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Health and Care Innovation Expo 2014, Pop-up University, Day 2. Long Term Conditions in a IAPT/Primary Care Psychology Service Dr Jon Freeman (Clinical Psychologist – Lead for LTCs)
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Long Term Conditionsin an
IAPT / Primary Care Psychology Service
Dr Jon Freeman (Clinical Psychologist – Lead for LTCs)
Facts and Figures
15m in England (>30%)
condition that cannot be cured but can be managed
through medication and/or therapy
chronic pain – 20%arthritis – 14%asthma – 5% obesity – 30% diabetes – 4%IBS – 10%CFS – 3%COPD – 2%
1/3 significant levels of distress chronic pain (50% dep 30% anx) diabetes (40% dep 40% anx)
impacts on self-care and physical health
nearly doubles cost70% of H&S care spend 15-20% of the pop. who have 3+ LTCs
Where does Psychology fit?
Aim:
improve health, reduce distress (and cost!)
How?
Cognitive Behaviour Therapy (CBT)
good, developing evidence base
Feelings
LTC Thoughts
Behaviours
Common Traps
hopeless & scared
diabetes “What’s the point?!” “It’s going to get me in the
end”
make no lifestyle changes pretend it’s not really
happening
anxious & frustrated
pain “Pain means damage” “I will press on on a good
day”
do less & less over time boom & bust
low & guilty
“I’ve let my family down” stroke “I’m not the person I used to be” “I’ll never do XYZ again”
withdraw from others, ruminate
not engage in rehab
• psycho-education (e.g. monitoring symptoms, identifying patterns, understanding condition & mind/body link, stress)
• behavioural change (e.g. goal setting, pacing, communication, sleep hygiene, relaxation, stress management)
• cognitive change(e.g. modifying and/or relating to unhelpful cognitions mindfully)
ALWAYS WITH A ‘MOTIVATIONAL INTERVIEWING’ HAT ON
COPD (Howard et al., 2010)↑mood, ↓A&E attendance, ↓bed days, ↓meds Every £1 Ψ input, saved £3 in admissions
Refractory Angina (Moore et al., 2007)↑mood, ↓emergency admissions (33%, saving £1337/pt/yr), ↑health
Cancer (Simpson et al., 2001) ↑mood, ↓expenditure by 23% - 2yrs post-Ψ
Diabetes, hypertension, asthma (Spurgeon et al., 2005) ↑mood, ↓admissions, secondary care referrals
Arthritis, stroke, lung disease, heart disease (Lorig et al., 1999)↑mood, ↓admissions, ↓bed days
Rheumatoid arthritis (Sharpe et al., 2001)↓admissions, ↓injections, ↓physio referrals
Low back pain (Lamb et al., 2010)↓resources, costs less than half of other interventions (e.g. physiotherapy)
What does the legislation say?
Joined-up, holistic workingProvide earlier helpSelf-management approach (CBT based)EmpoweringIAPT
Healthy Lives, Healthy PeopleNo Health Without Mental Health
Talking Therapies: a 4-year plan of action NICE
LIFT Psychology Service
developed 1993
opt-in service
community based
stepped-care
1st wave IAPT site
dh pathfinder site
The past 4 years…
- 0.4wte clinical health psychologist- small ‘core team’ built up over time - developing self-management courses- training and supervision to all LIFT staff (MI & CBT skills for physical health – individual and group-based interventions)- building bridges with physical health services- promotion & education to all, including GPs,
nurses, hospital staff, etc
Our self-management courses
2 hours, 1 day/week, 5 weeks, in community venues, opt-in
2 staff (usually assts, b4 or b5) facilitating group discussion
CBT-based techniques: - rationale for CBT - common traps - stress and relaxation - mindfulness - goal setting - activity management (prioritising, planning, pacing) - thoughts - communication - setbacks
chronic painchronic fatiguefibromyalgiairritable bowel syndrometype 2 diabetestype 1 diabetes strokemultiple sclerosis cardiac stressobesity non-epileptic attacks
plus, input on rehab programmes for acute back pain and pulmonary disease
This is about improving and complimenting existing service provision
and
improving accessibility
2% of people with chronic pain actually get to a specialist pain service……
Outcomes
- Minimum Data Set Questionnaires (mood, anxiety, work and social adjustment)
- Additional Questionnaires (specific LTC, QoL, service-use, subjective outcome)
- Qualitative Feedback Questionnaires
Stroke course n=31
Caseness -15
Post data 7/12 made CS changes for phq & gad
68% engaged
Positive shift on SSQOL & EQ-5D
CGIS: Much better (42.9%), Little better (42.9%),
No change (14.2%)
Cardiac course n=22
Completers – 19
Caseness – 9
Of which, 6 made CS changes
17 positive changes on the CAQ, most of which
huge shift
- “It has really helped me be more aware of my thoughts and actions and their implications and
given me the tools to try to change and see there is a way forward little by little” (pain)
- “Until this course started I had never spoken to another stroke patient. It helped tremendously with thoughts and how to mange / defuse them and how
to recognise and use the 3 P’s” (stroke)
- “I have found it to be very helpful. The sessions were well run, the leaders certainly "knew their
subject" and ran the course extremely well. They hardly used any notes which was really refreshing -
they were really pleasant and friendly and made everyone feel at home” (fatigue)
Cardiac course attendee
phq – pre 4 post 3
gad – pre 3 post 4
wasa – pre 32 post 10
caq – pre 29 post 16
Lots of avoidance and seeking reassurance
By the end of the course, theatre, driving
independently, and joined local walking group
Step 3 Individual Work – diabetes
Pre (phq 16, gad 20, wasa 21, PAIDS 29)
Not going out by self, not driving, sick leave,
monitoring sugar levels++,
9 appts
Post (phq 2, gad 5, wasa 10, PAIDS 2)
Back at work full-time, driving, walking, monitoring s
sugar levels more helpful frequency)
The importance of wide engagement…
- talk to our wider colleagues and services- get ‘buy-in’ - need for clear understanding (see the benefit & signpost patients appropriately)- self-management, non-stigmatising focus- understood within the wider context (e.g. specialist teams, support groups) - create / capitalise on opportunities for joint working - get it in local care pathways
Challenges along the way…
Capturing meaningful data, in an appropriate way
Access for some courses / areas
Understanding it and keeping it in the awareness of wider colleagues (so they can signpost appropriately)
The old chestnut of stigma
Sense of threat from other services
Thank you for listening