Dr Ihsan Kader & Dr Rachel Brown Edinburgh IHTT IK/RB

Transcription

1 Dr Ihsan Kader & Dr Rachel Brown Edinburgh IHTT 1

2 Declaration of interest none 2

3 Plan Brief history and evidence Edinburgh IHTT Challenges including standards Data Quality Improvement Future plans 3

4 4

5 Brief history Australia in the 70s, also USA, Canada Birmingham, Islington, Bradford in the 90s England Late 1990s crisis in acute care, very high bed occupancy, many admissions to private beds NHS Plan 2000, NSF 5

6 Scotland MHA (Scotland) 2003 Delivering for Mental Health - National standards for crisis services 2006 Lothian Kaizen 2008 MH Strategy

7 7

8 Evidence Study Admissions Detentions Bed occupancy satisfaction Glover et al % (all ages) Little impact Johnson et al No change 2005 Jethwa et al % Keown et al % emergency but 20% - STDC/CTO Tyrer et al 2010 No difference Crawford et al 9% No change 12% Forbes et al 2010 No change in all - Barker et al % 7% 8

9 Crisis resolution / home treatment teams and psychiatric admission rates in England Glover et al. (2006) Observational study, 229/ 303 teams, Admission data mapped to crisis team data For all admissions <64yo admissions generally fell by 11% Less impact on bed use Assertive outreach no reduction in admissions 9

10 Randomised controlled trial of acute mental health care by a crisis resolution team: the north Islington crisis study Johnson et al 2005 Ethically approved 135 randomised to CRT; 125 to CMHT / IP / crisis house CRT less likely to be admitted reduced bed use Compulsory admissions not affected Client satisfaction better with CRT 10

11 Effects of a crisis resolution and home treatment team on in-patient admissions Jethwa et al 2007 Naturalistic observational study from Leeds, 2 years before & 1 year after implementation 1 team (2 consultants; 1 SG; 3 TMs; 12 keyworkers, 7 others) 24 hr, 7 day/ week - permanently open 37.5% reduction in monthly admissions (total n=4353) 11

12 Intensive Home Treatment, admission rates and use of Mental Health Legislation Forbes et al 2010 Midlothian IHTT Admission to REH No change in admission rates Duration of stay unchanged Increased rates of detention 12

13 Controlled comparison of 2 CRHTs Tyrer et al 2010 Measured impact on bed days & readmissions Total bed days reduced Compulsory admissions up by 31% No difference in service satisfaction, Quality of life, social functioning 13

14 The impact of CRHT services on service user experience and admission to psychiatric hospital Barker et al % reduction in admission from November 2008 (cf 8% fall b/w November 2003 and November 2008) (p<0.0001) Mean length of stay reduced by 9 days (p<0.0001) No in Readmissions ( 4% (p=0.152)) No in detentions ( 17% (p=0.335)) Extremely positive user & carer feedback 14

15 Cochrane review Joy et al studies included; 25 excluded Home treatment reduces readmissions (NNT =11; RR=0.72) 45% those in HT unable avoid admission HT reduces family burden more cost effective than hospital no difference in death or mental state 15

16 16

17 17

18 Fidelity Open 24/7 mobile Gatekeep ALL admissions Multidisciplinary especially dedicated consultant psychiatrist Early discharge Team size 14 staff/150k population/25 case load 18

19 19

20 NAO VfM 2007 CRHTs reduced pressure on beds 40% sample were early discharges Clinical benefits Increased patient satisfaction Reduces stigma and social exclusion 600 cheaper per crisis episode 20

21 NAO VfM 2007 Not enough high fidelity teams especially consultant psychiatrists This can restrict their ability to provide comprehensive, multi-disciplinary care, as well as the extent to which they are integrated and accepted within local mental health services Gatekeeping not rigorous 21

22 Edinburgh IHTT October 2008 High Fidelity model Staffing Pre-operational period Separate MHAS (crisis arm) 22

23 Before 2009 traditional care model & multiple routes to admission A&E CMHT GP PET REH Police 23

24 Delays to discharge REH CMHT REHAB Community support 24

25 From 2009 shifting the balance of acute care from hospital to community GPs MHAS CMHTs IHTT REH 25

26 Key Components Of Edinburgh s Model 24 hour/7 day availability Rapid response Gatekeeper to all potential admissions Flexible visiting (frequency / duration / intensity) Medical staff involved/available Mobile Clearly targeted caseloads Remain involved throughout the crisis Facilitate early discharge 26

27 27

28 28

29 MWC Overwhelmingly positive view of home treatment services Users and carers largely highly satisfied No consistent model equally no one size fits all highly valued Reduced admissions, reduced use of beds and length of stay However not all areas have such services Inconsistency of staff a problem for some 29

30 Challenges & criticisms Fragmentation of care Challenge to hierarchy No open access (Edinburgh GPs) Suicide rates is risk management adequate? Compulsory admissions continuing to Uncertainty over sustained in admissions Inconsistent application of model benefits Shift working affecting therapeutic relationships Family/carer work neglected/squeezed 30

31 31

32 IHTT Referrals Referrals IHTT Assessments Taken on - Avoided hospital admission Taken on - Early discharges 32

33 Referrals IHTT Assessments Taken on - Avoided hospital admission Taken on - Early discharges Totals

34 Outcome of Referral 100 Outcomes (2016) Referrals Assessed Rejected at Triage Taken on Admitted at Triage Admitted at Assessment Admitted later 34

35 Referral Source (2016) IHTT Caseload - Referral Source % 6% 14% CMHT 5% 1% Consultant GP 28% In-pts MHAS RIE 40% Other 35

36 Demographics Age/Gender of IHTT Caseload 2016 male female >65 36

37 Diagnoses (2016) 60 All Diagnoses Psychosis Depression Bipolar Anxiety Personality disorder Alcohol/Drugs 37

38 CGI on Initial Assessment (2016) Severity of Illness (CGI) Normal Borderline ill Mildly ill Moderately ill Markedly ill Severely ill 38

39 CGI on discharge (2016) Global Improvement (CGI) Very much improved Much improved Minimally improved No change Minimally worse Much worse 39

40 User Satisfaction (N=67) 2016 HOW MUCH BETTER DO YOU FEEL YOU GOT DURING YOUR TIME OF IHTT SUPPPORT? DID YOU FEEL SAFE WHILE BEING SUPPORTED BY IHTT? MUCH BETTER SLIGHTLY BETTER THE SAME NO BETTER 0 ALL THE TIME MOST OF THE TIME A LITTLE OF THE TIME NOT AT ALL 40

41 User Satisfaction (N=67) 2016 WERE YOU GIVEN ENOUGH INFORMATION ABOUT YOUR CARE & TREATMENT? HOW EASY WAS IT TO ACCESS IHTT BY PHONE? YES NO 0 VERY EASY QUITE EASY NOT VERY EASY 41

42 User Satisfaction (N=67) 2016 DID YOU FEEL ABLE TO TALK TO THE TEAM INVOLVED IN YOUR CARE WHEN YOU NEEDED TO? DO YOU FEEL THE STAFF DID WHAT THEY SAID THEY WOULD DO? ALL OF THE TIME MOST OF THE TIME A LITTLE OF THE TIME NOT AT ALL 0 all of the time most of the time a little of the time 42

43 Feedback comments The support given to me by the team was outstanding. Throughout the process I felt safe and listened to and reassured that although my recovery was slow it would happen. The support from IHTT was amazing. It was the most positive experience I have had of any mental health care in my life. I am so grateful for the excellent work that the team did and I'm grateful to be so well now. Terrific service, all came over as genuinely caring, good people. Probably saved my life, they have my eternal gratitude. I don't think IHTT did anything but check I was alive every day. 43

44 44

45 45

46 46

47 47

48 CRHTs in Scotland Crisis Network/SCAIN survey Accuracy of data Different models (even within same board) 48

49 49

50 SCOTTISH CRISIS RESOLUTION/HOME TREATMENT NETWORK SERVICE MAPPING REPORT NOVEMBER 2010 Contents 1. Background 2. Resources 3. Working hours 4. Acute mental health assessment 5. Gate keeping 6. Crisis Resolution 7. Alternatives to Admission 8. Early discharge 9. Age range of patients 10. Multidisciplinary Assessment 11. Referral to CRHTT 12. Data of success 13. Future Plans Common Abbreviations Used In Report CMHT: CRHTT: IPCU: OOH: MHAS: URT: Community Mental Health Team Crisis Resolution Home Treatment Team (used synonymously with Intensive Home Treatment Team) Intensive Psychiatric Care Unit Out of Hours Mental Health Assessment Service Urgent Referral Team 50

51 7. How do you provide the role of intensive home based support as an alternative to inpatient admission? NHS Board In hours Out of hours Notes Ayrshire & Arran CRHTT CRHTT Borders CRHTT No service Dumfries & Galloway CRHTT for Dumfries and Nithsdale CMHT for other CRHTT for Dumfries and Nithsdale Fife No service No service Forth Valley CRHTT, C community rehab team are also sometime involved as part of package CRHTT of care, augmenting CMHT Grampian CMHT, medics, URT, Liaison medics, crisis CPN, Liaison Greater Glasgow & Clyde Greater Glasgow CMHT, CRHTT, Car Gomm CRHTT Clyde CRHTT No service Highland CMHT, medics (both Argyll & Bute only) Medics (Argyll & Bute only) Lanarkshire CMHT CMHT weekend & Public Holidays Crisis Assessment Service Lothian East Lothian CRHTT CRHTT (until midnight then MHAS in Edinburgh) Edinburgh CMHT, CRHTT, MHAS CRHTT, medics, MHAS Midlothian CRHTT CRHTT, 12 midnight to 8am provided by CRHTT s in Edinburgh. Medics as part of CRHTT/CMHT. Some CMHTs more able than others to organise this intensive input, e.g. Stewartry CMHT West Lothian No service No service Shetland CMHT, GP CMHT, GP Tayside CMHT, AMHRT in Dundee No service Western Isles No service No service CRHTT will be carrying out this process in hours later in the year. 51

52 Optimising care Crisis Network 2010 Wheeler et al 2015 HTAS CORE SG KPIs 52

53 Critical ingredients of CRHTs Wheeler et al 2015 systematic review Quantitative studies (25): suggest gatekeeping, extended hours & medical cover are important to effectiveness in reducing admissions Qualitative studies: stakeholders value integration/continuity with other services, time to talk, not seeing too many people, rapid access and accessibility. But overall limited evidence! 53

54 54

55 HTAS at a glance Service provision and structure Staff, appraisal, supervision and training Assessment, care planning and transfer or discharge Interventions 55

56 56

57 57

58 Team Development 58

59 Improvements 59

60 Improvements 60

61 Improvements 61

62 Remaining Challenges 62

63 Future Projects? 63

64 64

65 Contact details 65

66 Questions? 66