Rapid, Assessment, Interface and Discharge Liaison Psychiatry Model (#2960)

Idea Description
Overview of Innovation:
The primary aim of this document is to provide an overview of the Rapid, Assessment, Interface and Discharge model and provide an evidence base for the adoption of the model. This document provides supporting evidence to the implementation of the ambitions set out in the Five Year Forward View for Mental Health to introduce evidence-based treatment pathways across mental health services.

It states: ‘by 2020/21, NHS England should invest to ensure that no acute hospital is without all-age mental health liaison services in emergency departments and inpatient wards, and at least 50 per cent of acute hospitals are meeting the ‘core 24’b service standard as a minimum’ to ensure provision of liaison mental health services in all general hospitals

For more information, please refer to the National Rapid, Assessment, Interface and Discharge Plus Newtork, here.
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Overview summary:
The co-occurrence of mental and physical health problems is common, leading to poorer health outcomes and increased healthcare costs. Birmingham and Solihull Mental Health NHS Foundation Trust developed the RAID model for liaison psychiatry services as a pilot in Birmingham. The RAID multi-disciplinary team assesses A&E attendees/inpatients 24/7 who might have mental health problems, and provides e-training. There is now a RAID service in every hospital in Birmingham and Solihull and 27 organisations nationwide have taken up RAID. 
Challenge identified and actions taken :
The co-occurrence of mental and physical health problems is very common among patients, often leading to poorer health outcomes and increased healthcare costs. People can face lengthy waits before being referred on to the relevant service.
Birmingham and Solihull Mental Health NHS Foundation Trust developed the RAID (Rapid Assessment, Interface and Discharge) model for liaison psychiatry services in December 2009 as a pilot in City Hospital in Birmingham, with an investment of £0.8 million. The RAID team, comprising nurses, psychiatrists, psychologists and physicians assistants, will promptly assess anyone 24/7 attending A&E or who is a hospital inpatient, who might have mental health problems.
The RAID network, which is supported by WMAHSN, was established to strengthen links between RAID services to facilitate collaborative working on research and innovation projects, facilitate adoption of RAID and improve and expand the overall service provided by RAID across the NHS. 
Impacts / outcomes: 
  • Following the success of RAID in City Hospital, the trust now has a RAID service established in every acute hospital in Birmingham
  • 27 organisations nationwide have now taken up RAID
  • In its 2014 document Achieving Better Access to Mental Health Services by 2020, the Department of Health highlighted strong evidence that the RAID model can deliver clinically and cost-effective care to patients with a range of mental health problems
  • A paper published in The Psychiatric Bulletin (2013) uses data from admissions to all 600 beds in City Hospital between December 2008 and July 2010. The paper showed that the main direct effect of the RAID model was on time to readmission:
  • The rate of readmission in the RAID group was four for every 100 patients, while in the pre-RAID group it was 15 for every 100
  • Including the RAID-influence group, the total reduction in readmissions is estimated to be 1,800 over 12 months. This equates to a saving of 8,100 bed-days per year
  • There is also a strong indirect effect resulting from the broader influence on those not referred to the service, in the form of reduced lengths of stay: the RAID-influence group demonstrated an average length of stay 3.2 days shorter than that of the pre-RAID group. This corresponds to a total saving of 13,935 bed-days per year
  • The RAID model is estimated to save between 43 and 64 beds per day, which is equivalent to two-three wards
  • Most of the savings were accrued by geriatric wards
  • The study estimates the potential savings to be £4-6 million per hospital by reducing both admissions and length of stay
  • The service won a prestigious HSJ Award for innovation in mental health in 2010
  • RAID was highlighted in 2011 in an NHS Confederation Mental Health Network briefing paper which documented the benefits of liaison psychiatry
  • An independent economic evaluation of the original RAID service was produced by the London School of Economics and Centre for Mental Health in 2011
  • RAID was cited in an a 2012 HSJ article, “Liaison psychiatry can bridge the gap”
  • An economic evaluation of the RAID roll-out across Birmingham was produced in 2013 by the local Commissioning Support Unit, Midlands and Lancashire CSU
  • Further liaison psychiatry service guidance which discusses the range of potential models was produced for the South West Strategic Clinical Network for Mental Health, Dementia and Neurological Conditions in 2014
  • A RAID review was commissioned from the University of Birmingham’s Health Services Management Centre, with six West Midlands implementation sites involved (2015)
  • Dementia and self-harm e-learning, tailored for acute trust staff, has been delivered to more than 60 staff in each module across two acute trusts
  • A national RAID Network has been established to support organisations and individuals who are using or planning to use Psychiatric Liaison models. To date two meetings have been held, the second of which had Geraldine Strathdee, National Director for Mental Health, as a key speaker. The RAID network’s first event attracted delegates from across the region, along with people from across England and the wider UK. 61 people from 24 organisations attended the first event, and 64 people from 31 organisations registered for the second event. In total, representatives from 41 different organisations registered to attend, with 17 new organisations coming to the second event. This has created a mechanism for sharing best practice for liaison services nationally. In addition, the network’s long term funding has been secured by BSMHFT in partnership with East London NHS Foundation Trust
  • The national RAID Network is supported by a website and newsletters
  • Two academic organisations, two acute trusts, two mental health trusts and three industry bodies were involved in project delivery.
Which local or national clinical or policy priorities does this innovation address:
• This is a priority area for the government, with a £30 million targeted investment in effective models of liaison psychiatry in more hospitals announced in October 2014 as part of its aspiration to put mental health care on an equal footing with physical healthcare • The NHS Five Year Forward View emphasises proper funding and integration of mental health crisis services, including liaison psychiatry.
Supporting quote for the innovation from key stakeholders:
John Short, Chief Executive at Birmingham and Solihull Mental Health NHS Foundation Trust, said: “RAID has a track record of improving quality of care for patients and also saving money and has been independently evaluated and highlighted nationally as a best practice model for liaison psychiatry. We are delighted to host this network in order to bring together teams from across the NHS to share knowledge and learning and further develop and improve the RAID model for the future.”
Plans for the future:
The RAID review will be used to drive consistency and to support the tailoring of RAID services regionally, to local needs and context while remaining true to the core principles which enable successful delivery. 
Tips for adoption:
  • Innovative new approaches can make an important contribution to improving outcomes and relieving pressures on other parts of the health system – but there are unlikely to be ‘magic answers’ or panaceas. Even where a new model appears to have significant early success it is unlikely to be something that can simply be imported/bought in in order to solve all problems locally
  • Many participants felt that RAID had delivered (or had the potential to deliver) real benefits. However, the way in which RAID was planned, resourced, staffed and supported were perceived to be key factors influencing its success
  • New services do better when they receive the support of senior managers and where the service is sufficiently resourced – a number of participants talk of a ‘critical mass’ that was needed to instigate real change
  • RAID was more favourably evaluated by participants when services included a focus on older adults and where the service addressed the needs of inpatients, in addition to having a role in reducing waiting times in A&E
  • The RAID service, designed to operate across a number of different services, could not be sufficiently evaluated by using single outcome measures i.e. reduced waiting times or cost savings
  • New models are designed in a specific way for a reason, and there needs to be a degree of fidelity to the underlying model if the successes of early service models are to be replicated. Only partially implementing a new approach is unlikely to work. Certainly, those Trusts that have taken the RAID model and implemented only a proportion of the new approach shouldn’t be surprised if it doesn’t deliver what a full model might
  • At the same time, new ways of working need to be designed and implemented in ways that are appropriate within the context of existing local services, personalities and relationships. This means that models cannot be imported wholesale, but that there is a legitimate process of adaptation (which may take time to plan and implement)
  • Taken together, the two bullet points above suggest a tricky balance between being clear on/remaining true to the key elements of a successful model, whilst also being flexible about how best to implement in different local contexts. Adaption of the model needs to be mindful of existing services that are in operation and of local populations
  • ‘Soft’ outcomes matter too – even if they are harder to measure. It may take time for all outcomes to be produced because of “teething difficulties” as a service establishes itself and because an attitudinal change towards mental health is hard to achieve
  • Paying attention to practicalities is important (for example, access to IT and appropriate accommodation/space near to linked services). In order to have an integrated service, teams need to be physically close to each other and be able to access joint notes
  • Developing new ways of working takes time, and is as much about developing new relationships as anything else. By definition, liaison is a two-way process, and attention needs to focus on the host organisation as well as on the new service
  • Above all, we need to be clear about the outcomes we are trying to achieve by looking to a new service. Improving patient experience is a different type of outcome from trying to hit a 4-hour access target, which is different again from raising awareness of mental health issues amongst hospital staff, facilitating swift discharge, preventing readmissions and/or freeing up staff time to focus on other priorities. While it may be possible for one approach to do a number of these things at once, being clear about what success would look like seems to be an important precursor to knowing whether or not something has actually succeeded in practice.
Contact for further information:
Katie Saunders
0121 371 8061
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Innovation 'Elevator Pitch':
This is a risk stratification model that aims to predict and prevent crisis by segmenting the mental health patient population by risk and likelihood of an acute mental health crisis.
Overview of Innovation:
Currently, the response to mental health crisis is mostly reactive. To address the increasing pressures faced by the urgent care services by patients presenting with mental health crisis, prevention and early intervention must be prioritised. This will not only alleviate pressure of several emergency care services but will also improve patients’ prospect by ensuring  timely interventions that avoid patients’ mental health deteriorating further.

The Rapid, Assessment, Interface and Discharge Plus project, in partnership with Telefonica Alpha, aims to achieve this by developing and validating a risk stratification model and algorithm to predict mental health crises. The risk stratification model will use four years of pseudonymised clinical and sociodemographic data to capture potentially robust predictors from a wide range of sources to provide an overall indication of a patient’s risk of experiencing a mental health crisis.

By applying the model onto the Trust’s mental health population, we can stratify the patients into different risk groups and subsequently target the highest risk segment of the population for preventative early intervention with improved accuracy. This information will be provided to clinicians who will determine the necessary measures required to prevent the progression from high-risk status to actual mental health crisis. This will act as a ‘clinical support tool’ for clinicians in making their decision and does not replace the clinicians decision on how to manage patients.

The project will look at how the risk stratification model can be implemented into practice, working with Community Mental Health Teams (CMHTs) to pilot the model. The model will be refined, tested and validated by a team of data analysts, clinicians and to embed it into systems for routine clinical care. Using this tool can help improve patient care by avoiding unnecessary admission, presentation at A&E, or potentially prevent an escalation in the worsening of a patient’s mental health state.
Stage of Development:
Trial stage - Trial stage to prove that the idea actually works as intended
WMAHSN priorities and themes addressed: 
Mental Health: recovery, crisis and prevention / Long term conditions: a whole system, person-centred approach / Wellness and prevention of illness / Digital health / Innovation and adoption
Benefit to NHS:
In a pressurised financial environment, faced continually with greater challenges to meet quality objectives, this innovative product can simultaneously improve patient outcome by reducing intensity and/or preventing mental health crisis as well as reduce costs by stopping the over saturation of emergency services.
The use of technology systems and data is at the centre of the NHS Five Year Forward View. It highlights how the use of data and technology will transform outcomes for patients and citizens. The insights derived from the risk stratification model will help the NHS explore how the information/ data they hold could be used in clinical settings to benefit patients. It will highlight patterns in the data that can be used to develop proactive preventative measures to support mental health patients.  The ability to stratify risk and predict those who might be at risk of mental health supports frontline mental health clinicians to de-escalate situations before crises arise. This leads to improved patient outcomes by avoiding the further deteriorating on mental health and potential saving where the intervention has prevented an entry to the crisis care system.
The reduction in demand for emergency and inpatient mental health services will relieve the pressure from the crisis care pathways resulting in enhanced patient experiences, improved staff support and morale, and greater efficiency and effectiveness within urgent care mental health services to respond to current and future patient needs.
Initial Review Rating
1.00 (1 ratings)
Benefit to WM population:
Mental health crisis is a significant and increasing problem across Birmingham and Solihull. The number of crises in the region has increased by an average of 7% year on year for the past 5 years and is projected to increase further in the future, according to the Midlands and Lancashire CSU. Therefore, this places increased level of pressure on urgent care services and it is important to be able to introduce proactive measures to stop at risk patients from going into crisis.

The redesign of the crisis care pathway is a key NHS England target for CCGs and a central theme within the STPs. Within the Birmingham and Solihull STP, one of the key mental health objectives is to ‘Manage – preventing mental health crises and managing them better when they do’. Identification of at risk patients and supporting them by intervening sooner fall in line with the STP objective and while this tool doesn’t directly prevent the onset of crisis, it helps refine predictions and manage at risk patients proactively. The use of data-informed decision making leads to better clinical outcomes for West Midlands patients and can potentially release both capacity and resources across the emergency and urgent care system
Current and planned activity: 
The risk stratification model was developed collaboratively between BSMHFT and Telefonica Alpha as part of the Rapid, Assessment, Interface and Discharge Plus NHS Test Bed. The pilot work testing is being supported by The Health Foundation.
The tool is planned to be tested in real time by Community Mental Health Teams (CMHTs) in Birmingham and Solihull from September 2018. The CMHTs were identified to be in the most suitable position to be able to utilise a predictive model for crisis presentation into their working practice. The patients at risk will be flagged in real time and this will be reviewed by the CMHTs and an effective intervention put in place to avert the crisis. A robust evaluation is being conducted by the CSU looking at the effectiveness of the tool in supporting clinician’s decision making.
Return on Investment (£ Value): 
Return on Investment (Timescale): 
Ease of scalability: 
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