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
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
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.
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
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.
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.
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.
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.
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
The Parameters
Mental Health
Substance Misuse
Older Adult
Mental Health
Physical morbidity
Psychological morbidity
Deprived area
Inner city
PROCESS
The product: Rapid Assessment Interface Discharge
BOUNDARY FREE
TRAINING
COMMUNITY FOCUS
EARLY INTERVENTION
SINGLE POINT
OF CONTACT
RAPID RESPONSE
24x7 SERVICE
RAID
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
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
RAID evaluation
RESPONSE
COSTQUALITY
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.
Top 7 reasons for referral
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
Ward Response
Target Met; 83%
Target Not Met; 10%
Not Assessed; 1% Not Recorded;
6%
Target Met
Target Not Met
Not Assessed
Not Recorded
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
Practice improvement
Yes; 95%
Neutral; 5% No; 0%
YesNeutralNo
Medical diagnosis coding Comparing pre-RAID and RAID period
RAID diagnosis
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
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%
RAID evaluation
RESPONSE
COSTQUALITY
RAID evaluation
RESPONSE
COSTQUALITY
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
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
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
RAID sample mean vs. population mean
A confidence level of 95% was obtained.
1. Length of stay: Retrospective Matched Control Study
Length of stay: Comparing the groups
P value= 0.01
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
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
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).
4. Savings: Re-admission
Group Re-admission per 100 patients
Retrospective (3500) 15 (505)
Partial RAID (3200) 12 (408)
RAID (850) 4 (42)
5. Survival after discharge: Survival analysis
Older People Re-admissions
Group Re-admissions per 100 patients
Control group (pre-RAID)
19 patients
RAID influence 22 patients
RAID 5 patients
Survival Analysis: Elderly
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.
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.
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
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
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
What is next?
• RAID Manual
• RAID Engine
• RAID Network
• How to improve the model?
• What works?
• Which bit for which patch!