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Integrated care :
3 years of progress and ‘jugular’ actions needed
Dr. Geraldine Strathdee, National Clinical Director for Mental Health
.@DrG_NHS
Kings fund March 2016
This talk:
• Why do we need Integrated care
• What’s the impact on clinical and economic outcomes
• Where is integrated care happening
• What will drive it further and faster
• Can we agree a charter of principles
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Why do we need integrated care?
Why does the NHS need to integrate mind and body care ..because mental ill health it is very common, & untreated it does not go away. It leads to significantly poorer clinical, rehabilitation & life expectancy outcomes, increased service use & poor economic outcomes : 4500 international scientific references available on request!!
Mental ill health is common
Common Conditions Outcome impact
Primary care :
30-50% of daily workload
Depression & anxietySubstance misuseChildren's conditionsPsychosis PTSDMedically unexplained symptoms
Premature mortality : 15-25 yearsPhysical health deaths & SuicidesReduced Quality of life in LTCsRecovery from illness slowPatient safety Crisis and frequent attenders
Acute care
40+ % of A&E breaches40% acute beds 20-80% acute outpatient clinics
Alcohol & drugsDepression & self harmDementiaPsychosis relapseCo-occurring depression/ anxiety in cancer, stroke, CVD, COPD, liver, ICUs, bariatric clinics, dermatology
Premature mortality Reduced Quality of life for LTCsSlow or poor Recovery from illnessPatient safety Poorer Patient experience Frequent crisis & elective attendancesLonger LOS & delayed discharges
Prisons & offenders
70-80% especially young men
ADHD, ASDDepression Substance misuse PDPsychosis
Premature mortality Lifelong poor outcomes
Integration of care is essential for step change in England’s health care & mental health access
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• Integrated history taking & assessment at registration & in consultations
• Integrated treatments and care pathways
• Integrated teams: sessions or skillmix of ‘physical’ or ‘mental’ staff or ‘alliance pathways’
• Integrated case conferencing for frequent attenders, admissions, detentions
• Integrated Workforce training at undergrad, post grad and CPD
• Integrated National clinical audits & Inquiries, National confidential inquiries,
• Integrated NICE guidelines, NICE Quality Standards, NICE indicators
• Integrated research, genome programme,
• Integrated payment tariffs, CQUINs, and incentive systems for primary, acute, MH
• Digital Maturity for people & their clinicians to access their own integrated care records
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National context: Prime Minister announced MH as a national priority, Life Chances Jan 11th
5 Year Forward view & taskforce: Lifespan approach based on HMT deep dive economics
Being Born well Best early years
Living and working well
Growing older well Dying well
Building Positive mental health
in individuals & communities
Prevention of mental ill health
Improving access toIntegrated
Timely Effective care for all new patients
Transformationof services to
deliver value, better outcomes, quality & personalized Right Care & integration
Integrating physical, social, mental health care for individuals and communities
NHS | Presentation to [XXXX Company] | [Type Date]7
BuildinIntegrated NHS Choices information & self management tools
For the 16 mental health care pathways we have commissioned Biopsychosoical integrated care
Using every proven implementation strategy to built in sustainability and continuous quality improvement and gathering and publishing PROMs, PREMs, CROMs
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Right TimeRight Care NICE standards for the common crisis conditions & services & pathways ✓ Information
✓ Physical health
✓ Medication
✓ Psychological therapies
✓Right suicide prevention
✓ Rehabilitation & Recovery care plans for training/ employment
✓ Right carer and social network
✓ Crisis & relapse prevention
✓ Maximizing digital potential
Right OutcomesRight Team
✓ PROMs
✓ PREMs
✓ CROMs
✓ Employment
Right team- Compassionate,- Coaching,- Coproduction - Recovery focus- Multi disciplinary/ agency
Right implementation & Continuous Quality improvement
✓ Commissioning guidance
✓ Baseline national audit
✓Regional implementation teams
✓ Workforce plans
✓ Data collection plans
✓Clinical dashboards for teams
✓ Accreditation networks
✓Digital Maturity plans
✓ 5 ALB & Regulation
✓ Big Data & innovation plans
The 5YFV road map for integrated pathways
Open Data network new data Nov 2015
https://www.thersa.org/discover/publications-and-articles/reports/getting-the-message-on-mental-health/
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CQUiN for integrated physical care Indicators (Assessment + Intervention) by Setting
Setting Count of CasesCQUIN
PerformanceAcute inpatient ward 3166 46.34%
Child and adolescent mental health ward 77 64.94%High dependency/rehabilitation ward 573 68.06%Low secure unit 698 63.32%Medium or high secure unit 640 74.53%Older adults ward 419 48.69%Other 129 67.44%PICU 266 60.53%Grand Total 5968 54.93%
Acute care : transforming acute care and care homes & achieving integration through liaison mental health teams & care pathways
in A/E 24/7:
Productivity gains
Reductions in 4 hour wait breaches
Admissions by 40% into acute hospital wards & care homes: Repeated Attendances for self harm and other conditions
Acute delirium assessment ward
for people with dementia
Productivity gains
80% go back home with a well organized personal health care package and are not admitted into a care home
Acute wards where 40%
patients have Mental illness
Productivity gains
Increases the discharge ratesReduces LOS
Reduces expensive unnecessary investigations and operations
LTC clinics in acute care & primary care where 40-70% have
untreated depression &
anxiety
70% people with liver disease, 40% people with cardiac disease, 40% with long disease, 60% with irritable bowel syndrome, 80% in pain clinics
Patients get treatment and
Repeat OPCs are reducedUnnecessary diagnostics are avoided
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Liaison mental health teams: 4 components of productive care
Chris Hilton :Liaison beyond the hospital
Daily GP advice line
Integrated Care ProgrammeMonthly multidisciplinary care planning groups for patients with long term conditions
Integrated mental health in Intermediate Care team(Consultant and RMNs)
Whole systems integrationPlanning model of care for Early Adopter projects and future Local Hospital
Primary care education and supervision
Palliative Care Hospice and Community Pilot
HIV Mental Health assessments
Community dementia Liaison nurse
Integrated long term condition psychotherapy services
Support for Primary Care Mental Health Workers
IAPT & Clinical Psychology Interfaces
Outpatient clinics for MUS/LTC
Primary care mental health : progressing towards integrated care PA
CS
and
MC
Ps
Prevention in High risk groups
Self assessment and self management
Common conditions
Repeat attenders & MUS
Long term & severe mental illness
• Psychosis: Enhanced psychosis outreach services +3rd sector
• MUS: Collaborative care for MUS medically unexplained symptoms e.g. Tavy/Hackney
• LTCs: Integrated physical & mental treatment in groups for LTCs
• Common: direct access psychological therapies for depression & anxiety
• CYP: Intermountain primary care CYP model
• Perinatal: Integrated perinatal community teams in reaching to acute clinics & PC
• Eating Disorders: community teams
• Registration: e Chat from New Zealand
• Prevention :Pan city on line digital platforms
Cancer & Diabetes: the evidence & best practice case examples of integrated care
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Diabetes integrated care: http://www.slcsn.nhs.uk/scn/mental-health/mh-physical-care-diabetes-082014.pdfCancer integrated care: http://www.londonscn.nhs.uk/publication/psychological-support-for-people-living-with-cancer/
Fundamental principles & jugular actions for integrated care
1. Integrated care should be the norm, not the exception
2. Fundamental principle : If there is a likely comorbidity of physical & mental ill-health of > than 20% , teams need the skillmix of staff with new competencies
3. The 5ALBs should commit to integrated clinical care pathways & digital maturity in all commissioning guidance & regulation
4. The AOMRCs & professional bodies should move to evidence based integrated care & training
5. A new breed of management leader is needed: logistics & supply chain process engineers to help patients and clinical teams develop efficient pathways
6. Commissioning & economics experts are needed to develop the economic modeling tools to make integrated care a reality
If we make as much progress in the next 3 years as we've made in the last 3, England can dump Decartes!
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