York integration seminar [5.4.12] (c brand et al)

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Christian Brand et al

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York integration seminar [5.4.12] (c brand et al)

  1. 1. Community mental health teams for olderpeople: the outcomes and costs of differentways of workingChristian Brand, Michele Abendstern, SueTucker, Mark Wilberforce, Rowan Jasper, DavidChallis PSSRU Personal Social Services Research Unit at the University of Manchester
  2. 2. Disclaimer: This presentation presents independentresearch funded by the National Institute for HealthResearch (NIHR) under its Programme Grants forApplied Research Programme (Grant ReferenceNumber RP-PG-0606-1109). The views expressed arethose of the author(s) and not necessarily those of theNHS, the NIHR or the Department of Health. PSSRU Personal Social Services Research Unit at the University of Manchester
  3. 3. Background and aims• Part of a larger study: ‘National trends and local delivery in old age mental health services: towards an evidence base’• 3 strands (I. „balance of care‟, II. community mental health teams for older people, III. care home liaison)• Focus on CMHT strand today: Integration and its effectiveness PSSRU Personal Social Services Research Unit at the University of Manchester
  4. 4. Mixed methods approachFrom a national survey of all CMHTsOP in Englandwe selected 4 „high‟ integration teams and 5 „low‟integration teams We interviewed 42 staff members on their views on integration (covering all staff groups, approx. 60 minutes per interview) From the teams‟ caseloads, we collected data on socio-demographic and clinical profiles as well as service receipt details for 948 CMHT clients (193 clients were also interviewed in person) We conducted a work satisfaction survey of all CMHTOP staff in the chosen NHS trust areas (295 participants in 38 teams) PSSRU Personal Social Services Research Unit at the University of Manchester
  5. 5. Definition of integrationIntegrated team = A multidisciplinary team which• Had at least one social workerPlus at least 6 of the following features:• A single manager between health and social care• Accepted referrals directly from non-medical sources;• A single point of access;• Used the same or at least shared assessment document• A single client database or two that were accessible to all staff• Allocated a single care coordinator across health and social care• Used a single care plan which included both health and social care information• Could access both health and social care resources. PSSRU Personal Social Services Research Unit at the University of Manchester
  6. 6. Initial concept: high vs. low integrationTeams Team Team characteristics type5 examples* Low- Co-located multidisciplinary health team integration with single manager located within the team4 examples* High Co-located health and social care integration team with single manager located within the team* Teams were purposefully chosen as typical examples of „different ways of working‟ as identified in our national survey (n=376) PSSRU Personal Social Services Research Unit at the University of Manchester
  7. 7. Revised concept: high vs. low integration vs. ‘network team’ or ‘nominally’ integrated teamTeams Team Team characteristics type1 example Network Like low integration, but with separate Degree of Integration managers for individual disciplines4 examples Low- Co-located multidisciplinary health team integration with single manager located within the team1 example Nominal Like high integration, but with separate integration health and social care managers3 examples High Co-located health and social care team integration with single manager located within the team PSSRU Personal Social Services Research Unit at the University of Manchester
  8. 8. Findings I: the voice of practitionersHow does the nature and extent ofintegration within the team help or hinder your ability to provide an effective service? PSSRU Personal Social Services Research Unit at the University of Manchester
  9. 9. Findings I: overview1. Features of working in integrated teams found to be beneficial to practice by staff (emphasis on social work membership)2. Features of working in non-integrated teams found to impede practice by staff (emphasis on social work membership)3. Complexities of working in an integrated team4. Summary findings PSSRU Personal Social Services Research Unit at the University of Manchester
  10. 10. Benefits of a multidisciplinary team• A wide range of easily accessible skills and expertise to support service users It widens your knowledge and• The potential to enhance the skills of we’re not there all individual members by the informal for anybody else learning between colleagues that this other than the fostered Client, so it is beneficial Team manager PSSRU Personal Social Services Research Unit at the University of Manchester
  11. 11. Benefits of an integrated team: social work membership It is a huge• Specific mental health expertise benefit…They are …very skilled and they• Knowledge of social services have a good knowledge procedures and funding of the Mental Health• The ability to access social care Act and they have good resources directly knowledge of• Direct access to social care safeguarding … they information just bring a different• Wider perspective dimension really Consultant, integrated team PSSRU Personal Social Services Research Unit at the University of Manchester
  12. 12. Benefits of an integrated team: social work membership• Shared case ownership I can dip into my colleagues case load where there’s a• Shared goals social care need identified• Informal Social worker, without them having to … go integrated team through the process of joint working referring to …[social services]• Intra-referring you are sitting alongside them, you can have a chat and discussion about the patients beforehand…So you are Team manager, not referring them blind … you are nominally referring to a colleague, which is a lot integrated team quicker because you are not sending it out of the office, onto a waiting list PSSRU Personal Social Services Research Unit at the University of Manchester
  13. 13. Benefits of an integrated team: social work membership• A single point of access – leading to a holistic …all the referrals are going to approach and input one place…and then as a team they will discuss the medical/social component Consultant, and respond integrated team together…otherwise I feel the multidisciplinary part of the work will take place but in stages PSSRU Personal Social Services Research Unit at the University of Manchester
  14. 14. Features found to impede practice in non-integrated teams: lack of social work membership we make the referral to• Slow response and lack of [a central number] … and communication then that tends to sit on Nurse, non-integrated a waiting list …we don’t team even know when it• Lack of shared understanding happens unless we and goals actually keep checking ...they are interested, but …just…in• Limited joint working their bit and … they are just thinking, well if it is open to that Team manager, CPN…they want to look for a care non-integrated team provision … and get [out] PSSRU Personal Social Services Research Unit at the University of Manchester
  15. 15. Features found to impede practice in non-integrated teams: lack of social work membership• Loss of data in case they …ring the person and … transfer say, - „I‟ve had a referral from the OT, I‟m coming out to see you‟. … I might have had a• Support breakdown due to discussion with that person limited understanding of and taken a long time to get mental health work by them to agree, and because generic social workers of the dementia they might have already forgotten. They would get a phone call and then say, - “no I didn‟t ask for anybody”, so then… [the OT, non-integrated social worker] wouldn‟t go team out PSSRU Personal Social Services Research Unit at the University of Manchester
  16. 16. Features found to impede practice in non-integrated teams what one organisation sees as• Lack of single the higher priority.., the other manager might not …. and if you had OT, non-integrated one who has an understanding team of our service then that might be better• Difficulty of access to information [We]’ve got..5 IT systems, none of which talk to each other….I can’t get on the social workers site…if you just opened those lines of Team manager, non-integrated communication a little… that team would be a huge improvement. PSSRU Personal Social Services Research Unit at the University of Manchester
  17. 17. Obstacles to effective working in integrated teams• Where social workers were expected to complete two sets of records, one for health and one for social care• Formal internal referral systems• Complexities of managing and supervising across disciplines and agencies• Use of ‘specialists’ for generic work….OTs and Psychologists….(all multidisciplinary teams?)Perhaps evidence of integration not having gone far enough PSSRU Personal Social Services Research Unit at the University of Manchester
  18. 18. Summary of Findings I Key attribute Integrated team Non-integrated team Limited understanding of Shared responsibility service user needs and goals & each other‟s pressuresSocial worker in team Ease of access to Difficulties in or not specialist skills and accessing social resources services Joint work and Limited joint work holistic approach PSSRU Personal Social Services Research Unit at the University of Manchester
  19. 19. Findings II: client outcomes and costs of servicesMultiple outcomes Multiple cost types Risk of mental health inpatient Service receipt/cost* of admission community mental health support Service receipt/cost* of social Time to inpatient admission care package Risk of care home admission Total costs* Quality of life score (interview) * Calculated as monthly costs at baseline Satisfaction with services and key worker (interview) PSSRU Personal Social Services Research Unit at the University of Manchester
  20. 20. Findings II: statistical modelling All outcomes and costs were analysed withvarious forms of regression models: i.e. predicting the variable while controlling for other known characteristics (principally socio-demographic and clinical profile)The main aim: comparing different team types PSSRU Personal Social Services Research Unit at the University of Manchester
  21. 21. Findings II: outcomes Possible effect of Other groupOutcome variable high integration effects („nominal‟ Other team effects (vs. low) and „network‟) Risk of mental Network team health inpatient Higher risk (x5) resembling high admission integration (x4) Higher risk and Network teamTime to inpatient slightly later resembling high admission (timing) integration Much higher riskRisk of care home in one team only admission (high integration) Quality of life No systematic group effects, but one team (low integration) score scoring consistently above average and another (also low integration) scoring consistently below averageSatisfaction with services/key But: sample size was limited! worker PSSRU Personal Social Services Research Unit at the University of Manchester
  22. 22. Findings II: service receipt and costs Possible effect of Other groupOutcome variable high integration effects („nominal‟ Other team effects (vs. low) and „network‟) Higher Both have higherCost of community expenditure expenditure MH support (+80%) (+50%) More likely to Care package receive (x1.6); receipt lower needs! Conditional upon receipt, no systematic differences; butCost of social care high integration teams reach more service users (hence packages higher total expenditure) Higher Both have higherTotal service cost expenditure expenditure (+50%) (+50%) PSSRU Personal Social Services Research Unit at the University of Manchester
  23. 23. Findings III: Exploring the impact of integration on staff outcomes Satisfaction Measures Intention to quit Job characteristics related to stress (autonomy, demands, control) Postal survey Face-to-face interviews Data N=295 (n=42) PSSRU Personal Social Services Research Unit at the University of Manchester
  24. 24. Findings III: Exploring the impact of integration on staff outcomes Poorer outcomes in integrated teams Survey data But mainly due to social work membership and greater job insecurity Being managed by different profession reduced outcomes (tested on nurses only) Evidence of mix of Outweighed byInterview data social worker frustrations of working in dis/satisfaction non-integrated team PSSRU Personal Social Services Research Unit at the University of Manchester
  25. 25. Conclusions and other observationsFindings I:• Non-integrated teams have to work harder to implement good practice (not supported by structures)• But: other types of integration (setting/sector) are equally importantFindings II:• Integrated services associated with more service use whilst not preventing acute inpatient and care home admissions relative to low integration teams• But: methodological and data limitations confound the findingsFindings III:• Lack of clear evidence that integration either improves or reduces staff outcomes• Interestingly: support workers have more positive outcomes in both team types PSSRU Personal Social Services Research Unit at the University of Manchester

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