Follow up of Early Intervention for. Psychosis (EIP) Service User. Outcomes

Transcription

1 Follow up of Early Intervention for Psychosis (EIP) Service User Outcomes Laura Drage Commissioned by Dr Anita Brewin, Consultant Clinical Psychologist / Clinical Lead, Bradford and Airedale Early Intervention Service

2 Table of Contents Introduction...3 Literature Review...3 Early Intervention 5 Service Costs...5 Service Design...6 Aims...8 Method...10 Audit Tool...10 Procedure...10 Ethical Considerations...10 Results...11 Descriptive Statistics...11 Service Involvement Pathways...13 Primary Care Re-referrals to EIP...14 Secondary Care Discharges...15 Discharge Destination: Potential Factors...16 Additional Information...17 Discussion...19 Sample Characteristics...19 DUP...19 Discharge Destination...20 Primary Care...20 Secondary Care...21 Enhanced Care...22 Methodological Evaluation...22 Recommendations and Dissemination...23 References...24 Tables and Figures Figure 1. Illustration of EIP Service Involvement Pathways at Discharge and at 1 year follow-up... 9 Figure 2. Service Involvement following EIP discharge Figure 3. DUP and Discharge Destination Table 1: Distribution of Audit Sample by Locality, Age, Ethnicity and Duration of Untreated Psychosis (DUP) Table 2. Service Destinations on Discharge from EIP and after 1 Year... 13

3 Introduction The Bradford and Airedale Early Intervention in Psychosis (B&A EIP) Team is a service for people aged years, who may be experiencing their first episode of psychosis. The care pathways of EIP service users (SUs) following discharge is considered by commissioners to be an appropriate indication of SUs recovery and the standards of care they received. This audit was commissioned to clarify the service involvement of former service users of B&AEIP one year after their discharge. Literature Review Contemporary psychiatry uses the term psychosis to describe a variety of conditions associated with schizophrenia (American Psychiatric Association [APA], 2013). Psychosis is commonly characterised by the presence of hallucinations (distortions in perception, e.g. seeing, hearing or smelling things others cannot) and/or unusual beliefs ( delusions ) or specific unusual behaviours. Psychotic symptoms commonly lead to anxiety and depression, thought disorder (a disruption to the flow of consciousness evidenced in unusual speech) and resultant social isolation and impaired functioning. Kay, Flszbein and Opfer (1987) classified symptoms as positive, negative and general and developed a standardised clinical interview measure to assess these symptoms called The Positive And Negative Syndrome Scale (PANSS). Positive symptoms include delusions, hallucinations, persecutory ideation, and conceptual disorganisation. Negative symptoms could include blunted affect, avolition (emotional and social withdrawal and an appearance of disinterest). General symptoms include depression, anxiety, and somatic symptoms. Individuals could meet the criteria for a diagnosis of psychosis when their most prominent positive symptom persists for more than a few seconds and occurs more than once each week ( moderate severity or score of 4 on the 3

4 PANSS) for at least one month or they may have several positive symptoms with a milder severity for a similar length of time (APA, 2013). At the point of referral to an EIP team, it is sometimes unclear whether an individual is experiencing psychosis since psychotic-like symptoms can be transitory; vary on a continuum of severity (Myin-Germeys, Krabbendam & van Os, 2003) and are experienced by many in the general population (Jansen et al., 2004; van Os, 2003; 2004). Individuals may be in a prodromal (high risk) stage of developing psychosis (Yung et al., 2008) where symptoms are milder or less established. Alternatively, they may not be experiencing psychosis per se but have symptoms in common with psychosis. For example, auditory hallucinations can be experienced by individuals with diagnoses of PTSD, borderline personality disorder, and bipolar disorder (APA, 2013) and EIP services include such individuals (Brewin, 2010). The ambiguities inherent in the referral process may mean that clients leave the service with no diagnosis or an alternative one. The referrer (frequently the GP) may use a checklist to assess suitability for referral to an EIP (see Appendix A). This should include recent life stressors, since there is strong evidence to suggest that psychosis is induced through environmental influences, in particular social deprivation and trauma (Bentall et al., 2012; Varese et al., 2012). Suitability for referral should satisfy criteria relating to the quality and timing of the onset symptoms. A client meets criteria for three-year EIP support if: it is suspected that they are experiencing their first episode of psychosis; this is their first presentation to mental health services with suspected psychotic symptoms and they have not yet received treatment; or the onset of their first psychotic episode is less than three years ago (EIP Service Operational Policy; Brewin, 2014). 4

5 Early Intervention EIPs are specialist services established with the purpose of reducing treatment delay at early onset of psychosis, thereby reducing the duration of untreated psychosis (DUP), promoting recovery and preventing relapse (Lester et al., 2009a). The rationale for early intervention is supported by substantial evidence that individuals who receive care close to the onset of their psychotic experiences, usually in adolescence or early adulthood, have a more positive long term prognosis including: fewer and less severe positive symptoms, improved overall recovery and sustained full-time employment (Chang, 2000; McGorry et al, 2002; Perkins et al., 2005). However, other factors are important contributors to this predictive relationship, namely, premorbid functioning and coping resources (Craig, 2000; Verdoux, 2001) highlighting these as relevant characteristics to assess. Unfortunately, DUP is also difficult to reliably measure. The calculation is based on assessing the approximate date of onset of psychosis (OP) and onset of criteria treatment (OCT) and subtracting OP from OCT. The OP can be calculated from medical records or from personal accounts of when the client or others first noticed psychotic features (whichever came first). OP is defined as the SU s first experience of a symptom that would reach moderate severity or score 4 on the PANSS. Depending on the service, the definition of OCT can vary. At B&AEIP team, criteria treatment includes the date the SU took their first dose of antipsychotic medication (if they continued this for one month) or a significant reduction in symptoms (scoring <4 on the PANSS). Service Costs Although overall prevalence rates of psychosis in the UK are relatively small in comparison with other mental health issues, service provision incurs high costs (McCrone, 2008). Approximately 30% of the costs of supporting individuals with psychosis are met from public money (e.g. income support); the remaining 70% of the expense is incurred 5

6 indirectly through lost economic productivity (Mangalore & Knapp, 2007) since individuals experiencing psychosis may struggle to gain and maintain employment. Including lost productivity costs, McCrone (2008) estimated that, in 2007, the total service cost for schizophrenia and related disorders was 4 billion and is expected to rise to 6.5 billion by This motivates investment in services that aim to prevent or reduce the likelihood of an individual s first psychotic episode developing into a more severe and enduring mental health problem, incurring further long-term spending. The specialist care provided through EIPs has been shown to be cost effective in the long-term. McCrone, Knapp and Dhanasiri (2008) found that at one year and three year time points, EI service intervention saved 35% on the overall cost of care for the individual with psychosis compared with standard care intervention. This saving was largely dependent on the rate of inpatient (re)admission meaning that if the individual was admitted to hospital the financial gains of EI were significantly reduced. However, evidence indicates that inpatient admission rates are significantly lower for SUs who received EIP care (Craig et al., 2004; IRIS guidelines, 2011; McCrone, 2008), which positively contributes to the long-term financial gains of EI. In order to continue to receive funding EIPs are required by commissioners to continue evidencing this strength. EIP teams therefore conduct audits and service evaluations to capture their specific service provision for the local population. Service Design Referrals to the B&AEIP are received by the hub team. Each client referred is allocated a care navigator who will assess the client s suitability to receive a three-year EIP service. The hub team build a formulation of the individual s experiences and, if suitable for EIP intervention, the care navigator will establish an initial care plan for the client with the newly allocated care coordinator (staff member responsible for individual SU s care), working in 6

7 one of the four locality teams ( clusters ) serving the client s area. The four clusters are: District North, District South, Airedale and City. EIP service design is an evidencebased reform that endorses a youth-friendly, engaging (assertive outreach) approach to community mental health intervention that bridges primary and secondary care (IRIS Guidelines, 2012). Minimum service provision involves care coordination (including faceface contact according to SU needs, often on a weekly basis) and medication reviews. There may also be optional support from a recovery and inclusion or support worker and psychological intervention (individual and family therapy). In order to evaluate the overall intervention provided for SUs, a general indicator of care standard has been determined, based on the SU s destination at discharge and at one year follow-up. Internationally, EIP implementers set targets for outcomes including an aspiration that 80% of (SUs) will be discharged back to primary care (under the care of a GP) after approximately 3 years of EIP support. However this target is based on Australian research ( EPPIC study) reporting symptom remission and occupational and vocational involvement at follow-up 7 years later (Jackson& McGorry, 2010). Following this, UK guidelines suggest that EIPs should aim to discharge a minimum of 50% of service users back to primary care following three years of service support (IRIS Guidelines, 2012). B&AEIP team has demonstrated continual improvements in relation to these goals since its inception in Between January-December 2010, 50% of service users were discharged to primary care, increasing to 63% in The targets for EIPs mean that it is vital for EIPs to monitor discharge rates as an overall measure of the standard of care provision, and also collect additional information that provides context to the data, e.g. SUs life circumstances following discharge and EIP service engagement. This audit has been undertaken to check whether B&AEIP continued to meet IRIS standards between April 2012 and April

8 Aims The general aim of this audit is to clarify the status (service involvement) of former SUs discharged between April 2012-April 2013, following three-years of support (variable depending on individual needs). The service involvement pathways, including EIP standards, are illustrated in Figure 1 below. Specifically, the audit aims to identify: 1a) whether individuals discharged from EIP to their GP are re-referred to other mental health services within 12 months, gathering evidence about potential reasons for this. 1b) the nature of service involvement for those re-referred, e.g. short term crisis input, referral to community mental health teams (CMHTs), admissions to hospital (with or without detention under the mental health act (MHA) 2) if referred directly to secondary services, whether people stay engaged and what other services they access. This audit is a pilot as it involves collecting data at different time points to previous service audits (December and July) and includes details regarding possible reasons for the outcomes. It will also be used to assess EIP discharge decision making. 8

9 Fig ure 1. Illu stra tion of EIP Ser vice Inv olve men t Pat hwa ys at Disc har ge and at 1 yea r foll owup 9

10 Method Audit Tool Dr Anita Brewin (Consultant Clinical Psychologist) and Laura Drage (Clinical Psychologist in Training) developed a screening tool to record relevant information when searching the SU database (see appendix B). Procedure The audit involved screening electronic notes using the Bradford District NHS Trust information database Rio. The SU records that were audited were discharged one year prior to the start of data collection. The auditor accessed SUs status of service involvement at the relevant time points and the EIP referral and discharge letters. Additional information was gained by screening clinical notes for evidence of post-discharge life events, whether individuals moved between services and why. If SUs required further support, the nature of that involvement was recorded (see aim 1b). Additionally, care coordinators for the SUs in this sample were asked to rate the SU s level of engagement with B&AEIP support. All information was collated into an Excel Spreadsheet for analysis and key findings (service involvement at discharge and follow up and DUP data) were checked by another auditor to ensure the accuracy and reliability of the data reported. Ethical Considerations As the project was an audit, national ethical approval was not required. The details of the project were approved by Bradford District Care NHS Trust R&D department. All information was recorded anonymously for SUs using a unique, personalised ID code. All data files were password protected and stored on encrypted storage devices. 10

11 Results Descriptive Statistics Findings from this audit are compared with previous B&AEIP audit data and servicespecific target figures. A total of 65 SUs were discharged from the four different clusters between April : 12 from Airedale, 28 from City, 8 from District-North and 17 from District-South. SUs who left the geographical area within the follow-up period, and those receiving support from CAMHS (Child and Adolescent Mental Health Services) aged 14-15, were excluded from the final sample. This overall figure was smaller than anticipated since previous audits show B&AEIP discharged approximately 100 SUs annually. The discrepancy in sample sizes may be due to two reasons: previous audits included CAMHS SUs, and discharge data was collected between different months to previous audits. SUs were grouped into 3 age groups. On admission to EIP, 6 of the 65 were aged 16-18, 31 were aged and 28 were aged The mean age =24.7 (sd=5.1) median =24. Ethnicity data revealed: 25 of the 65 were of South Asian / Pakistani origin, 28 White British, 5 Black African / Caribbean, 7 mixed ethnicity, and 2 chose not to disclose this information. The B&AEIP 2014 DUP target is for 100% of SUs admitted to the service to have DUPs <6 months, the median for each quarter should be <3 months. Of the 41 SUs whose DUP was recorded on admission to EIP, the median DUP was 92 days (approximately 3 months), mean =164.1, sd =190.13, range =0-545 days. 23 of the 65 SUs (35%) had a DUP <3 months and 29 of the 65 SUs (45%) met the <6 month target; however, a total of 12 SUs (18%) had DUPs >6months and 24 of the 65 had unknown DUPs, (see Appendix C for chart). 11

12 Table 1: Distribution of Audit Sample by Locality, Age, Ethnicity and Duration of Untreated Psychosis (DUP) Age Ethnicity DUP Asian / White Black Mixed Not <3 months <6 months >6 months Not Cluster Location City North South Airedale Pakistani British African / / Other Disclosed Known Caribbean Total

13 Service Involvement Pathways The main question of this audit was to clarify the service involvement of former SUs discharged between April 2012-April 2013 immediately after, and one year following discharge. Results are shown in Table 2, (see Appendix D & F for cluster results). Table 2. Service Destinations on Discharge from EIP and after 1 Year Discharge Destination Service at 1 Year Follow-up N (% of total) GP Secondary Care GP 23 (35) Of these 16 (25) 7 (10) Secondary Care 42 (65) Of these 3 (5) 39 (60) Total Overall, the EIP discharged approximately one third of SUs back to their GP between April 2012 and April This is inconsistent with B&AEIP audit data from previous years which showed that 63% of SUs were discharged to primary care in These results do not meet the national targets of an 80% discharge rate to primary care or the minimum requirement of a 50% discharge rate. Within the group of SUs discharged to GPs, approximately one third (7 of the 23) of these were in mental health services one year later and 16 (35%) were in primary care. Of the 42 SUs discharged to mental health services, 9 were under consultant outpatient service only, 1 required enhanced care (inpatient/other residential care), 28 received community mental health support and 4, assertive outreach support. After one year, 3 of the 42 had left mental health services. 13

14 If SUs frequently move from their discharge destination to a different service, this could suggest the discharge destination was an inappropriate choice. Therefore, a change in frequencies test was performed to establish how many SUs had moved between services at the one year followup stage, and whether this was significant. McNemar s (1947) non-parametric test requires that for 1 degree of freedom the chi-squared value should be 3.84 to reach significance. In this calculation the number of SUs discharged to GPs who had moved back into services one year later =a. The number of SUs discharged to secondary care who were discharged to GPs one year later =b. (a-b-1)squared / (a+b)= 7-3-1squared /7+3= 9/10=0.9. This result is not significant showing that SUs are most likely to remain where they were discharged to one year later. A non-significant result may also reflect insufficient sample size, however, visual inspection of the figures shows a relatively low frequency of movement between services. This suggests appropriate discharge decision making from B&AEIP. Primary Care Re-referrals to EIP To evaluate further the soundness of decision making regarding discharge of GP rereferrals, and to address aim 1a, a closer inspection of the qualitative data was carried out. This involved looking at the reasons for re-referral, circumstances at discharge, and subsequent life events. Soundness of EIP decision-making at the point of discharge was based on:. whether the SU was re-referred with psychosis. whether this was anticipated at the point of discharge and consistent with crisis plans 14

15 the gap between discharge from EIP and relapse; the shorter the gap the more questionable the decision making, as it seems likely that the SU could not manage without service support. The soundness of the decisions were classified as: good, the SU was discharged to a service appropriate for their needs ; poor, an alternative decision should have been made with the available evidence; and questionable, involving mixed evidence. This additional data inspection revealed that 10 of the SUs discharged to primary care were re-referred to secondary services, although 3 of the 10 were unsuitable re-referrals not accepted by secondary services. From the 10, 5 were considered good decisions by the EIP, 3 were questionable and 2 were poor (avoidable errors). Addressing aim 1b, regarding the nature of service involvement of this subgroup one year post-discharge: 3 of the 10 were out of mental health services; 1 was receiving consultant outpatient support alone; 1 gained support from a substance misuse service; 4 were being supported by a CMHT; and 1 was a voluntary admission. The circumstances around re-referral and EIP decision making are described in more detail in appendix E. Secondary Care Discharges To address aim 2, data was collected regarding the type of service to which the SU was referred, since this indicates the level of support the SU needs. This data, alongside their one-year post-discharge location is displayed in Figure 3. 15

16 GP Consultant Out-Patient CMHT AOT Enhanced South Dx South 1 Yr Post Dx CityDx City 1 Yr Post Dx North Dx North 1 Yr Post Dx Airedale Dx Airedale 1 Yr Post Dx No of SUs CMHT= Community Mental Health Team, AOT= Assertive Outreach Team, Enhanced= inpatient / other, Cons OP= consultant outpatient only. Figure 2. Service Involvement following EIP discharge Very few former EIP SUs required enhanced care at discharge, n=1 was discharged to a residential therapeutic community. At follow-up this increased to 2 SUs receiving inpatient care (one of whom was detained under the MHA). Since so few SUs were acutely unwell following B&AEIP support it suggests effective service provision. Additionally only 4 SUs were transferred to AOT s (services offering a similar level of intensive intervention to EIPs) and 3 of the 4 remained there one year later. Discharge Destination: Potential Factors According to literature, shorter DUPs frequently predict better recovery outcomes. In this sample, more SUs with >6month DUPs were referred to secondary care than those with <6month DUPs (see Table 2 below). To test if there was statistically significant relationship between DUP 16

17 length and discharge destination (indicative of the SU s stage in recovery) a 2-tailed, Z test calculation of proportions was performed comparing the number of SUs discharged to secondary care with either <6 month or >6 months DUP. The results were not significant (p>0.05), however, non-significant results may be due to the small and discrepant size of the subgroups. DUP and Discharge Destination Secondary Care < 6 months > 6 months GP Figure 3. DUP and Discharge Destination Regarding age, younger SUs (aged 16-18years), were more commonly referred to secondary care services (8 of the 10, 80%). The eldest SUs (aged years old) were more frequently referred to primary care than other age groups (13 of the 28, 46%). See appendix G for more details. Regarding ethnicity, more SA/P than WB SUs were discharged to primary care, however statistical tests show this difference was not significant (see appendix H for test results and chart). Additional Information Supplementary qualitative data was collected regarding SUs involvement prior to and following discharge. This was partly to answer the question 2 of the aims, relating to the nature of involvement in services and partly to help understand why the level of care in the discharge destination was required. Key data is displayed in appendix H. EIP involvement data included; 17

18 level of engagement in the EIP service, rated by the relevant care coordinator as either no/poor engagement, partial or well engaged ; data regarding the SUs diagnosis or formulation at the point of discharge from EIP; and comorbidities alongside psychotic symptoms. Data indicating the level of service involvement (e.g. stable CMHT support or crisis support) post discharge was converted for simplicity into number of pathways (to care) post discharge ; and life events which were categorised into mostly positive, mostly negative, both and not known. A similar number of SUs in each category means that it is difficult to interpret potential reasons why SUs followed their specific service involvement pathways post discharge. 18

19 Discussion Sample Characteristics The total sample of 65 was lower than expected since previous audits found B&AEIP usually discharge approximately 100 SUs from clusters each year. It is possible that the smaller sample size is due to the exclusion of CAMHS SUs (aged 14-15) in this audit. Additionally, the start and end points of data collection (April rather than July and December) may be responsible for the discrepancy in discharge frequency, as it is known that referral rates fluctuate over time. The smaller sample is more likely to show a prominent skewed distribution (Field, 2004) meaning no clear conclusions can be drawn as this group of SUs may have greater needs than those preceding them. A systematic replication of this process annually would gain a larger sample and provide more reliable information to assess longitudinal service standards. Overall, younger SUs were more frequently referred to secondary care services. This is consistent with research by Malla et al. (2002) who found that individuals who experienced their first psychotic episode at a younger age had poorer pre-morbid adjustment (coping resources) and experienced a greater extent of conceptual disorganisation and low mood. Clemmenson et al. (2012) also found that onset at a young age predicted poorer long-term outcomes more generally. DUP The results from this audit found that B&AEIP did not reach the challenging target of responding within 6 months to 100% of SUs experiencing their first psychotic symptoms (Brewin, Gill & Ding, 2014). Some factors are out of EIP control. For example, psychotic symptoms may not be identified or understood by the individual or those around them, and the majority of referrals to B&AEIP are made for individuals not previously known to mental health services (ibid). Also DUP is notoriously difficult to measure and there is much variability in how this is reported in research literature (Compton et al., 2007). It is therefore unsurprising that there was a proportion of missing DUP data in this audit. Missing data may be due to, EIP staff not recording this information, 19

20 difficulty assessing the OP and/or difficulty with identifying the OCT. The former may be due to an insidious onset of symptoms, and/or discrepancies in reports of the onset; the latter because it is difficult to assess what caused a significant change in the SUs symptoms and when this occurred. Finally, even when psychotic symptoms are identified, there are barriers to individuals accessing care, e.g., social and self-stigma (Birchwood et al., 2007; Boydell, 2006; Dinos, et al., 2004). To address the difficulty in identifying psychotic symptoms and social stigma, B&AEIP provide public health education and consult with GPs to encourage rapid referrals to EI services. Alongside DUP, B&AEIP also record DUEI, which is the time between referral and the first contact with the EIP care coordinator. DUEI was not collected in this audit due to the complex process it entails. A future replication would benefit from collecting DUEI data since it is a more accurate measure of service response. Another drawback of evaluating DUEI is that it involves the assumption that B&AEIP are offering what the SU needs for their recovery at the first contact with their care coordinator (a clinically significant change in symptoms) which is unlikely. Discharge Destination Primary Care Overall, approximately one-third of SUs were discharged to primary care and of this group some returned to secondary care one year later leaving a quarter of the overall sample in primary care at follow-up. This is inconsistent with the 63% primary care discharge record from the previous B&AEIP audit, using a similar method of data collection with a larger sample but a different focus (e.g. employment and housing status). The discharge destination, like the discharge frequency, could be affected by the time of year the data was collected. The fact that discharge destination of SUs remained largely unchanged at one year post-discharge, combined with the qualitative data from the 10 GP re-referrals, suggests that decision making at discharge was accurate in the majority of cases (in line with SU needs) demonstrating patient-centred care. 20

21 Transfer to primary car could be further improved by adopting a more structured approach, similar to the 6 month transfer phase before discharging SUs to secondary care. B&AEIP could invest resources to enhance communication with GPs in discharge planning stages. Secondary Care In general the rate of discharge to secondary services (65%) with 60% remaining in secondary care one year later, is greater than in previous years and the 20-50% target range required by IRIS Guidance (2012). However this target is based on research (EPPIC; Jackson & McGorry, 2010) involving participants with different demographic characteristics (in particular, ethnicity) from the B&AEIP SUs. Additionally, these voluntary participants who engage in follow-up assessments 7 years later may not be representative of SUs in the NHS. This audit, unlike EPPIC and previous audits, did not include measures of vocational involvement or symptom severity. The focus was to collect data not previously been collected (i.e. service involvement). If data regarding general functioning was included in this audit, the results may have revealed a more positive and authentic perspective on SUs overall recovery (Davidson et al. 2005; Farkas, 2007). SUs transferred to secondary care will not necessarily access intensive support. Of those transferred to secondary services 9 of the 42 (21%) were only receiving contact from outpatient psychiatry. Outpatient consultations can be infrequent (e.g. 1 hour every 3 months) therefore it can involve a similar amount of support as primary care. This means that 9 SUs, alongside the 23 SUs discharged to primary care, were managing their recovery without intensive service support. Similarly, face-face support from CMHT staff is commonly less frequent than EIP support due to the larger caseloads of CMHT staff. Only 4 SUs were discharged to AOTs which parallels the intensity of EIP service provision. This contextual information reframes the majority of secondary care discharges as a step-down from B&AEIP service provision. Consequently, the discharge destination data may not capture the benefits of B&AEIP service provision. 21

22 Finally, significant life events cannot be controlled by B&AEIP service support, therefore negative experiences that lead the SU to require secondary care support may not necessarily reflect poorly on the service. If the SU s need is greater than what they could receive in primary care, it would have been inappropriate for care coordinators to discharge SUs to their GPs simply to meet EIP targets. Overall, the findings imply that B&AEIP staff utilise a good decision-making strategy. Enhanced Care Importantly, few SUs required inpatient or residential support immediately following and one year post-discharge. This is consistent with research suggesting reduced costs that justify the EIP intervention (McCrone, Knapp and Dhanasiri, 2008) and is a positive overall outcome for B&AEIP. Methodological Evaluation Data collection was performed by an external auditor who was unfamiliar with SUs in B&AEIP. Whilst, this promotes impartiality, less familiarity with the SU database means that accuracy may have been compromised. To overcome this and enhance reliability, key data was checked by another staff member. DUP data was collected by the service prior to this audit, and service engagement data involved the service lead compiling care-coordinator reports of service engagement for each SU. This procedure was chosen to extract subjective knowledge of the SUs which was crucial to understanding which service was appropriate for individual SUs. It was used in combination with objective data, therefore minimising potential bias. This audit was designed to meet aims relating to SUs service involvement at two particular time-points (discharge and the same month one year post-discharge). The data therefore forms a snapshot impression that may be misleading. For instance, in a specific month in a year a client may be in secondary care but the following month the client may have been discharged to primary care. The data collection time-points could be responsible for the discrepancies between this audit data and previous annual audits. 22

23 Additional qualitative data was collected about service involvement throughout this one-year period, but reported simply as number of pathways following discharge and categorised into four groups. The converted quantitative data is limited in accurately representing service involvement compared with qualitative data, since the type of service support accessed is not reported. Therefore, future reports could include naming which services were accessed by each SU throughout the year following discharge. Finally, the audit tool required a level of data collection greater than could be captured in this report. This did not compromise ethical standards because the data was anonymised and qualitative information was needed to address the key aims of the audit. Recommendations and Dissemination 1) Systematically replicate this audit annually to gain a larger sample. Consider findings in the context of existing audits. 2) Record the choice of discharge destination, including expectations of the SU s pathway based on the crisis and contingency plan at discharge (i.e. if a re-referral expected). 3) Engage GPs in the discharge planning stage with a view to reducing the number of inappropriate re-referrals. 4) Include data on SUs general functioning in addition to discharge destination. The findings and recommendations of this audit will be presented to the Service Governance Group and B&AEIP clinicians in November

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29 Appendix A 29

30 Appendix B Re-referral Audit (Cluster version) EIP discharge approximately 100 people a year from the service. EI s progressive audit (Jul 2013) suggests that approximately half of these individuals are discharged away from mental health services (though our goal is to continually improve on this figure). This baseline audit aims to clarify the proportion of those discharged from mental health services (when discharged from EI) that return to them within a year of discharge from EI and to clarify if there is any pattern to this by checking on certain evidenced factors. It is a preliminary audit and does not check what happens to those discharged that don t return. It doesn t claim to make any statement regarding this population or how successful or otherwise their recovery has been. Service user RIO number (unique identifier): Discharge destination: 1. Transferred to other secondary care mental health services [ ] If transferred, to which service: Outpatient clinic only [ ] CMHT [ ] AO [ ] Other [ ], specify: 2. Discharged from secondary care mental health services to GP +/- non statutory/ voluntary sector support [ ] Pathways post discharge (taken from RIO entry/exit referrals, in the year after discharge/ transfer from EI): No pathways (no change) [ ] Pathway 1: Pathway 2: Pathway 3: Pathway 4: Pathway 5: etc. SUMMARY: For those discharged from secondary mental health services: Remained away from mental health services [ ] Returned to services [ ] For those transferred to other mental health services: Remain in services [ ] Transferred to alternate mental health service [ ] 30

31 Discharged from services [ ] For those re-referred, reason for re-referral (from referral letter and/or core part 1; referral related presenting problem ): Not known [ ] Recurrence of psychosis [ ] Other mental health problems (pre-existing) [ ] Other mental health problems (new) [ ] Other, specify [ ] Factors that might account for outcomes/changes to outcome (in terms of discharge destination): Age on admission to EIP (from entry/exit): Date of referral to EI Hub: - Date of Birth: Length of EI service provided (from entry/exit): Date of discharge from EI Cluster: - Date of referral to EI Hub: Less than 3 years [ ], why? Approx 3 years [ ] Greater than 3 years [ ], how long in total? DUP (from audit data): Bradford City [ ] Bradford District (South) [ ] Bradford District (North) [ ] Airedale [ ] Number of pathways to care (from audit data): Services provided (when with EI, from TL/CC): Did not engage actively with service [ ] Offered and engaged with: Care coordination (all) [ ] Consultant Psychiatry [ ] Psychological therapy input [ ] Recovery coordination [ ] Support work/sudw [ ] Other mental health services [ ] Other substance misuse services [ ] Other housing support services [ ] 31

32 Gender: Male [ ] Female [ ] Ethnicity: White British [ ] South Asian. Pakistani [ ] Other [ ] Diagnosis/formulation at discharge (from TL/CC): Comorbidities, prior to and during time with EI (other mental health symptoms, substance use, personality presentation, aspergers; from TL/CC): Medication (Antipsychotic or other) at discharge (from TL/CC): What taken: Who prescribed: Significant life events since discharge (from referral letter and/or core part 1; referral related presenting problem ): Non known/detailed: [ ] Apparently positive events [ ] Apparently negative events [ ] Detail; 32

33 Appendix C. DUP on Admission to EIP Not known 37% < 3 months 35% > 6 months 19% < 6 months 9% 33

34 Appendix D 30 Discharge Destination by Cluster Airedale Dx Airedale 1 Yr North Dx North 1 Yr City Dx City 1 Yr South & South & West Dx West 1 Yr MHS GP 34

35 Appendix E Discharge decisions for those discharged to the GP that were re-referred back to EIP within 1 year. Where 1 Year Post EIP SU ID Discharge? Circumstances around re-referral Decision Re-referred due to trauma history. Consistent with Out of Service detail of discharge plan. Good Re-referred but did not need secondary care services Out of services (stayed in CMHT only 1 month). Good Discharge at insistence of service user. Re-referred almost immediately. Consistent with Inpatient discharge/contingency plan. Good Out of Service Not taken on by service re-referred to. Good Re-referred regarding trauma and mood difficulties. Consistent with discharge plan from EIP. Didn t engage with other secondary care services and subsequently discharged from them also, with minimal Cons OP intervention. Good Re-referred with clear relapse of psychosis. discharge from EIP due to disengagement with services CMHT Attendance at A&E consistent with Discharge plan. Questionable Re-referred with clear relapse of psychosis, having stopped medication and having had child, the latter of CMHT which couldn t have been anticipated. Questionable 35

36 Re-referred for drug use, chaotic lifestyle, vulnerability to exploitation. No evidence of psychosis until +1 year post discharge. But clearly vulnerable CDAT & social and not able to keep themselves safe with or without service referral the support of services. Questionable Considered to be psychotic within 6 months of CMHT discharge from EIP. Not Good Re-referred with a formulation of Emotionally Unstable Personality Disorder (with psychotic features), rather than clear relapse of psychosis. Clearly not able to cope without support of services CMHT Repeated crises since discharge from EIP. Not Good 36

37 Appendix F Type of Service Involvement of EIP Discharges Airedale Discharged to Airedale 1 Year Post Discharge North Discharged to North 1 Year Post Discharge Secondary total = 5 Secondary total = 6 Secondary total = 6 Secondary total = 7 CMHT / AOT / IHTT 3 CMHT / AOT / IHTT 4 CMHT / AOT 6 CMHT / AOT / IHTT 6 Consultant Outpatient only 1 Consultant Outpatient only 1 Consultant Outpatient only 0 Consultant Outpatient only 0 Enhanced other 1 GP / Voluntary 0 GP / Voluntary 0 Enhanced Inpatient 1 GP / Voluntary 6 GP / Voluntary 5 GP / Voluntary 2 GP / Voluntary 1 CMHT / AOT / IHTT 1 CMHT / AOT / IHTT 0 Consultant Outpatient only 0 Consultant Outpatient only 0 City Discharged to City 1 Year Post Discharge South Discharged to South 1 Year Post Discharge Secondary total = 19 Secondary total = 20 Secondary total = 11 Secondary total = 11 CMHT / AOT / IHTT 15 CMHT / AOT / IHTT 14 CMHT / AOT / IHTT 7 CMHT / AOT / IHTT 7 Consultant Outpatient only 4 Consultant Outpatient only 2 Consultant Outpatient only 4 Consultant Outpatient only 2 GP / Voluntary 3 GP / Voluntary 1 Enhanced Inpatient 1 GP / Voluntary 9 GP / Voluntary 5 GP / Voluntary 6 GP / Voluntary 5 CMHT / AOT / IHTT 3 CMHT / AOT / IHTT 1 Consultant Outpatient only 1 Consultant Outpatient only 0 37

38 Appendix G Age & Discharge Destination Dx Yr Dx Yr Dx Yr MHS GP 38

39 Appendix H: Ethnicity and Discharge Destination Approximately half of South Asian/Pakistani (SA/P) SUs (13/25) were discharged to GPs; a higher rate of discharge to primary care than other ethnic groups. A Chi-Square Fisher's exact test (two-tailed) was performed to assess if there was a difference between the two largest ethnic groups (SA/P and WB). It was not significant, p= (p<0.05), which may be due to the small size of the subgroups. Ethnicity & Discharge Destination MHS GP South Asian / Pakistani. Dx South Asian / Pakistani. 1Yr White British. Dx White British 1 Yr Black African / Caribbean + Mixed Ethnicity Dx Black African / Caribbean + Mixed Ethnicity. 1 Yr Not Disclosed Dx Not Disclosed 1 Yr 39

40 Appendix I: Supplementary Information categorised by discharge location Discharged to... Supplementary Information Primary Secondary Total / Care Care 65 Level of Well engaged Engagement Partial EIP Poor / no engagement Psychotic symptom description Diagnosis at Discharge Comorbidities Psychosis/Schizophrenia Bipolar Disorder Personality Disorders No diagnosis / not psychosis Not Recorded Physical Health Problems Substance Use Mood / Forensic / LD / Other Not Known Positive Life events (mostly...) Negative Both Not Known Number of pathways post discharge > Not Known