CASE STUDY: THE ADULT MENTAL HEALTH (AMH) MODEL-REDESIGN OF INTEGRATED SERVICES FOR WORKING AGE ADULTS WITH SEVERE MENTAL ILLNESS. Summary The Adult Mental Health (AMH) model is a new initiative which has been developed by South London and the Maudsley NHS Foundation Trust (SLAM) for working age adults with severe mental illness. It is a clinically led solution to the current financial challenges and has been conceived by the trust, and developed with commissioners. It aims to adopt enhanced, more assertive multi-interventional community services reducing relapse rates and allowing more effective early intervention for those in crisis. Its objective is to reduce frequency and number of inpatient admissions, supporting a move away from bed based towards community care. Three options were considered. AMH was selected for the combined reasons of patient safety, quality and the safest way to deliver savings. The service restructure and transfer of care was completed by 1 st September 2014 and the evaluation process has started. A reduction of 28% bed use is anticipated by September 2015. Key facts Run by South London and the Maudsley NHS Foundation Trust, the AMH model aims to prioritise and refocus care in the community, ensuring that patients are treated closer to their homes, and in many cases, in their homes directly. The model has been rolled out in two of the trust s boroughs Lambeth and Lewisham, with discussions ongoing with their commissioners in Southwark and Croydon. It requires community teams to move from a case load of around 40 patients and service users to 20, ensuring that care can be provided in a more targeted and proactive way. It provides an increase in evidence based interventions available in the community Its aim is to reduce inpatient admissions by 28% by September 2015 with many additional potential benefits including better identification and triage of patients in the community, improved waiting time for assessment and more joined up working between primary, secondary and social care. The issue SLAM provides mental health services across the boroughs of Southwark, Lambeth, Lewisham and Croydon. Although the challenges and issues facing the four boroughs are slightly different, all were experiencing significantly higher levels of new cases of psychosis. The trust was concerned that they were not able to provide the service that patients needed within the resources available. NHS Providers Page 1
The initiative was started due to multiple factors recognised by the trusts and the CCGs: Growing financial challenges: investment in mental health services had been low and in at least one of the boroughs it had been severely underfunded (Croydon). At the same time, due to tightening budgets, significant savings had required across the local health economy Recognition that demand was increasing: the areas covered by the trusts have some of the highest levels for new psychosis in London (figure 1) Operating procedures were not efficient: This led to gaps in coordination of services and reactive approach to treatment. Caseloads for community teams were unmanageable: in many situations, community teams were having to cope with double the commissioned level which meant that the focus was crisis management rather than prevention. FIGURE 1: NEW CASES OF PSYCHOSIS IN GREATER LONDON The proposed solution The proposal was to redesign the service to deliver savings while delivering an enhanced service for patients that improves safety and quality. This service model is a first in the UK, although aspects of the service have been implemented in Australia and Germany (Hamburg). The service involves: A single point of access assessment and liaison service which assess and signpost all referrals to ensure people who do require a secondary care level of support receive it from the most appropriate part of the service as soon as possible, and that those who do not require secondary care are signposted to services within primary care and the local community. Teams with smaller case loads, with emphasis on engagement and greater delivery of specific interventions to create optimism and focus on improvement based on the Early Intervention model NHS Providers Page 2
Home treatment teams where possible replace or shorten an admission. This specialist care is preferred by clients. Relapse prevention teams focussing on the high risk patients and looking at prevention and early detection of relapse to reduce the number of crisis and admissions. One of the two services also provides specialised out of hospital mood disorder clinic as a day service The teams are multidisciplinary, involving both health and social care staff; the latter are paid separately by the local authority. The patient group covered by the service is working age adults from 18 to 65 years old, although there is increasing collaboration with child and adolescent mental health (CAMH) teams in order to make smoother transition to adult services and they retain overseeing over 65s where appropriate. The model requires significant up-front investment in community services to deliver savings from beds, which is funded primarily by commissioners with some additional investment from the trust on a invest to save model basis, whereby investing upfront in this model will generate savings for the trust and the commissioners should admission levels and bed occupancy start to stabilise and reduce. Assumptions around savings are based on best available research evidence however similar models have not been adopted elsewhere at this scale so actual savings may differ. Implementation The new model of working has been implemented in Lambeth and Lewisham and the trust is in negotiations with CCGs in Croydon and Southwark to roll out the model in these boroughs. Funding CCG have recognised the lack of investment in mental health and are financing the project on a recurrent basis, including the double running of services based on the reduction of specific targets: 28% reduction in occupied bed days and 10% discharges of long term psychotic patients into primary care after treatment. These targets have been set on the basis of current patterns of demand, and for those already identified as requiring psychosis care. It might be that admission levels and demand for services remain stable, or even increase in line with demographic pressures, and these needs to be considered as variables in the model for evaluation. Operational There was an increase in the number of teams which were mapped to the local GP networks but these were smaller in size. Caseload for teams was reduced to enable more proactive working rather than managing crisis. It required a shift in the way teams were working, so new team processes were specified and assessed to ensure that new working models were adopted. The model was set to promote cooperation through improved relationships and more proactive client support. As an example, it was stipulated NHS Providers Page 3
that 3 times a week the home treatment and early intervention teams would meet together so that information about clients was shared and interface between teams could be discussed. Enhanced interventions are being provided earlier to promote recovery and return to long term primary care support where possible. The skill-mix of the staff in the service has changed as a result of the roll-out of the new service. The assessment team has more experienced clinical staff to provide more in-depth assessments, and to ensure that patients are placed with the right clinical academic group. Therapy teams have increased the number and experience levels of their therapists. Social care staff are also integrated into the teams. Though employed by local authorities, they are often managed by healthcare staff at the trust. Assessment An extensive and detailed range of measures are being tracked to assess the impact of the service redesign, both qualitatively and quantitatively. This has been done in collaboration with the Institute of Psychiatry, Psychology and Neurosciences and the trust has been fortunate enough to get experienced researchers involved in the evaluation framework for the model. The measures being collected include a range of outcomes including patient reported measures, staff and team working metrics and process measures of whether the new model of working is being adhered to. Regular reports of current performance are shared with CCGs to ensure that the project is on target and commissioners have been very supportive of the need to assess the evaluation of the model over a much longer term, rather than requiring results immediately. However, the suite of metrics has also been used to ensure that the new model is being implemented as planned and will enable management in the trust to assess its effectiveness. The outcome Given that the service only launched in September, and that more data is needed to determine the effectiveness of the model, further time is needed to understand the specific outcomes. However, there are a number of aims behind the service: Improve entry point to the service with closer interface working with primary care. Upskilling GPs to ensure that people are referred to the appropriate team, followed by a review by an expert assessment team will help ensure that patients are more appropriately placed in the right treatment team. This will help the flow of patients into the right treatment teams more effectively and without delays. At the same time, this also means that patients having undergone treatment can be more safely discharged in to primary care. Increased investment means that teams have a caseload of 20, rather than around 40. This enables them to offer more targeted and personalised treatment. NHS Providers Page 4
Reduce hospital bed use and escalation of clients condition by using early intervention and effective interaction in community teams to provide appropriate client support. The approach supports appropriate stratification of service users. Prevent crisis by proactive support of stable but at risk clients within community care settings. Encourages trust staff to move from a hospital to community setting to ensure that they have the appropriate skills to deal with new models of care. Benefits to patients include availability of more evidence based interventions at home, fewer admissions into hospital leading to a reduction in stigma and enhanced social inclusion. It has been agreed that the impact of the new model of working will not be seen for 18 months. Hence there is no current detailed evaluation of the service available. This will be published in September 2015. The lessons learnt The initiative is currently in the implementation phase. Lessons learnt to date include: Sign-off for the model at the trust and commissioner level took longer than anticipated, even though this did not require a public consultation as it was about investment and new services, rather than a consolidation of existing ones. Over 15 user and carer involvement events were scheduled to ensure buy-in for the model. This was important as it highlighted some of the concerns some users might have with the new model, such as having to move to a new care coordinator in the new model. Time between starting the new teams and running the model was not quite enough to allow all the interface conversations required. Now there is transition period where old team staff support the new staff, especially for patients with high needs and levels of risk. Learning and implementation takes place through conversations, therefore, it is important to allow the time for staff interaction, discussion and learning and set realistic timescales for implementation.. This requires a new way of working for the staff and therefore cultures and processes will take time to embed. Challenges The model is being implemented in an integrated health and social care service. Close working relationships with social care colleagues are required to ensure all statutory requirements continue to be met by both organisations. Working relationships with primary care colleagues are key to ensuring through-put and capacity. The model requires sign off by commissioners who are contributing significantly to the upfront funding on an invest to save basis. In the current financial climate, a commitment to additional investment has been incredibly difficult to justify. A range of engagement events have been held for the general public, service users, carers and staff. Sign off for the model has been subject to agreement by the local scrutiny committees. NHS Providers Page 5
Recruiting experienced staff to the new roles was a practical challenge. This has lead to extensive work in training and development of staff wishing to move into the new community roles and developing a comprehensive induction training packages. It has also developed a collaboration with Southbank University to create a mental health specialist advanced nurse practitioner course, which could be the first of its kind in the country. Conclusion SLAM has implemented a new model of therapy services for Adults that provides more effective and proactive treatment in the community for clients in Lewisham and Lambeth. This new model has shown initial reductions in hospital admissions, improvements in the way staff collaborate to deliver care across teams and increased engagement with primary services. A detailed evaluation of the new way of working will be completed in September 2015. Contacts Fran Bristow, AMH Programme Director, fran.bristow@slam.nhs.uk NHS Providers Page 6