Liaison Psychiatry Model (#2960)

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Idea Description
Overview of Innovation:
The primary aim of this document is to provide an overview of the Liaison Psychiatry 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
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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 model for liaison psychiatry services as a pilot in Birmingham. The Liaison Psychiatry multi-disciplinary team assesses A&E attendees/inpatients 24/7 who might have mental health problems, and provides e-training. There is now a service in every hospital in Birmingham and Solihull and 27 organisations nationwide have taken up the service. 
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 model for liaison psychiatry services in December 2009 as a pilot in City Hospital in Birmingham, with an investment of £0.8 million. The Liaison Psychiatry 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 Liaison Pschiatry network, which is supported by WMAHSN, was established to strengthen links between Liaison Psychiatry  services to facilitate collaborative working on research and innovation projects, facilitate adoption of the model and improve and expand the overall service provided by Liaison Psychiatry across the NHS. 
Impacts / outcomes: 
  • Following the success of Liaison Psychiatry in City Hospital, the trust now has a Liaison Psychiatry service established in every acute hospital in Birmingham
  • 27 organisations nationwide have now taken up Liaison Psychiatry
  • In its 2014 document Achieving Better Access to Mental Health Services by 2020, the Department of Health highlighted strong evidence that the 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 model was on time to readmission:
  • The rate of readmission in the Liaison Psychiatry group was four for every 100 patients, while in the pre-Liaison Psychiatry group it was 15 for every 100
  • Including the Liaison Pschiatry-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 Liaison Psychiatry-influence group demonstrated an average length of stay 3.2 days shorter than that of the pre-Liaison Pschiatry group. This corresponds to a total saving of 13,935 bed-days per year
  • The Liaison Psychiatry 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
  • Liaison Psychiatry 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 Liaison Psychiatry service was produced by the London School of Economics and Centre for Mental Health in 2011
  • Liaison Psychiatry was cited in an a 2012 HSJ article, “Liaison psychiatry can bridge the gap”
  • An economic evaluation of the Liaison Psychiatry 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 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 Liaison Psychiatry 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 Liaison Psychiatry 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 Liaison Psychiatry 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: “Liaison Psychiatry 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 model for the future.”
Plans for the future:
The Liaison Psychiatry review will be used to drive consistency and to support the tailoring of Liaison Psychiatry 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 Liaison Psychiatry had delivered (or had the potential to deliver) real benefits. However, the way in which Liaison Psychiatry 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
  • Liaison Psychiatry 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 Liaison Psychiatry 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 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
katie.saunders@bsmhft.nhs.uk
0121 371 8061
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Overview summary:
Dr Amit Arora at University Hospital of North Midlands (UHNM) has developed a Frailty Passport for frail elderly patients. The Frailty Passport is a patient held diary that holds the patient’s statement of preferences and wishes for the rest of their life.

This project aims to discuss advance care planning with frail elderly patients and as a by-product also reduces unplanned admissions and length of stay by communicating a personalised integrated care plan that is agreed by all parties involved- putting the patient right at the centre of care.
Challenge identified and actions taken :
It has been reported that frail elderly patients often have multiple hospital admissions. They often get readmitted to hospital because they are not always asked what they want when approaching the end of life. These discussions often happen at an inevitable or imminent stage of end of life rather than when approaching end of life. The aim is to issue the Frailty Passport and extend it to those frail patients ‘approaching end of life’ to enable ‘dignity in death’ rather than discussing advance care plans when death is imminent.

Therefore, this project strives to create an intervention service that puts the patient at the centre of their care plan. It aims to reduce unplanned admissions and length of stay, by establishing an integrated personalised care plan- bridging communication and care between all providers. This is done by the passport being completed in conjunction with the patient, their families and the medical teams. A Multi-Disciplinary Meeting (MDT) is organised to create an inclusive environment where all information can be shared regarding the Frailty Passport. The patients GP is also involved and is informed of the passport. It only becomes valid if the GP agrees to the contents after discussions with the patient, or their representative. This then enables patients to spend more time out of hospital.
Impacts / outcomes: 

The Frailty Passport is intended to be used by health and social care professionals. The passport incorporates advanced care plans, supporting the patient or a new or revised care plan(s), in relation to the social situation, activities of daily living, crisis management plans, ceiling of care, and end of life plans including DNACPR documentation. Therefore, documenting and respecting patient wishes. This has achieved many positive outcomes which are mentioned below:
  • By streamlining care and improving communication across the traditional boundaries of primary care, secondary care, ambulance services, social care, housing and care homes it improves the whole experience for both health and social care in later years.
     
  • The written information is given to relevant staff in health, social care, carers and care home as guidance about matters that have been discussed in detail with patients (and/or representatives) and their medical records. This improves the quality of life, dignity, choice and autonomy.
     
  • As the passport streamlines care it avoids unwarranted hospitalisation, facilitate discharges, readmission and lists patient’s wishes and preferences. It also aims to improve the patients experience across the whole NHS for the rest of their life.
     
  • As this written plan is agreed by the MDT it will give enough confidence to health and social care staff to follow patient’s wishes.
     
  • The Frailty Passport has been listed as a good practice example by NHS England.
Overall, the Frailty Passport has been effective by clearly communicating the patient’s wishes and putting them at the centre of the care plan. It also gives written information to health and social care staff and provides medico-legal assurance.
Which local or national clinical or policy priorities does this innovation address:
At the moment the Frailty Passport is being used at UHNM and has plans to spread to other Trusts who are interested in the innovation. The priority this innovation addresses is: • To reduce healthcare related harm as complex elderly patients are at risk when admitted as an emergency (NHS England). • Preventing individuals from dying prematurely. • Enhancing the quality of life for individuals with long term conditions. • Helping individuals to recover from episodes of ill health. Furthermore, the Frailty Passport innovation ensures: • Ensures that patients have a positive care experience. • That the treatment and care for patients is in a safe environment, protecting them from avoidable harm.
Supporting quote for the innovation from key stakeholders:
Dr Amit Arora said- Traditionally Health and Social Care professionals are widely acknowledged to use syntactic language, current practice within the project when liaising with patients is to use terminology that can be understood by all involved. Acting as an advocate on behalf of the patient and family ensures that patients were given opportunity and support to discuss their wishes, concerns and suggestions for advance care planning. Also, highlighted was that the Frailty Passport is vital to ensure that patients and family fully grasped what was being communicated. The Frailty Passport also provides the reassurance of a clear documented and agreed written care plan to the care home staff when deciding what to do in the event of clinical deterioration in condition.

Here is some feedback that was given about the Frailty Passport in a few short quotes from individuals who have utilised the Frailty Passport:

“The best service I’ve had.”

“I wish every old person can have one of these”.

“This is the first time I have been asked about such an important issue”.

“This is absolutely fantastic”.
Plans for the future:
The USP of this innovation is that the boundaries between Acute Community, Primary, Social and Mental Health Care are able to successfully align to another. The introduction of the Frailty Passport results strong communications with all parties involved improves hand overs and improves the quality of patient care and satisfaction.
  • The next step for the Frailty Passport is to work towards the sustainability of the project and possibly modelling and scaling to meet the current demand.
     
  • Parameters could also be developed, which will enable identification of groups of high-risk patients at an earlier stage. This will facilitate early intervention and allow a more effective use of resources.
     
  • It could be hoped that a predictive model could be introduced in the future.
At present the teams can be alerted about the presence of the Passport by a notice at the back side of front door and is only available in a paper copy but an electronic format is being planned for further roll out. Evidence showed that health and social care can be difficult to understand and navigate as only 55.5% knew how to access further information or support. This will be an area for future improvement. 
Tips for adoption:
Adopting the Frailty Passport includes utilising a multi-disciplinary case management approach, which is linked to the management of multi-morbid patients can facilitate a reduction of reliance on acute based care.

Adopting the Frailty Passport enhances communication and has proven to be a valuable tool in enabling all stakeholders to fully understand and comprehend what’s planned how it will be facilitated and who is responsible. 

By adopting the Frailty Passport patients, carers and family have been fully involved in the project and always include their own planning and MDTs.

If you would like more information on the Frailty Passport please contact Amit Arora: amit.arora@uhnm.nhs.uk
Contact for further information:
If you would like more information please contact Dr Amit Arora: amit.arora@uhnm.nhs.uk
 
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Innovation 'Elevator Pitch':
Using pathways and simulations to generate a synthetic population, informed by known population and health statistics, to act as a safe and effective testing environment for digital health solutions.
Overview of Innovation:
We are using pathways and simulations to generate a synthetic population, informed by known population and health statistics. This is intended to act as a testing environment, providing evidence for the decision-making, implementation and evaluation of all policies that impact health, whilst eliminating the risk of using real patient data.

The process involves conducting a document analysis on relevant documents, clinical guidelines and standards to set the scope of the project and identify the important information items that need to included in the model. Existing pathways can be used or, based on evidence from the document analysis, new pathways created to include care, disease progression or system management pathways. A synthethic population is then generated using Census data for the specific locality, to reflect the same demographic distributions of the real population. This population are then run through the pathways and at each clinical interaction on the pathway, a digital exhaust can be produced that reflects those seen in real systems. The pathway execution stage also produces an event log detailing the steps and relevant information (e.g. costs and waiting times) for each individual in the population. These outputs can then be analysed using data visualisation tools to provide an interactive dashboard that visually tracks, analyzes and displays they key performance indicators (KPI), metrics or key data points needed for the project.

This approach can be used to support service design, business case development, clinical engagement, user prototyping, supplier testing, training, demonstration, software product testing and resources for hackathon events.

This is a scalable and reusable approach that will be of particular value following the implementation of the GPDR in May 2018 when anyone interested in data-driven improvements for health will need synthetic data.
Stage of Development:
Evaluation stage - Representative model or prototype system developed and can be effectively evaluated
WMAHSN priorities and themes addressed: 
Digital health / Innovation and adoption
Benefit to NHS:
This approach has many valuable use cases for the NHS, including:
  1. Service design 
    • Building pathways in a standard format and using a realistic synthethic population, the workload, outcomes and risk factors affecting the service can be illustrated and reviewed
  2. Business case development 
    • Running the model twice, once with and once without a planned service change, allows the delivery, benefits and risks of a new service to be monitored
  3. Clinical engagement 
    • Engaging pathway diagrams and credible synthetic health records bring a project and the use case to life, helping to engage clinicians throughout a project, enabling issues and misunderstandings to be identified and resolved early
  4. User prototyping
    • Providing realistic data for early prototype screens and documents to verify user needs and set expectations will facilitate an easier, quicker and cheaper process of iteratively building, testing and adapting ideas
  5. Supplier testing
    • Providing an extensive set of synthetic data is able to simulate a wide range of scenarios for system testing, without using real patient data that has privacy restrictions
  6. Training 
    • Generating live synthetic data that is close to the real population in terms of age/sex/household composition/clinical history can be used to train clinicians on how to use the current systems, without using real patient data
  7. Demonstration
    • Using a population and clinical pathways that are relevant to the specific customer is more engaging and better for demonstrating the value of the product for the clients use case
  8. Software product testing
    • Synthetic data, that replicates real patient data but is free from privacy restrictions, can be generated to provide software developers with a rich testing framework, allowing them to build, test and improve their products before deployment
  9. Hackathon resources
    • Providing a synthetic population and library of pathways prior to an event will help to set the scope of the hackathon
    • A toolkit to generate relevant test data can then also support projects that emerge during the hackthon, improving the productivity and value of these events
Initial Review Rating
3.00 (1 ratings)
Benefit to WM population:
This approach will improve the safety and efficiency of patient care in the health service in the West Midlands, support interoperability and innovation and ensure patient data is protected from privacy and confidentiality issues. This will have a huge range of benefits for the West Midlands population, from better care to more control over the use of their data.
Current and planned activity: 
We currently have two proof-of-concepts projects;
  1. Supporting a business case for a Fracture Liaison Service 
  2. Generating the FHIR resources and profiles for a synthethic population of asthma patients
We are looking for research partners or Trusts interested in putting together a joint-bid for some EU funding to explore and assess the technical feasibility and commercial potential of this approach. We would also be interested in working on individual use cases with digital leads or with standards development organisations to develop this as a system-wide approach.
Return on Investment (£ Value): 
high
Return on Investment (Timescale): 
0-6 mon
Ease of scalability: 
Simple
Regulatory Approvals:
Please describe any current regulatory approvals you have achieved and how they were met/ in progress/planned.
Commercial information:
Please describe how the product/service is being developed commercially, whether in development, trials, pilot or full commercial delivery. Include the results you have from any market/demand surveys and forecasts . Please include any research you have on the broader commercial opportunity for the innovation both within the health sector nationally and internationally.
Investment activity:
Please describe what stage of investment you have reached and whether you are seeking additional rounds of investment. Please include cash investment as well as investment of soft assets such as access to specialist equipment, knowledge, trial base etc. and indicate the types/sources of your investment such as grants etc.
Regional Scalability:
Please describe how the innovation could be scaled across the WM region. Have you implemented at scale in any other regions?
Measures:
What outcomes are you hoping to achieve and what are the measures that you will use to gauge the success of the innovation and how will these assessments be made? Please ensure that you have quality, safety, cost and people measures.
Adoption target:
What are the targets for adoption across the WM and what are the minimum viability levels?
Investment sought:
What investment are you looking for in order to support wider adoption of this innovation and what have you managed to secure to date? Please provide a breakdown of these costs if possible.
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