Mental Health Care Pathways Local Examples of Pathway Development, Joint Working & Adherence

1. Mental Health Care Pathways Local Examples of Pathway Development, Joint Working & Adherence East Midlands Mental Health Commissioning Network Amanda Kemp (Deputy Director NHT) Claire Holmes (Interim Lead PbR & Pathways) 9th October 2013

2. Care Pathway Development

3. Care Pathway Development The good…… • Service user & carer involvement • Clinical engagement • Commissioner support • Other trust’s sharing experiences • The pace! The bad….. • Clinical disagreement re process • Lack of engagement from some • Timescales

8. Care Pathway Development in NHT 2013

9. The Journey….

10. Mental Health Care Clusters Non Psychosis 1-4 mild/moderate/severe 5-8 very severe & complex Psychosis 10 First Episode 11-13 Ongoing or recurrent 14-15 Psychotic crisis 16-17 Very severe engagement Cognitive Impairment 18-21

11. Super Clusters Level of Need Cluster pathways

13. Care Pathway Example Case Vignette Cluster 5 Ms X, 47 years old Ms X has been referred to the Crisis team following an assessment on a medical ward after she took an overdose of her insulin. She has a 4 week history of increased suicidal thoughts which came to a head yesterday when she took an overdose of her insulin. Luckily, her daughter came round to her house and found her and called an ambulance. Ms X reports significant low mood, poor sleep, increased anxiety, increased alcohol intake, can’t identify any protective factors and showing evidence of self-neglect.

14. Care Pathway Example cont…Cluster 5 Two recent major life events, grandchild was stillborn and last week had the funeral. Also sister who she was close too had a recent stroke and is not expected to leave hospital. Also 2 years ago her husband of 18 years left her and still feels a lot of anger around this. Now lives alone. Ms X had also had a recent medical admission following poor diet intake and admitted she hadn’t taken diabetic medication properly for 4 days prior to that admission. Over the last 4 weeks she has been having increased thoughts of self-harm including walking into traffic, taking an overdose and has easy access to means via her insulin medication. Since the two major life events Ms X admits she struggles to see any hope for the future or mood getting better and not sure how much longer she will be able to cope if things don’t get better.

15. Care Pathway Examples Cluster 11: Ongoing or recurrent psychosis (low need) Key features: • History of psychotic symptoms that are controlled with minor if any problems. • Period of recovery with full or near full functioning • Possible self-esteem issues, social isolation, vulnerable. • Low level of need & risk. • Will be looked after in a community setting. • Could be managed in primary care after a period of stability. • If enduring mental health issues may have physical health problems. • Social care support may be required.

16. Care Pathways: AdherenceCQUIN 2013/14 2.1 Pathways & Outcomes • Pathway development: The trust will define a package of care for each individual care cluster. The packages of care should specify the range of core interventions as well as setting out a menu of options that will meet the needs of the individual service user. The packages of care should include social care and should define voluntary sector and social care services. First draft of Pathways by Oct 2013 • To improve the number of people who are 1.     Cluster caseloads (% Clustered) 2.     Adherence to cluster review periods • To monitor the following 1.     Cluster Caseloads (client numbers) 2.     Adherence to Care Transition Protocols 2.2 Step-down • The Trust will undertake analysis and review all patients in clusters 1-3 and 6-7 to determine their care pathway and package of care and ensure timely transitions between Primary and Secondary care Adult Mental Health Services.

17. Care Pathways: Adherence • CQUIN target met for Q1 and likely to be met for Q2 • Challenge around ability to cluster people within the required 2 appointments which may lead to loss of income under new payment system. • Performance monitoring arrangements and overall governance for PbR & pathway development has improved through strengthening internal accountability arrangements including production of new performance reports. • Also monitored monthly through joint meetings with Commissioners. • Clustering accuracy continues to be an issue. To improve compliance a full time clinical trainer has been recruited. • New staff training programme started, places also available for CCG staff • Trainer is deployed internally to work with teams where there are concerns around practice and clustering.

18. Care Pathways: Joint workingOpportunities: • Whole systems approach to mental health care • This is an opportunity to do things differently • It has made the Trust think critically about the way services are delivered • Working in partnership with service users & carers/ families • Working with Commissioners to deliver change; funding of joint PbR/ pathway role. • Ease of access into secondary care services and discharge when appropriate is critical; expansion of CRHT as a key interface service • Recruitment of Peer Support Workers to facilitate the implementation of care pathways • NHT is testing out care pathway implementation now with a view to full roll out by April 2014.

19. Care Pathways: Joint Working Challenges: • Primary care/ secondary care interface critical • Discharge from secondary care and prompt access into services is not without its challenges • Physical healthcare support is required as part of holistic care; how far is this provided within secondary mental health care? • Social care support when needed with increasing thresholds and tighter budgets • Role of the third sector- both an opportunity and a challenge in providing mental health care.

20. Thank you for listening Any questions?