IAPT Recovery Workshop 21 April 2016

Transcription

1 Intensive Support Team & Yorkshire and the Humber Mental Health Network IAPT Recovery Workshop 21 April 2016 April

2 Welcome! Andy Wright, Y&H Network Advisor on IAPT, Yorkshire & the Humber Clinical Network

3 Housekeeping: #YHSCN_MHDN

4 Enhancing Recovery Rates in IAPT Services: Lessons from the national data and local innovation.

5 IAPT So Far Revolutionized treatment of anxiety & depression Stepped care psychological therapy services established in every area of England. Self-referral. Approx 15% of local prevalence seen in services Around 60% have course of treatment (approx 530,000 per year) Outcomes recorded in 97% of cases (pre-iapt 38%) Very strict (depression & anxiety) recovery criteria Nationally 45% recover and further 16% improve. A third of CCGs have recovery > 50%, some > 60%. Variability must be the next focus.

6 What is our current variability? Recovery rate: 45% (range 19%** to 69%) (47.9% Jan16) Reliable Improvement: 61% (range 24% to 73%) Reliable deterioration: 6% (range 3% to 11%) Problem descriptor: 68%* (range <1% to 100%) Average number of sessions: 6.3 (range 2.3 to 9.4) Percent of sessions DNA: 12% (range 5% to 27%) Average wait time: 30 days (range 5 to 154 days) Notes: * up from 62% in 2013/14. ** data completeness issues, true low probably 30%

7 Enhancing Service Recovery rates How? Lessons from analysis of national data Service innovation projects (Oxford AHSN) Clinical Leadership Public Health England Fingertips Tool (This afternoon).

8 Lessons from analysis of national data (Gyani et al, IAPT Year one) Services with higher recovery rates Higher average number of sessions Use stepped care appropriately Core of experienced staff NICE compliant treatment Self-referral (less sessions to recovery) Initial severity also predicts recovery

9 IAPT Year 7 A wealth of information in HSCIC s 3 rd Annual Report ( ) makes it possible to explore a range of predictors (correlates) of clinical outcomes using multiple regression. Two outcome indices were modelled Reliable improvement (%) Reliable recovery (%)

10 Patient Experience Questionnaire: Tables 17a, b, c Post Assessment Questions YES (%) Post-treatment Questions % Most or All Times Given information about options for choosing a treatment? Did you have a treatment preference? Were you offered your preference? YES (4.2 NO 14.4 n/a) Staff listened to you and treated concerns seriously? Service helped you better understand and address your difficulties? Felt involved in making choices about your treatment and care? Satisfied with your assessment? 73.7* (23.8 NO) Got the help that mattered to you? Have confidence in your therapist and their skills? Between 57,000 and 74,000 responses, which is less than 10%. * Completely or mostly satisfied Clearly, very positive but note that PEQ was only completed by 11% (50,937) of patients who had finished a course of treatment

11 Which Therapies are available? DIT 0.3% IPT 1% Therapy Type CCGs CBT 211 Counselling 180 IPT 141 Couples 95 DIT 77 Employment Support 59 Other Hi 185 Psychoeducational peer support 4% Employment support 0.1% Pure self help 9% Guided self-help 21% Behaviour activation 4% Counselling 10% Not specified 17% Couples 0.2% 85% of CCGs offer CBT and Counselling (universal offer) 96% of CCGs offer at least 2 High intensity therapies, 75% offer at least 3, 48% offer at least 4 of 5 High intensity therapies But capacity for Couples, IPT and DIT needs to increase (plans in place) CCBT 1% Other LI 9% CBT 20% Other HI 4%

12 Are IAPT Therapies being deployed in line with NICE Guidance? (Table 5b) Problem descriptors are missing for 33% of cases When problem descriptors are specified most therapy types are being deployed in line with NICE Guidance Full range of high intensity therapies used when depression is a problem (depression & mixed anxiety & depression codes) Mostly CBT for anxiety disorders BUT there are two deviations from NICE Pure self-help given to 14,284 people, but not recommended. In GAD Counselling given to 2,517 people, but not recommended

13 Are deviations from NICE guidance associated with lower recovery rates? (Tables 5a & 5b) Self-help: GAD: Guided 50% vs Pure 36% (p <.0001) CBT 54.7% or Guided Self-help 59.9% vs Counselling 45.7% (ps<.0001)

14 Overall Outcomes: Candidate Predictors (9) Problem descriptor completeness (%) Average number of sessions Average wait time DNA rate (% of sessions) Social deprivation score of CCG Number of High intensity therapies available to some degree (1-5) Number of patients who are seen Proportion of patients who get a course of therapy Paired score completeness (%)

15 Two step analytic procedure Step One Simple correlations Step Two Drop variables that are not correlated with outcome Enter into multiple regression all variables that are correlated with outcome on their own

16 Model for Reliable Improvement (predicts 65% of variability) Predictor Beta significance Problem descriptor completeness (%).112 <.05 Average number of sessions.097 <.05 Average wait time <.001 DNA rate (% of sessions) <.05 Percent of patients who get a course of treatment.201 <.001 Paired score completeness.505 <.001 Number of patients who are seen <.05 Social deprivation of CCG Note. Bold indicates predictor adds significantly to the model

17 Model for Reliable Recovery (predicts 43% of variability) Predictor Beta significance Problem descriptor completeness (%).122 <.05 Average number of sessions Paired completeness score.426 <.001 Social deprivation score of CCG <.001 Average wait time DNA rate (% of sessions) Percent of patients who get a course of treatment Number of patients who are seen Note. Bold indicates predictor adds significantly to the model

18 Simple correlations Predictor Reliable Improvement Problem descriptor completeness (%) Average number of sessions Average wait time DNA rate (% of sessions) Percent of patients who get a course of treatment Paired score completeness Number of patients who are seen Social deprivation of CCG Number of Hi therapies available to some extent Reliable Recovery Note. Bold indicates a significant (p<.05) correlation

19 Recovery and Number of Sessions by Problem Descriptor (Tables 9e & 4) Problem Descriptor Recovery Rate (%) No of Sessions Specific Phobia GAD Panic Disorder OCD Mixed Anx & Dep Depression Social Phobia PTSD Agoraphobia

20 Enhancing Recovery rates (conditions): monitor your outcomes for individual conditions (1) HSCIC 3 rd Annual Report provides a breakdown of national IAPT performance by ICD-10 code for the first time. Important clues. Obsessive-compulsive disorder Recovery rate above average (48%) Highest average number of sessions (9) Almost all therapy CBT (low & high intensity) BUT Very few patients treated in IAPT (2 %) and almost none in some services

21 Improving Recovery rates(conditions): monitor your outcomes for individual conditions (2) Specific Phobias (63%), Generalized Anxiety Disorder (55%), Somatoform Disorders (55%), & Panic Disorder (53%). In RCTs recovery rates usually higher than for depression. Same true in IAPT data (compare above with 45% for depression) Treatment mostly as expected except for GAD (too much counselling, given NICE guidance and Gyani findings). BUT access for specific phobias and panic disorder low SO, we are under-accessing conditions for which IAPT is highly effective

22 Improving Recovery rates (conditions): monitor your outcomes for individual conditions (3) Agoraphobia (36%) and Social Anxiety Disorder (44%). Also conditions for which RCT recovery rates are usually higher than for depression. Not true in IAPT data. WHY? Both require longer sessions and therapist to do some work out of office.? Happening in IAPT (ditto for video feedback). In social anxiety disorder a third of treatment sessions are for interventions NOT recommended by NICE (low intensity therapy).

23 Improving Recovery rates: monitor your outcomes for individual conditions (5) Posttraumatic stress disorder (38% recovery). In RCTs and large scale audits of specialist clinics recovery rates 60-80%. Not in IAPT on average (though some services do achieve 60% or higher). WHY? Around 20% of sessions are with therapies NOT recommended by NICE (especially low intensity). A challenging treatment for CBT therapists to deliver. Is our workforce sufficiently trained in trauma focused CBT (or EMDR)? Are our therapists sufficiently confident? Is there a need for CPD?

24 Local Collaborative Networks Oxford AHSN Anxiety & Depression Network covers 5 IAPT services, 12 CCGs. treat >20,000 per year formed in Jan 2014 Aim to increase overall recovery rate by 5% achieved 10% increase (46% to 56%) while national rate stayed constant at 45% Quarterly workshops sharing knowledge & planning innovations.

25 Local Collaborative Networks Items covered in workshops Paired outcome data completeness. Assessment procedures (screening instruments, workshop on getting right problem descriptor, mixed anxiety & depression problem). In-depth look at recovery by clinical condition Local CPD workshops for clinicians Analyses of local data & profiles data

26 Is IAPT triage missing some disorders? (Cernis, Pimm & Clark, 2016) Problem Descriptor PWP Triage PDSQ Screener Major Depression 48% 63% Generalized Anxiety Disorder 29% 56% Social Anxiety Disorder 7% 52% Mixed Anxiety & Depression 6% - Somatization - 43% Panic Disorder 2% 42% Post-traumatic Stress Disorder 1% 40% Agoraphobia 1% 37% Obsessive-Compulsive Disorder 1% 35% Health Anxiety <1% 35%

27 Improving Recovery rates: clinical leadership, staff supervision and CPD NHSEngland workshop with some high recovery rate services A consistent theme Leadership focused on recovery and reliable improvement data in an inquisitive and staff supportive manner Staff get personal feedback benchmarked against service average or other therapists Personalized CPD programmes for staff

28 Further Reading

29 Plan, Do, Study, Act: a methodology for enhancing recovery in your service Buckinghamshire Healthy Minds Dr John Pimm, Clinical Lead

30 Buckinghamshire Healthy Minds IAPT Pathfinder and 1 st wave site One of two IAPT services provided by Oxford Health LTC Pathfinder - COPD Partnerships - Richmond Fellowship employment advice, - Relate couples therapy Well established regional network IAPT services AHSN IAPT network

31 Buckinghamshire Healthy Minds continued Referrals Jan Dec 8,781 9,194 Entering tx Jan-Dec 6,614 7,271 Bucks estimated no anxiety depression 43,357 43,357 Proportion entering tx 75.32% 79.08% Proportion of prevalence entering tx 15.25% 16.77% 65 and over entering tx 15.06% 14.54% BME entering tx 14.46% 15.20% LTC entering tx 31.19% 33.24% Average problem descriptor 93.59% 97.34%

32 Proportion of Estimated Buckinghamshire Population Prevalence Entering Treatment 18.00% 16.00% 14.00% 12.00% 10.00% 8.00% Access Rate 6.00% 4.00% 2.00% 0.00% Q4 2012/13 Q1 2013/14 Q2 2013/14 Q3 2013/14 Q4 2013/14 Q1 2014/15 Q2 2014/15 Q3 2014/15

33 Waiting Times 100% 100% 99% 99% 98% Chiltern 6 Weeks Chiltern 18 Weeks Aylesbury Vale 6 Weeks Aylesbury Vale 18 Weeks 98% 97% 97%

34 Plan, Do, Study, Act (PDSA) Langley, et al (2009)

35 The Problem - PLAN Average recovery rates below 50% Variation over time, location and step Difference between recovery rate and reliable improvement (people discharged after making good progress but not getting to recovery) Repeated attempts to understand and intervene small and short term effect

36 Recovery Rate 2013 (by month)

37 What did we DO? Review of clinical notes for all patients discharged not recovered Identify themes/common patterns in the data

38 Study - Themes and patterns Clients discharged with reliable improvement but not recovered Clients stepped out to counselling above caseness Clinicians unaware or not attending to cut offs Clients stepped up without a trial at step 2 Failure to repeat ADSM

39 ACT Monthly performance report for all therapists includes Attendance, Recovery rate, DNA Rate, Completion Rate, Targets, etc. Change procedures, training and supervision Asked staff to aim for 65% recovery Check recovery rate weekly, check practice changed, feedback to staff regularly Adherence to the stepped care model Adequate dose of treatment step 2/3 Offering CBT, IPT, EMDR, Mindfulness, couples therapy for depression at step 3 Simultaneous PDSA cycles

40 Recovery Rate Sept 2013 Dec 2014

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42 Number of Cases Change in Referrals, Entering Treatment & Treatment Completers No of Referrals for Service Number Entering Treatment Number Completing Q4 2012/13 Q1 2013/14 Q2 2013/14 Q3 2013/14 Q4 2013/14 Q1 2014/15 Q2 2014/15 Q3 2014/15

43 Number waiting for step 3 treatment No. People on Step 3 Waiting List 50 0

44 Step Up Rates 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% % Step 2 only % Step 3 only % Step 2 & 3 Total step up rate 30.00% 20.00% 10.00% 0.00% Q4 2012/13 Q1 2013/14 Q2 2013/14 Q3 2013/14 Q4 2013/14 Q1 2014/15 Q2 2014/15 Q3 2014/15

45 Average Number of Sessions Treatment Dose Step 2 only Step 3 only Step 2 & Q4 2012/13 Q1 2013/14 Q2 2013/14 Q3 2013/14 Q4 2013/14 Q1 2014/15 Q2 2014/15 Q3 2014/15

46 Clinical Activity: Number of Treatment sessions provided Total Number of Step 2 & 3 Treatment Sessions Total Number of Step 2 Treatment Sessions Total Number of Step 3 Treatment Sessions Q4 2012/13 Q1 2013/14 Q2 2013/14 Q3 2013/14 Q4 2013/14 Q1 2014/15 Q2 2014/15 Q3 2014/15

47 Number of Minutes Clinical Activity: Number of minutes of treatment provided Total Number of Minutes of Treatment Total Number of Minutes of Step 2 Treatment Total Number of Minutes of Step 3 Treatment Q4 2012/13 Q1 2013/14 Q2 2013/14 Q3 2013/14 Q4 2013/14 Q1 2014/15 Q2 2014/15 Q3 2014/15

48 Maintaining Change Continued attention to service, team & individual recovery rates Identifying & tackling new and old themes Staff turnover & drift need to train & re-train CPD developing expert practitioners (Tracey, et al. 2014) Recovery rates problem descriptors PTSD, social anxiety etc.

49 Key Learning Examine your data Improve your data quality Study people discharged non-recovered identify themes Facilitate & monitor change with a structured improvement methodology e.g. PDSA

50 Reliable Improvement Rate 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% Chiltern Reliable Improvement Rate Aylesbury Reliable Improvement Rate Bucks Reliable Improvement Rate 20.00% 10.00% 0.00%

51 Number of Treatment sessions Total Number of Step 2 Treatment Sessions Total Number of Step 3 Treatment Sessions Total Number of Step 2 & 3 Treatment Sessions Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 2012/ / / / / / / / / / / /16

52 Number of Minutes of Treatment Total Number of Minutes of Treatment Step 2 only Total Number of Minutes of Treatment Step 3 only Total Number of Minutes of Treatment Step 2 & 3 only Total Number of Minutes of Treatment

53 Group Discussion

54 Breakout Session 1 What actions can you take in your service to improve recovery rates?

55 Time for a break? 15 minutes only please!

56 Group Discussion and Feedback

57

58 IMPROVING RECOVERY RATES IN BANES Nothing in this presentation is new or clever (sorry) What works in one service may not work in another so it s important to know your own service Most of the strategies employed are time consuming, laborious and involve lots of data analysis.

59 IMPROVING RECOVERY RATES IN BANES Background To The Service Getting To Know You Back To The Specification What Makes A Good Service Degree of Attention Maintenance Innovation

60 BACKGROUND TO THE SERVICE Service Commissioned in August 2013 as an IAPT plus service Organisational changes at point of service commencement Initially using a Least Intervention First Time model Poor engagement in the model and service by staff who, in some cases, had experienced being TUPE-ed across three services

61 JULY 2014 Data system poorly used or understood Data System not set up for needs of service Not achieving targets Lack of clarity and understanding of service protocols Lack of clarity about pathways Data cleanse

62 DATA JUNE 2014 OCT 2014 Performance Indicator a. Entered Treatment (15% pop) b. Waiting time: 3 day Contact (95%) c. Waiting time : First Therapeutic Contact 14 days (80%) d. Waiting time: LI (80%) Contacts d. Waiting time: LI (80%) Groups e. Waiting time: HI (90%) Contacts e. Waiting time: HI (90%) Groups f. Wait time: Step LI to HI (10%<) g. Demographic Data (100%) h. DNA First Therapeutic Contact (10%<) June July August Sept Oct 3.2% 4.3% 5.9% 7.8% 9.8% 100.0% 100.0% 100.0% 100.0% 100.0% 47.0% 66.9% 72.2% 56.6% 65.4% 29.4% 26.8% 27.8% 57.2% 55.2% 100.0% 100.0% 100.0% 88.9% 48.9% 100.0% 100.0% 77.8% 100.0% 100.0% 100.0% 100.0% 100.0% 50.0% 37.5% 0.0% 100.0% 66.7% 97.2% 95.9% 97.5% 97.0% 97.4% 3.2% 7.8% 6.6% 9.0% 12.0% i. DNA LI (10%<) 12.6% 9.3% 12.1% 12.4% 12.7% j. DNA HI (10%<) 1.0% 1.4% 0.0% 0.0% 0.0% k. DNA Groups (10%<) l. Clinically Significant Improvement (90%) m. Sick pay and Benefits (20%) n. Recovery Rate(50%) o. Patient Feedback Responsesbenchmarking 27.0% 35.1% 26.1% 28.1% 29.4% 53.5% 45.0% 60.3% 50.3% 52.7% 63.0% 50.0% 62.5% 87.5% 60.0% 26.0% 38.0% 45.0% 44.3% 45.6% 4.2% 13.2% 6.2% 8.4% 6.0%

63 GETTING TO KNOW YOU Understanding the team dynamics Understanding the wider team and support systems available (Local management structures within the organisation, Commissioner, IAPT National Team, Trust Infomatics team and Account Manager with IAPTus Data System) Getting Into The Data

64 BACK TO THE SPECIFICATION What had been commissioned? What were the targets? Analysing the service as is and comparing to service spec What isn t working well drop outs/recovery rates

65 NATIONAL DATA Year One Data Analysis:- Gyani, Shafran, Layard & Clark (2013) Behav. Res. Ther. Services with higher recovery rates had:- 1. Higher average number of sessions 2. Use stepped care 3. Core of experienced therapists 4. Self-referral = less sessions for recovery 5. NICE compliance leads to higher recovery Depression: CBT = Counselling GAD: CBT > Counselling Guided self-help > pure self-help

66 Access near 15%* Recovery > 50%* WHAT MAKES A GOOD SERVICE Reliable improvement substantially higher*(clinically significant improvement on slides) NICE recommended treatments at NICE recommended dose* (current average 6 sessions, should be 9-10) Stepped care used Adequate size workforce. Experienced core Regular outcome focused supervision

67 WHAT MAKES A GOOD SERVICE (2) Leadership supportive of staff, inquisitive about outcome data, feedback to individual staff and linked personal CPD. Most patients receive a course of treatment (ratio number complete treatment / enter treatment. Mean 62%. Range from < 20% to > 70% )* Patients problems identified (high completeness of ICD-10 codes. Currently range from 100% to <1%)* Range of non-cbt treatments (not only counselling)*

68 WHAT MAKES A GOOD SERVICE (3) Know what you re treating Know how your staff are performing Engage the staff in the development of the service Examine recovery rates Examine treatment rates Keep checking the data

69 DEGREE OF ATTENTION Meeting with GP surgeries and asking for feedback on service so far Is the data system doing what it needs to? Checking and double checking local reports against National figures Staffing checking skill mix and where the gaps are in the service provision

70 COMMISSIONER MEETINGS Good support and direction from Commissioner Developing trust Commissioner has both detail and strategic focus Commissioner has made time to help develop and support the service Involving CCG Data Performance Analyst

71 ATTENTION TO DETAIL Looking at all clients dropped out of treatment over 6 months-why? How? What had been offered? Review of ALL discharged cases who had failed to recover Closing all open cases that were not engaged in treatment Looking for themes in the data

72 CHANGING THE CULTURE We are here to help people get better and no longer require treatment. Quality of supervision New protocol around entry into service (the importance of a good assessment and to engage service users) New protocols around discharge of clients Understanding the MDS and engaging staff in recovery

73 CHANGING THE MODEL All clients self referring or being referred receiving a good quality initial assessment which focusses on engagement, motivation, socialisation, goal setting and psycho-education. Review appointments offered and actively encouraged after a contracted treatment if not recovered All assessment and review appointments conducted by qualified PWP s or HI s. Robust follow up s-meaningful letters No-one discharged at step 2 without having been taken to supervision. Using the tools in hand to inform treatment options repeating treatments if necessary Making sure ADSM s being used Clustering (training for staff and implementation)

74 AND MORE DATA! IAPT Monthly Provider Report Data 14/15 Out-turn Jan-15 Feb-15 Mar-15 Apr-15 May-15 15/16 YTD Performance Indicator National or Local Indicator Number of people who have depression and/or anxiety disorders The number of people who have been referred for psychological therapies PHQ13_02 20,409 1,701 1,701 1,701 1,701 1,701 3,402 National 4, Number of referrals by GP OR Other Professional Local Number of referrals (Self Referral) Local 3, Total number active referrals waiting for assessment Local The number of people who have entered psychological therapies PHQ13_01 3, Number of patients discharged Local 3, % Moving to recovery PHQ13_06 44% 60% 62% 66% 65% 65% 65% Number of patients with a diagnosed Long Term Condition (active cases Step 2) Number of patients with a diagnosed Long Term Condition (active cases Step 3) Number of patients re-referred to the service within a 3 month period of discharge Local Local Local The number of people retaining employment National 1, The number of people moving off sick pay and benefits National % moving off sick pay and benefits Local 65% 33% 100% 80% 75% 67% 67%

75 MAINTENANCE Good supervision and line management structures in place CPD for team Checking and rechecking the data Being on top of flow through service Keeping up with National developments and IAPT information (ERG/HESW/National IAPT Team/National Strategic Clinical Networks) Keep looking for ways to improve

76 MAINTAINING THE GAINS Performance Indicator April May June July Aug Sept Oct Nov Dec Jan a. Entered Treatment (15% pop) 1.57% 2.69% 4.51% 6.34% 7.82% 9.32% 10.66% 12.50% 13.71% 15.37% b. Waiting time: 3 day Contact (95%) 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% c. Waiting time : First Therapeutic Contact 14 days (80%) 87.0% 89.3% 79.1% 82.9% 79.9% 80.8% 78.1% 87.8% 88.3% 89.8% g. Demographic Data (100%) 98.05% 97.76% 97.52% 99.90% % % % % % % m. Sick pay and Benefits (20%) 75.0% 66.7% 70.0% 75.0% 60.0% 25.0% 80.0% 66.7% 50.0% 50.0% n. Recovery Rate(50%) 65.3% 65.2% 62.0% 61.7% 68.0% 67.7% 61.2% 64.8% 66.9% 60.0%

77 SERVICE ASSESSMENT APPTs Accreditation framework CQC Regular record checking Random checks on all data, pathways, clustering and treatment Random course checks

78 CURRENT POSITION Access Rate Access Rate

79 CURRENT POSITION Recovery 70.0% 65.3% 67.9% 65.2% 62.9% 62.00% 65.7% 61.7% 63.3% 68.0% 67.3% 67.7% 66.7% 61.2% 62.5% 64.8% 62.2% 66.9% 63.8% 60.0% 50.0% 40.0% 30.0% Recovery 20.0% 10.0% 0.0%

80 CURRENT POSITION 120% 100% 80% 60% 40% Recovery % Recovery Mild % Recovery Moderate% Recovery Severe% 20% 0%

81 CURRENT POSITION Type Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Recovery % 65.31% 65.19% 62.00% 61.74% 67.96% 67.68% 61.21% 64.77% 66.94% 60.00% Recovery Mild % 83.33% 92.31% 80.00% 75.00% % 86.67% 82.35% % 72.73% % Recovery Moderate% 70.18% 64.79% 72.86% 69.23% 69.81% 80.46% 68.18% 72.92% 71.83% 63.16% Recovery Severe% 70.18% 50.00% 53.45% 47.83% 58.14% 46.55% 45.00% 46.88% 58.54% 48.89% ReliableRecovery % 64.58% 61.19% 52.00% 58.26% 62.14% 62.20% 51.52% 56.82% 58.06% 56.92% ReliableImprovement % 66.67% 70.38% 58.58% 58.55% 60.00% 61.54% 61.54% 59.29% 58.82% 79.31% NoChange % 28.33% 25.92% 40.40% 36.84% 42.22% 35.10% 36.54% 38.94% 37.91% 0.20% ReliableDeterioration % 5.00% 3.70% 4.04% 6.58% 0.74% 4.33% 4.81% 2.65% 5.88% 4.14% ClincallySignificantInprovement % 82.29% 77.10% 69.69% 65.13% 71.11% 73.08% 75.96% 66.37% 66.67% 73.79% 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Recovery % ReliableRecovery % ReliableImprovement % NoChange % ReliableDeterioration % ClincallySignificantInprovement %

82 USING ALL OF THE INFORMATION The data can provide us with lots of service information Fluctuations in the data should be investigated Benchmarking and data outliers are important flags to use

83 POINTS TO CONSIDER Using the data to inform service design Knowing your service by knowing the data 1. Individual therapist recovery rates (and understanding why) 2. Recovery by diagnosis and treatments 3. Recovery and deterioration by service user profiles

84 INNOVATION LTC s Diabetes CQUIN 15/16 and Access for men 16/17 Treatment via internet Developing the PD pathway Working with other organisations Peer Support and Co-facilitation SMI Pathway?

85 CHALLENGES Capacity NICE recommendation recently for referral to IAPT becoming QOF for GP s Increasingly target driven making sure we use the right, sustainable targets to reduce perverse incentives PWP development and career pathways in order to enhance staff retention Psychological pathways across Primary and Secondary Care with no gaps Prioritising IAPT in a shrinking financial climate

86 REFERENCES Enhancing recovery rates in IAPT services Alex Gyani, Roz Shafran, Richard Layard & David M Clark ecovery%20rates%20in%20iapt%20services(lsero).pdf IAPT 3 Year Report DoH

87 Thank you for listening

88 Questions and Answers

89 Time for some lunch? The workshop will reconvene at 13:45

90 The IAPT Fingertips Tool. Google Common mental health disorders profiles tool

91 Public Transparency: A Revolution for Data processing Mental Health Services IAPT services required submit to NHS Information Centre every month 50 data items per patient covering demographics, diagnosis, type of treatment and pre & post treatment scores. Common Mental Health Disorders Profiles Tool (Fingertips) Displays numerous IAPT indices at CCG level. Makes it easy for services, commissioners and public to see how they are doing, and how they compare with neighbours. Intended to facilitate sharing of knowledge between service & help services judge the success of their innovation

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95 Thames Valley CCGs

96 Enhancing Recovery Reflections from the Intensive Support Team Els Drewek Head of Intensive Support NHS Improvement Leeds 21 st April

97 This presentation will cover Summarise the key factors that we think impact on patients recovery Describe common findings from in-depth diagnostic visits and desktop assurance reviews in relation to recovery Show you how we look at HSCIC data and use additional data provided by services and compare them with national ranges or averages. National team update for

98 98

99 Expectations from IAPT services in the IAPT Quality Standards From the start of the program clear expectations on: Brief Intervention at Step 2 /Step 3, CMHD (i.e. Clusters 1 to 4) but no barriers so some in clusters 5 and above. Delivering range of psychological therapies in line with NICE Guidance By a trained Workforce Appropriate Supervision Now with a greater focus on At the right time No barriers to Access The most appropriate therapy for a patient s condition Commissioning and services developed to meet local need Outcomes are recorded 99

100 Enhancing Recovery (1) - High Impact Changes identified by provider organisations at a national workshop (July 2014). 1 Triage and Choice Choice of treatments and access to alternative pathways Being able to identify the problem or diagnosis being treated (provisional diagnostics recorded). Providing NICE recommended therapies aligned to those conditions 2 Leadership and Staff Engagement Stable leadership with a real focus on recovery Attention to staff wellbeing Clinical Supervision particularly to reflect on patients who are not improving Workforce A stable core of fully trained, experienced staff in the service

101 Enhancing Recovery (2) - High Impact Changes identified by provider organisations at a national workshop (July 2014). 4 Optimised Performance Management System Stepping people up if they have failed to recover Reliable and complete data; Optimised clinical productivity by data/ performance reports being available to the whole team and used in case management 5 Commissioning The service is of sufficient size; Commissioning clear pathways; Avoiding perverse incentives 1 0

102 Reliable Improvement National comparison of Relationships between Recovery and Reliable Improvement Q % 80% 70% 60% 50% 40% 30% 20% 10% 0% 0% 10% 20% 30% 40% 50% 60% 70% 80% Recovery Rate

103 National comparison of Recovery Rates for CCGs by Deprivation decile) 70% Recovery and Deprivation 60% 50% 40% 30% 20% 10% 0% High deprivation Low deprivation

104 Recovery Rates - some of the factors Is the result of. Primary Reason Right therapy Right number of sessions Right data Contributing Factors Right staff Drop out rates Appropriate utilisation of stepped care Leads to. Presenting problem Poor processes High DNA rates Low productivity Not using specific ADSM scales Long waits etc. etc.

105 Enhancing Recovery Primary reasons Right Therapy Right Numbers of Sessions Reporting of Data e.g. Choice and NICE recommended for the patient s condition Right staff and Step 2 Challenges Outcomes from Groups

106 Staffing Step 3 Choice of Therapies and staffing - example High-Intensity Therapist Type Staff in post condition. Current Step 3 Ratio NICE-Suggested Ratio 1,2 CBT 46.5.% 68% - 73% Counselling for Depression 23.5% 3% - 5% Counselling 23.5% 0% IPT 0% 11% - 17% Couples Therapy 6.5% 3% - 5% Psychodynamic 0% 5% EMDR 0% 2% 1 Suggested ratios derived from (a) NHS England Action for Choice of Therapies (ACT) working assumptions, based on NICE Guidance and relative prevalence of conditions (Prof David Clarke) (b) NICE National Collaborating Centre for Mental Health Estimates (Prof Steve Pilling) Data provided by a Trust for a CCG wide service. Choice is still limited. There is a high percentage of counselling, half of which is not IAPT compliant N.B. The suggested ratios are a guide. Commissioners must make their own decisions on the exact ratios of NICE recommended treatments that would be appropriate for the needs of the population. 2 Assumes patients with a particular condition would choose equally between the NICE-recommended options for that

107 Example of Recovery Rates by Step Data from a Service visited by IST: Recovery rates for all three therapist groups are lower than expected but counsellors (Step 3) and Step 2 are significantly below the expected levels. Good Step 2 services achieve 60%.

108 Enhancing Recovery Primary Reasons Right Therapy Right Numbers of Sessions Right Data e.g. Drop out Rates Long Waits Poor Processes Low Productivity Contractual issues

109 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Mean and Median Sessions from HSCIC data (two or more sessions i.e. contributing to the recovery rates) 7.0 Mean Number of Appointments (Finished Course of Treatment) 6.0 Median Number of Appointments (Finished Course of Treatment) Provider National Provider National Means and Median sessions for Completed treatments (two or more sessions only, i.e. those contributing to the recovery rates) The graphs show that in this particular CCG service, consistently a low number of sessions is delivered compared with national averages, suggesting that very often NICE recommended dosage is not delivered. IST s observations are that to deliver the national standard (50% recovery), a service needs to have mean/median sessions at or above the national averages.

110 Over 20 Patients Profile of Sessions All patients, Trust data Patients Completing Treatment (Two or more appointments) There is a very high drop out rate at 2,3,4 sessions in both step 2 and Step 3, There are high numbers Step 2 patients with high numbers of sessions (9,10,11 sessions). The service felt step 2 therapists may be holding on to patients due to long waits for step up to step 3. At Step 3, 80 patients (8%) who ended in Step 3 had more than 20 sessions? Reasons. Step 2 (left axis) Step 3 (left axis) Sessions Completed

111 Profile of Sessions Step 3 Sessional Profile Step All Pts 2+ sessions Data from a provider There are high numbers of patients receiving 7 sessions (likely to be a first Assesand-Treat Appointment plus six sessions of therapy). As this is a Step 3 profile, IF associated with low recovery rates, are sessions being capped?

112 Commissioning / Contractual Issues Investment Activity Productivity Av Sessions 1 1 Investment must be linked to pathways; be clear what is being commissioned Underlying underinvestment is still an issue in a number of CCGs Providers need to deliver both on Activity (Access) and sufficient sessions (Recovery). Providers need to demonstrate they are effective and productive to make the best possible case for additional investment. PbR shadow monitoring expected during 2016 for implementation in 2017 on the basis of cost per case with payment on volume and on quality, eventually on a 50/50 basis.

113 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Long Waits for second treatment appointment Waits from First to Second Treatment Appointment in Month (Waiting Time Bands) Under 28 Days Over 28 Days Over 90 Days

114 Hidden Waits directly affect Outcomes 60% Waits from First to Second Treatment - December data 50% 40% 30% 20% 10% 0% 6,778 4,409 1,298 7,167 3, ,160 2, ,015 3, NHS England North NHS England Midlands And East NHS England London NHS England South % Patients Waited Up To 28 Days % Patients Waited Over 28 Days % Patients Waited Over 90 Days

115 1 1 5 Enhancing Recovery Primary Reasons Right Therapy Right Numbers of Sessions Right Data e.g. Recording of outcomes (Paired Scores) Problem Definition (Diagnostic Codes) Appropriate use of ADSMs Changes of Provider or IT System Changes

116 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Paired Scores PHQ GAD Completion 100.0% PHQ and GAD/ADSM Completeness 60% Recovery Rate 95.0% 50% 90.0% 85.0% 40% 80.0% 30% 75.0% 20% 70.0% 65.0% 10% 60.0% 0% CCG CCG

117 Problem Definition during treatment HSCIC data reported by two services Provisional Diagnosis at Treatment Provisional Diagnosis at Treatment Other, 1.38% Other, 16.33% Invalid, 91.70% Invalid, 4.00% PTSD, 0.17% OCD, 0.17% Mixed Anxiety/Depressive, 3.46% Generalised Anxiety, 0.35% Panic, 0.17% Specific Phobias, 0.17% Social Phobias, 0.17% Agoraphobia, 0.17% PTSD, 2.00% OCD, 2.00% Mixed Anxiety/Depressive, 4.67% Panic, 4.00% Specific Phobias, 0.67% Social Phobias, 1.33% Agoraphobia, 0.33% Generalised Anxiety, 21.33% Depression, 2.08% Depression, 42.67% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45%

118 Presenting condition: appropriate use of mixed anxiety and depression HSCIC data Provisional Diagnosis at Treatment Other, 19.17% Invalid, 14.23% PTSD, 2.77% OCD, 0.79% Panic, 0.79% Specific Phobias, 0.20% Social Phobias, 0.40% Agoraphobia, 0.20% Generalised Anxiety, 9.49% Mixed Anxiety/Depressive, 36.36% Depression, 15.42% 0% 5% 10% 15% 20% 25% 30% 35% 40%

119 What is available? IAPT Technical Guidance (Feb 2015) What is first treatment. What is not first treatment Whose responsibility is it to get it right How to report well on Recovery (Dec 2015) IST WebEx How to minimise reporting disruption when changing IT systems and providers New HSCIC guidelines (March 2016) Supplier/pdf/IAPT_Guidance_on_Changes_in_Provider_or_System_Supplier.pdf

120 1 2 0 Five year Forward view National team New national team to progress the LTC / progress to 25% Access As part of that, to strengthen IAPT Clinical Networks Continued focus on Recovery National HEE / NHS England on Step 2 Workforce Review of the IAPT Quality Standards and the Enhancing Recovery High Impact Changes Document Transfer of the IAPT Website to NHS England Website Shadowing of Payment by Results (PbR) for implementation in 2017 New IAPT Local CQUIN

121 Increased visibility of data: Recovery Dashboard to include the contributing factors in the NHS England Monthly Report CCG breakdown by provider in Recovery and Reliable Improvement by Step and by Therapy Type in HSCIC data Reports on patients waiting (incomplete pathways) and hidden waits for second treatments IST Offer and Continued Focus on Long waits Principles of Good Waiting List Management and understanding sustainable positions Capacity and Demand workshops, Action Learning Sets on bottom up C&D modelling using a new IAPT C&D tool 1 2 1

122 Els Drewek IAPT Intensive Support Team Questions

123 Maximising Clinical Performance and Recovery at Step 2 Best practice in supervision and delivering tailored treatments Judith Chapman, Clinical Director Seconded Intense Support team member from Talking Therapies Berkshire

124 Maximising Step 2 1. Clinical improvement 2. PWP empowerment 3. Use of reports to monitor and drive PWP team and personal improvements 4. Tailoring Care 5. Tips from my PWP team

125 Step 2 Berkshire Recovery-7 CCG s Step /162 Q2 Reliable Improvement Berkshire 60% West 62% East 58% Bracknell 74% 58% Slough 84% 58% WAM 73% 57% North & West Reading 71% 65% South Reading 70% 58% Newbury 79% 65% Wokingham 73% 64% 2015/16 Recovery Average

126 Key indicators of good clinical outcomes at Step 2 Stepped care use of step up to be encouraged- recovery can improve by 6% Correct problem descriptor and completion Triage prompts/checklists to identify, PTSD, Social Anxiety (under reported) Use of Anxiety Disorder Specific Measures Right dose?- increase number of sessions NICE Recommendations correct use of pure self help v guided self help

127 Triage Prompts eg PTSD HAVE YOU EVER EXPERIENCED AN EVENT/INCIDENT (OR EVENTS/INCIDENTS) WHERE YOU BELIEVED THERE WAS A SERIOUS THREAT TO YOURSELF OR OTHERS? (E.G. an assault, sexual assault, accident, or childhood abuse) DO YOU THINK THAT YOUR CURRENT DIFFICULTIES ARE IN ANY WAY RELATED TO THE/YOUR, EVENT/INCIDENT? DID YOU EXPERIENCE INTENSE FEELINGS OF FEAR, HELPLESSNESS OR HORROR? IN THE PAST TWO WEEKS HAVE YOU EXPERIENCED THOUGHTS, IMAGES OR NIGHTMARES ABOUT WHAT HAPPENED WHEN YOU DIDN T WANT THEM (INTRUSIVE

128 PWP Supervision and skills training to ensure quality Weekly case management-line manager with a senior PWP Step up case discussion-where? Fortnightly clinical skills supervision Hi intensity (ex PWP) Berkshire monthly 3 hour training programme supported in clinical skills CPD PWP focussed training & meetings

129 Can we increase the ratio of Step UP and how? Table Discussion Use of Stepping up What does our client Step 2 pathway look like? How as a service do we manage Stepping up?

130 Support Compassion Hope Quality PWP staff

131 The Step 2/PWP team Good overall service leadership and role models From top down reflect the value of a well trained, well led PWP service Embed values within your organisation Foster a learning, empowered step 2 Implement the PWP team ideas Retention issues :Band 6 and 7 PWP career progression

132 PWP s - supporting Recovery Problem descriptor training to ensure correct treatment intervention is offered or stepped up to Data completeness, paired scores Understanding clinical thresholds for recovery- (remind new staff) Offering extra sessions to clients not recovered using CMS Access to daily senior support, daily supervisor

133 PWP Personal development Encourage PWP career structure Empower PWP leads Supervision training PWP courses/conferences Encourage special interests such as perinatal/older adult training for PWP s

134 Embrace PWP leadership Regional networks to share best practice and learn from each other Supervision training, Trust excellent managers programme Band 6 + Weekly PWP & lead meetings to share issues or identify training needs this supports capacity planning sickness etc Identify key messages of the week plan PWP weekly content Review weekly data report Plan required changes in policies or processes

135 Empowerment of your PWP service- How? Share Ideas?

136 Quality monitoring Support Compassion Hope Change it if it isn t working!

137 Reports to manage quality Monthly Recovery review per CCG per step Step 2 Recovery per intervention of the service Weekly access and pathway capacity report Quarterly therapist individual reports improvement plans or congratulate Share recovery rates/per team/per month Caseload overview and supervision logs Diary open and transparent

138 Workforce planning /Access Targets (per week) total workforce Assess F2F GSH phone Sc 1/2 hr Treatment planning SC 15 min review SC 30 tel reviews total no of clinical hours Target NB. Does not include: Stress control direct entry Clients going to Well Being Group Assess number = access target + 10% 15% decline service after assessment 60% go to step 2 Of these 40% go to online CCBT (SilverCloud) 60% go to Guided self help

139 No. of Clinical Sessions Clinical Time (mins) Total clinical hours attended appointments Clinical Session - Therapist (each session) Individual PWP activity and recovery report Clinical Session - Appointment purpose Clinical Session - Primary Intervention Clinical Session - Attendance CLINICAN A Review only Wellbeing Course Attended CLINICAN A Triage and Treat Missing Did not attend - no advance warning given CLINICAN A Triage and Treat Missing Cancelled by CLIENT CLINICAN A Triage and Treat Other Low Intensity Attended CLINICAN A S2 TPS Other Low Intensity Attended CLINICAN A S2 Treatment Missing Cancelled by CLIENT CLINICAN A S2 Treatment Other Low Intensity Attended CLINICAN A S2 Treatment GSH (S2 CBT Workbooks) Attended CLINICAN A S2 Treatment Silver Cloud Attended CLINICAN A S2 Treatment Wellbeing Course Attended CLINICAN A S2 Treatment Wellbeing Course Did not attend - no advance warning given CLINICAN A S2 Treatment Wellbeing Course Cancelled by CLIENT CLINICAN A Phone SC Review Missing Cancelled by CLIENT CLINICAN A Phone SC Review Other Low Intensity Attended CLINICAN A Phone SC Review Silver Cloud Attended CLINICAN A Website SC Review Other Low Intensity Attended CLINICAN A Website SC Review Silver Cloud Attended CLINICAN A Recvery rate total

140 Weekly Case Management

141 23 clinical hours available and 3 hours training

142 Tailoring care BME Slough 53%, cultural training, specialist supervision, PWP s recruited to match the population,punjabi diabetes groups Higher levels of deprivation outreach programme of co-working & volunteer sector Follow up non engagers Older adults engagement Carers groups LTC conditions woven into service Peri-natal pathway

143 Ideas to manage waiting times Use of supported asyncronistic online CBT Stress control type psycho-education seminar/group open access Good administration booking system, admin book into cancellation slots, batch letters etc Good and fluid capacity plan Monitor wastage -have a good cancellation and DNA policy

144 Good Induction How we do things, key facts to know Shadowing or buddying with a PWP Includes a log book to monitor what they have or haven t completed. Observations with constructive feedback Sign off from team lead/supervisor believes they have demonstrated pwp competencies and are safe to work independently

145 Training matters Secure training places with good standards Liaise regularly with the university around trainee progress reviews Joint support plans in place uni and service to develop pwp s training additional service supervision, shadowing in service, extra supervision at university Retention : Select staff who will stay, develop a career structure

146 Improving access and waits Self referral Use of a good website Quick entry to service routes Online CBT Berkshire project 85% patients very satisfied recovery rates overall Y1 56% (14/15) Y2 80% (15/16) Direct access to online therapy pilot has increased access to men to 50%

147 Quality outcomes Support Compassion Hope

148 Thank you Any questions

149 Action Planning

150 Breakout Session 2 Your Future Plan: What next steps will you take to enhance outcomes for your patients/population

151 Plans for further expansion of IAPT in this parliament (up to 2020).

152 Next Steps (1) Additional funding (approx 600 m) announced in Autumn Statement to ensure that: significantly more people will have access to talking therapies every year to 2020 Increase access to IAPT to at least 25% of prevalence

153 Next Steps (2) IAPT Expansion will: Focus on anxiety & depression in context of long-term physical health conditions and medically unexplained symptoms (MUS). Create co-located physical and mental health services. Continue to expand choice of therapies (including mindfulness). Greater use of digital platforms to maximize geographic reach, deliver therapy in people s homes when they have time to work on their problems Internet therapy programmes with asynchronous therapist support Video conferenced therapy sessions Typed therapy sessions Blended care Expansion of employment advisors

154 Next Steps (3) Extend benefits of IAPT to SMI Outcome & reporting monitoring for all patients Staff trained in latest NICE recommended treatments Extend Children and Young People s IAPT

155 Panel Discussion

156 IAPT Recovery Workshop Thank you for Attending! Please don t forget to fill out your evaluation forms!