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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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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

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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.

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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

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Alzheimers 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.

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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 20092010, 14 January 2010.

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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.

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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 outcomes Kripalani 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) 76-80 National Institute for Clinical Excellence (2010) Guidelines for Self harm.

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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

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The Parameters Mental Health Substance Misuse Older Adult Mental Health Physical morbidity Psychological morbidity Deprived area Inner city PROCESS

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The product: Rapid Assessment Interface Discharge BOUNDARY FREE TRAINING COMMUNITY FOCUS EARLY INTERVENTION SINGLE POINT OF CONTACT RAPID RESPONSE 24x7 SERVICE RAID

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The pre-RAID (traditional) service (Cost 0.6m) Consultant Liaison Psychiatrist 1.0 WTE Currently Funded Specialist Doctor 1.0 WTE Currently Funded Band 7 Nurse MHOP 1.0 WTE Currently Funded Band 6 Nurse Liaison 1.0 WTE Currently Funded Band 6 Nurse Liaison 1.0 WTE Currently Funded Band 6 Nurse MHOP 1.0 WTE Currently Funded Band 7 Social Worker 1.0 WTE Currently Funded Band 6 Nurse MHOP 1.0 WTE Currently Funded Admin Band4 1.0 WTE Social Worker Band 6 Nurse Liaison 1.0 WTE Currently Funded

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The upgraded RAID service (cost 1.4m) Consultant Liaison Psychiatrist 1.0 WTE Currently Funded Band 7 Nurse MHOP 1.0 WTE Currently Funded Band 7 Nurse Liaison 1.0 WTE Currently Funded Band 6 Nurse Liaison 1.0 WTE Currently Funded Band 6 Nurse Liaison 1.0 WTE Currently Funded Band 6 Nurse MHOP 1.0 WTE Currently Funded Band 7 Social Worker 1.0 WTE Currently Funded Band 6 Nurse MHOP 1.0 WTE Currently Funded Admin Band4 1.0 WTE Consultant Psychiatrist Mental Health of Older People RAID Team Manager Specialist Doctor Lead Nurse Substance Misuse Consultant Psychologist Mental Health of Older People Assistant Research Psychologist Consultant Psychiatrist Substance Misuse Specialist Doctor Band 6 Nurse MHOP 1.0 WTE Currently Funded Band 6 Nurse Liaison 1.0 WTE Currently Funded Band 6 Nurse Substance misuse 1.0 WTE Currently Funded Admin Band4 1.0 WTE

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RAID evaluation RESPONSE COST QUALITY

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Referrals Origin of referralNumber of referrals16-64 years65 years +Mean age Accident and Emergency (A&E) 83396%4%36.4 years Poisons Unit 51796%4%34.6 years Wards 67541%59%65.6 years Steadily increasing referrals 300+ monthly referrals Only 30% patients known prior to RAID.

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Top 7 reasons for referral

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A&E Response

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Ward Response

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Teaching and evaluation A lovely insight from a very experienced practitioner 158 hospital staff trained: All completed the evaluation

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Practice improvement

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Medical diagnosis coding Comparing pre-RAID and RAID period RAID diagnosis

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Patient satisfaction: Feedback RangeModeMedianMean 0 to 5544.2

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Staff satisfaction: Feedback RangeModeMedianMean 2.5 to 5544.2

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RAID evaluation RESPONSE COST QUALITY

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RAID evaluation RESPONSE COST QUALITY

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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-admissions Many other areas not in this study Use of security Staff Retention and recruitment Complaints Use of antipsychotics

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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

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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: 8.4 Sub RAID Inf mean: 5.2 Sub Control mean: 10.3 Sub RAID mean:9.4

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RAID sample mean vs. population mean A confidence level of 95% was obtained.

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1. Length of stay: Retrospective Matched Control Study

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Length of stay: Comparing the groups P value= 0.01

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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

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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

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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).

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4. Savings: Re-admission GroupRe-admission per 100 patients Retrospective (3500)15 (505) Partial RAID (3200)12 (408) RAID (850)4 (42)

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5. Survival after discharge: Survival analysis

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Older People Re-admissions GroupRe-admissions per 100 patients Control group (pre- RAID) 19 patients RAID influence22 patients RAID5 patients

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Survival Analysis: Elderly

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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.

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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.

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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

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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

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Comparison of diagnoses Prospective Data

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What is next? RAID Manual RAID Engine RAID Network How to improve the model? What works? Which bit for which patch!