the Care Clusters:

Table 10 Care Cluster High Level Outcomes Super Cluster Care Cluster High Level Expected Outcomes 1 2 3 4 5 Non Psychotic Psychotic Organic Improvement & Discharge with minimum transition to higher clusters (deterioration) Improvement & Discharge with minimum transition 6 7 Stability & Discharge 8 9 NA 10 Improvement & Discharge with minimal step up (deterioration) 11 Stability & Discharge 12 13 Improvement, Stability, minimal step up (deterioration) & Discharge 14 15 Improvement 16 17 Improvement, Stability & Discharge 18 Stability & Discharge or Deterioration & step up to higher Clusters 19 Deterioration in Cognitive functioning with possible stability/improvement in other factors 20 21 4.5 CARE CLUSTER INITIAL ASSESSMENT TOOL The purpose of the Care Cluster Initial Assessment Tool (CCIAT) is to guide clinicians to allocate the service user to one of 21 Care Clusters (post initial assessment) which describes people who, although their specific diagnosis may be different, have similar levels of need. The CCIAT within RIO works on an algorithm based on the12 HoNOS Scales/Questions and a further 6 additional Scales/Questions. Each scale is given a rating from 0 (no problem) to 4 (severe to very severe problem) and question prompts are available and must be used to assist with accurate scoring. Following the selection of a Super Cluster and the rating/scoring of these questions the clinician must use information provided from their Assessment and use clinical judgement to allocate the appropriate Care Cluster NOTE: The Care Cluster Initial Assessment Tool has been designed for use at the first Care Cluster allocation in any new Assessment Period (i.e. the assessment and clustering of new or re-referrals to services) only. It is not to be used for reviewing Care Clusters. 4.6 CARE CLUSTER REVIEW TOOL The purpose of the Care Cluster Review Tool is to guide clinicians to correctly allocate a Care Cluster at review. The Care Cluster Review Tool captures the 12 HoNOS & 6 Additional Questions scores so they can be used as an Outcome Measure, but does not use an algorithm to predict a Care Cluster. Care Cluster Selection is a clinical choice based on whether the service User has experienced a level of Recovery, Minimum/No Change, Deterioration or Change in Diagnosis. The clinical selection is guided by the Care Cluster Transition Protocols 4.7 WHEN SHOULD CARE CLUSTERS BE ALLOCATED AND REVIEWED? Initial Assessment - A Care Cluster must be allocated to a person if following assessment they are to be offered services/interventions. This is termed as the Initial Care Cluster and must be allocated at the end of the initial assessment. Transfers between SSSFT Mental Health Services are not defined as initial assessments Review A Care Cluster must be reviewed at the following points in a patient s journey in accordance with the Local Review periods: All planned CPA or other formal care reviews including Discharge from Mental Health Services

Table 11. Care Cluster Review Periods Cluster Cluster Review Care Cluster Label No Interval (maximum) 0 Variance 6 months 1 Common mental health problems (low severity) 12 weeks 2 Common mental health problems 15 weeks 3 Non-psychotic (moderate severity) 6 months 4 Non-psychotic (severe) 6 months 5 Non-psychotic (very severe) 6 months 6 Non-psychotic disorders of overvalued Ideas 6 months 7 Enduring non-psychotic disorders (high disability) 6 months 8 Non-psychotic chaotic and challenging disorders 6 months 9 Blank Care Cluster Not applicable 10 First episode in psychosis 6 months 11 Ongoing recurrent psychosis (low symptoms) 6 months 12 Ongoing or recurrent psychosis (high disability) 6 months 13 Ongoing or recurrent psychosis (high symptom and disability) 6 months 14 Psychotic crisis 4 weeks 15 Severe psychotic depression 4 weeks 16 Dual diagnosis (substance abuse and mental illness) 6 months 17 Psychosis and affective disorder difficult to engage 6 months 18 Cognitive impairment (low need) Annual 19 Cognitive impairment or dementia (moderate need) 6 months 20 Cognitive impairment or dementia (high need) 6 months 21 Cognitive impairment or dementia (high physical need or engagement) 6 months Note: Care Cluster reviews must be aligned to Care Programme Approach (CPA) reviews. The Review frequencies quoted are outer limits, not absolute frequencies. When a Service User reaches the Review interval specified for their Care Cluster, the Care Co-ordinator must carry out a review of the HoNOS Score and re-affirm or re-allocate a Care Cluster as necessary. Any other point where a significant change in planned care is deemed necessary; Unplanned reviews, Hospital admissions Transfer to another Team/Service e.g. Referral to CRHT Note: When a change in the planned care is required, such as a referral to CRHT or admission to hospital etc, then it is necessary for the Care Co-ordinator to carry out a review of the HoNOS Score and re-affirm or re-allocate a Care Cluster as necessary. This review should be carried out without delay and the information passed to the receiving Team/Ward. Clinicians must always check the previous Super Cluster (Non Psychotic, Psychotic, Organic), the allocated Cluster and scores and bear these in mind in deciding which Cluster descriptions best meet the Service User s historical and current presentation Non Psychotic Care Clusters are NOT used as a stepped care model in the sense that the Care Cluster is reduced as the Service User symptoms, needs etc improve. If symptoms become more severe or condition becomes enduring (evidenced by HoNOS Scores and Cluster descriptions) then the Service User should be allocated to a Care Cluster which best describes their condition and provide the service/intervention level appropriate to need. When the agreed optimum level of recovery had been reached (evidenced by lower or maintained HoNOS Scores) the Service User must be discharged on the Care Cluster which provided the level of interventions that facilitated the recovery In many Non Psychotic cases it is appropriate that the Service User remains on the same Care Cluster even though their needs/presentation fluctuates (as evidenced in higher or lower HoNOS Scores) throughout their care spell e.g. Care Cluster 6, 7, 8.

Psychotic Care Clusters - Before a Service User is reallocated to a Care Cluster with interventions of a lower level of intensity, the assessed recovery needs to have been significant and sustained over a protracted period of time. In most cases (except CC10, 14 & 15) this will be 12 months. As symptoms/condition deteriorates or the Service User relapses (evidenced by HoNOS Scores) then it s necessary to reallocate to a more appropriate Care Cluster. E.g. Move from Care Cluster 11 to Care Cluster 12, 13, 14 or 15 depending on severity of symptoms. As symptoms etc are controlled and levels of recovery are achieved (evidenced by lower HoNOS Scores) the Service User must be reallocated to a more appropriate Care Cluster. However the move to this Care Cluster requires the Service User to have met the criteria of the proposed Care Cluster for a protracted period of time. E.g. 12 months before moving from Care Cluster 13 to Care Cluster 12. Organic Care Clusters Generally Service User will only move up Care Clusters as condition deteriorates. Some move to lower Cluster (except 18 or 19) is possible if the Service User needs are being met. E.g. Physical health stabilised. Discharge from Mental Health Services Note: If a Service User is allocated to an appropriate Care Cluster at initial assessment and/or Review the treatment is successful (evidenced by lower HoNOS Scores) then the Service User must be discharged on that Care Cluster The purpose of the re-assessment of the Care Cluster is the evaluation of the Clinician Rated Outcome Measure (HoNOS). Care Cluster Transitions at Review are indicated within Table 12 below. These are based on clinical evidence and identify for each Care Cluster: the length of time Service Users may remain in Mental Health Services; a frequency for re-assessing the appropriateness of the Care Cluster; and the likelihood of each possible Care Cluster Transition. Only when a set of criteria have been met should the allocated Care Cluster be changed.

Table 12. Care Cluster Transitions at Review Care Cluster Review Period Indicative Period of Care Care Cluster Transitions (at Review) No Change in Diagnosis Improvement Minimal/No Change Deterioration Change in Diagnosis 0 6 Months 12 Months CC0 CC0 CC4, CC5, CC6 CC8, CC10, CC14, CC15, CC18 Comments Allocated when SU does not meet criteria for other Clusters but requires a MH Service. i.e. Low MH but high risk & Autistic Spectrum without MH needs 1 4 Weeks 12 Weeks CC1 CC1 CC2, CC3, CC4, CC5 CC8, CC10, CC14, CC15, CC18 CC1 not used in Secondary Care MH Services. 2 4 Weeks 15 Weeks CC2 CC2 CC3, CC4, CC5 CC8, CC10, CC14, CC15, CC18 CC2 not used in Secondary Care MH Services. 3 6 months 6 months CC3 CC3 CC4, CC5 CC8, CC10, CC14, CC15, CC18 CC3 not used in Secondary Care MH Services. 4 6 months 12 Months CC4 CC4, CC5, CC6 CC5, CC6, CC8, CC10, CC14, CC15, CC19 No change of Diagnosis - After 12 months allocate CC5, CC6 as indicated by the severity of symptoms and needs 5 6 months 3 years CC5, CC6 CC5, CC6 CC5, CC6, CC7 CC8, CC10, CC14, CC15, CC19 No change of Diagnosis - After 3 years allocate CC6, CC7 6 6 months 3 + years CC6, CC6 CC6 CC8, CC10, CC14, CC15, CC19 7 6 months 3 + years CC7 CC7 CC7 CC8, CC10, CC14, CC15, CC19 8 6 months 3 + years CC8 CC8 CC8 CC5, CC6, CC7, CC10, CC14, CC15, CC19 9 6 months NA NA NA NA NA 10 6 months 3 years CC10, CC11, CC12, CC13, CC16, CC17 11 6 months 3 + years CC11 CC11 CC10, CC11, CC12, CC13, CC16, CC17 CC14, CC15 CC12, CC13, CC14, CC15, CC16, CC17 CC5, CC6, CC8, CC19 CC19 CC7 not used for first presentation or returning patient.to Secondary MH Services After 3 years on CC10 SU should be reallocated to CC11, CC12, CC13, CC14, CC15, CC16, CC17 as indicated by the severity of symptoms and needs CC11 not used for first presentation to Secondary Care MH Services or Acute Care Pathway (CRHT & Inpatients) If the SU has had a referral to CRHT, Inpatients, MHA Assessment or have not been concordant with medication in the last 12 months then they must be stepped up to CC12, CC13, CC14 or CC15 as indicated by severity of symptoms and needs 12 6 months 3 + years CC11, CC12 CC12 CC13, CC14, CC15, CC16, CC17 CC8, CC19 If the SU has improved but had a referral to CRHT, Inpatients, MHA Assessment or have not been concordant with medication in the last 12 months then they must remain on CC12 13 6 months 3 + years CC12, CC13 CC13 CC14, CC15, CC16, CC17 CC19 If the SU has improved but had a referral to CRHT, Inpatients, MHA Assessment or have not been concordant with medication in the last 12 months then they must remain on CC13 14 4 Weeks 15 4 Weeks 8 12 weeks 8 12 weeks CC10, CC13, CC16, CC17 CC10, CC13, CC16, CC17 CC14 CC14, CC15 CC4, CC5, CC6, CC8, CC19 CC15 CC14, CC15 CC5, CC6, CC8, CC19 16 6 months 3 + years CC13, CC16 CC16 CC14, CC15, CC16, CC8, CC19 Can re- allocate CC16 or CC17 If the SU was on either of these Clusters immediately prior to Allocation of CC14 Can re- allocate CC16 or CC17 If the SU was on either of these Clusters immediately prior to Allocation of CC15 17 6 months 3 + years CC13, CC17 CC17 CC14, CC15, CC17 CC8, CC19 18 12 months 3 + years CC18 CC18 CC19, CC20, CC21 CC4, CC5, CC10, 19 6 months 3 + years CC19 CC19 CC20, CC21 20 6 months 3 + years CC20 CC20 CC21 21 6 months 3 + years CC21 CC21 CC21

4.8 Care Cluster Procedures, Responsibilities and Standards All clinical staff must: be familiar with and adhere to the Care Cluster Policy & Procedures, Responsibilities and Standards to guide and inform their practice Carry out their Care Cluster Responsibilities following agreed processes and record information as required on the Trust s clinical system. Table 13. Care Cluster Procedures, Responsible Clinician, Standards Procedure Clinical Area Responsible Clinician Standard Guidance - Within a Maximum of 2 x Face to Face (F2F) Contacts Community Assessing Clinician - 2 x F2F Contacts to be completed within 28 Calendar Days (*Memory Assessment/Diagnosis maximun 12 weeks) - Scoring of HoNOS meets the Red Rules for Care Cluster Allocated. If Red Rules not met record clinical rational for decision to allocate Cluster - Care Clusters Specific to Service Areas Table 3 - Care Cluster Scoring Profiles & Clinical Significance Appendix: 1 & 2 - NICE Guidance - Develop evidence based Care Plan Initial Assessment - Within 2 X F2F Contacts - Care Clusters Specific to Service Areas Tables 2 & 3 (Cases not Known or Open to Services) CRHT Assessing Clinician - Scoring of HoNOS meets the Red Rules for Care Cluster Allocated - Care Cluster Scoring Profiles & Clinical Significance Appendix: 1 & 2 - Develop evidence based Care Plan - NICE Guidance Inpatient Assessing Clinician - Within 2 Bed nights of Admission - Cluster Allocation back dated to Admission Time & Date - Scoring of HoNOS meets the Red Rules for Care Cluster Allocated - Care Clusters Specific to Service Areas Table 2 - Care Cluster Scoring Profiles & Clinical Significance Appendix: 1 & 2 - Develop evidence based Care Plan - NICE Guidance

- 5 Days Prior to Referral (Case Transfer) - Review Periods Table 11 Formal Review (Includes formal transfer /shared care of case to other Team or Service) - e.g. CMHT to CRHT CPA & Non CPA Community CRHT Inpatient Care Co-Ordinator or Lead Professional Joint Responsibility Inpatient/CRHT Clinician & Community Care Co-ordinator - Within maximum time period relevant to Cluster (Completed within 10 days prior to review date) - Clusters must follow/adhere to Cluster Transition Protocols - Reviewed/amend Risk & Care Plan - Within maximum time period relevant to Cluster - Clusters must follow/adhere to Cluster Transition Protocols - Care Cluster Transitions at Review Table 12 - CPA Policy - NICE Guidance - Review Periods Table 11 - Care Cluster Transitions at Review Table 12 - NICE Guidance - Care Clusters Specific to Service Areas Table 3 Referral/Transfer to Acute Care Pathway CRHT & Inpatient Services Community Care Co-ordinator or Referring Clinician - In hours Referral: 5 days prior to referral date - Out of Hours Referral: Within 72hrs of Referral Date/Time - Clusters must follow/adhere to Cluster Transition Protocols - Reviewed/amend Risk & Care Plan - Care Cluster Scoring Profiles & Clinical Significance Appendix: 1 & 2 - Care Cluster Transitions at Review Table 12 - CPA Policy - NICE Guidance Community Care Co-Ordinator or Lead Professional - Within 24 hours of Discharge Review - Clusters must follow/adhere to Cluster Transition Protocols - Care Clusters Specific to Service Areas Table 3 - Care Cluster Transitions at Review Table 12 - CPA Policy Discharge from Service CRHT Lead Professional - Within 24 hours of Discharge Review - Clusters must follow/adhere to Cluster Transition Protocols - Care Clusters Specific to Service Areas Table 2 & 3 - Care Cluster Transitions at Review Table 12 - CPA Policy Inpatient Inpatient Clinician - Within 24 hours of Discharge Review - Clusters must follow/adhere to Cluster Transition Protocols - Care Clusters Specific to Service Areas Table 2 - Care Cluster Transitions at Review Table 12 - CPA Policy Care Planning Community Care Co-ordinator or Lead Professional - Use HoNOS Scores (Clinical Significance) Scores 2, 3 & 4) to guide Interventions (appropriate to need & Service) detailed in Care Plan - Care Cluster Scoring Profiles & Clinical Significance Appendix: 1 & 2 - NICE Guidance

CRHT Assessing Clinician - Use HoNOS Scores (Clinical Significance) Scores 2, 3 & 4) to guide Interventions (appropriate to need & Service) detailed in Care Plan - Care Cluster Scoring Profiles & Clinical Significance Appendix: 1 & 2 - NICE Guidance - Care Cluster Scoring Profiles & Clinical Significance Appendix: 1 & 2 Inpatient Assessing Clinician - Use HoNOS Scores (Clinical Significance) Scores 2, 3 & 4) to guide Interventions (appropriate to need & Service) detailed in Care Plan - NICE Guidance - Use HonOS as the general Clinically Rated Outcome Measure (CROM) to: - Benchmark need at Initial Assessment - Identify improvement, deterioration or stability at review - Identify stability or improvement at Transfer/Discharge Outcome Measures Community CRHT Inpatients All Clinicians - Use SWMWEBS as the general Patient Rated Outcome Measure (PROM) to: - Benchmark need at Initial Assessment - Identify improvement, deterioration or stability at review - Identify stability or improvement at Transfer/Discharge - Patient Goals - Identify Patient Goals at Initial Assessment - Identify improvement, deterioration or stability at review by Goal Attainment - Identify stability or improvement at Transfer/Discharge by Goal Attainment Utlise symptom specific outcome measures as required e.g. PHQ9 & GAD7

4.9 Key Performance Indicators KPI DESCRIPTION No Caseload TARGET 1 Active Cases allocated an appropriate Care Cluster 100% 2 All allocated Care Clusters are reviewed with the maximum time period relevant to allocated Cluster 95% 3 Allocated Clusters are appropriate to Specific Service Areas 100% Initial Assessment 4 Care Cluster Allocation completed within 2 x Face to Face contacts or within 2 x bed nights if admitted to Inpatient Services 100% 5 2 x Face to Face Contacts completed within 28 calendar days 95% 6 HoNOS Scores meet Red Rules for Cluster allocated at Initial Assessment 95% Formal Review 7 HoNOS & Care Cluster Reviewed within maximum time period relevant to allocated Cluster 95% 8 Allocated Cluster at review adheres to Transition Protocols 95% Informal Review (Change in Circumstances) Transfer to CRHT/Inpatient Services 9 In Hours referral HoNOS & Cluster reviewed within 5 Days prior to referral date/time 95% 10 Out of Hours Referral HoNOS & Cluster reviewed within 72 hours of Referral date/time 95% 11 Allocated Cluster at review adheres to Transition Protocols 95% Discharge from Mental Health Services 12 HoNOS & Care Cluster reviewed within 24 Hours of Discharge Review date/time 95% 13 Allocated Cluster at review adheres to Transition Protocols 95%

5. Process for Monitoring Compliance and Effectiveness This Procedure will be reviewed 3 yearly or earlier in light of new national guidance or other significant change in circumstances. Compliance with this policy will be monitored through the mechanisms detailed in the table below. Aspect of Compliance or effectiveness being monitored Responsibilities Care Cluster Allocation Process Adherence to Care Cluster Review Periods Adherence to Care Cluster Transition Protocols Care Cluster data used in Supervision Monitoring Method - Supervision - Audit - Supervision - Audit - Supervision - Audit - Supervision - Audit - Audit Individual Department responsible for Monitoring MH Operational Forums MH Operational Forums MH Operational Forums MH Operational Forums MH Operational Forums Frequency for monitoring activity - Monthly - Annual - Monthly - Annual - Monthly - Annual - Monthly - Annual - Monthly - Annual Group/Committee/ Forum which will receive the findings/monitoring report Quality & Governance and the Finance & Performance Committees Quality & Governance and the Finance & Performance Committees Quality & Governance and the Finance & Performance Committees Quality & Governance and the Finance & Performance Committees Quality & Governance and the Finance & Performance Committees Committee/Individual responsible for ensuring that the actions are completed MH Operational Forums MH Operational Forums MH Operational Forums MH Operational Forums MH Operational Forums Development and implementation of Care Pathways Minutes of relevant Development Group MH Operational Forums - Monthly - Annual Quality & Governance and the Finance & Performance Committees MH Operational Forums Development and implementation of Outcome Measures Minutes of relevant development Group MH Operational Forums - Monthly - Annual Quality & Governance and the Finance & Performance Committees MH Operational Forums 6. References - DH Mental Health Clustering Booklet V5.0 Gateway Ref: 04421 (2016-17) - Monitor 2016/17 National Tariff Payment System: Gateway Reference: 04953. March 2016 - The White Paper, Equity and Excellence; Liberating the NHS - Wing, J. K., Curtis, R. H. & Beevor, A. S. (1999) Health of the Nation Outcome Scales (HoNOS). British Journal of Psychiatry, 174 (5), 432-434. - Self R; Rigby A; Leggett C and Paxton R (2008) Clinical Decision Support Tool: A rational needsbased approach to making clinical decisions. Journal of Mental Health..