Transcript Slide 1

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
What is wrong with us?
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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.
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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).
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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 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.
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
Inner city
Deprived
area
Mental Health
PROCESS
Substance
Misuse
Psychological
morbidity
Older
Adult
Mental
Health
Physical
morbidity
The product: Rapid Assessment
Interface Discharge
24x7
SERVICE
RAPID
RESPONSE
BOUNDARY
FREE
RAID
SINGLE
POINT
OF
CONTACT
TRAINING
COMMUNITY
FOCUS
EARLY
INTERVENTION
The pre-RAID (traditional) service (Cost 0.6m)
Band 7
Nurse
MHOP
1.0 WTE
Currently Funded
Band 6
Nurse
MHOP
1.0 WTE
Currently Funded
Band 6
Nurse
MHOP
1.0 WTE
Currently Funded
Specialist
Doctor
1.0 WTE
Currently Funded
Band 6
Nurse
Liaison
1.0 WTE
Currently Funded
Social
Worker
Consultant
Liaison
Psychiatrist
1.0 WTE
Currently Funded
Band 7
Social Worker
1.0 WTE
Currently Funded
Band 6
Liaison
Band 6
Nurse
Liaison
Currently Funded
Currently Funded
Nurse
1.0 WTE
Admin
Band4
1.0 WTE
1.0 WTE
The upgraded RAID service (cost £1.4m)
Consultant
Psychiatrist
Consultant
Psychologist
Mental Health of
Older People
Mental Health of
Older People
RAID
Team
Manager
Consultant
Liaison
Psychiatrist
Consultant
Psychiatrist
Substance Misuse
1.0 WTE
Currently Funded
Band 7
Nurse
MHOP
1.0 WTE
Currently Funded
Specialist
Doctor
Specialist
Doctor
Band 7
Social Worker
1.0 WTE
Currently Funded
Band 7
Nurse
Liaison
1.0 WTE
Band 6
Nurse
MHOP
Band 6
Nurse
MHOP
Band 6
Nurse
Liaison
Band 6
Nurse
Liaison
Band 6
Nurse
Liaison
Currently Funded
Currently Funded
Currently Funded
Currently Funded
Currently Funded
Currently Funded
1.0 WTE
1.0 WTE
Substance Misuse
Currently Funded
Band 6
Nurse
MHOP
1.0 WTE
Lead Nurse
1.0 WTE
1.0 WTE
1.0 WTE
Band 6
Nurse
Substance
misuse
1.0 WTE
Currently Funded
Assistant Research
Psychologist
Admin
Band4
1.0 WTE
Admin
Band4
1.0 WTE
RAID evaluation
RESPONSE
QUALITY
COST
Referrals
Origin of referral
Number of referrals
16-64 years
65 years +
Mean age
833
96%
4%
36.4 years
517
96%
4%
34.6 years
675
41%
59%
65.6 years
Accident and Emergency (A&E)
Poisons Unit
Wards
• Steadily increasing referrals
• 300+ monthly referrals
• Only 30% patients known prior to RAID.
Top 7 reasons for referral
Drug misuse
4%
Dementia/
Confusion
18%
Anxiety
6%
Deliberate self
harm
32%
Deliberate self harm
Depression
Alcohol misuse
Psychosis
Dementia/ Confusion
Drug misuse
Anxiety
Psychosis
9%
Alcohol misuse
13%
Depression
18%
A&E Response
Not Recorded; 17%
Not Assessed; 3%
Targets Met
Targets Not Met
Not Assessed
Not Recorded
Targets Not Met;
7%
Targets Met; 73%
Ward Response
Target Not
Met; 10%
Not Assessed;
1%
Not Recorded;
6%
Target Met
Target Not Met
Not Assessed
Not Recorded
Target Met;
83%
Teaching and evaluation
158 hospital staff trained: All completed the evaluation
Poor; 0%
Very poor; 0%
Neutral; 3%
Good; 36%
Very poor
Poor
Neutral
Good
Excellent
Excellent; 61%
‘A lovely insight from a very experienced practitioner’
Practice improvement
Neutral; 5%
No; 0%
Yes
Neutral
No
Yes; 95%
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%
Very poor to poor rating
Neither poor nor good rating
Good to excellent rating
Good to excellent
rating; 84%
Range
Mode
Median
Mean
0 to 5
5
4
4.2
Staff satisfaction: Feedback
Other; 5%
Referral to other
services; 8%
Liaison with other
services; 7%
Providing information
to patient; 10%
Advice on managing
patients; 12%
Advice on
medication; 11%
Support to
family/carers; 17;
8.17%
Support to patient;
10%
Support of staff; 11%
Education; 7%
Information sharing;
7%
Signposting; 4%
Range
Mode
Median
Mean
2.5 to 5
5
4
4.2
RAID evaluation
RESPONSE
QUALITY
COST
RAID evaluation
RESPONSE
QUALITY
COST
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
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
Sub Control mean: 8.4 Control Study
Sub Control mean: 10.3
Sub RAID mean:9.4
Sub RAID Inf mean: 5.2
359 cases
72 cases
Control (2873 Patient)
Mean: 9.3 days
RAID Influence (2654 Patient)
Mean: 4.74
RAID (886 Patient)
Mean: 17.6
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%
• 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= 9.3 days
240X9.3= 2,232 bed days
2232 ÷ 365= 6 beds/ day
• 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)
Percentage of patients
returning to their own
homes
Pre-RAID
Partial
RAID
RAID
34%
44%
67%
(1350 of 2873)
(1247 of 2654)
(708 of 884)
 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 (preRAID)
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
Screening Diagnosis
Multiple query Diagnoses in 156 Patients
162
37
19
10
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8
180
160
140
120
100
80
60
40
20
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200 177
180
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136
140
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76
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59 55
60
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17
20
0
Hospital Diagnosis
What is next?
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RAID Manual
RAID Engine
RAID Network
How to improve the model?
What works?
Which bit for which patch!