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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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