Clinical CARE CLUSTER POLICY Document Control Summary Status: Version: Author: Amended v1.2 Date: 16 November 2017 Mike Jones MH Payments & Care Cluster Programme Project Manager Approved by: Policy and Procedures Committee Date: 19.11.2015 Ratified: Trust Board Date: 26.11.2015 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 November 2015 November 2018 Care Cluster, HoNOS, Outcome Measure, Clinical Significance, Four Factor Model Care Cluster SOP s 1
Contents 1. Introduction... 3 2. Purpose... 4 3. Scope... 3 4. Philosophy... 4 5. Responsibilities, Accountabilities & Duties....5 6. Care Cluster Processes.7 7. Process For Monitoring Compliance And Effectiveness.7 8. References....8 Change Control Amendment History Version Dates Amendments V1.0 24/11/2015 Name change from Care Cluster Handbook to Care Cluster Procedures V1.1 16/11/2017 Updated References Remove wording Procedure Handbook and replace with and Standard Operating Procedures Updated MH job and Group titles 2
1. Introduction The Department of Health mandated the use of Care Clusters from April 2012 as the preferred currency for recording activity within all Mental Health Services for working age adults and older people in England. The purpose of this is to ensure Service Users coming into contact with Mental Health Services will be offered the right package of care, based on best practice, but personalised to meet their individual needs, and focused on supporting Service Users to move towards Well-being and Recovery Positive Experience of Care with Positive Outcomes 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. Care Clusters must be allocated/reviewed by the responsible clinician at the following points and within the given standards and timescales: - Initial Assessment - Review All planned CPA or other formal care reviews 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 - Discharge from Mental Health 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), Patient Goals (Goal Attainment Scale) and a Patient Reported Experience Measure (PREM). 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 This Policy supersedes The Care Cluster Policy V1.0 December 2013. This policy should be read in association with other Trust Policies, Standards and Procedures, in particular the Care Cluster Procedures and Care Programme Approach Policy 2. Purpose Care Clusters are an integral part of the overall Care Planning and Outcomes Framework. The purpose of this Policy and associated Care Cluster Procedures is to provide information, identify clinical processes, standards and responsibilities in the allocation, review and monitoring of Care Clusters. 3. Scope This policy includes all clinical and administrative staff of South Staffordshire & Shropshire Healthcare NHS Foundation Trust. The policy 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 3
to Learning Disability, Children & Adolescent Mental Health Services and Forensic Services The policy applies to all staff involved in the provision of the above services 4. Philosophy Both the Care Clusters and the Mental Health Payment Mechanism support the understanding of Service User needs and incentivises evidence based interventions with RECOVERY at the centre. Philosophy of Care: The focus of 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 Service User Journey: 1. Holistic Assessment (of strength, needs & aspirations) 8. Discharge 2. Summarise assessment findings (Mental Health CCAT) 7. Review (At maximum frequencies according to Care cluster) 3. Allocate a Care Cluster (Based on main presenting needs) 6. Implement agreed care package. (In partnership or a sole worker if one agency) 5. Negotiate individualised care package 4. Refer to Care Cluster specific Care Package (Containing relevant best practice guidance and setting out trusts standards of care) (Tailor care package to individual) Ref: CPPP 4
5. Responsibilities, Accountabilities & Duties The Board of Directors The Board of Directors has responsibility for the implementation and the monitoring of compliance of this Policy and Standard Operating Procedures. This responsibility is delegated to the Trust Chief Executive who will delegate lead responsibility to an Executive Director. Policy & Procedures Committee The Policy & Procedure Committee will monitor adherences to this and other related policies and report on practice to Trust Board of Directors. The Chief Operating Officer/Director of Nursing As nominated Executive Lead, the Chief Operating Officer is responsible for: Monitor and review the implementation of the Care Cluster Policy and Standard Operating Procedures Adequate resources and training being available to the clinical team. Monitoring staff attendance on training through the receipt of reports from the Training Department in line with the requirements set out within the Training Needs Analysis. The provision and monitoring of operational and clinical supervision to clinical staff. The Chief Operating Officer/Director of Nursing is responsible for resolving issues where there are differences of opinion, which cannot be resolved by the Clinical Directors in Mental Health and Specialist Services. Director Quality and Clinical The Director of Quality and Clinical is responsible for providing monitoring/audit processes regarding adherence to the policy. Heads of Service/Directors Heads of Service/Directors are responsible for: The implementation of the Care Cluster Policy and Standard Operating Procedures across the Directorates The ongoing review of the Care Cluster Policy and Standard Operating Procedures to keep it up to date with current best practice Providing reports to the Senior Management Team (SMT) and the Currency Development & Payment Systems Group on any issues associated with the implementation of the policy Facilitating effective joint working with internal and external partners and stakeholders Ensuring staff access relevant training as set out in the Training Needs Analysis. Currency Development & Payment Systems Group The Currency Development & Payment Systems Group will: Oversee the implementation of the Payment Mechanism process within participating Services as outlined within the Policy The ongoing review of the Care Cluster Policy and Standard Operating Procedures to keep it up to date with current best practice Operational The Mental Health Operational will oversee the Operational Management of Care Clusters within Clinical Practice and provide assurance to the Finance & Board and the Currency Development & Payment Systems Group in regard to: Clinical implementation and continued use of Care Clusters Development of Care Pathways (Care Cluster Standards Framework) 5
Ensuring quality evidence based interventions and Outcome Measures are agreed and implemented within Clinical Practice Ensuring Clinical Compliance with Care Cluster Standards and KPI s Managing operational issues as advised, taking action as appropriate to agree and facilitate any required changes Managing operational risks as advised, taking action as appropriate to minimise/manage risk Identifying linkages with other Programmes/Policies to ensure duplication of work is minimised as much as possible Identifying and proposing clinical audits as required Overseeing a communication/staff engagement strategy for the Care Cluster programme and to ensure adequate and regular communication is provided to staff Determining appropriate content and frequency for reporting to other Boards Maintaining awareness of the National Care Cluster Programme Heads of Service, Service Managers & Service Manager/Matrons Heads Service, Service Managers and Service Managers/Matrons are responsible for the implementation of the Care Cluster Policy and Standard Operating Procedures within their areas of responsibility. They will: Ensure all relevant staff access the agreed Care Cluster training. Oversee the actions to address any under-performance Provide a narrative to the Executive Lead as required Provide evidence of service improvements established to address performance Where performance is lower than specified targets, the Managers will provide the Heads of Service/Director with reasons for non-compliance; which will be reported to the relevant group. Pathway Managers, Quality Leads, Ward Managers Pathway Managers, Quality Leads and Ward Managers are responsible for implementation of the Care Cluster Policy and Standard Operating Procedures within their areas of responsibility. They will: Ensure all relevant staff access the agreed Care Cluster training. Ensure Care Clusters are part of Clinical & Managerial Supervision carried out on a monthly basis Ensure Care Cluster processes are carried out by community and inpatient staff Validate the data provided by the Business Support Officers and/or Information Team and address any identified breaches with the clinicians/clinical teams. Where performance is lower than the required target, the Clinical Team Leaders will provide the Service Manager with reasons for non-compliance and an action plan to address the deficit/issue Clinical Staff (Community & Inpatient) All clinical staff must: Attend the agreed Care Cluster training programme Be familiar with and adhere to the Care Cluster Policy and Standard Operating Procedures to guide and inform their practice. Carry out Care Cluster process and record information as required on the Trust s clinical system. Adhere to the Care Cluster Allocation, Review Periods and Transition Protocols Comply with standards to maintain compliance with both Community & Inpatient targets 6
Business Support Officers Business Support Officers must monitor compliance of Care Clusters Allocation, Standard Operating Procedures and report performance to Team/Clinical leads Information & Reporting Team The Information & reporting Team will: Provide reports as required from the Data Warehouse as per agreed specifications Provide Compliance/Non-compliance data (Dash- Board) to the Clinical Teams, Operational Management Groups, Finance and Sub Committee and Trust Board on a monthly basis. 6. Care Cluster Process Care Cluster Responsibilities, Processes and Standards and all associated information are contained in the SSSFT Mental Health Care Cluster Standard Operating Procedures, Version 1.1 Dated: 16 November 2017. 7. Process for Monitoring Compliance and Effectiveness This policy 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 Development and implementation of Care Pathways Monitoring Method - Supervision - Supervision - Supervision - Supervision Minutes of relevant Development Group Individual Department responsible for Monitoring Frequency for monitoring activity Group/Committee/ Forum which will receive the findings/monitoring report Committee/Individual responsible for ensuring that the actions are completed Development and implementation of Outcome Measures Minutes of relevant development Group 7
8. 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 needs-based approach to making clinical decisions. Journal of Mental Health. 8