Providing good outcomes for people requiring complex multi-agency interventions Tony Holland Cambridge Intellectual and De...
Background <ul><li>What services are required? </li></ul><ul><ul><li>Social support  </li></ul></ul><ul><ul><li>Primary ca...
Services for adults with LD Adult with an ID Family Informal community Statutory sector  Residential care – private/third ...
Specialist adult LD services <ul><li>The LDP </li></ul><ul><li>The commissioning of day and support services </li></ul><ul...
People with LD, families and others you support them General Practice and primary care services Five integrated community ...
Fenland East Cambridgeshire Huntingdonshire South Cambridgeshire Cambridge City Team base Map of Cambridgeshire Area Emers...
Problems <ul><li>No clear understanding of what specialist services are there to do – historical reasons for differences a...
Function of specialist LD services <ul><li>To provide care management and specialist health support to meet specific needs...
Function of specialist LD services <ul><li>Specific focussed roles: </li></ul><ul><ul><li>Mental health and challenging be...
Community teams <ul><li>Care managers </li></ul><ul><li>Music and art therapy </li></ul><ul><li>Nursing (LD) </li></ul><ul...
Internal total N = 71 External total N = 221 Referrals across all 5 Teams (N=292) included in START study and their source...
What issues were referrals made for  (N = 292) Referral Issue (In order of frequency) Review of support/care package Emoti...
In the context of LD  why is formulation so important? <ul><li>Potential complexity of need </li></ul><ul><ul><ul><li>Clin...
Clinical formulation <ul><li>A  clinical formulation  (or case formulation) is a theoretically-based explanation or concep...
Purpose of clinical formulation <ul><li>To bring clarity to a particular issue in situations of potential complexity </li>...
Formulation in context <ul><li>The function of those who provide social support is to enable people with LD to achieve the...
Integrative approaches to formulation <ul><li>Understanding the system that is a specialist LD service and what each part ...
Process of clinical formulation <ul><li>Reason for referral </li></ul><ul><li>Data collection </li></ul><ul><ul><ul><li>Hi...
The function of an IP service <ul><li>As a hospital based service to provide a safe environment for assessment and treatme...
Formulation in Clinical Practice Reason for referral Intervention FORMULATION History Examination Investigations Observati...
Applied behavioural analysis Delayed or atypical development Co-morbidities Autism spectrum conditions Behavioural phenoty...
Formulation in LD <ul><li>Complexity </li></ul><ul><ul><ul><li>Developmental </li></ul></ul></ul><ul><ul><ul><li>Biologica...
What is needed for formulation to take place <ul><li>Service structures that support integrative working practices – inter...
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LD Commissioning Workshop: Providing good outcomes for people requiring complex, multi-agency interventions

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Professor Tony Holland, University of Cambridge: (CLAHRC) -Providing good outcomes for people requiring complex, multi-agency interventions

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LD Commissioning Workshop: Providing good outcomes for people requiring complex, multi-agency interventions

  1. 1. Providing good outcomes for people requiring complex multi-agency interventions Tony Holland Cambridge Intellectual and Developmental Disabilities Research Group NIHR CLAHRC for Cambridgeshire and Peterborough www.ciddrg.org.uk
  2. 2. Background <ul><li>What services are required? </li></ul><ul><ul><li>Social support </li></ul></ul><ul><ul><li>Primary care </li></ul></ul><ul><ul><li>Specialist LD services </li></ul></ul><ul><li>Specialist services for adults with LD </li></ul><ul><ul><li>Function (what is the service there to do?) </li></ul></ul><ul><ul><li>Design (what should the service look like?) </li></ul></ul><ul><ul><li>Practice (how should specialist services practice?) </li></ul></ul><ul><li>What is required to meet the complex needs of a person with LD? </li></ul><ul><ul><li>The importance of formulation </li></ul></ul><ul><li>What is required of a service to make this possible? </li></ul>
  3. 3. Services for adults with LD Adult with an ID Family Informal community Statutory sector Residential care – private/third sector organisations Primary and secondary health care (NHS) LA led integrated community teams Supported living Commissioning (LA) Care management, specific ‘health’ responsibilities Access criteria NHS and Community Care Act 1991 Eligibility criteria: substantial and critical need
  4. 4. Specialist adult LD services <ul><li>The LDP </li></ul><ul><li>The commissioning of day and support services </li></ul><ul><ul><ul><li>Residential care </li></ul></ul></ul><ul><ul><ul><li>Supported living (personal budgets) </li></ul></ul></ul><ul><ul><ul><li>Supported employment, social firms etc </li></ul></ul></ul><ul><li>Managing the community teams for adults with LD </li></ul><ul><ul><ul><li>Care co-ordination </li></ul></ul></ul><ul><ul><ul><li>Specialist health support </li></ul></ul></ul><ul><li>*CPFT (directly manage) </li></ul><ul><ul><ul><li>Two in-patient services (mental health) (Cambridge and Peterborough) </li></ul></ul></ul><ul><li>*CPFT Cambridge and Peterborough Foundation NHS Trust </li></ul>
  5. 5. People with LD, families and others you support them General Practice and primary care services Five integrated community teams for adults with LD Two intensive Assessment and Support Service (IASS) (in-patient) Intensive Assessment and Support Service (IASS) (community) Regional secure services Generic secondary care services SPECIALIST SERVICES FOR ADULTS WITH LD STRUCTURES (CAMBRIDGESHIRE LDP) City, East, Fenland, Huntingdon, South Cambridge Peterborough Norwich Social support providers
  6. 6. Fenland East Cambridgeshire Huntingdonshire South Cambridgeshire Cambridge City Team base Map of Cambridgeshire Area Emerson & Hatton (2004)* showed that roughly 20 people in every thousand have an ID. 4.6 of these are likely to be known to local health and social services, but these numbers vary with age. Estimated population of Cambridgeshire in 2011 (aged 18-64): 619,400** Estimated number of people with an ID: 12,388* And the number known to local services: 2,849* **Projecting Adult Needs and Service Information (PANSI) www.pansi.org.uk
  7. 7. Problems <ul><li>No clear understanding of what specialist services are there to do – historical reasons for differences across the county; </li></ul><ul><li>Limited understanding of the cultural and other differences between health and LA; </li></ul><ul><li>No ‘design capacity’ within the specialist LD service – adhoc approach to change. </li></ul>
  8. 8. Function of specialist LD services <ul><li>To provide care management and specialist health support to meet specific needs of people with LD – interface with various stakeholders and particularly supporting primary care </li></ul><ul><ul><ul><li>Access to generic services </li></ul></ul></ul><ul><ul><ul><li>Health screening </li></ul></ul></ul><ul><ul><ul><li>Safeguarding </li></ul></ul></ul><ul><ul><ul><li>Advice (employment, social support, specific health etc) </li></ul></ul></ul><ul><ul><ul><li>To enable access to social support (eligibility criteria) </li></ul></ul></ul><ul><li>To support people with LD and their families and those that provide support with respect to: </li></ul><ul><ul><ul><li>Total communication environments </li></ul></ul></ul><ul><ul><ul><li>Skills development </li></ul></ul></ul><ul><ul><ul><li>Sexuality and other matters relating to adult life </li></ul></ul></ul>
  9. 9. Function of specialist LD services <ul><li>Specific focussed roles: </li></ul><ul><ul><li>Mental health and challenging behaviour </li></ul></ul><ul><ul><li>Assistance with eating and drinking (aspiration, choking, malnutrition etc) </li></ul></ul><ul><ul><li>Assessment and treatment of severe epilepsy (in collaboration with neurology services) </li></ul></ul><ul><ul><li>Matters relating to offending and the CJS </li></ul></ul>
  10. 10. Community teams <ul><li>Care managers </li></ul><ul><li>Music and art therapy </li></ul><ul><li>Nursing (LD) </li></ul><ul><li>Occupational therapy </li></ul><ul><li>Psychiatry (specialising in LD) </li></ul><ul><li>Psychology </li></ul><ul><li>Pysiotherapy </li></ul><ul><li>Speech and language therapy </li></ul>
  11. 11. Internal total N = 71 External total N = 221 Referrals across all 5 Teams (N=292) included in START study and their sources Health Care Management Self, partner, or member of family 18.1% (40/221) Services for people with LD 52.9% (117/221) GP or other primary care 14.5% (32/221) Other 14.0% (31/221) Missing value 0.5% (1/221)
  12. 12. What issues were referrals made for (N = 292) Referral Issue (In order of frequency) Review of support/care package Emotional/behavioural difficulties Physical health issues Communication assessment/support Safeguarding/risk Eating and drinking Other Sensory profile Access to health care and other diagnostic issues (eg decision-making capacity) Skills
  13. 13. In the context of LD why is formulation so important? <ul><li>Potential complexity of need </li></ul><ul><ul><ul><li>Clinical (skills of different disciplines required) </li></ul></ul></ul><ul><ul><ul><li>Health inequalities (CB and mental and physical ill-health) </li></ul></ul></ul><ul><ul><ul><li>On going, lifelong, and relational aspects of support and intervention </li></ul></ul></ul><ul><li>Complexity of support network </li></ul><ul><ul><ul><li>Families </li></ul></ul></ul><ul><ul><ul><li>Interagency (CJS, Health, Housing, LA etc) </li></ul></ul></ul><ul><ul><ul><li>Interface with different support providers (supported living, residential care etc) </li></ul></ul></ul>
  14. 14. Clinical formulation <ul><li>A clinical formulation (or case formulation) is a theoretically-based explanation or conceptualisation of the information obtained from a clinical assessment. It offers a hypothesis about the cause and nature of the presenting problems. </li></ul><ul><li>In clinical practice, formulations are used to communicate a hypothesis and provide framework to developing the most suitable treatment approach. It is most commonly used by clinical psychologists and psychiatrists and is deemed to be a core component of these professions </li></ul><ul><li>(Butler 1998 in Clinical Formulation, New York, Pergamon Press - quote from Wikipedia) </li></ul>
  15. 15. Purpose of clinical formulation <ul><li>To bring clarity to a particular issue in situations of potential complexity </li></ul><ul><li>To develop hypotheses the purpose of which are to inform interventions that are based on a sound theoretical understanding and can be evaluated </li></ul><ul><li>Formulation requires an understanding of the particular service and what it is there to do as it does of the person with an LD. </li></ul><ul><ul><ul><li>Social support provider </li></ul></ul></ul><ul><ul><ul><li>Specialist community team </li></ul></ul></ul><ul><ul><ul><li>Assessment and treatment IP service </li></ul></ul></ul><ul><ul><ul><li>Secure service </li></ul></ul></ul>
  16. 16. Formulation in context <ul><li>The function of those who provide social support is to enable people with LD to achieve their aspirations and those set out in VP (social model of disability) </li></ul><ul><li>The function of those who provide health support is to ensure that people with LD have good health so that their aspirations have the best possible chance of being achieved (bio-medical model, ABA, etc) </li></ul>
  17. 17. Integrative approaches to formulation <ul><li>Understanding the system that is a specialist LD service and what each part does and its purpose as a whole and the interfaces with other services </li></ul><ul><li>Identifying the key issues to be addressed with a given person with a LD and the skills and structures necessary to achieve the task </li></ul>
  18. 18. Process of clinical formulation <ul><li>Reason for referral </li></ul><ul><li>Data collection </li></ul><ul><ul><ul><li>History </li></ul></ul></ul><ul><ul><ul><li>Examination </li></ul></ul></ul><ul><li>Investigations </li></ul><ul><ul><ul><li>Medical </li></ul></ul></ul><ul><ul><ul><li>Cognitive </li></ul></ul></ul><ul><ul><ul><li>Functional </li></ul></ul></ul><ul><ul><ul><li>Communication etc </li></ul></ul></ul><ul><li>Observations </li></ul><ul><ul><ul><li>ABC chart </li></ul></ul></ul><ul><ul><ul><li>Mental state </li></ul></ul></ul><ul><ul><ul><li>Behaviour </li></ul></ul></ul><ul><li>Preliminary understanding (hypotheses) </li></ul><ul><li>Conceptual/theoretical perspective </li></ul><ul><ul><ul><li>Diagnostic (differential) </li></ul></ul></ul><ul><ul><ul><li>ABA </li></ul></ul></ul><ul><ul><ul><li>Systemic </li></ul></ul></ul><ul><li>Further data collection </li></ul><ul><li>Working hypotheses </li></ul><ul><li>Intervention(s) </li></ul><ul><li>Evaluation (outcomes) </li></ul>
  19. 19. The function of an IP service <ul><li>As a hospital based service to provide a safe environment for assessment and treatment when, because of the person health and/or their safety or because of a potential risk to others, it cannot be provided elsewhere </li></ul><ul><li>Through the processes of assessment and formulation to arrive at an understanding of the index problems and in partnership with the person with LD and others to undertake the necessary interventions to enable the person to live in the community. </li></ul>
  20. 20. Formulation in Clinical Practice Reason for referral Intervention FORMULATION History Examination Investigations Observations Accepted models of understanding Evidence-base for different interventions Good Clinical Practice
  21. 21. Applied behavioural analysis Delayed or atypical development Co-morbidities Autism spectrum conditions Behavioural phenotypes Physical illness Psychiatric illness Sequelae of abuse Triggering events Setting conditions Wider physical and emotional environment Theoretical models for understanding challenging behaviour FORMULATION: biological, psychological and social factors predisposing to, precipitating or maintaining such behaviours or abnormal mental state
  22. 22. Formulation in LD <ul><li>Complexity </li></ul><ul><ul><ul><li>Developmental </li></ul></ul></ul><ul><ul><ul><li>Biological </li></ul></ul></ul><ul><ul><ul><li>Psychological </li></ul></ul></ul><ul><ul><ul><li>Environmental </li></ul></ul></ul><ul><li>Communication </li></ul><ul><ul><ul><li>Person with an ID </li></ul></ul></ul><ul><ul><ul><li>Interdisciplinary </li></ul></ul></ul><ul><ul><ul><li>Interagency </li></ul></ul></ul><ul><li>Interdisciplinary </li></ul><ul><ul><ul><li>Conceptual models </li></ul></ul></ul><ul><ul><ul><li>Skills </li></ul></ul></ul><ul><li>Interventions </li></ul><ul><ul><ul><li>Multiple </li></ul></ul></ul><ul><ul><ul><li>Consent and capacity </li></ul></ul></ul><ul><ul><ul><li>Co-operation </li></ul></ul></ul><ul><li>Uncertainty </li></ul><ul><ul><ul><li>Limited history or informant only history </li></ul></ul></ul><ul><ul><ul><li>Uncertain mental state </li></ul></ul></ul><ul><ul><ul><li>Relational (social support) </li></ul></ul></ul>
  23. 23. What is needed for formulation to take place <ul><li>Service structures that support integrative working practices – interdisciplinary and interagency; </li></ul><ul><li>Understanding of and respect for: </li></ul><ul><ul><ul><li>procedural, cultural, and political differences between NHS and LA </li></ul></ul></ul><ul><ul><ul><li>theoretical and conceptual differences between disciplines </li></ul></ul></ul><ul><li>A clear understanding of the purpose of, and the relationships between the different components of a specialist LD service in the context of those they serve; </li></ul><ul><li>A recognition of the complexity and relational aspects of care and that good health and social support are closely linked </li></ul>

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