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Intelligence, Pathways & Payment Systems

David Kingdon ([email protected]) Professor of Mental Health Care Delivery

Collette’s journey

EIP pathway Acute care pathway Assertive outreach pathway Community mental health pathway Pre-psychosis Early psychosis Persistent psychosis Recovery Social services care Early intervention: care coordination & medication Safety & rehabilitati on: hospital medication & DBT Independence: support, reduced medication & CBTP Recovery - self manage ment

Preventative strategies Collaborative assessment of needs Effective intervention Intelligent guidance Responsive funding Psychosis & complex trauma (‘BPD’) programmes Systematic regular & responsive to service user ‘What’ & ‘when’ condition-based care pathways Outcome-focused reliable and relevant information Effective interventions & community care rewarded Integration of psychosis (EIP) & complex trauma initiatives HoNOS, WEMWBS DIALOG F&F Specific scales Imperial & Wessex Pathways & intervention coding National Mental Health Intelligence Network (incl. MDLDS+) Individual and stratified personal budgets

'More than 80% of patients with their first episode of psychosis will recover …. less than 20% will never have another episode.

Quoted by Marco M Picchioni, Clinical Lecturer in psychiatry and Robin M Murray, Professor of Psychiatry (2004) Robinson D, Woerner MG, Alvir JMJ, Bilder R, Goldman R, Geisler S, et al. Predictors of relapse following response from a first episode of schizophrenia or schizoaffective disorder. Arch Gen Psychiatry 1999;56:241-7.

National Mental Health Intelligence Network

http://fingertips.phe.org.uk/profile-group/mental-health

We can also describe general outcomes and compare against peer CCGs

 Figures show performance on a few key indicators, when compared to 10 similar CCGs Sources: Commissioning for Value Datapack, NHS Rightcare, Nov 2014

Understanding the needs of service users with psychosis: What does the data tell us?

Raw data licensed by Janssen Healthcare Innovation, 2013-14 7

We can estimate the need for psychosis care, e.g. in Wessex

Prevalence Incidence Sources: Prevalence – Public Health Fingertips; Incidence – www.psymaptic.org

 High prevalence in Dorset, Southampton, Portsmouth and Isle of Wight  High incidence in Hampshire 8

We also need to understand needs of people with psychosis within our services

Anonymised patient-level data across 3 years 2010/11-2012/13 Identify by ICD 10 Diagnostic Codes Mental Health Secondary and Community MHMDS Identify users with psychosis Identify by Lived Experience (HONOS) Acute Care A&E, Inpatient and Outpatient HES Identify by MH PbR Clusters 9

Diagnostic coding

• Diagnostic (ICD 10) coding in Mental Health & Learning Disability Dataset is only 15-20% but Hospital Episode Statistics inpatient coding is very high • MHLDDS technical specification: current data processing rules include the requirement to ignore all codings made outside a limited reporting period • Removing this coding in Table 22 and 23 of the MHLDDS technical specification v1.1 will substantially increase coding levels: “EVENTDATE Not Null AND >=

RP Start Date and <=RP End date. Any records not meeting the qualifying criteria will be ignored.”

26% of service users have psychosis (similar figure to QOF register)

Source: QOF register 2012-13 MH10 denominator without exceptions 60,524 18,705 15,951 = 85% of QOF Other mental health 44,573 Source: MHMDS 2010-2013 (3 years) Psychosis using defined criteria* Psychosis 15,951 (26%) Identifiable mental health service users in Wessex across 3 years* Source: Wessex AHSN user data contained in HES and MHMDS datasets licensed from HSCIC, 2014 11

Users with psychosis get admitted more frequently, and stay longer

*Across 2 years 2011-12 and 2012-13 115,710 805,116 58 Unknown 33

+77%

Other mental health Psychosis 15,750 All service users, 2 years 8% 30% Proportion of users that get admitted, 2 years 544,666 (68%) Total ward inpatient bed days, 2 years Average stay per person per year (days) Source: Wessex AHSN user data contained in HES and MHMDS datasets licensed from HSCIC, 2014 12

Black & Asian SUs are more likely to be admitted to mental health wards and tend to stay longer

13,708 240 217 White - British Asian or Asian British Black or Black British Service users, 2011-13 39% 30% 34%

+30%

% admitted to hospital, 2011-13 58 70 87

+50%

Average stay per person per year, 2011-13 Source: Wessex AHSN user data contained in HES and MHMDS datasets licensed from HSCIC, 2014 13

Users with psychosis use ~3 times as many healthcare professional contacts as users with other MH issues

*Across 2 years 2011-12 and 2012-13 92,054 1,803,508 33 32 Unknown

+177%

Other mental health 13 12 48% Psychosis 17% All service users, 2 years Healthcare Professional Contacts, 2 years 2011-12 2012-13 HCP contacts per service user Source: Wessex AHSN user data contained in HES and MHMDS datasets licensed from HSCIC, 2014 14

A&E attendance by those with psychosis is increasing faster than for other users

A&E visits per user per year 2.4

2.20

2.2

2.0

1.91

1.8

1.6

1.39

0.0

2010-11 8,853 10,906 2.30

1.99

1.40

2011-12 11,660

+7%

2.36

2.02

Users with psychosis Users with other mental health issues 1.44

Users with no known mental health issues 2012-13

+7% +4%

# of A&E visits by service users with psychosis  Wessex users with psychosis account for

£1.3m of the A&E spend in 2012-13

(@£ 108/attend.) 2010-11 2011-12 2012-13 Source: Wessex AHSN user data contained in HES and MHMDS datasets licensed from HSCIC, 2014 15

Psychosis users increasingly get admitted to non-mental health Trusts and stay longer

2,283 2,940 3,210

+9%

4,213 5,743 6,351

+11%

21,032 34,637 30,071

+15%

Users with psychosis % change from 2011-12 to 2012-13 Users with no known mental health issues (figures in ‘000s) 148 151 162

+7%

2010 11 2011 12 2012 13 Number of users getting emergency admissions at non-mental health Trusts 214 218 235

+8%

1,100 1,024 1,066

+4%

2010 11 2011 12 2012 13 Number of emergency admissions  Wessex spent at 2010 11 2011 12 2012 13 Total length of stay (days) least £7.2 million in 2012-13 on care for psychosis patients admitted to non-mental health Trusts (£ 210/bed day) Source: Wessex AHSN user data contained in HES and MHMDS datasets licensed from HSCIC, 2014 16

Many users with psychosis are seeking work but only 6% are definitely working

*Across 2 years 2011-12 and 2012-13 Employed Unable or unwilling to work Unemployed and seeking work Unknown Other Mental Health 7% 25% 7% 61% 46,300 Psychosis 6% 23% 15% (2,363) 56% 15,681 100%  Over 2,300 Wessex users with psychosis want to work but have not got the opportunity to do so Source: Wessex AHSN user data contained in HES and MHMDS datasets licensed from HSCIC, 2014 17

Users with psychosis are more vulnerable than those with other mental health conditions

Most recent Health of the Nation Outcome Scale scores; % of those with rating of 1 to 4 on each question

Overactive, aggr., disrupt. or agitated behaviour Q1 47% Non-accidental self-injury Q2 Psychosis (n=8,810) Other MH (n=14,323) Problem drinking or drug-taking Q3 Cognitive problems Q4 Physical illness or disability problems Q5 43% 46% 43% Problems associated with hallucinations, delusions Q6 65% Problems with depressed mood Q7 Other mental and behavioural problems Q8 Problems with relationships Q9 Problems with activities of daily living Q10 Problems with living conditions Q11 Problems with occupation and activities Q12 60% 54% 49% 58% 66% 75% 72% 74% 49% 56% 18 Source: Wessex AHSN user data contained in HES and MHMDS datasets licensed from HSCIC, 2014

Clinical rating ….. (HoNOS)

physical health substance use accom modation psychotic symptoms daily living skills self-harm depress ion job situation cognitive impair ment other symptoms relationah ips relation ships Friends & Family Warwick Edinburgh Mental Wellbeing Scale

How satisfied are you with your…

accom modation mental health physical health mental health profess ionals leisure personal safety medica tion practical help job situation partner/ family Do you want help with it?

Intervention coding

Assessment: Information: Care coordination/ MDT functions Psychological therapy/ empowerment Physical health interventions Recovery & Lifestyle Medication/ECT Family/Carer

Intervention coding (examples)

Care coordination/ MDT functions 5. Care planning & safety/risk planning 6. CPA / care plan & safety/ risk review/personalized budgets 7. Discharge meeting 8. Liaison, supervision & consultancy 9. Administration/ data entry/reports 10. Crisis contingency/advance decision planning Recovery & Lifestyle 18. Accommodation support 19. Financial support 20. Practical daily living support 21. Personalized budgets & social inclusion activities 22. Education/training/employment 23. Enabling activities/emotional support 24. Physical healthy lifestyle activities 25. Alcohol assessment and intervention 26. lllicit drugs assessment and interventions

Pathways Can they help with costing?

HIGH COST INPATIENT INDIVID -UAL COSTING

HIGH COST COMMUNITY COMMUNITY CLUSTERS

EIP/AOT Y-O-C Acute care pathway CPA Y-O-C Non-CPA Y-O-C Recovery

Level 1 Funded by the NHS secure or rehabilitation or private inpatient units

• Cost according to the placements patients need rather than the placement they are currently in: – use individually costed personal budgets – based on funding panel mechanisms/standard costs • Safeguards to ‘gaming’ in definition of Delayed Transfers Of Care (DTOC) – patient’s desire to move on – staffs’ motivation to provide effective treatment – audit and outcome measurement (PROMs). • Cost modelling to plan funding flows

Level 2 All other MH patients currently funded by the NHS & LA

• Inpatients account for 40-50% of the overall MH budget so need to dis-incentivise inappropriate care.

• Use year-of-care allocation where costs include projected inpatient usage (based on past year) • Need & resource use: – Group: Non-CPA, CPA, Early intervention in psychosis, Assertive Outreach (Clusters/severity). – Criteria driven with outcome & needs measures – Complexity factors e.g. comorbidities.

Payment Systems for Mental Health – can efficiently address levels and quantity of need – support implementation of evidence based interventions – reward positive outcomes and recovery

(Further details: http://bit.ly/1vt8anL )