Practicalities of introducing PbR in mental health – The care clusters

This post is one in a series on Payment by Results in mental health, written for both professional and personal reasons. The full series is introduced and linked to here, including a post with all references in it.

• Care cluster 0: Variance cluster – Despite careful consideration of all the other clusters, this group of Service Users are not adequately described by any of their rating profiles or descriptions.  They do however require mental health care and will be offered a service.

Non-psychotic clusters (1-8)

• Care cluster 1: Common 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.
• Care cluster 2: Common 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.
• Care cluster 3: Non Psychotic (Moderate Severity) – Moderate problems involving depressed mood, anxiety or other disorder (not including   psychosis).
• Care cluster 4: 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.
• Care cluster 5: 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 suicide and they may present safeguarding issues and have severe disruption to everyday living.
• Care cluster 6: 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.
• Care cluster 7: Enduring 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.
• Care cluster 8: Non-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.

• Care cluster 9: Blank cluster

Psychotic clusters (10-17)

• Care cluster 10: 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.
• Care cluster 11: 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.
• Care cluster 12: Ongoing 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.
• Care cluster 13: Ongoing 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.
• Care cluster 14: Psychotic Crisis – 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.
• Care cluster 15: 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 suicide and have disruption in many areas of their lives.
• Care cluster 16: Dual Diagnosis – This group has enduring, moderate to severe psychotic or affective symptoms with unstable, chaotic lifestyles and co-existing substance misuse. They may present a risk to self and others and engage poorly with services. Role functioning is often globally impaired.
• Care cluster 17: 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.

Organic (18-21)

• Care cluster 18: 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.
• Care cluster 19: Cognitive 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.
• Care cluster 20: Cognitive 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.
• Care cluster 21: Cognitive 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.

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