Integrated Care in Severe Mental Illness: Local Examples of Pathway Development, Joint Working & Adherence Cathy Riley Director of Pharmacy & Medicines.

Integrated Care in Integrated Care in Severe Mental Illness: Severe Mental Illness: Local Examples of Local Examples of Pathway Development, Pathway Development, Joint Working & Joint Working & AdherenceAdherence

Cathy RileyCathy RileyDirector of Pharmacy & Medicines OptimisationDirector of Pharmacy & Medicines OptimisationSouth Staffordshire & Shropshire Healthcare NHS Foundation South Staffordshire & Shropshire Healthcare NHS Foundation TrustTrust

What is an Integrated What is an Integrated Care Pathway?Care Pathway? ‘‘structured multidisciplinary care plans structured multidisciplinary care plans

which detail essential steps in the care ofwhich detail essential steps in the care of

patients with a specific clinical problem’patients with a specific clinical problem’ Sometimes called: ‘clinical pathways’, Sometimes called: ‘clinical pathways’,

‘critical pathways’, ‘care plans’, ‘care ‘critical pathways’, ‘care plans’, ‘care paths’ and ‘care maps’paths’ and ‘care maps’

However, there is no single definition of However, there is no single definition of integrated careintegrated care

Why should we want Why should we want develop Pathways for develop Pathways for SMI?SMI? The NHS has restructured many of its The NHS has restructured many of its

services based around the use of integrated services based around the use of integrated care pathways (ICPs)- easier to understand care pathways (ICPs)- easier to understand skill mix and resource required, useful to skill mix and resource required, useful to review evidence-based interventions and review evidence-based interventions and current practice (what brings value?)current practice (what brings value?)

Its easier to cost care if there is a consistent Its easier to cost care if there is a consistent pathway used (important for tariff approach)pathway used (important for tariff approach)

Its transparent to commissioners, service Its transparent to commissioners, service users and carers about what can be expectedusers and carers about what can be expected

In other settings, ICPs have been shown to In other settings, ICPs have been shown to reduce hospital costsreduce hospital costs

Why are few ICPs established Why are few ICPs established in SMI (in West Midlands)?in SMI (in West Midlands)?

National Institute for Health Research (Sep. 2011National Institute for Health Research (Sep. 2011)1:)1:

Found no systematic reviews of the effectiveness of ICPs specifically in mental Found no systematic reviews of the effectiveness of ICPs specifically in mental healthcare.healthcare.

Two well-conducted systematic reviews provide evidence that ICPs can improve Two well-conducted systematic reviews provide evidence that ICPs can improve some outcomes compared with usual care in some hospital settings. Very little of some outcomes compared with usual care in some hospital settings. Very little of the evidence included in these reviews comes from mental healthcare or UK the evidence included in these reviews comes from mental healthcare or UK settingssettings

Studies that have looked at the implementation of ICPs in mental health settings Studies that have looked at the implementation of ICPs in mental health settings in the UK NHS have generally reported on the experience of particular services. in the UK NHS have generally reported on the experience of particular services. The findings are of limited value for decision-making because of their lack of The findings are of limited value for decision-making because of their lack of methodological rigour and reporting of process outcomes and expert opinion methodological rigour and reporting of process outcomes and expert opinion rather than patient outcomes.rather than patient outcomes.

While there is some evidence suggesting that ICPs can reduce hospital costs, While there is some evidence suggesting that ICPs can reduce hospital costs, their relevance to MHTs is uncertain as most studies were not conducted in their relevance to MHTs is uncertain as most studies were not conducted in either the UK NHS or mental health settings.either the UK NHS or mental health settings.

Given the uncertainties around the generalisability of the evidence and the best Given the uncertainties around the generalisability of the evidence and the best ways to implement ICPs, it will be important to plan carefully for implementation ways to implement ICPs, it will be important to plan carefully for implementation of any change to services and to monitor resource use, costs and clinical of any change to services and to monitor resource use, costs and clinical outcomes during and after any change.outcomes during and after any change.

11http://www.york.ac.uk/inst/crd/pdf/Integrated%20care%20pathways%20evidencehttp://www.york.ac.uk/inst/crd/pdf/Integrated%20care%20pathways%20evidence%20briefing.pdf%20briefing.pdf

What are the Challenges What are the Challenges in ICP Development in in ICP Development in SMI?SMI?

Crossing BoundariesCrossing Boundaries: : Improving Improving integrated care for people with integrated care for people with

mental health problemsmental health problems Final Inquiry Report September 2013 Final Inquiry Report September 2013

(Mental Health Foundation)(Mental Health Foundation)““Good integrated care for people with Good integrated care for people with

mental health needs remains the mental health needs remains the exception rather than the rule”exception rather than the rule”

Mental healthcare Mental healthcare provision- based on a provision- based on a flawed paradigm?flawed paradigm? Physical and mental health are Physical and mental health are

fundamentally different (albeit each fundamentally different (albeit each having some impact on the other), having some impact on the other), requiring different specialist requiring different specialist approaches, and ignores the approaches, and ignores the common factors in the global common factors in the global determination of health and illness, determination of health and illness, which have biological, psychological which have biological, psychological and, in particular, social and, in particular, social components components

How can we better How can we better integrate?- integrate?- 2 underpinning 2 underpinning essentials:essentials: cross-boundary inter-professional training cross-boundary inter-professional training

and educationand education

having the right people in the organisation having the right people in the organisation – both leaders who will drive forward – both leaders who will drive forward integration at a strategic level and staff integration at a strategic level and staff who understand and respect the roles and who understand and respect the roles and responsibilities of other professions and responsibilities of other professions and are willing to work with patients and across are willing to work with patients and across organisational and professional boundariesorganisational and professional boundaries

Factors that facilitate Factors that facilitate good integration:good integration:- Information sharing systemsInformation sharing systems- Shared protocolsShared protocols- Joint funding & commissioningJoint funding & commissioning- Co-located servicesCo-located services- Multidisciplinary teamsMultidisciplinary teams- Liaison servicesLiaison services- NavigatorsNavigators- ResearchResearch- Reduction of stigmaReduction of stigma

Successful integrated Successful integrated carecare

““The future of effective integrated care The future of effective integrated care therefore lies primarily in recruiting, therefore lies primarily in recruiting, maintaining and developing a maintaining and developing a workforce, both in health and social workforce, both in health and social care, and in other organisations who care, and in other organisations who have contact with people with mental have contact with people with mental health needs, that is passionate and health needs, that is passionate and committed to the principles and committed to the principles and practice of holistic care and partnership practice of holistic care and partnership working” working”

What does the Royal What does the Royal College of Psychiatrists College of Psychiatrists say?say?

Whole-person care: from Whole-person care: from rhetoric to realityrhetoric to reality

Achieving parity between Achieving parity between mental and physical healthmental and physical health

Why bother? The facts Why bother? The facts (Schizophrenia Commission 2012) (Schizophrenia Commission 2012)

Prevalence of diabetes is 2-3 times higher for people Prevalence of diabetes is 2-3 times higher for people with schizophrenia with schizophrenia

61 % of people with schizophrenia smoke, compared 61 % of people with schizophrenia smoke, compared to 33% of the general population to 33% of the general population

People with SMI are twice as likely to die from heart People with SMI are twice as likely to die from heart disease, 3 x as likely to die of respiratory disease and disease, 3 x as likely to die of respiratory disease and 4x as likely to die of infections than the general 4x as likely to die of infections than the general population population

People with schizophrenia who develop cancer are 3 People with schizophrenia who develop cancer are 3 times more likely to die than those in the general times more likely to die than those in the general population. population.

Some more factsSome more facts

People with schizophrenia and bipolar People with schizophrenia and bipolar disorder die an average 25 years disorder die an average 25 years earlier than the general population, earlier than the general population, largely because of physical health largely because of physical health problems. problems.

11% of adult health care costs in the 11% of adult health care costs in the UK are attributable to physical UK are attributable to physical symptoms caused or exacerbated by symptoms caused or exacerbated by mental health problems. mental health problems.

Schizophrenia Schizophrenia CommissionCommission

The Commission believes that the neglect

of people’s physical health cannot be allowed to continue

Access

Education & training

Clarity of responsibility for management and monitoring Assessments

How far are we away How far are we away from this?from this?

Integrated care might also be considered to simplify Integrated care might also be considered to simplify the delivery of “shared care”, Lester (2005) giving a the delivery of “shared care”, Lester (2005) giving a GP’s perspective on health care for people with a GP’s perspective on health care for people with a mental illness:mental illness:

““Shared care enables a ‘best of both worlds’ scenario, Shared care enables a ‘best of both worlds’ scenario, with the opportunity to provide good-quality holistic with the opportunity to provide good-quality holistic care. Shared care should lead to pooling of expertise care. Shared care should lead to pooling of expertise and enhanced creativity in problem-solving. It should and enhanced creativity in problem-solving. It should also lessen the possibility that vulnerable patients are also lessen the possibility that vulnerable patients are ‘left in limbo’, with patients and carers feeling that ‘left in limbo’, with patients and carers feeling that they are failing to make progress through the mental they are failing to make progress through the mental health system….. Shared care also offers opportunities health system….. Shared care also offers opportunities for addressing long-standing issues regarding the for addressing long-standing issues regarding the morbidity and mortality of people with serious mental morbidity and mortality of people with serious mental illness”.illness”.

Focussing on Focussing on MedicinesMedicines New Dawn: Medicines New Dawn: Medicines

OptimisationOptimisation

Medicines Optimisation must be a Medicines Optimisation must be a feature of all ICPsfeature of all ICPs

Medicines Medicines OptimisationOptimisation Medicines SafetyMedicines Safety- - Avoiding harm from medicines Avoiding harm from medicines

- Ensuring good medicines - Ensuring good medicines governance and the safe and governance and the safe and secure use of medicines secure use of medicines

- Learning from errors and incidents - Learning from errors and incidents

Medicines Medicines OptimisationOptimisation Effective OutcomesEffective Outcomes- Ensuring optimal outcomes from medicines - Ensuring optimal outcomes from medicines

by implementing NICE guidance, evidence by implementing NICE guidance, evidence based practice and the rapid adoption of based practice and the rapid adoption of appropriate innovatory treatments appropriate innovatory treatments

- Delivering value for money from medicines - Delivering value for money from medicines and reducing pharmaceutical wasteand reducing pharmaceutical waste

- Helping all staff understand their own - Helping all staff understand their own responsibilities in optimising medicines use responsibilities in optimising medicines use

Medicines Medicines OptimisationOptimisation Patient experiencePatient experience - Ensuring decisions are made jointly and - Ensuring decisions are made jointly and

that patients and their carers are that patients and their carers are knowledgeable about their medicines. knowledgeable about their medicines.

- Providing support for patients at all points - Providing support for patients at all points and across all interfaces of healthcare. and across all interfaces of healthcare.

- Local decisions about medicines are - Local decisions about medicines are robust, transparent and in accordance robust, transparent and in accordance with NHS Constitution with NHS Constitution

- Care is integrated and personalised - Care is integrated and personalised around the individual patientaround the individual patient

Medicines optimisation is a Medicines optimisation is a more patient-focused more patient-focused approach to getting the approach to getting the best from medicinesbest from medicines

"Medicines optimisation is a vital agenda, not an agenda added on to something else we are trying to do, this is absolutely central to it."Sir David Nicholson, Chief Executive, NHS

Workforce Workforce DevelopmentDevelopment

PrescribingMedicines Administration & Care Co-ordinationPharmacyShared Decision Making

Realising the Benefits Realising the Benefits of Technologyof Technology

E-prescribing & administrationAssistive Technology (adherence)Technology to support non-pharmacological approachesChoice & Medication (good quality information)

Improving Medicines Improving Medicines SafetySafety

Currently, where there is a gap between best practice and current practice, this most commonly occurs around the monitoring of medicines. Lack of buy in to:Informed patient choiceTherapeutic trial to avoid side effects“Medical Model”…..caused historical lack of infrastructure and negative association with medicines

Monitoring of Monitoring of MedicinesMedicines

•Monitoring Effectiveness•Monitoring Side effects•Monitoring Adherence•Monitoring Physical Health at Initiation and during Continuation•Education and resources required so to provide individual & effective management & support

Partnership WorkingPartnership Working

Oversight while under the care of the GP

GP provision of prescriptions and physical testing

Confidence of community pharmacists to review mental health medicines

Innovation, Research, Innovation, Research, Spreading and Maintaining Best Spreading and Maintaining Best PracticePractice

•Developing a Centre of Excellence for

Medicines Optimisation in Mental

Healthcare: Bringing Medication to Life

– A Partnership Approach.

Integrated Care Integrated Care Pathways- Don’t Pathways- Don’t Forget:Forget: Physical healthPhysical health Supporting Medicines BetterSupporting Medicines Better