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Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician), Birmingham. Professor of Old Age Liaison Psychiatry, University of Warwick Visiting Professor of Mental Health and Ageing, Staffordshire University
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Page 1: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience.

George TadrosConsultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

Birmingham.Professor of Old Age Liaison Psychiatry, University of WarwickVisiting Professor of Mental Health and Ageing, Staffordshire

University

Page 2: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

What is wrong with us?• What is wrong with Liaison psychiatry?• What is wrong with our hospitals?• What is wrong with the system?• What can we do about it?• What is your answer?• What is going to be covered?

– Literature– RAID from the beginning till now– RAID in the future

Page 3: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

Recent evidence: Older People• Up to 70% of hospital beds are occupied by older

people. Audit commission, 2006, Living Well in Later Life.

• “The trend is likely to continue with major implications for the use of hospital resources” Government Actuary Department, 2002

• 2000-2010, hospital stay for 60-74 increased by 50%, over 75 by 66%. Hospital Episode Statistics, 09-10.

Mental disorder in older adults is a predictor of: Increased Length of Stay (LOS) Poorer outcomes Institutionalism (impacting on performance and efficiency)

• The majority of mental co-morbidity in acute hospital affecting older people is due to three disorders: Dementia, Depression and Delirium. Case for change- Mental Health liaison Service for Dementia Care in Hospitals., Strategic Commissioning Development Unit (SCDU), 21st July 2011.

Page 4: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

Evidence for need: Older people• Older adults and a typical 1000 bed DGH

– 700 beds occupied by older adults– 350 will have dementia– 480 for non-medical reasons– 440 with co morbid physical and mental disorder– 192 will be depressed– 132 will have a delirium– 46 will have other mental health problems.

• 500 beds hospital would have 5,000 admissions/annum, of whom 3,000 will have or will develop a mental disorders. Who cares wins, 2005.

• 70% of older people referrals to liaison services are not under the care of mental health services.

• In a typical acute hospital (500 beds), failure to organize dementia liaison services leads to excess cost of £6m/year

Page 5: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

Alzheimer’s society: Counting the cost (2009)

Concerns from Nursing staff :managing patients with challenging or difficult

behaviour,communication difficulties, not having enough time to spend with patients and

provide care.

Concerns from Families: nurses not recognising or understanding dementia, lack of personal care, patients not being helped to eat and drink, lack of opportunity for social interaction, the person with dementia not being treated with due

dignity and respect.

Page 6: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

GPs and community dementia care

• Only 47% of GPs had sufficient training in dementia management,

• A third were not confident in diagnosing dementia. • 10% of GPs aware of the National Dementia Strategy. • Only 58% of GPs believe that providing a patient with a

diagnosis is usually more helpful than harmful.• Significant numbers of dementia related admissions are

directed to acute hospitals through GPs referrals. • It also could be due to lack of coordination between

primary and secondary care. • National Audit Office (2010) Improving Dementia Services in England – an Interim Report. Report

by the Comptroller and Auditor, General HC 82SesSIon 2009–2010, 14 January 2010.

Page 7: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

Evidence for need: Alcohol and Substance Misuse

• Alcohol consumption increased over the last decade• 88% of adults in the UK drink alcohol,

– with 38% of men and 16% of women recognized as having an alcohol use disorder (Alcohol Needs Assessment Research Project, 2005).

• 15-20% of adult inpatients are alcohol dependent.• 12% of A&E attendances are alcohol related• 7-20% acute admissions have alcohol problems• Annual healthcare cost of £1.7 billion National Indicators for Local

Authorities and Local Authority Partnerships (2009)

• NI 39 (2009) Aim: Reduce trend in alcohol related admissions.

Page 8: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

Evidence for need: Self Harm

• In the top five reasons for admission in the UK.• Rates in the UK are among the highest in

Europe.• 170,000 admissions per annum in UK

• If training is inadequate it may lead to negative attitudes and poor care

• Patient non-engagement and repeated self-harm behaviour can lead to suicide

• Drains resources with little positive outcomesKripalani et al, (2010) Integrated care pathway for self-harm: our way forward. British Medical journal, 27:544-546 Kapur, N (2006) Self Harm in the general hospital. Psychiatry, 5 (3) 76-80National Institute for Clinical Excellence (2010) Guidelines for Self harm.

Page 9: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

Evidence for Need: General Psychiatry

• 25% of patients with a physical illness also have a mental health condition.

• 60% of over 60s• A&E work is primarily with younger people coming with

DSH, Alcohol problems and acute psychosis.• Depression & Anxiety - 2 to 3 times more common in

those with physical long-term illness.• Neuropsychiatry• Postnatal psychiatry• Eating disorders• MUPS:

– long term disability and dissatisfaction. – Present in most hospital specialities. – Care costs estimated at £3.1 billion per annum

Page 10: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

The Parameters

Mental Health

Substance Misuse

Older Adult

Mental Health

Physical morbidity

Psychological morbidity

Deprived area

Inner city

PROCESS

Page 11: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

The product: Rapid Assessment Interface Discharge

BOUNDARY FREE

TRAINING

COMMUNITY FOCUS

EARLY INTERVENTION

SINGLE POINT

OF CONTACT

RAPID RESPONSE

24x7 SERVICE

RAID

Page 12: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

The pre-RAID (traditional) service (Cost 0.6m)The pre-RAID (traditional) service (Cost 0.6m)

Consultant Liaison

Psychiatrist1.0 WTE

Currently Funded

Specialist Doctor

1.0 WTECurrently Funded

Band 7NurseMHOP

1.0 WTECurrently Funded

Band 6NurseLiaison1.0 WTE

Currently Funded

Band 6NurseLiaison

1.0 WTECurrently Funded

Band 6NurseMHOP1.0 WTE

Currently Funded

Band 7 Social Worker

1.0 WTECurrently Funded

Band 6NurseMHOP

1.0 WTECurrently Funded

AdminBand41.0 WTE

Social Worker

Band 6Nurse

Liaison1.0 WTE

Currently Funded

Page 13: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

The upgraded RAID service (cost £1.4m)The upgraded RAID service (cost £1.4m)

Consultant Liaison

Psychiatrist1.0 WTE

Currently Funded

Band 7NurseMHOP1.0 WTE

Currently Funded

Band 7NurseLiaison1.0 WTE

Currently Funded

Band 6NurseLiaison1.0 WTE

Currently Funded

Band 6NurseLiaison1.0 WTE

Currently Funded

Band 6NurseMHOP1.0 WTE

Currently Funded

Band 7 Social Worker

1.0 WTECurrently Funded

Band 6NurseMHOP1.0 WTE

Currently Funded

AdminBand41.0 WTE

Consultant Psychiatrist

Mental Health of Older People

RAID Team

Manager

Specialist Doctor

Lead NurseSubstance Misuse

Consultant Psychologist

Mental Health of Older People

Assistant ResearchPsychologist

Consultant Psychiatrist

Substance Misuse

Specialist Doctor

Band 6NurseMHOP1.0 WTE

Currently Funded

Band 6NurseLiaison1.0 WTE

Currently Funded

Band 6Nurse

Substance misuse1.0 WTE

Currently Funded

AdminBand41.0 WTE

Page 14: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

RAID evaluation

RESPONSE

COSTQUALITY

Page 15: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

Referrals

Origin of referral Number of referrals 16-64 years 65 years + Mean age

Accident and Emergency (A&E)

833 96% 4% 36.4 years

Poisons Unit

517 96% 4% 34.6 years

Wards

675 41% 59% 65.6 years

• Steadily increasing referrals

• 300+ monthly referrals

• Only 30% patients known prior to RAID.

Page 16: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

Top 7 reasons for referral

Page 17: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

A&E Response

Targets Met; 73%Targets Not Met;

7%

Not Assessed; 3%

Not Recorded; 17%

Targets Met

Targets Not Met

Not Assessed

Not Recorded

Page 18: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

Ward Response

Target Met; 83%

Target Not Met; 10%

Not Assessed; 1% Not Recorded;

6%

Target Met

Target Not Met

Not Assessed

Not Recorded

Page 19: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

Teaching and evaluation

Very poor; 0%Poor; 0% Neutral; 3%

Good; 36%

Excellent; 61%

Very poorPoorNeutralGoodExcellent

‘A lovely insight from a very experienced practitioner’

158 hospital staff trained: All completed the evaluation

Page 20: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

Practice improvement

Yes; 95%

Neutral; 5% No; 0%

YesNeutralNo

Page 21: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

Medical diagnosis coding Comparing pre-RAID and RAID period

RAID diagnosis

Page 22: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

Patient satisfaction: Feedback

Very poor to poor rating; 8% Neither poor nor

good rating; 8%

Good to excellent rating; 84%

Very poor to poor ratingNeither poor nor good ratingGood to excellent rating

Range Mode Median Mean

0 to 5 5 4 4.2

Page 23: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

Staff satisfaction: Feedback

Range Mode Median Mean

2.5 to 5 5 4 4.2

Liaison with other services; 7%

Providing information to patient; 10%

Advice on medication; 11%

Support to patient; 10%

Signposting; 4%Information sharing; 7%

Education; 7%

Support of staff; 11%

Support tofamily/carers; 17;

8.17%

Advice on managing patients; 12%

Referral to other services; 8%

Other; 5%

Page 24: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

RAID evaluation

RESPONSE

COSTQUALITY

Page 25: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

RAID evaluation

RESPONSE

COSTQUALITY

Page 26: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

Areas of savings Reducing Length of Stay Increasing diversion at A&E Increasing rates of discharge at MAU Rate of discharge from wards Destination of discharge Reducing rates of re-admissionsMany other areas not in this study

Use of securityStaff Retention and recruitment ComplaintsUse of antipsychotics

Page 27: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

3 Groups for the study

1. Pre- RAID group (control group) December 2008- July 2009 No changes/confounders between pre and post!!

2. RAID_ influence group December 2009- July 2010 RAID did not see patients, but had influence through training

and support

3. RAID group December 2009- July 2010 RAID patients

Matched groups: Matched age, gender, mental health code, medical diagnosis,

healthcare resource group (HRG)RAID patients were the most complex

RAID: average 9 different diagnostic codes RAID_ influence 3 different diagnostic codes

Page 28: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

Retrospective case-by-case Matched Control Study

RAID Influence (2654 Patient)Mean: 4.74

RAID (886 Patient)Mean: 17.6

Control (2873 Patient)Mean: 9.3 days

359 cases 72 cases

Sub Control mean: 8.4Sub RAID Inf mean: 5.2 Sub Control mean: 10.3

Sub RAID mean:9.4

Page 29: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

RAID sample mean vs. population mean

A confidence level of 95% was obtained.

Page 30: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

1. Length of stay: Retrospective Matched Control Study

Page 31: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

Length of stay: Comparing the groups

P value= 0.01

Page 32: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

Cost savings: LOS/ all age groups

• All ages:• Saving over 8 months=

797 + 8,493 =

9,290 bed days

• Saving over 12 months= 13,935 bed days

• Per day= 13,935 ÷ 365 =

38 beds per day

• Older people only:• Saving over 8

months= 414 + 8,220 =

8,634 bed days

• Saving over 12 months= 12,951 bed days

• Per day= 12,951 ÷ 365 =

35 beds per day

Page 33: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

2. Admission Avoidance at MAU: Cohort control study

• All ages• Control group;

– 30% of avoided admission at MAU.

• RAID and RAID influence group; – 33% avoided

admission at MAU– Increase of 9%

• Average LOS= 9.3 days 240X9.3= 2,232 bed days 2232 ÷ 365= 6 beds/ day

• Older people• Control group;

– 17% of avoided admission at MAU.

• RAID and RAID influence group; – 25% avoided

admission at MAU– Increase of 47%

• Average LOS= 22 days 111 X 22= 2442 bed days 2442 ÷ 365= 6 beds/ day

Page 34: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

3. Elderly Patient Discharge Destination

30% of elderly patients who come to acute hospitals from their own homes are discharged to care homes (national figures)

LSE estimated savings to our wider economy of £60,000/week (Social care cost).

Page 35: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

4. Savings: Re-admission

Group Re-admission per 100 patients

Retrospective (3500) 15 (505)

Partial RAID (3200) 12 (408)

RAID (850) 4 (42)

Page 36: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

5. Survival after discharge: Survival analysis

Page 37: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

Older People Re-admissions

Group Re-admissions per 100 patients

Control group (pre-RAID)

19 patients

RAID influence 22 patients

RAID 5 patients

Page 38: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

Survival Analysis: Elderly

Page 39: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

Savings: through increasing survival The savings calculated from survival assumes

patients readmission at same rate of retrospective patients

Over 8 months → 1200 admissions saved. Over 12 months → 1800 admissions saved.

Saving 22 beds per day = one ward Saving 20 beds per day comes out of elderly care

wards.

Page 40: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

Combined total savings: beds/day On reduced LOS

saved bed days/12 months= 13,935 bed days ÷ 365 = 38 days/day (35 beds/day for the elderly)

Saved bed days through avoiding admissions at MAU Saved bed days = 6 beds / day Elderly bed days saved= 6 beds / day

Increasing survival before another readmission Admissions saved over 12 months =1800 admissions Average LOS 4.5 days = 8100 saved bed days ÷ 365 = 22 beds/day 20 for the elderly

Total Saved beds every day = 38 + 22+ 6= 66 beds/ day (Maximum) {Elderly: 59 beds/day} = 21 +22+ 6= 49 beds/ day (minimum) {Elderly: 42 beds/ day}

2010: City Hospital has already closed 60 beds.

Page 41: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

London school of Economics, August 2011

• Very thorough, detailed and vigorous review• Very conservative estimation• Total savings:

• £3.55 million to NHS• At least 44 beds/day• £60,000/week to social care cost

• Money value• Cost : return = £1: £4

• Recommended the model to NHS confederation

Page 42: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

Number of patients with a Mental Health Diagnosis – Dementia Delirium and Depression

(Retrospective case notes and all screened in and out)

Please note there may be more than one diagnosis per person

Page 43: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

Comparison of diagnoses Prospective Data

Hospital Diagnosis

162

3719

3 10

020406080

100120140160180

None

Dementia

Depressi

on

Delirium

Other

Screening Diagnosis

177

136

7659 55

17 80

20406080

100120140160180200

None

Dementia

Depressi

on

Delirium M

CI

Other c

ogn. Im

p.other

Multiple query Diagnoses in 156 Patients

Page 44: Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician),

What is next?

• RAID Manual

• RAID Engine

• RAID Network

• How to improve the model?

• What works?

• Which bit for which patch!


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