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Better outcomes, better value: integrating physical and mental health into clinical practice and commissioning Tuesday 24 June 2014: 15Hatfields, Chadwick Court, London
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Are our models of care truly integrated? - psychological, social and
diabetes care
www.kcl.ac.uk 1
Dr Carol GayleDr Anne Doherty
BMJ Awards3DFD: Diabetes Team of the Year 2014
3DFD
Translation of research
Cross sector
integration
Health inequalities
Cost effective
Dissemination Parsonage M, Fossey M, Tutty C. Liaison Psychiatry in the Modern NHS. Centre for mental Health, London. 2012, p35.
Depression is common in diabetes and associated with worse health outcomes
.65
.7.7
5.8
.85
.9.9
51
3 6 9 12 15 18
Observation time (months)
Major depressive disorder
Minor depressive disorder
No/minimal depression
A cohort study of people with diabetes and their first foot ulcer: the role of depression on mortality. Ismail et al Diabetes Care 2007
Adjusted hazard ratio 3.23 (1.39 to 7.5)
Adjusted hazard ratio 2.73 (1.38 to 5.40)
Cum
ulat
ive
surv
ival
4
0
Social problems are common in diabetes
poor housingdebt
social isolation
inequities in access to
healthcare
ethnicityfamily roles & responsibilities
employment
Psychological care
Diabetes care
Social care
Parallel versus integrated services
Diabetes care
Psychological care
Social care
Necessary ingredients
Mental Health
Diabetes & physical health
Social interventionsPatient
Diabetes care only
PsychiatryDiabetes &
physical health
Social interventionsPatient
Pros:• nil
Cons:• No integration• Poorer outcomes – glycaemic
control, morbidity, mortality
IAPT
Mental Health Diabetes & physical health
Social interventionsPatient
Pros:• Psychological input
Cons:• Not integrated• No social component• No evidence of improved
biological outcomes• Uni-dimensional – cannot
accommodate complex patients with comorbidities, requiring medications, risk issues
CMHT
Mental Health Diabetes & physical health
Social interventions
Pros:• Full mental health input –
psychiatry & MDT
Cons:• Not integrated• No evidence of improved
biological outcomes• High threshold for service
Liaison psychiatry model
Mental Health Diabetes & physical health
Social interventionsPatient
Pros:• Full integrated mental health
input – psychiatry & MDT• Integration to varying degrees
with teams in secondary care
Cons:• Secondary care only• Limited social component –
usually only psychiatry/ psychology for outpatients
• General, not disease specific
Active ingredients of 3DFD• diagnostic assessment• risk management• psychotropics • brief psychological
treatments• family work
• medication support• biomedical monitoring• diabetes education• technology• complications
• debt management• housing support• occupational rehab• literacy• Advocacy
• patient-led MDT meeting
• increase self efficacy for diabetes
• HbA1c
Mental Health Diabetes & physical health
Social interventionsPatient
Integrated across the sectors
Diabetes care
Psychological care
Social care
secondary
community
primary
Characteristic Mean (SD)/Proportion (%)
Age (years) 47.4 (14.7)
Gender male 129 (39.7)
female 196 (60.3)
Ethnic group white 121 (39.4)
African/Caribbean 127 (41.4)
Asian 59 (19.2)
Postcode deprivation 35.2 (9.9)
Type of DM type 1 102 (31.4)
type 2 223 (66.8)
HbA1c (mmol/mol) 95 (21)
Characteristics of 3DFD referrals, n=325 (Oct 2012- Dec 2013)
12940%196
60%
Gender
Male Female
10231%
22369%
Type of Diabetes
Type 1 Type 2
12139%
12741%
5919%
Ethnicity
Caucasian African/Caribbean Asian/Other
Social Needs
05
10152025
Social support needs
Support worker assisting patient with type 2 diabetes with her housing situation
Psychiatric morbidity
Nil Known diagnosis New diagnosis New relapse0
20
40
60
80
100
120
Psychiatric diagnosis: new, known or relapse
Psychiatric Diagnosis
N
Main 3DFD outcomesPre 3DFD Post 3DFD Change score p-value
Mean (SD) IFCC HbA1c mmol/mol (n=185) 100 (23) 83 (22) 17 (17) <0.001
Mean (SD) Diabetes Distress Scale (n=54) 48.9 (16.2) 39.5 (19.9) -9.4 (19.3) <0.001
Mean (SD) anxiety score on GAD-7 (n=54) 9.1 (5.1) 5.8 (5.9) -3.3 (3.2) <0.001
Mean (SD) Outcomes Star score (n=54) 53.4 (11.5) 59.0 (15.9) +5.6 (9.4) <0.001
No of admissions to A&E/previous year (n=119) 141 77 -64 <0.001
No of bed days/previous year (n=119) 381 300 -81 0.08
No of recurrent admissions (days)/previous year (n=119) 10 (73) 4 (14) -6 (-59) 0.012
Improvements maintained at 2y
Comparisons
Glicazide Gliptin Dapagliflozin Lamb/Swk DICT (n=472) 3DFD (n=185)0
2
4
6
8
10
12
14
16
18
Improvement in Hba1c, mmol/mol
Agents producing improved glycaemic control
Impr
ovem
ent i
n H
bA1c
, mm
ol/m
ol
Cost benefit analysisCosts £94k/borough/year• 0.5
WTE Consultant liaison psychiatrist
• Community outreach worker
• Admin support and infrastructure
Savings £127k/borough/year (-on-year)• Short term:
reduction in unscheduled care
• Long term: reduction in developing diabetes complications
3DFD net saving £33K/borough/year
Patient testimonials
My name is Rochelle, I am a single parent with two children. I had difficulties controlling my diabetes. I became very depressed. 3DFD has managed to help me to overcome my fears of dealing with diabetes. I now use my insulins better.....Rochelle:(T1DM) HbA1c 15.2 to 8.7%
Conclusions
Psychiatric morbidity is a poor prognostic factor for diabetes outcomes (and other long term conditions)
Patients do not prioritise their diabetes care if they have social, psychological or psychiatric problems
Integrating mental health and social welfare directly into the diabetes team is a simple solution that integrates everything from the patient’s perspective
3DFD
Translation of research
Cross sector integration
Health inequalities
Cost effective
Dissemination
3DFD
Contact us
– kch-tr.3DFD@nhs.net – 0203 299 1350
– annedoherty1@nhs.net– carol.gayle@nhs.net
Mental Health Diabetes
Social interventio
nsPatient
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