Local Transformation of Early Intervention Services

Transcription

1 Local Transformation of Early Intervention Services Debasis Das MBBS, MD, MRCPsych, MSc(Health Services Management) Consultant Psychiatrist Quality Lead, School of Psychiatry, Health Education England- East Midlands Clinical Lead, EIP, East Midlands Mental Health Clinical Network

2 Disclaimer The views and opinion expresses in this presentation are my own and not necessarily reflective of that of my employing organisation/s. I have previously received honoraria for chairing educational meetings, presentations and consultancy fees from pharmaceutical companies, including sponsors of this meeting.

3 Transformation: definition Oxford Dictionary A marked change in form, nature, or appearance. A thorough or dramatic change in form or appearance Cambridge English Dictionary A complete change in the appearance or character of something or someone else, especially so that thing or person is improved

4 Overview of PIER Team Psychosis Intervention & Early Recovery First Episode Psychosis Service Serving Leicester City, Leicestershire and Rutland Population of just over 1 million Age Range: years ( until Oct 2016) years ( from Nov 2016)

5 Contents of the Talk How PIER is adapting services to the changing landscape Demonstrate our journey of continuous improvement Focus on a few areas: Access to services Psychological Therapy Physical Health Outcomes At-Risk Mental States

6 Early Intervention in Psychosis Access and Waiting Time Standard Quality Statement Adults with a first episode of psychosis start treatment in early intervention in psychosis services within two weeks of referral Adults with psychosis or schizophrenia are offered cognitive behavioural therapy for psychosis (CBTp) Adults with psychosis or schizophrenia have specific comprehensive physical health assessments.

7 NICE Guidance 2014 Psychosis and schizophrenia in adults: prevention and management Early intervention in psychosis services should be accessible to all people with a first episode or first presentation of psychosis, irrespective of the person's age or the duration of untreated psychosis. Five Year Forward Review: People experiencing a first episode of psychosis should have access to a NICE-approved care package within 2 weeks of referral. By April 2016 more than 50 per cent of this group have access to Early Intervention in Psychosis services, rising to at least 60 per cent by 2020/21.

8 Referrals by age (under / over 35s):

9 Access : Primary Care and Secondary Care referrals Education Primary care E-referrals Secondary care Timely Referrals PRISM Secondary Care Phone referrals

10 Waiting Times: Improved Business Processes Daily review of referrals Triage Reduction in delays Assessment Allocation to assessment slots MDT assessment quick decision Flexibility Evening Clinic assessments Flexibility of location for assessment

11 Two Week RTT Performance: (January to date)

12 Current breakdown by age (under/over 35s):

13 Psychological Therapy Out of 110 eligible patients, full data was available on 76 patients ( Jan - Dec 2013) There was available clinical documentation of 40% of study patients ( n=31) being offered CBT Of those undergoing CBT, 47% received upto 16 CBT sessions, as per NICE Guidance Transformation Plans: Improving CBTp Capacity: 2 in the process of recognition 3 undergoing Diploma programme 2 having Top-up training Improved Documentation Psychological Triage system Peer Groups

14 Physical Health Metabolic Monitoring: All new cases April 2011 and September 2012 Metabolic monitoring compliance with criteria, in first 12 months of care, was below 50% in all areas. Baseline personal and family history of diabetes and cardiovascular disease was recorded in less than 30% of cases. Monitoring of blood pressure, BMI, and waist circumference was recorded in less than 25% with baseline weight recorded in 39% Documentation of information in case notes was poor:

15 Physical Health: Improvement Plans

16 37% were discharged to primary care 33% to CMHT and 13% to other early intervention (EI) services(2010 data)

17 EIP Saves Money The Kings Fund report, Paying the Price (McCrone et al, 2008) predicted potential savings (per year) from full EIP service coverage in England over the next 20 years (McCrone et al, 2008) in excess of 60 million per year (on 2008 prices). Suicide is assumed to occur for 1.3 per cent of EI patients and 4 per cent of standard care patients. The estimated annual saving in suicide costs due to EI is 957 per person.

18 Service Level Stability of Outcomes Most patients have a stable continuity of care following discharge from an early intervention team Only a very small proportion of patients discharged from an early intervention in psychosis service move to another service in the 3 years following their discharge (8%) Movement of patients to a more intensive service after discharge from the early intervention in psychosis team was even lower (4%) Ahmed, S., Khan, R., Pursglove, D., O'Donoghue, J. and Chakraborty, N. (2015), Discharges from an early intervention in psychosis service: where do patients stand after 3 years?. Early Intervention in Psychiatry, 9:

19 Outcomes Measures HoNOS Health of the Nation Outcome Scales DIALOG is an outcomes measure to support structured conversation between patients and clinician focussing on the patients views of quality of life, needs for care and treatment satisfaction. Priebe, S., McCabe, R., et al (2007) Structured patient clinician communication and 1-year outcome in community mental healthcare: Cluster randomised controlled trial. The British Journal of Psychiatry, November : QPR Questionnaire about the process of recovery (QPR): A measurement tool developed in collaboration with service users Neil, Sandra T., Kilbride, Martina, Pitt, Liz, Nothard, Sarah, Welford, Mary, Sellwood, William and Morrison, Anthony P.(2009)'The questionnaire about the process of recovery (QPR): A measurement tool developed in collaboration with service users',psychosis,1:2,145 15

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21 Model of psychosis onset from the clinical high-risk state Fusar-Poli P, Borgwardt S, Bechdolf A et al ( 2013) The Psychosis High-Risk State A Comprehensive State-of-the- Art Review. JAMA Psychiatry. 2013;70(1):

22 At-Risk Mental States Clinical management (diagnosis and treatment) flowchart of the clinical high-risk state (HR) for psychosis. APS indicates attenuated psychotic symptoms subgroup BLIP, brief limited intermittent psychotic episode subgroup BS, basic symptoms subgroup FEP, first-episode psychosis GRD, genetic risk and deterioration syndrome subgroup and UPS unspecified prodromal symptoms subgroup Fusar-Poli P, Borgwardt S, Bechdolf A, Addington J, Riecher-Rössler A, Schultze-Lutter F, Keshavan M, Wood S, Ruhrmann S, Seidman LJ, Valmaggia L, Cannon T, Velthorst E, De Haan L, Cornblatt B, Bonoldi I, Birchwood M, McGlashan T, Carpenter W, McGorry P, Klosterkötter J, McGuire P, Yung A. The Psychosis High-Risk StateA Comprehensive State-of-the-Art Review. JAMA Psychiatry. 2013;70(1):

23 From: Howes, OD and Murray, RM (2014) Schizophrenia: an integrated sociodevelopmental-cognitive model. The Lancet, Vol383, Issue 9929,

24 Conclusion (1) Educational initiatives, flexibility and improvement in business processes appear to improve access and waiting times Change of systems can help improve outcomes - physical health monitoring in mental health Psychological therapy offer improving in service Stability in service level outcomes has been observed over time

25 Conclusion (2) Future Challenges? Patient level meaningful outcomes need to be developed -? Dialog or QPR Commissioning of ARMS ( At-Risk Mental State) services a priority for early detection and intervention in psychosis? Consideration of a 0-25 contiguous mental health service?

26 What makes EIP great? Flexibility Person-Centredness Positive Risk Taking Let s make EIP Great Again!