10th november 2017 · 10th november 2017 iapt programme . iapt programme ... r 2016/17 2017/18...
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10TH NOVEMBER 2017
IAPT Programme
IAPT Programme
Learning from Wave 1 and Wave 2 Early Implementers
Integrating IAPT with physical health pathways
IAPT-LTC
Ursula James – National IAPT Programme Manager
3
FYFV Commitments: Increase access to 1.5m people a year
15.58% 15.80%16.80%
19%
22%
25%
953960
1,020
1,160
1,3701,500
0
200
400
600
800
1,000
1,200
1,400
1,600
1,800
2,000
0%
5%
10%
15%
20%
25%
2015/16 2016/17 2017/18 2018/19 2019/20 2020/21
Nu
mb
er
of
peo
ple
accessin
g
treatm
en
t, t
ho
usan
ds
Access
Projected access rate
People accessing treatment (thousands)
• Two thirds of expansion, by 2020/21, to be ‘Integrated IAPT’ services – integrated with physical health pathways for people with long term conditions or distressing and persistent medically unexplained symptoms.
• In 2016/17 and 2017/18: Early Implementers supported centrally
• From 2018/19, CCGs to commission IAPT-LTC services locally
4
FYFV Commitments: Integrated IAPT services
5
NHS Operational Planning and Commissioning Guidance 2017-
2019• CCGs should commission additional IAPT services, in
line with the trajectory to meet 25% of local prevalence in 2020/21.
• Ensure local workforce planning includes the number of therapists needed and mechanisms are in place to fund trainees.
• From 2018/19, commission IAPT services integrated with physical healthcare and supporting people with physical and mental health problems.
6
FYFV Commitments: build capacity in the workforce
210
200 413 413338
390
400 755 755 630
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
0
100
200
300
400
500
600
700
2016/17 2017/18 2018/19 2019/20 2020/21 Cu
lmati
ve t
ota
ls o
f tr
ain
ed
sta
ff
Pro
jecte
d t
rain
ees e
ach
year
Projected trainee numbers
PWP trainees HIT trainees Culmative total Co-located staff in primary care
7
NHS Operational Planning and Commissioning Guidance 2017-
2019• Overall planning of workforce should include increasing the numbers
of therapists co-located in general practice by 3000 by 2020/21.
– We are calculating each CCG’s share of the additional 4,500 therapists and the 3,000 MH therapists in primary care
– This is based on simplistic assumptions using prevalence
– We will share these with regions and use them a starting points for refinement based on local intelligence
– This will be an iterative process
In wave 1 352 additional practitioners started working in primary care as a result of the expansion
• Getting outcome data on everyone is critical. It helped core IAPT go from 38% recovery (2009) to 51% now.
• LTC/MUS pilots fell below this standard – important to integrate data into business as usual (session by session, data view in every supervision, IT system support, digital input).
• Integrated services need to collect some additional data on the perceived impact of the LTC and healthcare utilization (e.g. CSRI)
• Important to be clear from the beginning about what to collect, when, why, and how data completeness is monitored.
Lessons from IAPT programme, including LTC/MUS: data is critical
8
9
2016/17 2017/18 2018/19
Outcomes
based tariffPreparation
Shadow
implementation
Full
implementation
Quality
PremiumQuality Premium Active
Supporting productivityDigital information for
commissioners scoping
Development of a digital therapy
endorsement programme
Guidance
Interim implementation
guidance for integrated
IAPT
Updated guidance for
integrated IAPT.
Updated Core IAPT
guidance published
New evidenceCommission analysis of
early implementers
Gather evidence for
analysis
Final evidence
from analysis
CommsRegular communications on the case for expansion – including
evidence, best practice and fit with system priorities
Fin
anci
al
Ince
nti
ves
Gu
idan
ce a
nd
bu
ildin
g ev
ide
nce
Aim:• To implement integrated psychological therapies at scale –
improving care and outcomes for people with mental health problems and long term physical health problems, and distressing and persistent medically unexplained symptoms.
• To learn how best to implement integrated psychological therapies at scale in an NHS context – moving from trials and pilots to business as usual.
• To build the return on investment case for integrated psychological therapies – demonstrating savings in physical health care.
• To build capacity in the IAPT workforce, starting the expansion of the workforce needed to meet 600,000 extra people entering treatment by 2020/21.
IAPT Early Implementer Programme
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IAPT-LTC Definition
What defines an Integrated IAPT service?
An integrated service will expand access to psychological therapies for people with long term health conditions or MUS by providing care genuinely integrated into physical health pathways working as part of a multidisciplinary team, with therapists, who have trained in IAPT LTC/MUS top up training, providing evidence based treatments collocated with physical health colleagues.
What defines an Integrated IAPT service?
An integrated service will expand access to psychological therapies for people with long term health conditions or MUS by providing care genuinely integrated into physical health pathways working as part of a multidisciplinary team, with therapists, who have trained in IAPT LTC/MUS top up training, providing evidence based treatments collocated with physical health colleagues.
It is important to keep this definition in mind when setting up your integrated service. It may be that while in the beginning all these requirements are not met however you should be aiming for a service model which satisfies all 3 of the criteria above.
Working with 22 areas covering 30 CCG’s in Wave 1 (started from January 2017), with further 15 areas covering 38 CCG’s in Wave 2 (started from April 2017)
Components of expansion programme:
IAPT EI Programme
Developing curricula &
training offer
Allocating funds for Early
Implementers
Guidance to support service
design / implementation
Data collection & analysis
Support for early implementers
HEE have commissioned
LTC training with courses already
started
Funding approved for Wave 1 and
Wave 2 sites
Integrated IAPT Evidence Based Treatment Pathway Draft available
Work Packages agreed, support available to EI sites
and workshops arranged
National workshops continuing. Yammer site is
working well. Site visits and implementation calls
with new Wave 2 sites completed. Delivery calls
with Wave 1 sites completed
London
Coastal West Sussex CCGCrawley and Horsham CCGMid Sussex CCG
Windsor, Ascot & Maidenhead CCGSlough CCGBracknell and Ascot CCG
Aylesbury Vale CCGChiltern CCG
Herts Valleys CCGWest Essex CCG
Cambridgeshire & Peterborough CCG
Greater Huddersfield CCGNorth Kirklees CCG
Harrogate & Rural District CCG
NEW Devon CCG
North East Hampshire & Farnham CCG
Wokingham CCGNewbury and District CCG North and West Reading CCGSouth Reading CCG
North Staffordshire CCGStoke on Trent CCG
Blackburn with Darwen CCGEast Lancashire CCG
Warrington CCG
Oxfordshire CCG
Swindon CCG
Portsmouth CCG
Richmond CCG
Hillingdon CCGSunderland CCG
Nottingham West CCG
Calderdale CCG
North Tyneside CCG
KeyIAPT Wave 1 CCGs Wave 1
Wave 2
London
Brent CCGHarrow CCGCentral London CCGWest London CCGHammer. & Fulham CCGEaling CCGHounslow CCG
Ashford CCGCanterbury & Coastal CCGSouth Kent Coast CCGThanet CCG
Sheffield CCG
Hardwick CCGNorth Derbyshire CCGSouthern Derbyshire CCGErewash CCG
Haringey CCGIslington CCG
Thurrock CCG
South East Staffordshire & Seisdon CCGCannock Chase CCGStafford & Surrounds CCGEast Staffs CCG
North East Lincolnshire CCG
Solihull CCG
Dorset CCG
Wyre and Fylde CCGChorley & South Ribble CCGWest Lancashire CCGLancashire North CCG
Bath and North East Somerset CCGWiltshire CCG
Coventry & Rugby CCGSouth Warwickshire CCGWarwickshire North CCG
Nottingham City CCG
Telford & Wrekin CCG
IAPT Wave 2 CCGsKey
Wave 1
Wave 2
15
What is available to support implementation?
CPD for therapists in psychological therapy for people with long term conditions / medically unexplained symptoms:
starting late 2016 & in 2017
Service design: implementation guidance available
Extra core trainees in 2016/17 and 2017/18 for IAPT EI and Universal
offer places
Sharing ideas and emerging practice from early implementers
Long term conditions
Area Co-location proposal DiabetesCOPD / Resp.
CVD / Cardiac
MUS Other
Blackburn With Darwen & South Lancs
Community respiratory teams & integrated care teams (aligned with GP clusters) X
Calderdale General practice X X XChiltern & Aylesbury Vale General practice, community teams & outpatients teams X X X Chronic painHerts Valleys & West Essex In development X X Chronic pain
Horsham and Mid Sussex , Coastal West Sussex & Crawley
LTC teams: specialist heart failure teams, diabetes nurse specialists, community respiratory nursing teams, proactive care teams X X X
North Staffordshire General practice, long term conditions teams X X Chronic pain
North Tyneside Primarily in general practice and primary care community teams X X X Chronic pain Cancer
Nottingham West Integrated local care team X X X Chronic pain
Pre-diabetes, dermatology, people in top 2% most at risk of admission to hospital
Portsmouth Specialist long term conditions teams X X XChronic painCFS
Sunderland Integrated community teams based in primary care X X X chronic pain cancer, obesity
Windsor, Ascot and Maidenhead, Bracknell and Ascot Community hubs (LTC teams) and GP practice clusters X X X
Wokingham, Slough & Windsor, Ascot & Maidenhead, Bracknell and Ascot Community hubs (LTC teams) and GP practice clusters X X XOxfordshire Integrated locality teams within the 6 GP localities X X X MUS, CFS
Greater Huddersfield LTC multidiscliplinary teams X X XPain management Dementia
Harrogate And Rural District LTC teams X XWarrington General practice X X
Richmond General practice, community teams and acute trust teams X X X X
Swindon In development - general practice linking to specialist teams X XHillingdon Secondary care teams X X XNEW Devon General practice, district hospitals, community hospitals X X X ObesityCambridgeshire and Peterborough
LTC teams and primary care mental health service from 2017/18 (to be located in general practice) X X X
NE Hampshire and Farnham In development X X X
Summary of Wave 1 Sites
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Summary of Wave 2 Sites
AreaGP practice /
primary care
Community
services
Acute services /
secondary careDiabetes
COPD /
respirato
ry /
Asthma
CVD/
cardiac /
Stroke /
Hyper-
tension /
CHD /
heart
failure
MUS /
Fibromy
algia/
Health
anxiety
Chronic
Fatigue/
ME
Chronic
Pain /
MSK
Other
BANES & Wiltshire CCGs ✓ ✓ ✓
Coventry and
Warwickshire STP✓ ✓ ✓ ✓
Derbyshire STP
South Derbyshire CCG✓ ✓ ✓ ✓
Dorset CCG ✓ ✓ ✓
East Kent CCGs ✓ ✓ ✓ ✓
North Central London
STP✓ ✓ ✓ ✓ ✓
North East Lincolnshire
CCG✓ ✓ ✓ ✓ ✓ ✓
North West London STP ✓ ✓ ✓ ✓
Nottingham City CCG ✓ ✓ ✓ ✓ Cancer
Sheffield CCG ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ IBS/ Cancer
Solihull CCG ✓ ✓ ✓ ✓
Staffordshire & Stoke-on-
Trent STP ✓ ✓ ✓
Telford & Wrekin CCG ✓ ✓ ✓ ✓ ✓
Thurrock CCG ✓ ✓ ✓ ✓ ✓ ✓
Co-located in Long term conditions
• There is enthusiasm in providers and CCGs to develop integrated services, and there are examples of services that are already providing psychological therapies in this way
• Joint working across NHS England national and regional teams, HEE, and the MH IST has strengthened the process and results from early implementers
• The financial context means some EI areas have had concerns about financial risk – for instance taking on staff – despite a strong savings case on integrated psychological therapies
• National direction is to support areas to make the case for the programme – the publication of the implementation plan helped in making clear direction of travel.
Learning from process so far
18
• Start early! Engagement, relationships and development of pathways does take time
• Develop a good implementation plan which is co-produced, has both physical and mental health input along with service user collaboration
• Think about future proofing the investment whilst developing the implementation plan, how local evaluation evidences savings
• When developing pathways, carefully consider local nuance – where lends itself to integrated working? What do the Right Care packs show?
• Mapping exercise to prevent duplicate commissioning- what is commissioned from the physical care envelope
Learning from EI’s- Commissioners
19
• Ensure there is clarity re the distinctions between IAPT LTC, Liaison Psychiatry and health psychology, and that the pathways between all three are clear
• Link in with existing work streams in physical health
• Can you make this work across the STP/ vanguard
• Use a patient focus group
• Use GP champions
• Consider what the GP priorities are in terms of conditions
Learning from EI’s- Commissioners (2)
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• Start early- Engagement, relationships and development of pathways does take time
• Make links top down and bottom up
• Cast your net widely
• Don’t underestimate the important of publicity and marketing- start this early too
• How should you brand your service to appeal to the target audience
Learning from EI’s- Providers
21
• Do you need to use alternative language
• Do you need to train PHC staff
• Can you dual train practitioners
• Be clear on the design - NOT signposting- need integration and co-location
• Need to think about how to “sell” this to physical health colleagues to demonstrate the benefits
• Designing the pathway so that the service can catch people when they are first diagnosed rather than further down the pathway
Learning from EI’s- Providers (2)
22
Headline figures for 16/17
23
133 PWP trainees were recruited as part
of the expansion
23 Integrated IAPT services started
delivery in January 2017 172 HI trainees
were recruited as part of the expansion
121 PWP’s started the LTC CPD training
3202 patients were seen in an
Integrated service in 16/17
143 HI’s started the LTC CPD training
IAPT- LTC
Achievements in 16/17
24
Funding moved from NHS England
to local areas
Data linkage problems have been solved in
some areas-we can tell you where
Integrated IAPT Manual completed
Commitment to additional training for
IAPT therapists
Networking between
sites-Yammer & workshops
Huge levels of recruitment
and collaboration between sites
Expansion when other
areas are shrinking
Patient stories being
collected
Plan for 17/18
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IAPT-LTC
45,000 patients
195 HI trainees
176 PWP trainees
207 HI CPD
260 PWP CPD
• Herts Valleys Clinical Commissioning GroupService user: “This service provided me with the space to talk about worries about my diabetes no one else has asked me about before. I really value that ... as well as the subsequent support,” Service user feedback.
• Nottingham West CCG“Patient post thoracic surgery left with significant pain and neuralgia. Became increasingly suicidal on higher doses of opiates. Since working with IAPT mood has improved and analgesia reduced. Lot of evidence that using a biopsychosocial model of pain can reduce the use of opiates and their depressive and endocrinological side effects.” GP Feedback
26
Feedback so far
• Great Western Hospital Swindon
"The cardiac rehabilitation team at Great Western Hospital have been finding it very helpful to have a much closer working relationship with the IAPT team. At the beginning of the project I invited the team to come and speak at a cardiology clinical governance meeting. This raised the profile of psychology support amongst the wider cardiology team.""We have been able to easily refer patients directly for one-to-one psychology input with a practitioner and referrals have been made by cardiac rehab specialist nurses, consultant cardiologists and cardiac technicians. We can also signpost our patients to a regular 'Living well with coronary heart disease [CHD]' stress management group."
27
Feedback continued..
• Sunderland CCG
Forging new referral pathways with physical health services has resulted in an integrated way of working with a range of specialist health services, including; stroke, dermatology, COPD and cardiology. Open lines of communication and referral pathways between mental and physical health services, coupled with a stronger understanding of the roles and remits of each service results in patients receiving a seamless and more informed experience of care and treatment. One particular pathway has been the introduction of Managing Pain and Fatigues courses by IAPT PWP’s within the physical health services and one client said:-“The course is very helpful and focused. I’m getting more into the mind-set of accepting change as opposed to thinking about what I used to be able to do. The course has made a significant and hopefully lasting impact.”Provider and Service User
28
Feedback continued
29
Feedback from GP – co-location“Forty-six per cent of patients referred to our Psychological Wellbeing Service for a mental health problem also have a physical health long term condition. These patients are used to being seen in their local GP practice, which is a familiar environment, providing both physical and mental health care, and most would choose to have their care provided here.”
“The feedback process, and the regular sharing of information between mental and physical health professionals, works well in multi-disciplinary team meetings, helping to ensure they are patient-centred. Effective communication and coordination of care in the primary care environment should also lead to an overall reduction in the number of patient referrals to secondary care, which releases capacity for patients that do need secondary care.”
“As a GP I consider that an important part of my work is to help make patients’ access to mental and physical health care as swift and easy as possible and that includes informing patients about the options available to access treatments and normalising mental health as part of the GP offer.”
• EI Site in the South has demonstrated so far:-
- 75% increase in specialist nurse use
- 49% reduction in GP appointments
- 52% reduction in A & E attendances
- 80% reduction in X-Rays
30
Initial Indications
• 16% of all STPs have all CCGs within them commissioning IAPT-LTC services
• 62% of all STPs have at least one CCG who has commissioned an IAPT-LTC service
• 38% of all STPs have no IAPT-LTC service currently commissioned
31
Existing coverage
32
What are the risks / opportunities?
Improve mental health outcomes and broaden the range of people
who access support
Show integrating mental health and physical health care is possible: inspiring broader
action, reducing stigma and improving parity
Convincingly show
integrated care reduces
cost
Expansion requires ~4000 new
therapists: mobilise training capacity, local workforce
plans
Savings profile may is a challenge for CCGs
to demonstrate
Workforce wellbeing is a priority –
expansion provides opportunity for staff
growth
• Integrated IAPT FAQs document
• Local evaluation guide
• Data quality guide
• Building the Business Case
• Integrated IAPT Data Handbook
• Evidence Based Treatment Guide for IAPT-LTC
• “How to” IAPT-LTC guide
33
Supporting documents
Integrated IAPT PathwaysHeart2Heart
DoH Cardiac LTC Pathfinder Project Dr Heather Salt
Consultant Clinical & Health Psychologist
National LTC Clinical Adviser NHSE
TalkingSpace Plus (IAPT Oxfordshire) Oxford Health NHS Trust
• Who am I?
• DoH LTC/MUS Pathfinder example: Oxfordshire Heart2Heart
• Why IAPT-LTC?
• What does a good IAPT-LTC service look like?– Learning from Wave 1 & 2
• What are the challenges?– Commissioners– Clinical leads– Service managers
35
Introduction
Aims of Heart2Heart
– Cost effective way to provide integrated physical/psychological care across acute hospital and community cardiac services in Oxfordshire
– Development of an integrated stepped care model (LIFT model: least intervention first time)
Cardiac Conditions & treatmentReduced or blocked blood supply
– Coronary Heart Disease, – Myocardial Infarction (heart attack)– Angina❖ Investigations❖ Cardiac bypass surgery❖ Stent & angioplasty❖ Medication❖ Lifestyle change
Pumping problems (Heart failure)– Cardiomyopathy (including Genetic)– Arrhythmia – Cardiac arrest❖ Investigations❖ Ablation, Pacemaker and ICD❖ Medication❖ Lifestyle change
38
Heart2HeartIntegrated stepped care model
Elliot,M.,Salt,H.,Dent,J., et al (2014)
OAHSN Anxiety and Depression (IAPT) Network
Heart2Heart IAPT LTC DoH Pathfinder Results 2012-14
0
2
4
6
8
10
12
14
16
Pre Post
PHQ9
GAD7
WSAS
0
2
4
6
8
10
12
14
16
Pre Post
PHQ9
GAD7
WSAS
Heart Failure patients: Cost of ALL Hospital
Visits (A&E, Inpatient and Outpatient)
REDUCTION IN
COST PER
PATIENT £
Treated group ie 2 or
more sessions (N=23)£1,635
Untreated group ie DNA
or 1 session (N=3)£302
CHD/MI patients: Cost of ALL Hospital
Visits (A&E, Inpatient and Outpatient)
REDUCTION IN
COST PER
PATIENT £
Treated group ie 2
or more sessions
(N=34)£4,793
Untreated group ie
DNA or 1 session
(N=29)£2,814
CHD/MI patients Heart Failure patients
CHD/MI patients: n = 67 Heart Failure patients: n = 39Anxiety and depression Anxiety and depression51% recovery rate 39% recovery rate
The Patient journey“Anxiety was more
disabling to me than my heart attack or the
surgery”
“After my heart attack I was feeling chest pain and I kept going to A & E
and hospital but they said I was fine. Then I saw the Heart2Heart
therapist and realised I was depressed. I’ve got a long way to go but I can get out of the house
now and I am thinking of returning to work”
“My ICD went off and I thought I was going to die. CBT has helped me with the trauma and I can now go out of the house again”
Monthly CBT supervision groups for the Cardiac Nurses
I feel more confident about asking patients how they are feeling and be able to support them emotionally
Supervision has helped me manage difficult patient issues because it gives my strategies I can use to help patients (and their carers) help themselves.
1. What is IAPT-LTC and how is it different to core IAPT IAPT?– Embedded in physical health pathways– Colocation– MDT working– KPIs - recovery and waits– Measures– LTC Top up training
2. Who works in an IAPT-LTC service?
3. How does IAPT-LTC link in with other services e.g. liaison psychiatry and clinical health psychology?
42
Why IAPT-LTC?
• Set up– Recruitment of trainees – Moving qualified staff into the IAPT LTC team– Clinical supervision– LTC top-up training – Implementation plan– Accessing patients with LTC/MUS – Stakeholder engagement and communication plan– Accommodation and co-location– Role of commissioners– Data collection, monitoring and data linkage
44
IAPT-LTC
• Trouble shooting– Recruitment of trainees – Moving qualified staff into the IAPT LTC team– Clinical supervision– LTC top-up training – Implementation plan– Accessing patients with LTC/MUS – Stakeholder engagement and communication plan– Accommodation and co-location– Role of commissioners– Data collection, monitoring and data linkage
45
IAPT-LTC
• Trouble shooting– Core IAPT stability
– Ongoing IAPT LTC funding
– Retention of staff
– Demonstrating clinical and economic benefits
– NHSD reporting
46
IAPT-LTC
1. Cardiac – CCG cardiac project board– Cardiac rehabilitation– GP cardiology clinic integration
2. Diabetes– CCG diabetes project board (STP)– Primary care Diabetes MDT– District nurse training
3. COPD– CCG COPD and Asthma project board– Pulmonary rehab– A&E frequent attenders & staff training
4. MUS:CFS/ME– Acute hospital and community integration
47
IAPT-LTC pathway development in Oxfordshire
• Prioritising integrated care
– Funding
– CCG support
• Expansion of IAPT workforce
– Trainees
– Stability of Core IAPT
– LTC Top-up training
• Accommodation
48
Challenges
• Increasing access rates (25% by 2020/21)• Accessing hard to reach groups
– Older adults– BAME– Men– Patients with multiple LTCs
• Maintaining stability of Core IAPT & KPI• Developing staff
– Duel trained– LTC top up training– Retention of staff
• Expansion of IAPT service– Trainee workforce
49
Wave 1 & 2 Successes
Data Linkage and Evidencing
Savings
Mike Woodall
Integration Analytics Lead
Why evaluate
• Identify what works and what doesn’t
work
• Understand key components of success /
failure
• Evidence improved outcomes
• Evidence savings
51
Available Support
• Evaluation Guide focusing on:
– Data Quality
– Evaluation Design
– Information Governance (IG)
– Data Linkage
– Outcome Metrics
• Slides from regional workshops
• Data specifications and reports from NHS
Digital - http://content.digital.nhs.uk/iapt
52
Defining your theory of change
53
Defining the evaluation question
• Effect of the intervention
• Relative to not having the intervention
• On X
• Measured as X
• Amongst people that have been
exposed to the intervention
• Against people that have not been
exposed to the intervention
54
Defining the evaluation question
• Effect of Integrated IAPT service
• Relative to no Integrated IAPT service*
• On healthcare utilisation
• Measured as A&E attendances
• Amongst people that have been seen by
Integrated IAPT services
• Against people that have not been seen
by Integrated IAPT services*
55
Metric Selection
56
Type Metric
Dia
be
tes
CO
PD
Ast
hm
a
Oth
er R
esp
irat
ory
D
ise
ase
Hea
rt d
ise
ase
Can
cer
MSK
Ch
ron
ic p
ain
Epile
psy
Skin
co
nd
itio
ns
Dig
est
ive
tra
ct
con
dit
ion
s
MU
S
Acute A&E Attendances ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Acute Emergency Inpatient admissions ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Acute Average length of acute hospital stay ✓
Acute Average number of acute excess bed days
AcuteUnplanned hospitalisation for chronic ambulatory care sensitive (ACS) conditions (adults)
✓ ✓ ✓
Acute
Complications associated with diabetes, including emergency admission for diabetic ketoacidosis and lower limb amputation
AcuteEmergency admissions for acute conditions that should not usually require hospital admission
AcuteEmergency readmissions within 30 days of discharge from hospital
✓ ✓ ✓
Acute Outpatient Attendances ✓ ✓ ✓ ✓ ✓ ✓ ✓
Acute Elective Inpatient admissions ✓
Ambulance Ambulance Conveyances to Hospital ✓
AmbulanceAll Ambulance activity (including See & Treat and Hear & Treat)
Primary Care Number of attendances (GP Appointments) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Primary Care Number of attendances (All Appointments)
Primary Care Number of Prescriptions \ Cost of Prescribing ✓ ✓ ✓ ✓ ✓
Diabetes
• The evidence around Diabetes shows that psychological interventions can be successful at
reducing HbA1C and therefore reducing activity related to suboptimal management and
complications of Diabetes. No specific healthcare utilisation metrics are highlighted in the
studies but the Integrated IAPT Programme is likely to have an impact on the following metrics
if it improves how patients manage their condition and reduces complications:
1. Emergency Inpatient Admissions
2. Unplanned hospitalisation for chronic ambulatory care sensitive (ACS) conditions
(adults)
3. A&E Attendances
4. GP Consultations
• References - NHS Confederation (2012) Investing in emotional and psychological wellbeing for
patients with long-term conditions
http://www.nhsconfed.org/~/media/Confederation/Files/Publications/Documents/Investing%20
in%20emotional%20and%20psychological%20wellbeing%20for%20patients%20with%20long-
term%20condtions%2016%20April%20final%20for%20website.pdf
• Knapp M, McDaid D, Parsonage M eds (2011) Mental health promotion and mental illness
prevention: the economic case. Department of Health - pages 31-32
• (http://www.lse.ac.uk/businessAndConsultancy/LSEEnterprise/pdf/PSSRUfeb2011.pdf)
57
Medically Unexplained Symptoms \ Chronic Pain
• One study looked at the impact of Cognitive behavioural therapy (CBT) on patients with
medically unexplained symptoms (MUS). The study showed savings on the following metrics
over a 3 year period with the proportion of savings attributed to each metric shown in brackets.
1. Emergency Inpatient Admissions (52%)
2. A&E Attendances (22%)
3. Primary Care Consultations (16%)
4. Outpatient attendances (5%)
5. Prescribing (5%)
• The metrics are applied to all medically unexplained symptoms
• Reference - Knapp M, McDaid D, Parsonage M eds (2011) Mental health promotion and
mental illness prevention: the economic case. Department of Health - pages 33-35
• (http://www.lse.ac.uk/businessAndConsultancy/LSEEnterprise/pdf/PSSRUfeb2011.pdf)
58
Selecting the right method
59
IAPT Data
Healthcare Utilisation Data
Linking datasets
60
Key people to involve
• Information Governance Experts
• Provider Data Team
• Clinical Leads
• Commissioners
• Analysts
61
Key actions required
• Develop a theory of change
• Identify outcome metrics
• Identify evaluation methodology
• Assure quality of Integrated IAPT data
• Undertake a Privacy Impact Assessment
• Identify who will link the data and undertake the analysis
• Decide on the Legal Basis for sharing data
• Develop Data Sharing Agreements
• Share data
• Link the IAPT and healthcare utilisation datasets
• Undertake analysis
62
v
Pennine Lancashire - Early Implementer site learning from experience and key challenges
Debbie ToppingMENTAL HEALTH SERVICE LEAD
“SUPPORT, ENCOURAGE, ENABLE”
Who are Lancashire Women’s
Centre’s
Women at Risk
Employment, Advice and Guidance
Learning and development
Mental Health Services
Centres in Accrington, Blackburn, Blackpool, Burnley and Preston
hubs & co location in numerous other venues Inc. Chorley, Lancaster, Bacup, Nelson, St Helens, Skelmersdale.
Issues which we can support you to address might include: Feelings of panic or anxiety • Depression and low mood • Phobias and compulsive behaviour • Family or relationship distress • Bereavement • Abuse either past or present
We offer a range of therapies including counselling, CBT, PWP, EMDR and specific therapies for victims of crime, children and perinatal. We can work with you to address all aspects of mental wellbeing, alleviate emotional distress and help you to bring about positive changes.
“ I feel that it has really benefitted me and helped me through a difficult time. I would definitely recommend it to others.”
Lancashire Care
Foundation Trust
Mark Hill – Clinical lead IAPT LCTAngela Longworth – Programme Leads IAPT LTC
What do we do? We promote increasing access to psychological therapies (IAPT) and work
with adults who may be struggling with common difficulties such as stress,
anxiety and depression
Mindsmatter offer a variety of services suited to need, deciding together via
a friendly welcome call to discuss current difficulties and talk about the
menu of service.
We have a range of services that are free of charge, easy to access and
aimed to suit needs to increase wellbeing.
The services we offer Lancashire wide…
• Stress Control Classes – 6 week course
• Telephone and on-line support (Silvercloud)
• Therapy groups e.g.. Panic, Living Life to the Full
• Brief one-one sessions with a Qualified Clinician offering guided self-help,
counselling or Cognitive Behavioural Therapy
Living Well Staffing Model 20 trainee PWPs – LWC
10 – commenced March 17
10 – commenced October 17
LTC Top up training for established PWP & HIT staff
6 HITs within LCFT (with 6 trainees to backfill)
3 HITs and 2 PWPs within LWC
Leadership Team – LWC & LCFT
Skill mix from mental & physical health
Comments from newly
trained PWP
“Only male trainee” “…huge amount of knowledge”
“…feel incredibly welcome and valued.”
“Training relatively straight forward- completely necessary”“feel lucky… to train as a PWP”
“…providing high standards of service.”
“The support at Lancashire Women’s Centres has beengreat…always somebody to approach”
“not being based in a clinical setting, flexible approach”
“delivering psychological supportwithin a community”
“ …setting beneficial to the clients remove barriers toengagement.”
“excited to see the service grow and progress in the future.”
Comments from a CBT LTC practitioner
“the specialist… training helped to highlight the varied ways
that ill health can have a negative impact on a person’s
experience of life”
“…encouraged me to incorporate
other relevant approaches…”
“…feel more confident …”
“…asking more…”
“…felt helpless, but now..
I don’t feel quite as lost!...”
“…easily be able to liaise with the nurses and
physiotherapists to ask questions relating to...my clients….”
“….get these questions answered by
the professional involved….”
“….now I am more at ease with making contact with physical health professionals
about a client because it does feel like our business. “
The Living well therapy offer
➢We are qualified Psychological Wellbeing Practitioners.
➢We deliver therapeutic support through groups and 1-1 sessions.
➢We are based in GP Practices and other community settings and offer our services within these spaces.
LWC ‘Living Well’ group
Psycho education for managing LTC and MUS to reduce low mood and anxiety, helping to develop strategies for self & Pain management and to increase independence and confidence to support the individual to better manage their physical health
In these groups we look at, Physical Health & WellbeingStress, Worry & Unhelpful ThinkingMood & MotivationBetter Sleep
Goal setting & Future Management.
LWC Current delivery
• Lancashire Women’s
Centre
• The Royale (GT
Harwood)
• Acorn Centre
• Great Harwood Med
Group
• Accrington JCP
• Accrington Pals
Health Centre
• Bootstrap
• Castle Medical
Group (Clitheroe)
• Appetite for
wellbeing (Nelson)
Group only
• Pendle Women’s
Forum (Nelson)
• Yarnspinners
(Nelson)
• Nelson CAB
• Harringtons LC
(Brierfield)
• Padium Medical
Centre
LWC Current delivery
• Barbara Castle Way MSK clinic• Pulmonary rehabilitation team • Your Support Your Choice• Lancashire Womens Centre• Blackburn JCP• Blackburn College• Darwen Health link• Blackburn NHS Physiotherapy• Age UK Hopwood court• Bangor Street CH C• Audley & Queens park NLC • Audley Sports centre• Little Harwood CH C• Bootstrap• Blackburn & Darwen Leisure
Centre• Blackburn & Darwen Carers • Spring Bank court – supported
independent living
• Lancashire Womens Centre
• Burnley College PadihamMed Centre
• Stubby Lee (BACUP)• Rawtenstall JCP• Apna Cente(Haslingden)• St Marys Primary
(Rawtenstall)
• Haslingden Health Centre
LWC – delivery in
development
• Salvation Army Clitheroe
• Accrington Victoria Hospital
• Accrington Carers link
• Accrington College
• Burnley College
• Padiham Med
Centre
• Haslingden Health
Centre
Generic CBT clinic –
Clear referral pathways into routine CBT clinic from Respiratory teams
Involvement in PR programme to deliver single session Psycho-education
Working on –
Appropriate referrals - Community team intervention during acute exacerbation
Shadowing respiratory clinicians to understand more and develop next steps
Key relationships –
Community Respiratory Teams – Pulmonary Rehab, respiratory nurses,
oxygen nurses
COPD & Pulmonary Rehab
Integrated Clinic –
Specialist clinic within the Diabetes community service setting.
Direct referral into IAPT LTC on same site
Involvement in monthly MDT alongside DSN, podiatry, dietician, medics.
Diabetes
Working on –
Integrated systems and processes e.g.. booking system within
Diabetes clinic
Key relationships –
Diabetes Specialist Nurses
CBT therapist
Specialist Group –
An eight-week course - evidence base largely from the PACE trial. The
course demonstrates cognitive behavioural strategies tailored for working
with depression and anxiety associated with pain/fatigue.
• CBT based therapy – cognitive restructuring, pacing activities, problem solving, relaxation.
Delivery of single session Psycho-education within Physiotherapy service 'Body and Mind'
Pain / Fatigue
Working on –Appropriate referrals and a ? step 2 group
Challenging Recovery rates
Complex Case managers – ward round
Relationships and pathways with pain management consultants
Key relationships –Physical Health Locality Co-ordinators & Integrated Neighbourhood Teams
START team (Mental health)
Communications department – internal/external publicity and press release
Integrated clinic –
Specialist CBT clinic within the cardiac clinic in the hospital setting.
Direct referral into IAPT LTC on same site
Involvement in cardiac rehab programme to deliver single session Psycho-education
Cardiac Rehab
Working on –
Appropriate referrals
Relationship building
Key relationships –
Cardiac Rehab nurses
Top Tips Give things a go! Review, and go again!
Develop relationships with colleagues – partnerships take time to work effectively -Patience Enthusiasm Persistence
Breadth of delivery & maximizing access -
Delivery of single session psycho-education & taster sessions within local communities
• ‘normalises’ IAPT LTC’ support
• promotes the service offer
• becomes a referral pathway
Utilise knowledge already out there:• Yammer group• Workshops• Make links with other IAPT LTC sites
Skill mix – utilize everyone!
Challenges
Paperwork/ Outcome Measures
Data – Health utilization
Targets – numbers v outcomes
Headlines…Referrals: Across the partnership a total of 754 IAPT LTC referrals have been received since April 2017
CSRI: Early indicators show an overall reduction in health care appointments including GP, Practice Nurse and diagnostic testing.
Integrated Pathways: Referrals from people with a LTC diagnosis have significantly increased (LCFT 30% increase)
Feedback
GP: ‘The Staff at our practice have been pleased with the work provided by LWC In helping patients manage their mental health issues. The service is liked by our patients as it's nearer to their home and delivered in their familiar environment by the experts’.
Pulmonary Rehab: We embrace the Living Well project. As part of our service we have always had service users with mental health barriers and therefore have struggled to manage their physical health too. We look forward to the joint working and ways of progressing.
Client feedback“ Good to talk to people feeling the same way ”
“ Feel much better for just speaking to you ”
“ I am in control of my life, I am controlling my thoughts more and relaxation is helping me to control my pain levels. ”
“ I have found the service really helpful, the staff at the centre are very friendly and my therapist has been brilliant at putting me at ease from our very first meeting. ”
Thank you …
…any questions ?