Tony woods and clare mahoney - Healthy Liverpool

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Better outcomes, better value: integrating physical and mental health into clinical practice and commissioning


Tuesday 24 June 2014: 15 Hatfields, Chadwick Court, London

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  • Stepped Care
    So in summary, stepped care is based on the twin principles of ‘least burden’ and ‘self correction’.
     
    Least burden means that the treatment should burden the service user and the health care system as little as possible.
     
    Self correction means that feedback mechanisms are in place so that service users are allocated to the appropriate level of care.
     
    For example, many patients with moderate/severe depression will benefit from brief psychological interventions and this may reduce the need for more intensive treatment.
     
    We therefore expect most people who need a clinical intervention to receive treatment at Step 2.
     
    In accordance with NICE guidance some patients (for example those with severe depression or anxiety disorders or PTSD) will be routed straight to high intensity (Step 3 interventions) rather than stepped first through low intensity interventions.

    Then there are some people who have received treatment at Step 2 but will need to be stepped up to Step 3.
     
    Step 3 care package
    Moving on to Step 3 therapy, this will include:
    Cognitive Behavioural Therapy (CBT)
    Interpersonal Psychotherapy (IPT)
    Brief Dynamic Interpersonal Therapy (DIT)
    Couple Therapy for Depression (CTfD)
    Counselling for Depression (CfD)
    Eye Movement Desensitisation and Reprocessing (EMDR)
     
    The service must also develop protocols for those who would benefit from a secondary care psychological therapy protocols to move from Step 3 to Step 4.
  • Tony woods and clare mahoney - Healthy Liverpool

    1. 1. Better outcomes, better value 24th June 2014 THE HEALTHY LIVERPOOL PROGRAMME – Joining Up Services NHS Liverpool Clinical Commissioning Group
    2. 2. Liverpool CCG 498,000 Patients 18 Neighbourhoods 94 Practices 3 localities 1 Organisation
    3. 3. CONTEXT • Poor health outcomes • Growing demand • Congested provider landscape • Estates changes and opportunities • Local authority cuts CONTEXT
    4. 4. Vision Provides a sustainability model of care Improves & maximises health outcomes Delivers first class quality care Outcomes Characteristics Programmes Settings Securing additional years of life Improving quality of life for people with LTCs Reducing Emergency Admissions Improve experience of hospital care Improve experience of outside hospital Fully engaged citizens Wider primary care at scale Modern model of integration High quality urgent and emergency care Highly productive elective care Concentration of specialist services in centres of excellence Prevention Neighbourhood Teams Specialist Community Services Hospital Services Mental Health Healthy Ageing Long Term Conditions Children Learning Disabilities Cancer
    5. 5. Outcome Ambitions Securing additional years of life for the people of England with treatable mental and physical health conditions Improving the health related quality of life of the 15 million+ people with one or more long- term conditions, including mental health conditions Reducing the amount of time people spend avoidably in hospital through better and more integrated care in the community, outside of hospital Increasing the proportion of older people living independently at home following discharge from hospital Increasing the number of people having a positive experience of hospital care Increasing the number of people with mental and physical health conditions having a positive experience of care outside hospital, in general practice and the community Making significant progress towards eliminating avoidable deaths in our hospitals caused by problems in care Outcome Ambitions
    6. 6. Strategic Outcome Ambitions by 2018/19 Reduce life years lost by 24.2% Improve quality of life for people with long term conditions from the second worst in the country at 65.3% to 71% Reduce avoidable emergency admissions by 15.3% To improve hospital patient experience to average of top 10 CCGs To improve out of hospital patient experience to average top 5 CCGs
    7. 7. Why Mental Health • Premature Mortality – excess mortality for SMI SMR 425.8 • High prevalence of common mental health problems in LTC • Prevalence three times higher for SMI for Diabetes and BMI 40+, twice as high for other LTC • Lower proportions under control or on treatments e.g., anticoags • 1 in 3 GP presentations for mental health issues • Significant pressures on secondary care • Integration of physical and mental health and focus on causes
    8. 8. New model for mental health 4.Hospital Based 3.Community based specialist service 2.GP & Neighbourhood 1. Prevention & Self Care Skilledandconfidentworkforce StrongcommissioningpartnershipwithLCC Cultureofcollaboration Shorter lengths of stay New assessment and care service Integrated care model that focuses on recovery, personalised care and independence. Delivered from x4 new community recovery and wellbeing centres*** Primary care team extended to include mental health practitioners, psychological therapists, benefits advice workers Community development initiatives include advocacy, peer support, counselling, bridgebuilding, timebanking, community learning, all accessible through a new directory for mental health and well-being. Assisted signposting for people who don’t have access to the internet Access to Recovery Campus and similar One gateway into both psychological therapies and wellness & preventative services= no ‘wrong door’ for referrersPeople with long term conditions and other risk factors have access to a range of psychological treatments Clinical liaison and collaborative working across all steps and all providers One point of access to all local mental health services 24/7 Street triage & reduction in inappropriate presentations & use of section 136 Fast response for urgent needs 1 – 3 week response for routine needs Modern accommodation with single en-suite rooms Centre of excellence for acute mental health care PICU and Section 136 suite at Clock View Fewer people treated out of area Fewer admissions Strongserviceuserandcareparticipation Shiftfrompaternalismtoco-production Sustainablethirdsectorcontribution Improved access to psychological therapies for people with SMI 15% of people with anxiety & depression have access to psychological therapies & 50% recovery
    9. 9. Working with complexity Low income, debt, isolation Ill health Mental distress
    10. 10. Liverpool primary mental health care strategy for adults • Psychological: all services will operate as a single system across steps and providers • Practical: advice on prescription • Social: peer support, education & employment support+++ • Physical: integration of mental and physical health care
    11. 11. Collaborative working CQUIN – secondary mental health care • Liverpool-wide system of liaison and collaborative working between primary and secondary mental health care • 5 CMHTs, 5 named liaison workers • Linking systematically to practices & neighbourhoods • Identification and treatment of the physical health care needs of people with SMI and LD • Shared learning & capacity building • Supported by a community of practice • Y2 includes improvements to discharge planning & LD liaison, reduction in MH presentations at A & E
    12. 12. Collaborative working CQUIN - psychological therapies • System of liaison and relationship development with primary care and secondary care • Identification of people with LTCs who have co-morbid common mental health problems. • Increased access to psychological therapies by people with LTCs • Focus on diabetes year 1 • Test out collaborative care approaches to joint assessment and joint working eg COINCIDE model • Primary care should feel that there is only one system of liaison
    13. 13. The pyramid of psychological need accompanying long term conditions LEVEL 1 General difficulties coping with illness and the perceived consequences of this for the person’s lifestyle, relationships etc. Problems at a level common to many or most people receiving the diagnosis LEVEL 3 Psychological problems which are diagnosable / classifiable, but can be treated solely through psychological interventions, eg mild and some moderate cases of depression, anxiety states, obsessive compulsive disorders. LEVEL 2 More severe difficulties with coping, causing significant anxiety or lowered Mood, with impaired ability to care for self as a result LEVEL 4 More severe psychological problems that are diagnosable and require biological treatments, medication, and specialist psychological interventions LEVEL 5 Severe & complex mental illness/ disorder requiring specialist mental health intervention(s)
    14. 14. Stepped model of care for psychological therapies STEP 1 GP: ACTIVE MONITORING DIRECTORY OF MENTAL HEALTH & WELLBEING SERVICES HEALTH TRAINERS ASSERTIVE IDENTIFICATION OF PEOPLE WITH MULTIPLE RISK FACTORS: SMI, LTCs, BME, ADVICE ON PRESCRIPTION MENTAL HEALTH & PSYCHOLOGICAL LIAISON STEP 2 INTEGRATED GATEWAY PWP (PSYCHOLOGICAL WELLBEING PRACTITIONERS) ACTIVE LISTENING, ASSISTED SIGNPOSTING & DIRECT ACCESS TO ADDITIONAL (non-clinical) SUPPORT CLINICAL ASSESSMENT & LIAISION TREATMENT: GUIDED SELF HELP; BRIEF INTERVENTIONS; CARE PLANNING COLLABORATIVE CARE STEP 3 HIT (HIGH INTENSITY THERAPIST) TREATMENT AT STEP 3 CBT, IPT, DIT, CCfD, CfC, EMDR etc. STEP 4 SPECIALIST THERAPISTS TREATMENT AT STEP FOUR ADDITIONAL SUPPORT CLINICALLIAISON ACROSSSTEPS
    15. 15. Next Steps to a Better Model for Mental Health in Liverpool Mental Health Transformation Board Inter Agency Working Better Use of Intelligence Innovation Commissioning for Outcomes

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