PsychologyInterventionsandCommunityNursing(PINC)Project:Accessingthehardtoreach

BerkshireEastIAPT-LTC

cCBT OnlineLTCDirect access

(wave1early implementer pilotsite)

IAPT-LTC• TalkingHealth– 1:1GSHtakingLTCintoaccount,F2F,telephoneoronlinesupport• HealthMakers – LTCSelf-managementcourses• HealthCoaches– CBTandGSHintegratedinlocalGPsurgeriesaspartoftheprimarycareteam• PINC – supportforhouseboundclients• OnlinecCBT LTCDirectaccess– OnlineCCBT• RehabClinics– Educationalsessionsandsupport• Step31:1CBT– CBTtakingLTCintoaccount,F2F,telephoneoronlinesupport

Initial Pilot WAM 2015/6 Ajointprojectbetweenpsychologyandcommunity/districtnursestargettingthosewithlongtermconditionswhoarehousebound,havehighusageofhealthservices,psychologicalproblemsandnotaccessingIAPTorCMHT.

TheKingsFundhavehighlighted theoverlapbetweenmentalhealthandwell-being, andlongtermconditions. Theyestimatecostsofmanagingpeoplewithlongtermconditionsandunderlying co-morbidmentalhealthconditionsasbetween£8bnand£13bninEnglandeachyear.

Nayloretal(KingFund,2012)

NICECG91GuidanceSTEP3:Persistentsubthresholddepressivesymptomsormildtomoderatedepressionwithinadequateresponsetoinitialinterventions;moderateandseveredepression

Medication,high-intensitypsychologicalinterventions,combinedtreatments,collaborativecareandreferralforfurtherassessmentandinterventions

STEP2: Persistentsubthresholddepressivesymptoms;mildtomoderatedepression

Low-intensitypsychosocialinterventions,psychologicalinterventions,medicationandreferralforfurtherassessmentandinterventions

ThisKingsFundpapersuggeststhatbyworkinginamorecollaborativeway,primarycareprofessionalscanbesupportedbyspecialistmentalhealthworkerstosupportpeoplewithLTconditionsinamoreholisticandcosteffectiveway.

•Nayloretal(KingFund,2012)

•

ProjectPlanAnumberofreportshaveemphasisedtheimportanceoflinkingphysicalandmentalhealthcarewithsuggestionsthatbenefitswouldbeimprovedrecovery/rehabilitation,andreducedre-admissionsanduseofhealthcare.Thisshortpilotprojectwouldaimtodothisby:

1.Usehighintensitytherapist/psychologyassistanttoreviewandusepsychologicalapproacheswith4-6patientseachplacingahighdemandforinputoncommunity/districtservices.

2.Provideanxiety/depressionmanagementworkshopforcommunity/districtstaff,and3monthlyreflectivepracticeconsultationsconcerningworkwithpatients.

3.Developaclearpathwaybetweencommunity/districtservices,IAPT,andpsychologyservicesintheCMHTe

ClinicaloutcomemeasuresAnxiety– GAD7Depression– PHQ9GeneralHealth– GHQandCORESelfEfficacy– GSECost/BenefitAnalysis– GPcontact/CommunityNursecontact/Hospitaladmission

SaraFantham– HeadofCommunityNursingEastBerkshire

“PINCishelpingprovidemoreholisticcareforpatients“

Small investment , great savingsMary’s story

• Multiple falls & fractures

• Osteoporosis• Housebound for 3 years

https://vimeo.com/166348519/615e3dd8b6

ClinicalOutcomes:SignificantreductionsinDepression&Anxiety.

The big impact of small interventions

• Suffered with constipation since child hood

• Long history of nausea, vomiting & vertigo• Surgery considered

• Dorothy's story: https://vimeo.com/166349431/f47882b69d

Small idea, big £££ savings

Identifier

Health Economy SavingsPreGPemerg.contact(no)

PostGPemerg.contact(no)

PreCMcontact(min)

PostCMcontact(min)

Unschhosp

admpre(no)

Unschhospadmpost(no)

Costsavings

approx(£)

Patient1 190 170 5 0 11,286Patient2 15 8 125 35 1 0 3,447.50Patient3 11 2 135 205 0 0 490Patient4 2 2 200 5 0 0 323.25Patient5 1 7 65 160 3 2 161Patient6 3 1 155 15 1 0 2,641Patient7 13 0 600 150 3 0 6,045Patient8 NK NK 65 35 0 1 -300Patient9 5 2 65 65 1 0 1,632Patient10 5 2 75 120 0 0 105Patient11 3 3 180 400 3 0 1,124Patient12 0 0 65 35 0 0 40.25

£8K Project costs = £27K savings

EastBerkshireProject2017

• ExtendedfromWAMtothewholeofEastBerkshirealongsideIAPT(ImprovedaccesstoPsychologicalTherapies)toofferahomevisitbasedserviceforpatientswithlongtermhealthconditionstocomplementtheiroffice,telephonebasedserviceandplannedGPSurgerybasedservices.PINCwillgiveaccessoverthenextyearto120patientswhocannotaccessIAPTduetobeinghousebound,havingmultiplehealthconditions,orhavingmobilityorcommunicationdifficulties.Thispatientinitiativewillgiveaccesstoaserviceforthosemostinneedwhocurrentlyusecommunityandphysicalhealthservicesandwhootherwisewouldnothaveaccesstosuchjoinedupcare.Staffareembeddedinthecommunityteams,useIAPToutcomemeasures,andliaisecloselywithcommunity.mental healthandIAPTservices.StaffarereceivingtrainingasoneoftheUKsearlyimplementersitesalongsideIAPTstaff.

February-AugustReferrals

• Atotalof101referrals.Theaverageageofpatientsreferredis76(range21-97),with 38malesand 63females.

Referralsandassessments.WAM&Bracknell Slough TOTAL

No.ofreferrals 65 36 101No.ofPatientsAssessed 35 29 64No.ofPatientsnotassessed&discharged 16 3 19

No.ofpatientsdeclinedassessment 7 0 7No.ofpatientsdiedbeforeassessment 3 1 4No.ofpatientsnotappropriateforPINC 6 2 8

No.ofpatientsassessedbuthadnotreatment 13 10 23No.ofpatientsdeclinedtreatmentafterassessment 9 8 17No.ofpatientssignpostedelsewhere 0 1 1No.ofpatientssteppeduptoCMHT 2 0 2No.ofpatientsdiedafterassessment 1 0 1No.ofpatientsassessedandreferredbacktoreferrer 1 1 2

No.ofpatientsenteredtreatmentbutdroppedout/didnotengage 6 1 7Noofpatientscompletedtreatment&discharged 7 6 13No.ofpatientsoncaseload 9 12 21No.ofpatientsonwaitinglistawaitingassessment&treatment 14 4 18

Reliableimprovementandrecoveryrates.

DepressionPHQ9WAM/Bracknell22%Slough60%ImprovementWAM/Bracknell11%Slough20%Recovery

AnxietyGAD7WAM/Bracknell33%Slough60%Improvement/recovery

Forthosewhocompleteinterventionsbiggestimpactisonanxietylevels

Videoexample

CaseExample

• Individualexample,maleaged45 referredwithdiabetescausingblindness,depression,suicidalthoughts,isolationandalcoholmisuse.• InitialscoresonIAPTmeasuresPHQ9of19indicatingdepressionofmoderateseverityGAD7of15indicatingsevereanxiety,andWSASof18indicatingsignificantfunctionalimpairment.• Endoftreatmentscores:- PHQ9scoreof6indicatingminimaldepressivesymptoms,GAD7scoreof0indicatingnoanxietyandWSASscoreof10whichisontheborderlineofthenormalpopulationscore.• Thescoreswouldfitinwiththepatient’saccountoflessfearofleavinghishome,andconsequentlyincreasedtripsoutwithfamilyandfriends,moreinterests,andlessdrinking.Thispatienthasdevelopedaparticularinterestinmindfulness.

PINCsofar….

• Ifthecorrectpatientsareidentifiedeg thosewithlongtermconditionsandco-morbidanxietyanddepressionwhorequireahomevisitbasedservicePINCcanmakearealdifferencetothesepatientslivesandfunctioning, significantlyreducedepressionandanxietyandreducetheneedforuseofservices.• Engagementcanbeaproblemwithsomepatients,seeingthemathomeandifnecessarybeingintroducedbyanursecanhelpwiththis,evenwiththisforsomepatientsitremainsaproblem.• SomereferralsareunsuitableforPINCeitherneedingtobesteppeddown(becausetheydon’thaveanysymptoms)toactivity/clubsavailableinthecommunityoruptoCMHTastheyhavecomplexmentalhealthproblemsbeyondtheremitofPINC(eg PTSD).AleafletisbeingproducedtooutlinetoreferrersandpatientsPINCsremit.• SustainabilityofimprovementmaybeanissueforsomepatientswhomayneedfurtherinputfromIAPTorHealthmakers postPINC.

PINCsofar…

• CommunityNursesreferrals,don’tlikefillinginforms,taskorientateddon’talwaysconsiderpsychologicalcomponent,talktomatron.• Highcancellationrateduetoillhealth• SessionalIAPTUSmeasuresoffputtingesp ifhavecommunicationissues.• PINCcanbepartofacomplexsystemofcare.• IfyouwouldliketoknowmoreaboutPINCcontact:-chris.allen@berkshire.nhs.uk