Early Intervention in Psychosis Network 29 June 2017 Stephen - - PowerPoint PPT Presentation

www.england.nhs.uk

• Stephen McGowan, EIP Clinical Lead for Y&H CN and NHSE (North) (Chair)
• Dr Steve Wright, Consultant Psychiatrist, TEWV (Co-Chair)
• Rebecca Campbell, Quality Improvement Manager and Sarah Boul, Quality

Improvement Lead

• Rebecca.campbell6@nhs.net and sarah.boul@nhs.net
• Twitter: @YHSCN_MHDN #yhmentalhealth
• June 2017

Yorkshire and the Humber Mental Health Network

Early Intervention in Psychosis Network 29 June 2017

www.england.nhs.uk

Yorkshire and the Humber Early Intervention in Psychosis Network

Welcome!

Rebecca Campbell, Quality Improvement Manager, Yorkshire and the Humber Clinical Networks

@YHSCN_MHDN #yhmentalhealth

Housekeeping:

HHonors

Y&H EIP Network Meetings so far…..

• 3rd March 2016, York – New Commissioning Guidance &

Key Concerns

• 7th July 2016, Leeds – Prescribing for FEP &

Implementing the EIP Access, CBTp Training and Waiting Time Standard Final Guidance

• 17th November 2016, Leeds – At Risk Mental State
• 2nd March 2017, Leeds – Children &Young People

Y&H EIP Network Meetings so far…..

Don’t Forget - Evaluation

Next Meeting

• 2 November 2017, 13:30-16:30, Novotel, Leeds
• Service User & Carers Involvement

13:35 National & Regional Update – Themes from the Self-Assessment & Deep Dives Moggie McGowan, Co-Chair, Clinical Advisor, Y&H IRIS, Y&H Clinical Network & NHS England North 14:00 Outcomes and Benefits – Local experiences of using a wider set of metrics including QPR and Dialog Simon Platt & Kate Quinn, SWYFT 14:20 EIP Matrix – EIP Service Self-Assessment & Action Planning Tool Sarah Amani, Senior Programme Manager, EIP Programme, South of England 14:50 Break 15:10 Introduction to Group Discussions Dr Steve Wright, Co-Chair, Consultant Psychiatrist, TEWV & Clinical Advisor, Y&H Clinical Network 15:15 Group Discussion – Outcomes & Metrics Each table to discuss:

• What are the best metrics for describing outcomes in

EIP?

• Ranking and how would you get the info?

All 16:15 Summary  Key Discussion Points – Top 10 Metrics;  Actions & Next Steps Dr Steve Wright 16:30 Close & Evaluation Moggie McGowan

Agenda:

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Yorkshire and the Humber Early Intervention in Psychosis Network

National & Regional Update

Moggie McGowan, Co-Chair, Clinical Advisor (Y&H IRIS & NHS England North)

10

Performance against the waiting time element of the standard

• From the Unify2 data collection, the 50% standard continues to be met nationally.
• From April 2017 data, all providers in the North region continue to meet the standard except for Pennine

Care.

Data quality

• Data quality of the MHSDS is still of concern, however, we are seeing convergence of referral and

performance data.

• Had originally planned to move to MHSDS as the official source of reporting from Q1 2017/18 (this data

is published in September 2017).

• However, data coverage and completeness is still an issue. Unify2 collection will run for an additional 3

months with the last collection covering September 2017.

Recording interventions and outcomes

• Increased focus on reporting of interventions and outcome data to MHSDS through SNOMED codes.
• Guidance being developed for EIP teams – out for consultation soon.
• National work to increase use of SNOMED more widely in mental health.

Assessing NICE-concordance

• In 2016/17, all EIP teams have undertaken a self-assessment assessing the second strand of the

standard (NICE concordance).

• EIP teams provided with report on their performance along with benchmarking information.
• Review process underway for CCQI self-assessment to ensure it is linked with National Audit of

Psychosis, CQUIN etc.

• Work underway to develop the MHSDS so it will be able to collect this information through SNOMED.

Update on EIP standard - National policy team

11

Workforce issues

• Continues to be major risk for EIP teams and CCGs.
• Regional coordination and solutions needed.

Looking forward

• Expansion of services to full age range and ARMS:
• Who is commissioned to provide care to +35s and under 18s.
• Data from MHSDS provides greater transparency.
• Further scrutiny on CCG baseline funding.
• Role of STPs in supporting expansion, workforce and delivery.
• Focus on care quality and outcomes as RTT data quality improves.

Mental Health Dashboard

• The dashboard is intended to help

monitor progress against the delivery of the Five Year Forward View for Mental Health.

• https://www.england.nhs.uk/mental-
• health/taskforce/imp/mh-dashboard/

Update on EIP standard - National policy team

Regional Update

• Deep Dive feedback and Review
• Agreed actions
• Review of CCQI Audit
• Workforce Calculator update
• Data Quality
• Training update
• Incidence/Demand
• Service User Involvement

Provider

1

Provider

2

Provider

3

Provider

4

Provider

5

Provider

6

Provider

7

AWT performance and MHSDS data flow Quality Self-Assessment: Good practice and areas that require improvement Summary of gap analysis (from refreshed workforce calculator) - workforce recruitment and skills Development and Investment plans, milestones and funding (in relation to 5YFVand NHS Improvement monitoring) Areas of best practice which could be shared across the region Are there any concerns to escalate/raise with the regional mental health operations group?

Summary of Post-Review themes

• Shortages of CBTp practitioners in a number of teams and uncertainty about

whether free training would continue to be available

• Similar re IPS training
• Meeting the physical health baseline is a challenge in many teams and most

needed to improve take-up of interventions for weight gain and smoking

• Bringing QPR and DIALOG into use is ongoing in most teams
• At Risk Mental State (ARMS) interventions are in their infancy in most teams
• Many teams have received investment to increase their workforces and

appear to have reasonable capacity now.

• Some haven’t
• There are also real concerns about rising demand
• At most meetings we managed to get providers and commissioners to agree

to a joint review of referral rates after the summer so any requirement for further funding could be fed into contracting reviews

• Poor appreciation of the 5YFV funding plans in most places and a great deal
• f interest in the IRIS illustration by CCG that had been presented elsewhere

in the North Region

Next Steps

 Written feedback to CCGs/Providers  Follow up by regional mental health operations group  Return visits on invite (CL/CN/DCO) in the autumn  Regional (North) summary of common themes to ensure a ‘do once and share’ approach to resolution/actions  Funding illustrations circulated through commissioner’s network  Y&H EIP Network to address the outcomes/themes.

EIP Announcement in 5 Year Forward View 17/18 18/19 19/20 20/21

New

11m 9m 10m 40m

Total

11m 20m 30m 70m Estimate of CCG Investment Year Populatio n of CCG* Populatio n of England* New EIP Investme nt for England New Funding in CCG 17/18 283193 58m 11m 53548 18/19 285029 58.5m 9m 43781 19/20 286855. 59m 10m 48620 20/21 288685 59.5m 40m 194393

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Review

Team leaders were asked to rank order the current standards as either higher, medium or lower importance:

MOST IMPORTANT CBT for Psychosis; Family Interventions; Assessment within 2 weeks; Physical health reviews; Care coordinator caseloads of 15; Stand-alone holistic multidisciplinary team; Crisis and relapse prevention planning; Personal recovery planning; Antipsychotic medication; Supported employment and education programmes. IMPORTANT Carer-focussed education and support programmes; Children have access to CYPMHS expertise; Monitoring take up of physical health interventions for weight management; Monitoring the no. of staff trained to deliver FI; Outcome measurement; Access to specialist drug and alcohol services; CBT for ARMS; Service users are offered/receive clozapine. LESS IMPORTANT Monitoring clinical supervision for CBT & FI; Monitoring the percentage of people who were not in work, education or training; Monitoring the no. of staff trained to deliver CBTp; 3- year treatment package; Detailing the types of supported employment programmes available; Counting the number of service users that disengaged; Monitoring take up of smoking cessation interventions.

20

35 100 160 80 40 105 10 40 90 110 60 45 15 90 175 71 92 56 67 25 101 13 43 132 40 107 88 115 51 91 157

5 BOROUGHS PARTNERSHIP NHS FOUNDATION TRUST BRADFORD DISTRICT CARE NHS FOUNDATION TRUST CHESHIRE AND WIRRAL PARTNERSHIP NHS FOUNDATION TRUST COMMUNITY LINKS (NORTHERN) LTD CUMBRIA PARTNERSHIP NHS FOUNDATION TRUST GREATER MANCHESTER WEST MENTAL HEALTH NHS FOUNDATION TRUST NAVIGO HUMBER NHS FOUNDATION TRUST LANCASHIRE CARE NHS FOUNDATION TRUST MERSEY CARE NHS TRUST NORTHUMBERLAND, TYNE AND WEAR NHS FOUNDATION TRUST PENNINE CARE NHS FOUNDATION TRUST ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST SHEFFIELD HEALTH & SOCIAL CARE NHS FOUNDATION TRUST SOUTH WEST YORKSHIRE PARTNERSHIP NHS FOUNDATION TRUST TEES, ESK AND WEAR VALLEYS NHS FOUNDATION TRUST Jan_Mar_16/17 Unify Entering EIP Treatment (rounded) Jan-Mar_ 16/17 MHSDS Entering EIP Treatment

Data Quality

• Training update
• Incidence/Demand
• Service User Involvement

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Yorkshire and the Humber Early Intervention in Psychosis Network

Outcomes and Benefits: Local experiences of using a wider set

• f metrics including QPR and Dialog

Simon Platt & Kate Quinn (SWYFT)

Demonstrating Outstanding EI Services through Outcomes

Kate Quinn (Wakefield EI) & Simon Platts (Barnsley EI)

Rationale for Chosen Outcomes

• Try to crystallise what is most important for clients,

service and targets

• Consideration of what we already collect on RiO
• Minimise impact of paperwork on Care Coordinators
• Ideally implemented with support of Assistant

Psychologist

• Time points – initial, 6 months, 1 year,

annually thereafter, discharge

Key things for Outcomes: Care Coordinators

• Estimated Duration of Untreated Psychosis
• First outcome form only and on CAARMS
• Broad categories (<1/3/6/12 months; >12 months)
• Engagement
• Service User
• Family (in wider definition of ‘family’)
• Admissions/relapses (some data also via RiO)
• Death (where applicable)

Key things for Outcomes: On Rio

• Waiting time (referral to treatment)
• Source of Referral
• Physical health: cardiometabolic assessment
• BMI
• Smoking
• Discharge destination
• Experience based issues – from HoNOS (items 1, 2, 3, 6, 9)
• Psychotic experiences
• Overactive, agitated, aggressive and criminal behaviour
• Non-accidental self-injury
• Problem drinking or drug taking
• Relationships

Key things for Outcomes: On Rio

• Accommodation: PSA ‘Housing Status’
• Vocational (training and occupational): PSA ‘Job Status’
• Friends and Family Test
• Self-reported recovery (QPR)
• Self-reported satisfaction (DIALOG)

DIALOG

Totally dissatisfied Very dissatisfied Fairly dissatisfied In the middle Fairly satisfied Very satisfied Totally satisfied Additional help wanted - Yes/No

How satisfied are you with your mental health? How satisfied are you with your physical health? How satisfied are you with your job situation? How satisfied are you with your accommodation? How satisfied are you with your leisure activities? How satisfied are you with your friendships? How satisfied are you with your partner/family? How satisfied are you with your personal safety? How satisfied are you with your medication? How satisfied are you with the practical help you receive? How satisfied are you with consultations with mental health professionals?

DIALOG: What is meaningful change?

• Mean scores of clinical samples are usually between 4 and 5
• mean scores of <4 are rare (inpatient groups in crises; depressed samples)
• Shift of 0.25 mean score would reflect a medium effect size
• Roughly equates to higher satisfaction in three life domains (or a shift in
• ne domain by three points)
• Mean score of >5 should be seen as sufficient QoL (with

absence of dissatisfaction with single life domains)

• No further need for EI involvement, unless specific reasons
• Every single step on every single item of DIALOG can reflect a

meaningful change

• Any improvement is worth having
• At all stages, expect ‘satisfaction with treatment’ subscale score

to be >4

PROCESS OF RECOVERY QUESTIONNAIRE

• 0. Strongly

disagree

• 1. Disagree

2 Neither agree

• r disagree
• 3. Agree
• 4. Agree strongly

1) I feel better about myself 2) I feel able to take chances in life 3) I am able to develop positive relationships with other people 4) I feel part of society rather than isolated 5) I am able to assert myself 6) I feel that my life has a purpose 7) My experiences have changed me for the better 8) I have been able to come to terms with things that have happened to me in the past and move on with my life 9) I am strongly motivated to get better 10) I can recognise the positive things I have done 11) I am able to understand myself better 12) I can take charge of my life 13) I can actively engage with life 14) I can take control of aspects

• f my life

15) I can find the time to do the things I enjoy

QPR: What are we interested in?

• No current norms that we’ve been able to get hold of
• Do not think that intra- and interpersonal scales from longer version

are applicable

• ? Slightly vague hope that scores improve
• We may be interested in some questions particularly, as they relate

to client’s psychological and social recovery

• I feel I am able to develop positive relationships with other people
• I feel part of society rather than isolated
• I feel that my life has a purpose
• I feel I have come to terms with things that have happened to me in the

past and move on with my life

Client Example – Wakefield, about to be discharged after full EIP service

• Estimated DUP: 3 months as reported by parents
• Referred by GP to CMHT: assessed & passed to EI
• Waiting time 1 month from referral to allocation

in EI

Physical Health Markers

• Smoker
• 2014 – smoking 20 cigarettes per day
• 2017 – smokes 1-5 cigarettes per day with

additional e-cigarette

• BMI 2014 – 25.2
• BMI 2017 – 22.9

HONOS 3 – ‘marked dependence’ to ‘no problem’

Engagement

• Client Engagement
• 2014 – 3 ‘moderate problem’
• 2017 – 0 ‘very good’
• Family Engagement
• 2014 - 1 ‘good’
• 2017 – 1 ‘good’

HONOS 9 – ‘mild problem’ to ‘no problem’

HONOS 6 – Problems with Hallucinations and Delusions ‘mild problem’ to ‘minor problem’

Relapses

• 2 admissions under the MHA
• 1st admission 65 days (start of treatment)
• 2nd admission 49 days
• 1 period under home treatment 23 days
• 1 DATIX re: admin processes

HONOS 1 – ‘mild problem’ to ‘no problem’

HONOS 2 – Non-Accidental Self Injury – ‘mild problem’ to ‘no problem’

Housing

• No changes
• Settled accommodation with family

Employment

• Long term sick/disabled on entry to service
• Now about to go to uni

QPR on Admission

QPR: total score of 10 (average 0.6)

• I feel I am able to develop positive relationships with other

people: 0 (strongly disagree)

• I feel part of society rather than isolated: 1 (Disagree)
• I feel that my life has a purpose: 0 (strongly disagree)
• I feel I have come to terms with things that have happened to

me in the past and move on with my life: 0 (strongly disagree)

QPR at discharge

QPR: total score of 30 (average 2)

• I feel I am able to develop positive relationships with other

people: 3 (Agree)

• I feel part of society rather than isolated: 3 (Agree)
• I feel that my life has a purpose: 2 (neither agree or

disagree)

• I feel I have come to terms with things that have happened to

me in the past and move on with my life: 4 (Agree strongly)

Other positives:

• Feeling better about self
• Engagement with life
• Control

Challenges:

• Assertiveness
• Sense that experiences have ‘changed me for the better’

DIALOG on Admission

DIALOG – Total 34 (3)

(Mean score of >5 should be seen as sufficient QoL)

DIALOG at discharge

DIALOG – Total 48 (4.36) QoL 32 (4), Treatment Satisfaction 16 (5.3)

High satisfaction with:

• Safety
• Practical help
• Contact with MH services

Less satisfied with:

• Accommodation
• Leisure activities
• Physical health

Family Satisfaction

Client and Family report they would recommend the service to family and friends (F&F Test)

Discharge Destination

Back to GP

Qualitative Feedback

Client: ‘Very happy with the level and content of current support provision and medication (thinking is much clearer). Feel comfortable to discuss issues with the team, talking about

• r around the issues helps a lot. I feel much better at letting go
• f distressing memories and I’m able to mindfully be in the

moment much more’ Parents: ‘Team have been well organised and professional especially Cat, she has been our life line in helping us to get our son better. Nothing is too much trouble for her, we can’t thank her and Insight enough for all their help’

Discharge Destination

Good Outstanding

60 15 5 20 GP transfer to secondary care forensic disengaged 80 10 1 9 GP transfer to secondary care forensic disengaged

Barnsley EIT: Discharge Destination

Good Outstanding

60 15 5 20 GP transfer to secondary care forensic disengaged 56% 19% 12% 2% 1% 0% 10%

Discharge Destination

GP/Primary Care CMHT- Caseload CMHT- Outpatient

• nly

AOT Substance Misuse Forensic Services

2010-2016 (190 clients)

69% 18% 4% 0% 0% 0% 9% GP/Primary Care CMHT- Caseload CMHT- Outpatient

• nly

AOT Substance Misuse Forensic Services

2015 – 2016 (47 clients)

0% 20% 40% 60% 80% 100% Entry Exit

None Occasional Regular Serious

0% 20% 40% 60% 80% 100% Entry Exit

None Cannabis (solely) Poly Drug Use (Inc. Cannabis)

Self-Harm & Substance Use

Ongoing Issues Getting people to use the measures!

Making the sessions accessible/available Making the measures relevant to practice and useful: helps client work and improves outcomes Debunking myths/expectations that clients won’t complete the measures (Lancashire SMI-IAPT used earliest/latest and sessional measures and people completed them)

Getting prompt feedback to care coordinators/clients re: scores/change, so see purpose to outcomes framework

Create outcomes feedback and combine with narrative accounts at discharge

Employ Trust-wide Assistant Psychologist to help with above?

South Region Early Intervention in Psychosis (EIP) Programme

Sarah Amani Senior Programme Manager @S_Amani

All slides and videos can be accessed here:

https://www.slideshare.net/sarahamani1/early-intervention-in-psychosis-programme-briefing-march-2017

Thank You

For more information please visit our information sites at: https://time4recovery.com @Time4Recovery

Hosted by

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Yorkshire and the Humber Early Intervention in Psychosis Network

Time for a break?

Early Intervention in Psychosis Network - June 29th 2017

Group Discussion:

Outcomes & Metrics

Steve Wright NHS England (North) Yorkshire & the Humber EIP Network

Outcomes & Metrics (1)

• Why do we need to measure outcomes?
• Because we are good at it

Outcomes & Metrics (2)

• What are the best metrics for

describing outcomes in EIP?

• How would you rank them in terms of

relevance, importance and feasibility?

• How would you get the info?
• How can data collection be embedded

in current work with minimum impact

• n workload?

Outcomes & Metrics (3) - SMART

• Improved person/family experience, WT
• Personalised – recovery star, DIALOG
• Functional - SOFA, QPR, SWEMWBS
• Clinical – symptom, PANSS,
• Social – education, employment, networks
• Physical Health – blue or green on Lester
• Service thresholds – MHA, IP days, datix,

discharge destinations, re-referrals etc.

• Long term vs short term, QALY

Outcomes & Metrics – why?

• To make sure we are doing what we say

we are doing?

• Improve services
• Evidence effectiveness (including costs

across the system)

• Visibility walls for teams
• Visibility walls for users/carers

(ownership & accountability)

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Each locality table to discuss:

• What are the best metrics for describing outcomes

in EIP?

• Rank the metrics in priority order and then discuss

how you would get the information required?

Group Discussion:

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Yorkshire and the Humber Early Intervention in Psychosis Network

Summary

• Key Discussion Points – Top 10 Metrics
• Actions & Next Steps

Dr Steve Wright, Co-Chair, Consultant Psychiatrist, TEWV & Clinical Advisor, Y&H Clinical Network

www.england.nhs.uk

• Thursday 2 November 2017, Novotel, Leeds, 13:30-

16:30

Date of the Next Meeting…

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Yorkshire and the Humber Early Intervention in Psychosis Network

Thank You for Attending!

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