Mental Health Collaborative- Reduction of psychiatric readmissions HEAT T4

Mental Health Collaborative- Reduction of psychiatric readmissions HEAT T4

Readmissions HEAT Target Collaborative approach High Impact change Areas Work to date Link (conflict?) with A&E attendance target Measures for improvement Sustaining improvement

Mental Health Collaborative Focus 3 Workstreams & 4 HEAT Targets Evidence based prescribing of anti-depressants and effective treatment of depression Improved inpatient processes and community mental health services (including crisis services) Timely diagnosis of Dementia and appropriate follow-up support Each underpinned by: Improvements in the quality of the service user experience

Readmissions HEAT Target To reduce readmissions of patients with an index admission of more than seven days by 10% by the end of 2009 Encourage best practice in discharge planning, crisis resolution, and support of individuals out of hospital

140 Number of patients with psychiatric readmissions as defined by HEAT target per 100,000 population for year ending 30th June 2006 120 100 80 60 40 20 0

Collaborative Approach Developing the time and skills to do improvement work Sharing ideas and good practice

Collaborative Approach Sharing ideas and good practice Events and Networks National Learning Events ( Time to deliver conference ) Regional Networks & National Networks (i.e. Crisis, Doing Well, Dementia) Putting people in contact Publications and Case Studies E-resources Shared space Database looking at how link to Piramhids Newsletters

Readmissions Workstream Focus of Improvement Activities Improve delivery and outcomes of assessments for admission Improve the Inpatient Experience Improve Discharge Planning Ensure all services are focused on sustaining wellbeing and recovery

Sustaining Wellbeing and Recovery Sustaining Wellbeing and Recovery Admission discussion/process Quality of the In-Patient Experience Discharge Readmissions: Primary Drivers/High Impact Change Areas

Delivering the Readmissions HEAT Target Improve design of care delivery processes Key elements of Generic Pathway that need to improve to deliver HEAT Target. Improve standard of clinical service delivered National workforce programmes relevant to improving pathway Current focus is on diagnosing the key issues with current systems and processes using: opathway Mapping, Value Streaming and Flow Analysis to identify: what adds value, un-necessary steps, duplication, rework because not done right first time, bottlenecks and hand-offs odata Analysis to identify variation and understand when this is justifiable and when it can be reduced odemand, Capacity and Queue Theory so understand what the demand is, what the capacity is to respond to it, opportunities to make more effective use of current capacity, when queues are caused because of the process design rather than a mismatch between demand and capacity, and where in the process there is a mismatch between demand and capacity. opdsa to pilot improvements Improve delivery and outcomes of assessments for admission ICP Standards 5,7,8,9 10,11,12,14,16,19,20 Modernising Medical Careers Rights, Relationships and Recovery Changing Lives (Social Work) Improve the Inpatient Experience ICP Standards 5,7,8,9 11,12,13,14,15,16,18,19,20 Modernising Medical Careers Rights, Relationships and Recovery Recovering Ordinary Lives (OTs) Improve Discharge Planning ICP Standards 5,7,8 16,17,20,21 Modernising Medical Careers Rights, Relationships and Recovery Recovering Ordinary Lives (OTs Changing Lives (SocialWork) Ensure all services are focused on sustaining wellbeing and recovery ICP Standards 5,6,7,8,9 10,11,12,13,14,15,16, 17,18,19,21, SIGN 30,60,74,82 Psychological Therapies Matrix Modernising Medical Careers Rights, Relationships and Recovery Recovering Ordinary Lives (OTs) Changing Lives (Social Work)

Reducing Readmissions- Impact on A&E attendances? By improving services for those with Severe and Enduring Mental illness will we reduce attendance at A&E? Or are those in Mental health Crisis a different population? Does the development of Mental Health Crisis/ Home Treatment services help?

Measurement can be used in different ways Measures for judgement used to judge against performance targets Measures for diagnosis data gathered to understand the process, see if there is a problem Measurement for improvement a few specific measurements, linked to objectives and aims, that demonstrate changes are making improvements Measurement for sustainability ensure that changes and the improved outcomes are maintained and are part of everyday practice.

Improvement Measures Reduction in readmissions (any LOS) within 133 days of discharge 95% SMR04 completeness at 2 months Reduce ALOS for 20% with longest LOS (balanced with 80% with shortest LOS) Patient experience measure

Improvement Measures Readmissions (within 133 days and any LOS) as % of total admissions (any LOS): Any LOS was selected to ensure both long and short stays are addressed. 133 days, 19 weeks (130 days actual) was calculated from the distribution 'bath tub' curve. The curve levels at 133 days. Readmissions after 133 days can be seen as 'natural relapses' Will identify patients with multiple readmissions

Improvement Measures SMR04 Completeness at 95%: Improve on 85% (ISD set) completeness so data can be more accurately recorded. Majority of boards are consistently 100% so 95% allows for some variance

SMR04 completness estimate by Health Board for October 2007 to September 2008 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Ayrshire & Arran Borders Fife Greater Glasgow & Clyde Highland Lanarkshire Grampian Lothian Tayside Forth Valley Western Isles Dumfries & Gallow ay

Proposed National Improvement Measure Three Average LOS Balancing measure for readmissions Break down by 80/20 otherwise data heavily impacted by a few longer term stays. By combining with readmission rates and benchmarking data can help indicate where LOS is excessively high or low

Readmissions Measures for improvement Readmissions should be a never event The local measure is aimed at driving readmissions down locally LoS and the 80/20 measure- designed to improve and understand capcity and flow Highlights 2 patient populations/ streams More complex but greater utility

Readmission within 133 Days P-chart showing Dumfries & Galloway psychiatric readmissions within 133 days as proportion of monthly admissions 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% UCL UWL Proportion Process Average LWL LCL 0% Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Proportion of Readmissions

Readmission within 133 Days P-chart showing Dumfries & Galloway psychiatric readmissions within 133 days as proportion of monthly admissions - Adult patients only Adult 60% 50% 40% 30% 20% 10% UCL UWL Proportion Process Average LWL LCL 0% Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Proportion of Readmissions P-chart showing Dumfries & Galloway psychiatric readmissions within 133 days as proportion of monthly admissions - Older Adult patients only Older Adult 120% 100% 80% 60% 40% 20% UCL UWL Proportion Process Average LWL LCL 0% Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Proportion of Readmissions

Readmission Measures Average Length of Stay Average Length of Stay (ALOS) broken down by shortest 80% LOS and longest 20% LOS Also looked at this by Adult and Older Adult specialties separately

Average Length of Stay Average LOS in Dumfries & Galloway for shortest 80% LOS for psychiatric admissions 45 40 35 30 25 20 15 10 5 0 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Average Length of Stay (days) Shortest 80% Month of discharge Average LOS in Dumfries & Galloway for longest 20% LOS for psychiatric admissions 1200 1000 800 600 400 200 0 UCL ALOS Process Average LCL Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Average Length of Stay (days) Longest 20% Month of discharge UCL ALOS Process Average LCL

Average Length of Stay - Adults Average LOS in Dumfries & Galloway for shortest 80% LOS for psychiatric admissions in adult patients 30 Shortest 80% 25 20 15 10 5 0 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Average Length of Stay (days) Month of discharge Average LOS in Dumfries & Galloway for longest 20% LOS for psychiatric admissions in adult patients 600 Longest 20% 500 400 300 200 100 0 UCL ALOS Process Average LCL Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Average Length of Stay (days) Month of discharge UCL ALOS Process Average LCL

Average Length of Stay Older Adults Average LOS in Dumfries & Galloway for shortest 80% LOS for psychiatric admissions in older adult patients Shortest 80% 200 180 160 140 120 100 80 60 40 20 0 UCL ALOS Process Average LCL Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Average Length of Stay (days) Month of discharge Average LOS in Dumfries & Galloway for longest 20% LOS for psychiatric admissions in older adult patients Longest 20% 4500 4000 3500 3000 2500 2000 1500 1000 500 0 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Average Length of Stay (days) Month of discharge UCL ALOS Process Average LCL

Elements of the patient experience Recognises service users strengths Maximises service user involvement Enables choice Supports social inclusion Respects diversity Promotes Equality Supports safety and positive risk taking

Improvement Measures Percentage of wards and CMHTs that have a negotiated patient experience improvement measure in place: To take patient experience into account when applying improvements To actively promote this through the services

Why not this measure? Too much room for local variation Missing an opportunity to link to other national work (SRI) But- if nationally set may not be locally valid in all areas How do we deal with these conflicting requirements?

Patient experience Moving towards a locally agreed target Monthly reporting on PDSA/ Improvement work in high impact change areas Highlighting the patient experience element Producing diverse examples Allowing sharing of good practice and initiatives- hopefully sustainable change

Patient experience The HEAT target is only relevant if it produces an improvement in the patient experience The KEY balancing measure The main ongoing focus of this workstream

1200 Progress towards Readmissions HEAT Target April 07 - March 08 or latest available position Target Actual 1000 800 600 400 200 0 Health Boards