Discharge Pathway Project

1. Discharge Pathway Project Girish Kunigiri Fabida Noushad Mohammed Abbas Colin Gell Sarah Cassie Ayesha Ahmed Terri Eynon

3. CMHT in Leicestershire Town Hall Chambers Melton Hawthorne Rutland Orchard Market Harborough Cedars

4. CMHT challenges in Leicestershire • Longstanding culture • Variation in practices across localities • Dependency on psychiatrist • Overloaded outpatient clinics • Waiting lists for first appointment (average 4-5 weeks; up to 13 weeks) • Clinicians struggle when Service User need to be seen urgently

5. Mental Health Facilitator (MHF)in Leicestershire MHF are mental health professions at Band 5/6/7 Managed in the primary care (along side the IAPT) Currently in the county (n=18 MHF) Role Help GP in assessment and management of SU with SMI (mild to moderate) Ensure SU on SMI register are followed up and have annual health check

6. Outpatient clinics • Consultant case load – 350-600 (largely on their own) • Average clinics by one community consultants 4-5/week; • Junior doctors 2-3 clinics/week No. of patients seen/week in outpatient clinics • 4-5 new • About 40-50 follow ups Discharge range : 35-127 per year per consultant

7. Outpatient clinics Leicestershire

8. East Midlands MH Trusts benchmarking audit

9. East Midlands MH Trusts benchmarking audit

10. East Midlands MH Trusts benchmarking audit

11. East Midlands MH Trusts benchmarking audit

12. Limitations of clustering exercise • Audit done in May 2011- however training of clinicians in clustering completed only by September 2011

14. Aim of discharge pathway project • To identify and discharge service users with SMI who have been stable back to primary care • To support the primary care in managing such patients

15. Intended benefits of the project To make efficient use of resources in secondary care services in managing service users with SMI To reduce waiting time to see urgent and new referrals in CMHT Clinicians to be able to provide more active psychological and crisis intervention to their SU Smooth transition of SU between primary and secondary care

16. Methodology • Set up a steering group • Rolled as a pilot in NWL from Feb 2011-Jan 2012 • Developed a tool to help identify SU who could be potentially discharged back to GP • Those stable for one year or longer with no interventions • Advice to primary care included (medication, early signs of relapse, risks and its intervention) • Consulted with all the clinicians and GP for their views on the tool • Clinician had option of using the tool at discharge or incorporate the content of it in their clinic letter to GPs

17. Methodology cont… Educated the CMHT Educated the GP Encouraged clinicians to review patients who are stable for discharge During MDT/CPA meeting OPC Discussing with patients and carers regarding discharge on their next appointment

18. Methodology cont… Joint decision to discharge to primary care When necessary involved MHF/GP Copy of the final care plan/clinic letter given to SU Fast tract when necessary Providing advice to primary care

19. Evaluation of the project Questionnaire sent at 6 months and 12 months post discharge To SU To GP Questionnaires identified Care provided in primary care Increase in workload in primary care Satisfaction by SU and GP

20. Results: Caseload

21. Referrals (n=117)

22. Discharges (n=143)

23. Type of discharge (n=143)

24. Diagnosis

25. Results- Evaluation • So far responses from 5 GP’s • Discharge letter helpful • Received help from secondary care when appropriate • None of these patients had personalisation and advance directive • No additional work • Patient responses- still awaited

26. Challenges LPT Clinicians Reluctant discharging SU Concerned that SU might not get the right care in primary care Wary about providing advice to primary care when SU not open to secondary care Practicality of fast track GP Concerned about increase in case load Expertise in managing when in relapse

27. Challenges cont… • Service Users • Concerned that there may be no continuity of care • Fear of delay in re-referral/acceptance by secondary care • SU choice • Issue with benefits

28. The way forward • Integrating the discharge pathway project with care pathway development • Continue to review existing caseload on a regular basis • Openness with SU about reasons for discharge • Setting the goals and duration of treatment when SU are first referred to the services

29. Integrating the discharge pathway results with care pathway development • Periodic review of care clusters • CPA • Change in clinical status • Set up maximum time frame • Defining possible time frame for each cluster

31. Cluster pathway 11

32. Conclusions • Significant proportion of service users are in secondary care who are relatively stable and could be managed in primary care. • Service users should receive the right care at the right time and for right period of time. • This pilot has shown that 32 patients were stable enough to be discharged. • Service evaluation have shown satisfaction within GP’s. There needs to be a cultural shift with clinicians and service users in bringing this change. • Integrating results with care pathway development is the way forward.

33. Acknowledgements • Christine Green & Sue Scarborough • Clinical staff • GP’s • Service users