Older people s mental and physical health: strengthening Primary Care Dr Paul Hopper 2013 Quality care, when and where you need it
Contents 1. Introduction - the scale of need 2. Current approaches 3. Placing mental health care in a Long Term Condition context 4. Placing long term condition care in a mental health context 5. Conclusion References
1.0 Introduction - the scale of need Between now and 2030, the elderly population of Hampshire will increase steadily there will be 20% more over-65s in 7 years time, increasing to 50% more by 2030 (POPPI 2013). Levels of long-term condition morbidity are likely to rise even more steeply, as the over-80 age group will be the fastest-growing sector of the population. In a health - and social care - system which is even now struggling to meet demand, the demographic demand has the potential to be overwhelming. At the same time, the NHS National Outcomes Framework identifies five key domains against which all NHS organizations will need to report. These are: 1. Preventing people from dying prematurely; 2. Enhancing quality of life for people with long term conditions; 3. Helping people to recover from periods of ill health or following injury; 4. Ensuring that people have a positive experience of care; 5. Treating and caring for people in a safe environment and protecting them from avoidable harm. In order to achieve progress in all of these areas while keeping pace with the demographic demands, we have to make urgent and fundamental changes. This briefing suggests that a key component of any new approach will be the realignment of physical and mental health care. This is borne out by the Kings Fund finding that 4.5 million people in the UK have both long-term physical conditions and mental disorders. All other factors being equal, the presence of a mental disorder increases the costs of managing long-term physical conditions by an average of 45%. There are a variety of reasons for this, including the reality that people with mental disorders are less likely to seek appropriate health care in general, are less likely to take prescribed medication, and are less likely to manage their own risk factors. Of course this is a generalisation but in funding terms, the additional cost imposed by having a co-morbid mental disorder amounts to between 8 billion and 13 billion annually in other words approximately 8% of the entire NHS budget (Naylor et al 2012). 2.0 Current approaches There is a growing consensus that, wherever possible, health care should be provided outside acute hospital settings. However, community services are not yet being financed in a way which would allow them to offer a genuine alternative to acute hospital admission. Meanwhile GPs and other services face being overwhelmed by demand. Various initiatives have been set up to improve out-of-hospital care. For example, there has been a recent county-wide move in Hampshire to align community mental and physical health teams more closely particularly so in the case of older people s mental health teams where integration is proceeding rapidly in most areas. This sharing of skills, underpinned by the use of single care plans, facilitates seamless care. Another example is the outreach of specialist services into primary care to provide education to healthcare staff and to promote standardised care pathways. Although this seems to make intuitive sense, the evidence from international reviews is that such initiatives make only a limited difference to clinical practice and therefore outcomes (Thielke et al 2007). A further local example has been the introduction of risk stratification and multidisciplinary virtual ward meetings, which help GPs and community teams to focus on those most at risk. An example of the value of this approach is the South Devon and Torbay PCT/CCG Virtual Ward initiative, which has been successful in reducing emergency admissions significantly. However, the typical virtual ward is only able to focus on those most at risk, usually around 1-5% of the population, and has little impact on the broader mass of patients lower down the scale who are also chronically unwell in terms of having long term conditions. Given the relatively modest benefits of these initiatives, we have to ask whether there is more that can be done.
3.0 Placing mental health care in a Long Term Condition context There are certain core components which underpin effective Long Term Condition management. These are: Systematic Identification of those at risk (for example through risk stratification) Self-management support (including education, signposting, goal-setting and motivational interviewing) Use of evidence-based care protocols Coordination of care by providers (for example through single care plans) The glue which seems to bring together these components most effectively is the role of the care advisor/ navigator (referred to in the literature variously as care manager, or case manager, and occasionally care coordinator). This is an emerging role, not the same as current models of care coordinators - who are typically senior qualified specialists carrying a caseload of highly complex patients. The new breed of care advisor/ navigator may not be a health or social care professional, but would have specific training in the proactive monitoring of patients, navigation through care systems, and self-management support techniques. Many of the mental disorders seen by Older People s Mental Health services are, in effect, long-term conditions. This implies that if the same principles of management were applied as for physical long-term conditions, there should be improved outcomes. There is growing evidence that this is exactly what happens. The IMPACT ( Improving Mood, Promoting Access to Collaborative Treatment ) Programme has been implemented in centres across the United States and has published convincing data to show that when care advisors are used systematically to follow up people identified in primary care as having depression (often alongside long term physical conditions), their clinical outcomes are significantly better, even years after the care advisor support has stopped. Even more striking is that the overall healthcare costs of these patients is reduced, year-on-year (Unutzer et al 2008). A similar service is offered by the McArthur Foundation s RESPECT ( Re-Engineering Systems for Primary Care Treatment of depression ) Programme. Once again, the role of the care advisor in supporting primary care is crucial, and has been shown to result in significantly improved clinical outcomes (Dietrich et al 2004). The physical health of people with severe mental illness is very much poorer than for the rest of society. This group s life expectancy is on average 15-25 years lower. Through the use of Long Term Condition principles of care, the P-CARE ( Primary Care Access, Referral and Evaluation ) Programme in Atlanta, Georgia, provided monthly general nurse contact to all attenders at an Adult Mental Health clinic. After 2 years, health outcomes were significantly better and net costs savings were generated (Druss et al 2011). 4.0 Placing long term condition care in a mental health context Outcomes for individual physical conditions can be improved through the systematic management of co-morbid mental disorders. The Pathways Study in Washington State offered care coordination to patients with diabetes, who also had depression. The group which had received care coordination for 1 year had significantly improved health outcomes, and went on to incur lower overall health care costs for each of the 5 years of follow-up (Katon WJ et al 2008). The Hillingdon Study in Greater London offered CBT-style education, training and goal setting to a cohort of elderly patients who had COPD. After 6 months there was not only a significant improvement in mood symptoms, but also significantly reduced hospital attendance with breathlessness - leading to significantly reduced overall health costs (Howard et al 2010). Similar patterns of improvements in symptoms, costs and quality of life have been found in other longterm conditions such as coronary heart disease, when self management support included a mental health component. Age UK s Newquay Pathfinder project designs in the routine involvement of voluntary sector workers, acting as care advisors/navigators, for all older people deemed by their GPs to be at risk due to their long term conditions.
5.0 Conclusion It may seem a statement of the obvious that physical and mental health care are inseparable, but in reality our current systems do a good job of keeping them apart. Rationalisation of community care teams is a necessary step, but in itself not sufficient given the scale of transformation required. Emerging evidence is showing us that much more can be done at primary care level, if GPs are to be freed up to see the patients who really need them. In the same way that older people with mental disorders will do better if they can access self-management support from their GP practice, there will also be significant benefits to older people with physical conditions when their self management support addresses mental health needs. One of the keys to unblocking the system will be to bring the care advisor/navigator role into primary care, to provide the proactive long term support (in conjunction with others) which genuinely alters the course of long term conditions and benefits patients wellbeing. Alongside this, GPs will need systematic support from relevant specialists to promote care planning - the success of which the advisor/navigator will promote and monitor. This triad of GP, specialist and care advisor/ navigator, has the potential to transform healthcare in Hampshire in terms of costs, GP satisfaction and most importantly patient experience. References Dietrich AJ, Oxman TE, Williams JW, Schulberg HC, Bruce ML, Lee PW, Barry S, Raue PJ, Lefever JJ, Heo M, Rost K, Kroenke K, Gerrity M, Nutting PA. (2004) Re-engineering systems for the treatment of depression in primary care. British Medical Journal. 329:602-604 Druss B, Von Esenwein S, Compton MT, Zhao L, Leslie D. (2011). Budget impact and sustainability of medical care management for persons with serious mental illnesses. American Journal of Psychiatry 168(11): 1171-1178 Howard C, Dupont S, Hazelden B, Lynch J, Wills P. (2010). The effectiveness of a group cognitive behavioural breathlessness intervention on health status, mood and hospital admissions in elderly patients with chronic obstructive pulmonary disease. Psychology, Health and Medicine 15(4): 371-385 Katon WJ, Russo JE, Von Korff M, Lin EHB, Ludman E, Ciechanowski P. (2008). Long term effects on medical costs of improving depression outcomes in patients with depression and diabetes. Diabetes Care. 31(6): 1155-1159 Naylor C, Parsonage M, McDaid D, Knapp M, Fossey M, Galea A (2012). Long Term Conditions and mental health. The Kings Fund. Projecting Older People Population Information System (poppi.org.uk) 2013 Thielke S, Vannoy S, Unutzer J (2007). Integrating Mental Health and Primary Care. Primary care: clinics in office practice. 34:571-592 Unutzer J, Katon W, Fan M, Schoenbaum M, Lin E, Della Penna R, Powers D. (2008). Long-term cost effects of collaborative care for late-life depression. American Journal of managed care. 14:95-100