INFORMATION STANDARDS GOVERNANCE PROCESS INFORMATION STANDARD Draft FINAL PROPOSAL FOR NEW OR CHANGED (INCLUDING RETIRED) INFORMATION STANDARD Project to develop dataset to inform KPIs / AOF targets for Adult Mental Health Crisis Resolution Services November 2008
INFORMATION STANDARD FINAL PROPOSAL FOR NEW OR CHANGED (INCLUDING RETIRED) INFORMATION STANDARD This document should be completed using the GUIDANCE ON COMPLETING THE INFORMATION STANDARD FINAL PROPOSAL NOTIFICATION SUBMISSION TEMPLATE REVISION HISTORY Date of this revision: Version Revision Summary of Changes no. date 0.1 20 Nov 08 Draft Final proposal Changes marked SUBMITTED BY: Document completed by: Emrys Elias Role & organisation: NHS Wales Delivery and Support Unit FEEDBACK TO BE PROVIDED TO: Feedback will be provided on the Proposal within 10 days of the WIGSB meeting. If the feedback is to be directed to another nominee please provide the name and contact details below. Name: Emrys Elias, NHS Wales Delivery and Support Unit Peter Martin, Mental Health Policy Branch, WAG Email: emrys.elias@dsu.wales.nhs.uk Peter.martin@wales.gsi.gov.uk SUBMISSION PURPOSE Proposal submitted for: Final Approval If this Proposal submission is not for formal approval then please state the specific aspects on which you would like more detailed comments. Specific Areas for WIGSB to comment on when not submitting for formal approval at the Proposal stage Page: 2 of 13
SECTION 1: BACKGROUND 1. Information Standards Reference Number [From Information Services Division] IGRN 2008 / 017 2. Name of Information Standard Collection of dataset to inform and measure KPIs / AOF targets for Mental Health Crisis Resolution Services 3. Type of change a) Introduction of new standard 4. Type of standard [Select all that apply] a) Operational b) Strategic 5. Introduction In Wales there has been an ongoing modernisation of services into a community focussed model of care. In response to the modernisation agenda Mental Health services have become more community focussed supporting a notion of normalisation. In patient services have reduced in number and services have been reconfigured to form integrated locally based provision in the community. The modernisation of services has been supported by WAG performance targets influenced by the All Wales Mental Health Strategies (1989 & 2003) and latterly the Mental Health NSF An earlier Mental Health performance target that related to the introduction of Crisis Resolution Services was: All health communities to put in place mental health crisis resolution and home treatment services. [Target date: 31 st March 2006] (Outcome to reduce total inpatient mental health bed days for adults of working age by 5% in 2006/07 and 25% in 2007/08) From a review undertaken by the All Wales Crisis Resolution Group during 2007/2008 it is evident that crisis resolution service models are at different stages of development across Wales, and have no common indicators to inform on the effectiveness of service delivery. The SAFF Target in place tends to focus on the requirement to have a service in place but there is little reference to the requirements of service delivery. Three NHS Trusts agreed to participate in a pilot: Gwent Healthcare NHS Trust, North Wales - Central NHS Trust and Hywel Dda NHS Trust. A Project Team was established and chaired by the Performance Improvement Manager, Mental Health DSU. Clinical and managerial input was provided to the Project Team by each of the participating Trusts, LHB representation from each Region, NLIAH, Swansea University, Opinion Research Services (for service user evaluation) and representation from the All Wales Crisis Resolution Group. The Project commenced on the 1 st May 2008 with a completion date of November 2008. The outcome of the pilot has been the development of a dataset to inform KPIs on Crisis Resolution Home Treatment. KPIs were agreed within the project group and have been informed from the dataset. Conversely the dataset informs the measurement of performance against the KPIs. From this work AOF targets have been developed and are to be proposed for inclusion within the 2009/10 AOF target group. Page: 3 of 13
6. Sponsor Peter Martin, Policy Lead Mental Health, WAG 7. Developer Emrys Elias, NHS Delivery and Support Unit 8. Implementation Date The pilot project has been completed and the collection of the dataset could be finalised and implemented to the service as soon as possible. The dataset collection would need to be in place on or before 1 st April 2009 to inform the relevant AOF targets. Page: 4 of 13
SECTION 2: BUSINESS JUSTIFICATION 9. Purpose This submission relates to Adult Mental Health Crisis Resolution Services and relates to the findings of a pilot project undertaken between May and September 2008. The aim of the project was to develop KPIs to inform on the effectiveness of Crisis Resolution Services and a data set that collects standard data for the purpose of determining activity which informs on service performance, benchmarking and service planning and can be used for the implementation of appropriate AOF Targets. Crisis Resolution Services have been implemented in response to SAFF Target 17 as per WHC (2005)048 Policy Implementation Guidance on the development of Crisis Resolution/Home Treatment services in Wales. Across Wales service models are variable, ranging from a comprehensive multidisciplinary team approach, to a single person service, to no service at all. It is reported by the All Wales Crisis Resolution Services Group that in a review undertaken in May 2008 only three out of sixteen Crisis Resolution Services in Wales meet the WHC (2005) Policy Implementation Guidance. Services have been developed differently across Wales as a consequence of differing commissioning agendas, differing interpretations as to what constitutes a Crisis Service, varying service models and limited or no finance to implement services effectively Where Crisis Resolution Services are not implemented appropriately there is a continued reliance on secondary care services to manage risks that could be managed in a different way within the community. Subsequently there could be an inefficient use of inpatient beds and patients would be cared for in inappropriate care settings. A project was established to provide the opportunity to monitor progress against the delivery of the Crisis Resolution Service by piloting KPIs and a dataset that reflect the requirements of the WHC (2005)048: A crisis resolution/home treatment service should be able to: Act as gatekeeper to mental health services, rapidly assessing individuals with acute mental health problems and referring them to the most appropriate service provide immediate multi-disciplinary, community based treatment 7 days a week for individuals with acute, severe mental health problems for whom home treatment would be appropriate, Ensure that individuals experiencing acute, severe mental health difficulties are treated in the least restrictive environment, as close to home, as clinically possible Remain involved with the client until the crisis has resolved and the service user is inked into ongoing care. If hospitalisation is necessary, the service should be actively involved in discharge planning and provide intensive care at home to enable early discharge Reduce service users' vulnerability to crisis and support service users to develop effective coping skills The AOF Target 2009/2010 was developed as a result of the review work and is as follows: Crisis Resolution/Home Treatment services and other community services Each NHS organisation must ensure that: 95% of service users admitted to a psychiatric hospital between 0900 and 2100 will have received a gate-keeping assessment by the CRHT service prior to admission; 100% of service users admitted to a psychiatric hospital, who have not received a gate keeping assessment by the CRHTS, will receive a follow up assessment by the CRHTS within 24 hours of admission Reduce the number of readmissions (within one year) for those that have had a hospital admission of over 7 days by 10% compared with 2008/09. Page: 5 of 13
The attached tool is intended to enable organisations to report on performance of the AOF target and inform on the demand and capacity of services and support an informed awareness on the effectiveness of local mental health service models as defined within the All Wales Mental Health Strategy (2003). It is evident from the findings of the Pilot Project where Crisis Resolution Services have not been commissioned appropriately and that Crisis Services are not able to respond to crisis as per the requirements of the WHC (2005) 048. It is usual practise for alternative services such as Community Mental Health Teams to manage crisis when a service does not have appropriate capacity. The proposed KPIs will therefore enable informed performance management of Crisis Resolution Services. 10. Scope The project and therefore dataset relates to all adults (18-65) as described in the Mental Health Strategy for Wales (2003) accessing Crisis Resolution Services. The data set and KPIs derived through its use within the Pilot project will relate to all adult patients referred to Welsh NHS Trusts. KPIs have been derived from the data collected during the pilot and through discussion with the service during the pilot stage. These KPIs have in turn led to a narrower focus of AOF targets. It is proposed that the data collection will not only inform the proposed AOF targets but the KPIs highlighted below. 11. Funding No extra funding is expected to be required to implement the project / collect the proposed dataset as it is expected that organisations should already have processes in place. 12. Support This proposal is supported by the Performance Management Team, Mental Health Policy Directorate and Delivery and Support Unit. The pilot project participants through their involvement have noted the requirement for the proposed dataset. Page: 6 of 13
SECTION 3: HEALTH INFORMATION STRATEGIC AND OPERATIONAL FIT 13. Strategic Fit As no other plans to develop national information systems to support operational processes / performance are known to be in place. It is proposed to adopt this dataset which will inform on the Health community progress toward the management of mental health crisis within the community and the delivery of the requirements of the All Wales Mental Health Strategy (2003). 14. Operational Fit The current data collected on Crisis Resolution Services refers specifically to each locality having a service in place. The data collection within the project relates to access to services, referral type, coordination of care, home treatment and utilisation of inpatient services and is described in detail in the proposal field 16. The dataset has been developed in conjunction with 3 NHS Trusts and has been based on the work previously undertaken by the All Wales Crisis Resolution Network. This has aimed to ensure that the data burden on Services / Trusts has been minimised and that maximum benefit has been achieved from the data proposed to be collected. The method of data collection included the use of a specific proforma used by each crisis resolution Home Treatment worker where information on service activity is collected on a daily basis and then entered onto an excel spreadsheet. The sum of information co-ordinated and reported on a monthly basis. 15. Known standards in use nationally and internationally The DOH has reviewed Crisis Resolution Services within England and produced a paper (Jan 2008). The evidence from the review has been used to inform the development of the data set and the KPIs for the project. Scottish: Reduce hospital admission rates by 10% (by end December 2009). Reduce the number of readmissions (within one year) for those that have had a hospital admission of over 7 days by 10% (by end December 2009). There will also be qualitative measures which will incorporate the following: Acceptable locations for and quality of care to service users. Improvement of service user experience in management of episodes of crisis care; and Increase/improve social inclusion. Page: 7 of 13
SECTION 4: THE PROPOSAL 16. Proposed Solution Proposal Tool was developed from the Crisis Resolution Pilot project. Baseline Information Evidence of findings of the review supported the development of the audit tool Data Set A data set has been established for Crisis Resolution services, utilising the evidence base, best practice, and the reported experience in England (Attachment 1 ). Data definitions are described as follows: 1. Total number of referrals received Number of referrals received by the CRHT services, whether accepted, inappropriate or rejected. Referral definition - A referral is an individual who's need is such that they are likely to require imminent admission to hospital due to their mental health needs or the immediate risks surrounding them" A referral can be made by a GP, Consultant Psychiatrist, or any member of the CMHT. 2. Total number of appropriate referrals accepted for assessment Total number of referrals that are appropriate and accepted onto caseload by service for assessment. Accepted Referrals are working age adults with severe mental illness who are experiencing an acute episode or who are in crisis to such an extent that admission to hospital would be required without such intervention. It should also be for people who are ready to leave hospital but require intensive support to facilitate safe discharge. 3. Rejected appropriate referrals not assessed due to lack of capacity Number of rejected referrals not assessed by CRHT service due to lack of capacity of that service to assess patient. Number of inappropriate referrals can be derived from the above data items: 1 (2+3) = All referrals receive a risk assessment which informs on the decision making for the appropriate patient pathway. 4. Referrals by time band Number of referrals received and accepted in each three hour time band, with each service operating varying office hours. Standard hours of service should be between 9am and 9pm. 5. Time between referral and initial contact Time in hourly bands (up to 4 hours) between referral and initial (face to face) contact by CRHT team. If face to face contact is more than 4 hours an option of either Crisis or Home Treatment contact over 4 hours has been defined. This represents Crisis (Urgent) and Home Treatment (Routine) workload. Telephone only contact option has been included if contact is not face to face Page: 8 of 13
(this is not limited to time bands) but has been included to reflect workload that is undertaken but is not accepted onto caseload of CRHT services. 6. Duration of Home Treatment Duration of Home Treatment either less than or greater than 6 week standard as defined in WHC(2005) 048 7. Discharge destination Discharge destination from Home Treatment service either to referrer after assessment (no Home Treatment provided), to CMHT or to GP. 8. All admissions Hospital (Mental Health Inpatient Unit) Admissions to hospital either agreed by CRHT, admissions not agreed within standard CRHT hours 9am to 9pm (e.g. not agreed or no CRHT involvement) or admissions that occur outside CRHT hours. The CRHT service should be involved in (gate keep) all admissions within the hours of 9am to 9pm. The CRHT service is required to provide follow up to any patient who is admitted without Crisis Resolution involvement / assessment. If any admissions occur outside CRHT hours these patients should be identified by the CRHT team the following day on the Inpatient ward. Patients who have not had any contact with the CRHT team can therefore be identified. 9. Follow up assessment undertaken by CRHT service The number of follow up assessments that have been undertaken with patients either admitted outside CRHT standards hours (9am 9pm) or those admissions who had no CRHT involvement within standard hours (9am 9pm). 10. Bed occupancy Monthly bed occupancy for Mental Health inpatient beds gate kept by the CRHT team, including and excluding leave beds. This relates to beds gate kept by the CRHT service at midnights that are unoccupied / occupied. Bed occupancy including leave beds is also required as this relates to the processes and systems that occur with patients on long term leave that have not been discharged, therefore still occupying the bed. There is an issue with patients being inappropriately put on leave for long periods of time where they could have been discharged. This indicator will allow measurement of this issue. Managing Information Each Trust will be required to provide data, collected in a standardised format (currently Excel) and forwarded to a central source (the DSU on the fifth working day of each month) Data should be recorded throughout the month or local systems could be interrogated to provide the relevant data. Data relating to CRHT services and Mental Health Inpatient Admissions may be currently collected on separate systems. The requirement to retrieve data relating to CRHT caseload and Mental Health Inpatient admissions will be required. The operational practice of this requirement will be assessed using the Impact Assessment tool and reported back to WIGSB in the final approval submission. Performance Indicators Performance Indicators have been introduced within the pilot sites which reflect the service requirements as defined within WHC (2005)048 : Page: 9 of 13
1.The Crisis Resolution Service will act as gatekeeper for every potential admission to inpatient services. (95%) 2. Each Person referred to the Crisis Resolution Services will receive a face to face contact assessment within 4 hours (100%) 3. Each person referred to the Crisis Resolution Service will meet the referral criteria for Crisis Resolution Services as per WHC 2005 048 (Target 100%) 4. Each person referred to the Crisis Resolution Services will remain with the service no longer than 6 weeks from the day the person is accepted onto the caseload (Target 100%) The above KPIs have been implemented from the dataset collected through the pilot project. These have been further refined, as has the dataset set to inform the measurement of these KPIs. Some of the above KPIs have been selected to be used as AOF targets for the 2009/10 framework period. These proposed AOF targets are listed below: 95% of service users admitted to a psychiatric hospital between 0900 and 2100 will have received a gate-keeping assessment by the CRHT service prior to admission; 100% of service users admitted to a psychiatric hospital who have note received a gatekeeping assessment by the Crisis Resolution Home Treatment Service will receive a follow up assessment by the CRHT within 24 hours of admission; Reduce the number of readmissions (within one year) for those that have had a hospital admission of over 7 days by 10% compared with 2008/9 17. Fitness for Purpose The proposed dataset has been refined in conjunction with the three pilot sites to ensure robustness, validity. The defined KPIs have been assessed as being specific, measurable, achievable, realistic and timely. As the KPIs have been derived from the proposed dataset there is sufficient robust data included in which to measure against each KPI. Likewise with the proposed AOF targets the dataset has been developed to provide robust data from which to monitor against. 18. Testing / Pilot Testing as per description of Pilot re. field 16. 19. Information Governance The proposed dataset consists of aggregated data in line with NHS Wales governance requirements for further confirmation with WIGSB. Data collected in the proposed dataset is not patient identifiable and adheres to any Calidcott guidelines. 20. Commercial Considerations There are no known commercial considerations Page: 10 of 13
SECTION 5: IMPACT ASSESSMENT 21. Impact Assessment The impact assessment of the proposed dataset will be evaluated using the Impact Assessment tool provided by HSW data definitions department during November/ December 2008. This will be sent to all Trusts to evaluate the impact of the data collection on the service and information departments. The results of this impact assessment will be reported in the final approval submission to be submitted to WIGSB in December 2008. Page: 11 of 13
SECTION 6: IMPLEMENTATION PLAN 22. Implementation plan The implementation plan is as follows: Draft final proposal including draft audit tool presented to WIGSB 20 November 2008 Impact Assessment with NHS November / December 2008 Review of impact assessment and refine audit tool December 2008 Final proposal to WIGSB 18 December 2008 Issue to NHS by 31 January 2009 First quarter audit undertaken April June 2009 First report from audit July 2009 23. Official Documentation Page: 12 of 13
SECTION 7: MAINTENANCE AND REVIEW 24. Maintenance Process Review of tool will be undertaken in April 2010 after 12 months use. 25. Planned review dates Page: 13 of 13