The journey of RAID through evolution

Transcription

1 The journey of RAID through evolution George Tadros Consultant in Old Age Liaison Psychiatry, RAID Lead Clinician, Birmingham, UK Professor of Old Age Liaison Psychiatry, Warwick Medical School, University of Warwick Visiting Professor of Mental Health and Ageing, Staffordshire University Vice-Chair, faculty of Old Age Psychiatry, Royal College of Psychiatry

2 Recent evidence: Older People Up to 70% of hospital beds are occupied by older people. 70% of older people referrals to liaison services are not under the care of mental health services. 500beds hospital would have 5,000 admissions/annum, of whom 3,000 will have or will develop a mental disorders , hospital stay for increased by 50%, over 75 by 66%. In a typical acute hospital (500 beds), failure to organize dementia liaison services leads to excess cost of 6m/year The majority of mental co-morbidity in acute hospital affecting older people is due to three disorders: Dementia, Depression and Delirium. Dementia CQUIN (FAR) Mental disorder in older adults is a predictor of: Increased LOS Increased readmissions Increased Institutionalism (impacting on performance and efficiency) Other poorer outcomes

3 Evidence for need: Alcohol and Substance Misuse 88% of adults in the UK drink alcohol, with 38% of men and 16% of women recognized as having an alcohol use disorder 12% of A&E attendances are alcohol related 7-20% acute admissions have alcohol problems Annual healthcare cost of 1.7 billion RAID Research at Hospital front door (AMU) April 2013 Used MUST-G Findings: Hospital identify that 1% of elderly admissions have alcohol related problems, using FAST. Our research team using MUST-G identified 18% of older people coming to AMU have alcohol related problems

4 Evidence for Need: General Psychiatry 25% of patients with a physical illness also have a mental health condition. 60% of over 60s A&E work is primarily with younger people coming with DSH, Alcohol problems and acute psychosis. Depression & Anxiety - 2 to 3 times more common in those with physical long-term illness. Neuropsychiatry Postnatal psychiatry Eating disorders MUPS: long term disability and dissatisfaction. Present in most hospital specialities. Care costs estimated at 3.1 billion per annum

5 Traditional Models of Liaison Psychiatry Consultant led, consultant sessions Nurse led service Service provided from mental health base. Outward referrals 9:00 5:00, 8:00 8:00!! services Weekdays, weekends!! Out of hours support Food for thoughts. Is RAID Liaison psychiatry? How RAID is different from Liaison Psychiatry?

6 The product: Rapid Assessment Interface Discharge 24x7 Service BOUNDARY FREE RAPID RESPONSE TRAINING RAID SINGLE POINT OF CONTACT COMMUNITY FOCUS EARLY INTERVENTION

7 The upgraded RAID service (cost 1.4m) Consultant Psychiatrist Mental Health of Older People Consultant Psychologist Mental Health of Older People RAID Team Manager Consultant Liaison Psychiatrist Currently Funded Consultant Psychiatrist Substance Misuse Band 7 Nurse MHOP Currently Funded Specialist Doctor Specialist Doctor Band 7 Social Worker Currently Funded Band 7 Nurse Liaison Currently Funded Lead Nurse Substance Misuse Band 6 Nurse MHOP Currently Funded Band 6 Nurse MHOP Currently Funded Band 6 Nurse MHOP Currently Funded Band 6 Nurse Liaison Currently Funded Band 6 Nurse Liaison Currently Funded Band 6 Nurse Liaison Currently Funded Band 6 Nurse Substance misuse Currently Funded Assistant Research Psychologist Admin Band4 Admin Band4

8 The upgraded RAID service (cost 1m) Consultant Psychiatrist Mental Health of Older People Consultant Liaison Psychiatrist Clinical psychologist/ Band 8 or above Team Manager Band 8a Band 7 Nurse MHOP Currently Funded Physician Assistance FY1 or CT1 or SpR Band 7 Nurse Liaison Currently Funded Band 6 Nurse MHOP Currently Funded Band 6 Nurse MHOP Currently Funded Band 6 Nurse MHOP Currently Funded Band 6 Nurse Liaison Currently Funded Band 6 Nurse Liaison Currently Funded Band 6 Nurse Liaison Currently Funded Band 6 Nurse Substance misuse Assistant Research Psychologist Admin Band4 Admin Band4

9 RAID evaluation RESPONSE QUALITY COST

10 Referrals Origin of referral Number of referrals years 65 years + Mean age Accident and Emergency (A&E) Poisons Unit Wards % 4% 36.4 years % 4% 34.6 years % 59% 65.6 years Steadily increasing referrals 350+ monthly referrals (goes up to 700 referral/month at QEHB) Only 30% patients known prior to RAID.

11 Top 7 reasons for referral Drug misuse 4% Dementia/ Confusion 18% Anxiety 6% Deliberate self harm 32% Psychosis 9% Alcohol misuse 13% Depression 18% Deliberate self harm Depression Alcohol misuse Psychosis Dementia/ Confusion Drug misuse Anxiety

12 A&E Response Not Assessed; 3% Not Recorded; 17% Targets Met Targets Not Met Not Assessed Not Recorded Targets Not Met; 7% Targets Met; 73%

13 Ward Response Target Not Met; 10% Not Assessed; 1% Not Recorded; 6% Target Met Target Not Met Not Assessed Not Recorded Target Met; 83%

14 Teaching and evaluation 158 hospital staff trained: All completed the evaluation Very poor; 0% Poor; 0% Neutral; 3% Good; 36% Very poor Poor Neutral Good Excellent Excellent; 61% A lovely insight from a very experienced practitioner

15 Patient satisfaction: Feedback Very poor to poor rating; 8% Neither poor nor good rating; 8% Very poor to poor rating Neither poor nor good rating Good to excellent rating Good to excellent rating; 84% Range Mode Median Mean 0 to

16 Staff satisfaction: Feedback Referral to other services; 8% Other; 5% Liaison with other services; 7% Providing information to patient; 10% Advice on managing patients; 12% Advice on medication; 11% Support to family/carers; 17; 8.17% Support of staff; 11% Education; 7% Information sharing; 7% Support to patient; 10% Signposting; 4% Range Mode Median Mean 2.5 to

17 Savings and wider financial Benefits Potential Benefits of RAID Social care Outcomes Considered in this Study Complaints Patient satisfaction Staff sickness Staff satisfaction Acute staff confidence in dealing with MH conditions 1. Inpatient LoS A&E savings Demand for community MH services 2. Readmission rates 3. Admission avoidance Discharge destination MH outcomes SUIs Quality Acute staff training Security Referring / Signposting to community MH services

18 3 Groups for the study!! 1. Pre- RAID group (control group) December July 2009 No changes/confounders between pre and post!! 2. RAID_ influence group December July 2010 RAID did not see patients, but had influence through training and support 3. RAID group December July 2010 RAID patients Matched groups: Matched age, gender, mental health code, medical diagnosis, healthcare resource group (HRG) RAID patients were the most complex RAID: average 9 different diagnostic codes RAID_ influence 3 different diagnostic codes

19 case-by-case Matched Control Study Sub Control mean: 8.4 Sub RAID Inf mean: 5.2 Sub Control mean: 10.3 Sub RAID mean: cases 72 cases Control (2873 Patient) Mean: 9.3 days RAID Influence (2654 Patient) Mean: 4.74 RAID (886 Patient) Mean: 17.6

20 Length of stay: Comparing the groups P value= 0.01

21 Cost savings: LOS/ all age groups All ages: Saving over 8 months= ,493 = 9,290 bed days Saving over 12 months= 13,935 bed days Per day= 13, = 38 beds per day Older people only: Saving over 8 months= ,220 = 8,634 bed days Saving over 12 months= 12,951 bed days Per day= 12, = 35 beds per day

22 2. Admission Avoidance at MAU: Cohort control study All ages Control group; 30% of avoided admission at MAU. RAID and RAID influence group; 33% avoided admission at MAU Increase of 9% Older people Control group; 17% of avoided admission at MAU. RAID and RAID influence group; 25% avoided admission at MAU Increase of 47% Average LOS= 9.3 days 240X9.3= 2,232 bed days = 6 beds/ day Average LOS= 22 days 111 X 22= 2442 bed days = 6 beds/ day

23 3. Elderly Patient Discharge Destination 30% of elderly patients who come to acute hospitals from their own homes are discharged to care homes (national figures) LSE estimated savings to our wider economy of 60,000/week (Social care cost).

24 4. Savings: Re-admission Group Re-admission per 100 patients Retrospective (3500) 15 (505) Partial RAID (3200) 12 (408) RAID (850) 4 (42)

25 Savings: through increasing survival The savings calculated from survival assumes patients readmission at same rate of retrospective patients Over 8 months 1200 admissions saved. Over 12 months 1800 admissions saved. Saving 22 beds per day = one ward Saving 20 beds per day comes out of elderly care wards.

26 Combined total savings: beds/day On reduced LOS saved bed days/12 months= 13,935 bed days 365 = 38 days/day (35 beds/day for the elderly) Saved bed days through avoiding admissions at MAU Saved bed days = 6 beds / day Elderly.. = 6 beds Increasing survival before another readmission Admissions saved over 12 months =1800 admissions Average LOS 4.5 days = 8100 saved bed days 365 = 22 beds/day 20 for the elderly Total Saved beds every day = = 66 bed/ day (Maximum) {Elderly: 59 beds/day} = = 49 bed days (minimum) {Elderly: 42 beds/ day} 2010: City Hospital has already closed 60 beds.

27 London school of Economics, August 2011 Very thorough, detailed and vigorous review but conservative estimation Total savings: 3.55 million to NHS At least 44 beds/day 60,000/week to social care cost Money value Cost : return = 1: 4 Recommended the model to NHS confederation RAID expanded in Birmingham to 5 acute hospitals across three acute Trust, 3600 beds Now RAID is being implemented in over 20 trusts across the country.

28 RAID+ Vs RAID A New RAID Model at MAU 1. What if we move RAID to the hospital front doors? 2. Does early screening improve patients outcomes? 3. Is RAID early intervention (RAID+) more cost effective than RAID? MAU Discharge effect Comparing current RAID with RAID+ MAU screening LOS, RA rates, Discharge destination

29 Number of patients with a Mental Health Diagnosis Dementia Delirium and Depression (Retrospective case notes and Screened patients

30 RAID Screening - Groups Screened ve Screened ve Screened 421 Clinical Filter + ve Filter ~ ve Filter ~200 Referred to RAID 135 Not Referred to RAID ~86 + ve RAID ~105 - ve RAID ~30

31 Length of Stay

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33 New RAID research findings Length of stay: Screened by RAID+ at MAU reduces LOS on average by extra 4 days comparing to RAID Readmissions: Hazard Ratio for Referred patients is 0.64, p-value Patients referred and seen by RAID stays in the community 35% more than patient not referred by RAID Creating new screening tool

34 Independent RAID Financial Evaluation by Central Midlands CSU Led by : Steven Wyatt Rapid Assessment Interface And Discharge Liaison Economic Evaluation of the Birmingham and Solihull Roll-Out October 2012

35 Data Sources and Data Flows BSMHFT CM CSU Collate data on RAID contacts*; NHS Number Date Setting Match to SUS A&E and IP tables and collate identifiers (not PI) of relevant attendances and admissions Locate these attendances and admissions in local SUS and national HES tables

36 Wider Potential Benefits Potential Benefits of RAID Outcomes Considered in this Study Inpatient LoS A&E reattendance rates Time in A&E Readmission rates Admission rates fro A&E Time to readmission Acute Prov / Comm Social care Security Complaints Patient satisfaction Staff sickness Discharge destination Quality Staff satisfaction Acute staff confidence in dealing with MH conditions Demand for community MH services SUIs Acute staff training Referring / Signposting to community MH services MH outcomes

37 A&E Activity Outcomes Concurrent Controls Outcome Cases Controls Admission from A&E 13.7% 22.4% Difference (95% CI) 8.7% (6.8% %) Notes Sig. at 99% Average Duration in A&E 4h 20m 2h 43m 97m (83m 111m) Sig. at 99% Average Number of Reattendances within 28 days* (0.40 to 0.61) Sig. at 99% Average Number of Reattendances within 90 days* (0.57 to 0.78) Sig. at 99% * Applies to subset of cases seen between July 2012 and November 2012

38 A&E Financial Outcomes Concurrent Controls Commissioner Cost Provider Cost Cases Controls Cases Controls All % 22% 14% 22% Admitted % 91% 90% 90% Located & Costed ,615 Cost 286, , , , Grossed -Up Cost 319, , , ,505 Difference -498, ,875

39 Inpatient Activity Outcomes Concurrent Controls Outcome Cases Controls Difference (95% CI) Notes Average Length of Stay Days (0.5 to 0.7) Sig. at 99% Average Number of Readmissions within 28 days* (-0.01 to -0.05) Sig. at 99% Average Number of Readmissions within 90 days* (0.04 to 0.13) Sig. at 99% * Applies to subset of cases seen between July 2012 and November 2012.

40 Inpatient Financial Outcomes Concurrent Controls Commissioner Cost Provider Cost Cases Controls Cases Controls All* 33,750 33,750 33,750 33,750 93,1% 93.1% 93.1% 93.1% Matched 31,414 31,414 31,414 31, % 99.0% 99.6% 99.6% Located & Costed 31,093 31,093 31, ,238 Cost 50,656,320 52,162,644 65,110,245 70,042,352 Difference 1,506,323 4,923, Grossed-Up Difference 1,635,107 5,318,846 * To avoid double counting, this number excludes cases seen by RAID in AE and then admitted

41 Financial Outcomes Summary Concurrent Controls Full Tariff / Average Cost ( 000s) A&E Inpatient Grossed- Up Total* Savings Share Marginal ( 000s) Commissioner Saving 498 1,635 2,133 36% 640 Provider Spend ,319-5,892 Income ,635-2,133 Saving 74 3,684 3,758 64% 1,127 Total Saving 5,892 1,768 Full Costs 3,295 Incremental Cost 1,976 Saving / Incremental Cost

42 Activity Outcomes by Site Site Admission via A&E Length of Stay cases controls diff cases controls diff Heartlands 14.3% 28.7% -14.4% Good Hope 19.4% 29.2% -9.8% Solihull 20.2% 11.2% +9.0% City 11.4% 17.3% -5.9% UHB 10.9% 19.1% -8.2% All 13.7% 22.4% -8.7%

43 Financial Outcomes by Site ( 000s) All HoEFT City UHB Full Cost 3,295 1, Incremental Cost 1, Commissioner Savings AE Provider Savings AE Commissioner Savings IP -1,635-1, Provider Savings IP -3,684-3,161-1, Total Savings -5,892-5,008-1, Net Savings (@ full cost) -2,597-3, ,347 Net Savings (@ incremental cost) -3,916-4, ,062 Savings / Full Cost Savings / Incremental Cost

44 Conclusions - Activity Primary Activity Outcomes Patients seen by RAID in A&E were significantly less likely to be admitted than controls. Patients seen by RAID on inpatient wards had a significantly lower average length of stay than controls. Secondary Activity Outcomes Patients seen by RAID in A&E spent significantly more time in the department than controls and were more likely to reattend with 28 and 90 days. Financial savings: Savings associated with reduced acute utilisation were 3 times greater than the incremental cost of the RAID Service if commissioner costs are calculated at full tariffs and providers costs are calculated at the average reference costs. 64% of these savings fell to providers and 36% to commissioners. Most of the savings came as a result of reducing lengths of stay rather than admission avoidance.