Providing an Accessible Mental Health Liaison Service to a General Hospital:

Challenges and Solutions

 

Dr Vishelle Kamath

Consultant Psychiatrist

SEPT

Background The L & D – a large district general

hospital

A wide and diverse population from 3 different counties

£3.6 million - The total cost to the commissioning body, NHS Luton, for admissions to the L&D for psychiatric presentations including dementia, self-harm and substance misuse was approximately (2011 -2012)

Background continued... A high proportion of patients in general

hospitals have co–morbid mental health problems, leading to poorer health outcomes and increased healthcare costs.

[Joint Commissioning panel for mental health]

Mental health service users2 have double the rate of hospital attendances compared to the general population3 – across A&E, inpatients and outpatient services

[ The Health and Social Care Information Centre (HSCIC)]

The Problem

The current level of psychiatric input into the L&D cannot meet demand.

ObjectiveTo develop a psychiatry service that :

Will meet the demand

Is accessible to all patients Will measurably improve outcomes with regards to health,

finances, patient and carer experience

Be implemented by December 2013

Root cause Analysis

L&D

Media/Expectation

National Drivers

Root cause Analysis

• The current model of mental health service provision to the L &D is one of ad hoc psychiatric consultations with separate services for adults and older adults (those aged 65 and over).

• The growing demand for psychiatric assessments and input cannot be met at the current levels of resource allocation

• The result of this inequality between supply and demand is placing immense pressure on the hospital

- increased lengths of stay

- hospital acquired infections, poorer patient experience and poorer health outcomes.

Strategic Options

Continue with the Existing Service

Augment the existing service

Commissioned Psychiatric Liaison Service

Comparison of StrategiesStrategy Cost Effective

nessQuality Accessi

bilityRisks Stakehol

der Support

Time to effect

Potential saving

Continue with existing service

↑

Augmented Service

↑

Commissioned Psychiatric Liaison Service

↓

Key Milestones

Modelling of Options Implementation

Trial of Augmented

Service

Re-evaluation

Position statement

Idea generation

Consultation with

Stakeholders

Business planning &Service

Specification

The beginning

Implementation Steps

Pathways & Operational Policies

Risks and risk management strategies

Outcome Measures and KPI’s

Financial management & Reporting

arrangements

IT systemsWorkforce recruitmentGovernance Structures

Service Review

Evaluation Plan

Strategic Aim

• Equitably accessible, high quality service that improves patient outcomes

• To facilitate efficiency in the service with a resulting financial saving

Short Term

• Improved patient experience • Improved quality of care

Long Term

• Better patient satisfaction• Financial savings

Measurable Outcomes

Reduced length of inpatient stay in the general hospital

Avoidance of admission to the general wards

Reduced frequency of readmission after discharge

The proposal costs approximately £300,000 per year

The cost savings are based on the analysis of data at Birmingham City Hospital RAID service between 1st December 2009 31st July 2010*Savings from reduced Length of Stay = £1.75 million

Improved patient and carer satisfaction

Improved patient choiceReduced delays in

accessing mental health input

*Economic Evaluation of Liaison Psychiatric Service Centre for Mental 2011

Agreed KPI’sKPI Comment/Query Notes1.To reduce the number of emergency admissions.

This refers to emergency admissions via A/E to the L&D.

If L&D admissions, SEPT will be dependent on L&D to report.

2. To reduce the number of readmissions.

This refers to emergency readmissions via A/E to the L&D.

If L&D readmissions, SEPT will be dependent on L&D to report.

3. To reduce the number of delayed discharges from the L&D due to mental health causes.

Will need to define which delayed discharge codes will need to be monitored.

SEPT will be dependent on L&D to report.

4. EAU admission avoidance in L&D

This is to monitor those patients that are admitted to the Emergency Admissions Unit in the L&D from A&E.

Measure used in the economic evaluation of RAID by the LSE. The rationale is that the RAID model demonstrated a reduction in admissions to the equivalent unit within the general hospital

5. Monitoring of discharge destinations e.g. more people discharged home

Secondary measure suggested in the economic evaluation of RAID by the LSE.

SEPT will be dependent on L&D to report.

6. Length of time from referral by L&D to;

Could compare to pre service implementation if baseline information gathered.

a) 1 working day for assessment on base wards

b) CRHT response times to A&E to be reduced from 4 hours to 1 hour

Agreed KPI’s cont….7. To reduce L&D delayed transfers of care due to MH causes.

Will need to define which codes will need to be monitored.

8. Increase in referrals to Psychiatry Liaison Team (PLT).

Would need a baseline, not available as a new service, could suggest a trajectory.

9. Total number of referrals.

10. Proportion of referrals assessed as appropriate.

11. Patient/carer satisfaction before and after implementation.

To be measured by Patient experience team, to work with L&D patient experience team.

12. L&D hospital clinical teams satisfaction before and after service implemented

To be measured by patient satisfaction team.

13. L&D Hospital staff awareness of liaison service.

To be measured by patient satisfaction team. .

Lessons Learnt• So a new service..... Why all the fuss?

The right proposal by

The right provider

The right time

• Transformational Leadership• Influence and relationships• Achieving consensus – unfiying objectives

Lessons Learnt .....

• Stakeholder management• SEPT

– Stellar reputation as a provider of excellent services– Track record of successful service transformation

• The spending paradox

Spend Averse Climat

e

Investing to save

Lessons for me

Maintaining momentum...

Lessons for me

Time distortion!

Lessons for me

Sequential problem solving

Lessons for me

More than just numbers....

Thank you!