Why SUICIDAL BEHAVIOURS ? THE SCALE OF THE PROBLEM?

1. Wexford/Waterford Mental Health Services:Steve Lamb S.C.A.NProject NurseSuicideCrisisAssessmentNurse

2. Why SUICIDAL BEHAVIOURS? THE SCALE OF THE PROBLEM? • According to WHO around one million people worldwide currently die by suicide each year and 10 to 20 times more attempt suicide. This represents on average: one suicide death every 40 seconds and one attempt every 3 seconds (WHO 1999).

3. Impact of Suicides: ‘Suicide is without doubt one of the saddest events in human experience. It leaves devastation in its wake as relatives, friends and communities struggle with feelings of shock, loss & and rejection’ [Mary McAleese – President of Ireland 2005 [Extract of speech @ Forum for integration & partnership for Suicide Prevention]

4. S.C.A.N Why Primary Care/GP services? ‘Primary care is the first point of contact that people have with health and personal social services. Primary care is the appropriate care setting for 90-95 per centof all health and social service needs’ Primary Care: A New Direction DoHC 2001 p7. ‘In Ireland the vast majority (79%) see their family doctor/GP as their first point of professional contact if they thought they had a mental health problem’ Mental Health in Ireland – Awareness & Attitudes. 2007 p 24 HSE. Dublin ‘Over 75% ofsuicide descendents had contact with Primary Care service providers in the year before their death’ Luoma et al 2002 ‘The Irish public identify suicide, alcoholism & depression as the most important mental health related problems which require to be acted upon ‘ Mental Health in Ireland – Awareness & Attitudes. 2007 p 24 HSE. Dublin

5. S.C.A.N – Policy and Strategy REACH OUT: Action Points 11.1 to 11.4 Recognise the unique opportunity for primary care to be pro-active in matters of early diagnosis, intervention, treatment and enhanced suicide prevention for those experiencing personal crises and distress.

6. Suicide Crisis Assessment Nurse (SCAN) Pilot Project intentions: Development and deliver a ‘fast track’ priority referral system from primary care to community support resources and/or community based mental health services for individuals experiencing a suicidal crisis, who contact primary care services (GP) in the Pilot locales. SCAN Sites: 1. Dublin Cluain Mhuire (Urban) 2. Wexford (Rural). Suicide Crisis Assessment Nurse (SCAN) TheResearch & Evaluation intent: To evaluate(quantitative and qualitative outcomes)of the introduction of the fast track priority referral and assessment system for individuals experiencing a suicidal crisis who contact their GP/Primary Care Team. Note: Project supported and funded by the National Office for Suicide Prevention [NOSP: Reach Out Strategy] S.C.A.N – The Project.

7. SCAN is: New primary care approach to the assessment and care management for those in suicide crisis. SCAN Projects sought to :-Establish an expert mental health nursing resource that WOULD: Be available, accessibleand speedy in providing a response to GP’s requests for a timely assessment of those in DSH/Suicide Crisis Carry out a comprehensive (bio-psycho-social) needs & risk assessment of the client within the GP surgery. (Ref: NICE 2004 & RCP 2010) Work collaboratively in partnership with the GP [& the wider specialist specialist psychiatric services]– to institute a health/social care plan to meet the risks and care needs of the client SCAN POSTER So what is S.C.A.N. ?

9. SCAN Wexford - accomplishmentsAn Action Research Projectphased …from: Pilot Project to a Local Integrated Mental Health Service Phase 1: SCAN: 2008‘Preparation & research phase’ Actions:Pilot of SCAN estd - 1. MDT steering group estd- 2operational guidelines agreed - 3 NOSP SLA, approval & support - and partnership approach with Cluain Mhuire agreed. 5GRASP SCAN Operational Phase 1: Piloted SCAN service within Wexford South sector ONLY (circa 70k pop.) SCAN available: Mon – Fri to 20 GP Practices. Nurse 1.0. wte (Project & Clinical Nurse) _______________________________________________________________ Phase 2: SCAN: 2009 – 2010‘Reflective and ‘going forward’ phase’ Reflections: Steering Group reflect upon low referrals rate (39 ref in 8 months) vs high percentage uptake by GP’s (90% of GP’s utilised the service) + plus anecdotal positive feed back from GP’s/Service Users. SCAN Operational Phase 2: SCAN operational across ALL Wexford North & South Locales (circa 130k pop.) SCAN available: Mon- Fri to 38 GP Practices. Nurse resource 1.7. wte (Clinical Nurses).

10. SCAN Wexford- accomplishments:A Phased Action Research Project…from: Pilot Project to a Local Integrated Mental Health Service Phase 3: SCAN 2010-to- presently:‘Consolidation and evaluation phase’ SCAN Ongoing Operational Phase 3: ACTIONS: SCAN remains operational across BOTHWexford North & South (circa 145k pop.) Nurse resource 2.2. wte. (SCAN Nurses + Locum cover). ___________ In addition, SCAN Nurses further ‘integrated’ with the WGH Liaison Services enabling the provision of: • A clinically expanded (wider Liaison role) 7 day Wexford General LMHN service • A SCAN/Liaison inter service acute hospital liaison cover rota • Weekly case work/clinical supervision session with Consultant Psychiatrist/ADON. • SCAN integrated with Locality CMHT’s operations & practice.

11. SCAN was made available to over 100 GP practices across South County Dublin (population 180k) and County Wexford (population 126k). Over 90% GP’s used and re-used the SCAN service. Throughout the project period circa 660 people in self-harm / suicide distress were seen and assessed by the SCAN Nurse. All client referrals were responded to in a speedy/efficient manner and largely all clients were seen and assessed within the their own GP surgery, reducing stigma, increasing uptake (circa 3% failure to attend rate) and achieving a GP/SCAN ‘shared care’ approach. Identified client needs were met through diverse statutory and community care pathways of mental health services, local counselling services and locality social care networks. Psychiatric admission for those in suicide crisis was significantly reduced (admission rate to acute psychiatry in-patient services from a SCAN Nurse assessment of less than 5%) and just 40% of SCAN assessed clients were referred onto locality CMHT’s. The majority of ‘next care’ management plans of SCAN assessed clients involved the utilisation of alternate primary care supports, community counselling and voluntary community care services. SCAN Winner of the 2009 Aramark Healthcare Professional Innovation Award. SCAN pilot projects accomplishments 2007-2012:

12. SCAN pilot projects accomplishments 2007-2012: SCAN pilot project provider sites reflected that: • SCAN is an effective and efficient solution to a long-standing CMHT/Primary Care service gap. • SCAN was seen to provide appropriate speedy response to those in self-harm/suicide distress. • SCAN reduced clinical care inter-service acrimony and improved upon service user and GP care response satisfaction ratings*. • SCAN improved upon ‘needs led’ referrals to psychiatric services and other community care agencies.

13. Research Evaluation of the Suicide Crisis Assessment Nurse (SCAN) Service http://www.nosp.ie/scan-report-2012.pdf

14. SCAN EVALUATION Wexford & Cluain Mhuire: • Dr Stephen Bradley Lead Researcher School of Nursing and Midwifery, NUIG. • Dr Brendan Kennelly Health Economist, NUIG

15. Qualitative: Interview cohorts : former SCAN clients (face-to-face; n=12) current and former SCAN nurses (face-to-face; n=6), GPs with experience of utilising the SCAN service (telephone; n=14). Focus Groups cohorts: SCAN CMHTs (face-to-face; n=5 teams (Wexford/Cluain Mhuire). One non SCAN (TAU service) An additional x1 face-to-face focus group with a CMHT from an area with no experience of a SCAN service, so as to explore ‘usual care’; On-line Questionnaire – ‘Skip logic’ – 46 items Quantitative: SCAN GPs and Non-SCAN GPs of the 257 GPs invited, 127completed the questionnaire yielding a response rate of 49.4% Documentary Analysis of SCAN records Economic analysis utilising decision-tree modelling Evaluation Methods/ Respondents

16. SCAN Evaluation Outcomes The NUIG focused literature review concluded that: A service like SCAN provides a fast-track referral system to mental health services, supports the development of a therapeutic alliance between healthcare professionals and clients, represents a personalized approach to care, is based in the community and fosters a collaborative approach to care.

17. SCAN Evaluation Outcomes • Without SCAN, all professionals recognised that referral and/or admission to mental health services was often a ‘default’ position, with the de facto development of a possibly inappropriate psychiatric history: • Cluain Mhuire: 63% ‘social issues’ (n=159) • Wexford: 62% ‘social issues’ (n=503) “Before, I think we often as GPs felt we had very little resources other than using a sledgehammer to crack a nut which was basically admit patients’’ (DR06)

18. SCAN Evaluation Outcomes Clinicians were frustrated by the delays and uncertainty that regularly accompanied the process of referral/admission: “it would have involved a huge amount of telephoning and not being able to get hold of people… the service… really wasn’t very good for this sort of patient. It was very bad actually and trying to get urgent appointments was a complete disaster” (DR04)

19. SCAN Evaluation Outcomes • As well as a gateway role, SCAN was found to have a therapeutic value that was identified as pivotal by clients; apparently contributing to the perception that they were being ‘taken seriously’: “It was a very positive experience. It was emotional but she helped me a lot. She helped me to say things, made me feel comfortable enough to say things even though I'd never met her before that “(CL08) “I think it’s very therapeutic in itself… it’s not just the SCAN nurse kind of gleaning the bits of information from them and trying to assess their risk. I mean, it’s also quite therapeutic… free of charge which is important for people (DR01)”

20. ‘we always found it fantastic in that… we would just have numbers that we could phone directly…  if the nurse wasn’t available immediately they would always get back to us very quickly’ (GP) ‘I couldn’t believe how quick it all happened. I think the response time was brilliant … I think the response time is a major factor in it’ (Service User) SCAN was seen as accessible, efficient and prompt in responding to referrals and undertaking timely assessment of those patients in suicide crisis

21. SCAN Evaluation Outcomes • GPs interviewed described the support provided by SCAN, both overt in terms of assessment / intervention and ‘hidden’ in terms of informal advice, as ‘empowering’: “it empowered me to deal with suicide and intervention of suicide crisis… I can now feel as a GP I have resources to deal with crisis and suicide crisis or the expression of suicide ideation and it just has revolutionised my management… (DR06)

22. SCAN Evaluation Outcomes • Overall, GPs with access to SCAN services rated the service significantly higher on its impact on identified patient outcomes than those who had access to traditional mental health services. ‘the provision of [a SCAN] service to people who are acutely upset and who have declared that they might actually harm themselves, has made the management of that particular group of patients much easier and much more satisfactory’ (GP)

23. Outcomes GPs who had access to a SCAN service rated their overall satisfaction with the service as significantly higher than those GPs in the non-SCAN group:

24. Economic Analysis • The effectiveness of programmes such as SCAN is difficult to capture using traditional quantitative economics or health services research methods Under reasonable assumptions about the size of effect, the SCAN service resulted in a reduction of healthcare costs. SCAN service would pay for itself if it resulted in 23 fewer people being admitted for an average ‘in patient’ stay.

25. SCAN Evaluation Outcomes a final reflection SCAN FORMER CLIENT: ‘I know for me it [SCAN] has been wonderful and the help that I did get, it really brought me out. It carried me over that period. I needed the help. .. without that help, I don't know where I would be today. I mightn't be sitting here talking to you’

26. SCAN in Summary: SCAN: The aim: • SCAN pilot projects were established to explore a primary care/community mental health partnership response to adult primary care clients presenting to their GP with self harm / suicide distress. SCAN: The accomplishments (Subjective & Objective): • SCAN has demonstrated that a client centred, rapid primary care focussed response service to self-harm/suicide crisis clients is functional andbeneficial for those individuals in self-harm/suicide distress who present to their GP. Furthermore, outcomes indicate that similar SCAN services can be introduced across Irish primary care/mental health healthcare systems to the benefit of clients, GPs and psychiatric care providers.

27. SCAN – Post Pilot Projects & Research Evaluation What Next?= SCAN ‘Roll-Out’:- NOSP achieved 2013 funding to support the roll-out of a further circa 8 SCAN Services within new Mental Health Locales across Ireland.- In addition; Going forward, NOSP will seek future budgetary allocation to support the provision of SCAN a service within each Mental Health Locale across Ireland.

28. SCAN • QUESTIONS?