2Esteem Glasgow Patient group 16-35 yrs with first episode psychosis Assessment and treatmentIn- patient and out-patient care, crisis and assertive outreachWorking with familiesMaximising recoveryMinimising trauma
3ESTEEM Clinical Model Home based care Formulation derived care plan Integrated Care PathwayHolistic approachEvidence based interventions with timely access to psychological therapies ( 70 % caseload referred to Clinical Psychology)Co morbidity ( 66% substance/alcohol abuse, 35% depression, 10% Autistic Spectrum Disorder)
4Currently 3 teams across Greater Glasgow Clinical Co-ordinatorsCommunity Psychiatric NursesOccupational therapistsSupport workersConsultant and other grades of PsychiatristConsultant and other grades of Clinical Psychologist
5Correspondence updating GP at a minimum of every three months DELIVERY TARGETS (from relevant ICP Condition-Specific Standards / ESTEEM Policies)Psychoeducational, psychological, psycho-social therapies delivered within 3 months of referral, with subsequent reviews of individual’s progressEvidence based medication algorithm is followed, including for medication resistant psychosis (e.g. SIGN; NICE guidelines)If patient disengages, continue to engage with family as required OR transfer of care between services / discharge to GP. If discharged < 2 years, log reason for dischargeCorrespondence updating GP at a minimum of every three monthsSuspected psychosis:Assessment within 5 daysAllocate key-workerAssertive engagementCollateral historyAssessment discussed with MDTMDT assessment if requiredDepression Screening (BDI-II)If discharge: Inform referrer of assessment outcome / advise re. re-referral if problems persistMDT Formulation within 12 weeks, inc. plan of interventionsReview of 1st care plan 3 months from formulation1. Self Report Questionnaires (BDI-II, AUDIT, DAST, SAS) at 0-6 weeks and 12 weeks completed by service-user with staff member2. Self Report Questionnaires at 6 months and 12 months completed by service user with Research Assistant unless agreed for staff member to administer.3. PANSS IS COMPLETED BY PSYCHIATRIST (with negotiation this can be passed on to other PANSS trained staff)4. Service Engagement Scale and AUS/DAS are completed by key-worker in collaboration with MDT (e.g. at formulation session)5. ECGI is completed by ‘carer / main social or practical support figure in client’s life’ with RA or staff memberOUTCOME MEASURES & FORMSComplete the following for all confirmed cases of First Episode PsychosisClient & Carer Consent ProceduresPositive and Negative Syndrome Scale (PANSS)Beck Depression Inventory (BDI-II)Alcohol-Use Disorders Identification Test (AUDIT)Drug Abuse Screening Test (DAST)Alcohol & Drug Use Scales (AUS/DUS)ESTEEM Service Receipt Inventory(Entry Form – completed by 6 weeks)PANSSBDI-IIAUDIT/DAST/AUS & DUS Service Engagement Scale (SES) & Service Attachment Scale (SAS)Experience of Care Giving Inventory (ECGI)ESTEEM Service Receipt Inventory (3 month)Consider if at risk of arrested recovery if SES score > 12 and prioritise formulation / re-formulationSESSASProcess of Recovery Questionnaire (QPR)ESTEEM Service Receipt Inventory (6 month)Consider if at risk of arrested recovery if SES score > 12 and prioritise re-formulationAUDIT/DAST/AUS&DUSQPRECGIESTEEM Service Receipt Inventory (1 year)ESTEEM Service Receipt Inventory (2 year)Consent to long-term follow-upExit InterviewICP REVIEWS: DOCUMENTS & ASSESSMENTSRisk assessmentADMIN:Personal Data SheetStandard letter acknowledging referral sent to GP / referrerICP diary initiated from date of acceptance onto ESTEEM caseloadPSYCISPhysical Health CheckGASSInitial assessment document to GP/referrer with outcome (acceptance/discharge)ICP Review MeetingICP Indicator Forms (OT / Psychology)AVONHONOSGlasgow Risk ScaleCopy of ICP care plan to client/GPSchedule annual MDT case discussionICP Annual ReviewICP Indicator Forms (OT/psychology)Predischarge ICP reviewTransfer of Care Document, inc. copy to GPREFERRAL0 - 6 WEEKS3 MONTHS6 MONTHS1 YEAR2 YEARESTEEM First Episode Psychosis Service NHS Greater Glasgow & Clyde
6SIGN RecommendationsThere is consistent evidence that EI services have benefit for engagement rates, readmission rates, access to family interventions and other psychological interventions and rates of functional recovery in patients with first episode psychosis.
7Cost Effectiveness of Early Intervention “Early Intervention costs more in the first year of care (compared to standard care) because of the higher rates of contacts with multi professionals, thereafter per patient EI costs considerably less than standard care, largely due to inpatient savings” ( Knapp et al., 2011)“ If EI services extended to cover the total population of England, estimated net savings to the NHS would amount to £290 million, increasing to £ 550 million if wider economic savings were taken into account” Department of Health
8Glasgow Edinburgh First Episode Psychosis Study 2006-2009 Three centres in Glasgow (ESTEEM), Edinburgh (EPSS and Adult CMHT services)Study aimed to characterise a sample of participants, investigate the role of attachment in the evolution of psychiatric symptomatology and service engagement
9OUTCOMES DUP Edinburgh 23 weeks vs Glasgow 13 Days as in-patients Edinburgh 72 vs Glasgow 33 ( in first 12 months)Glasgow patients had less positive symptoms and lower scores on general psychopathology
10Figure 2.4b: Five-fold variation in bed days for admissions with a primary diagnosis of psychosis for individuals aged years
12The Mental Health Policy Implementation Guide (DOH 2001) 14 to 35 year age entry criteriaFirst three years of psychotic illnessAim to reduce the duration of untreated psychosis to less than 3 monthsMaximum caseload ratio of 1 care coordinator to 10–15 clientsFor every 250,000 (depending on population characteristics), one teamTotal caseload 120 to 1501.5 doctors per teamOther specialist staff to provide specific evidence based interventionsThis guidance based upon best practise within specialist teams where the evidence comes from.
13NEIP Core service features (2005) Stand-alone service modelDedicated consultant psychiatrist inputFull age range (14^35 years)Care provided for up to 3 yearsAssertive community outreach workExtended opening hoursCase-loads of 10^15Adolescent provisionPrimary care referralDesignated access to acute beds
14Models of implementation in UK Specialist Team ModelThe service is provided through a stand-alone specialist team.All staff work predominantly for the team and have a shared task to provide EIP services.This is the model based on evidence from early EI and Assertive Outreach services.
15Dispersed or CMHT Model The service is provided by staff (full or part-time) embedded within an existing service, usually a Community Mental Health Team (CMHT). Staff are expected to follow core principles of care, but often have limited contact with people in similar roles. Limited evidence (See Fowler et al. 2009)
16Hub and Spoke ModelThis model is a cross between the above two models. The service is provided by staff who are be embedded in ‘spokes’, often CMHTs, and in the central ‘hub’. The hub usually provides access to leadership, specialist skills and support to the spoke workers. This model is often found in rural areas.
17Benefits and deficits of EIP service models (Dodgson & McGowan, 2010) Specialist Dispersed H & SEvidence Base to support X XPromotes team approach X XPromotes clear EIP valuebase/philosophy X ?Consistency of practice X Promotes recruitment andretention ? ?Promotes development ofspecialist skills X ?Strong local presence X Value for money ? ?May benefit othercommunity teams ? Easy to ring-fence EIPresource X ?
18Outcomes from service models Fowler et al (2009) compared comprehensive EI service with CMHT service with specialist EI workers attached to CMHT:Generic CMHT, only 15% individuals made full or partial recovery at 2 years.Specialist EIP workers in collaboration with traditional CMHT care, 24% made a partial or full recovery.Comprehensive EI service, 52 % made full or partial recovery at 2 years and significant reductions in admissions was an added benefit.
19Delivering EIP Each model has strengths and weaknesses Specialist team best outcomesChallenge is to establish the model that is most pertinent to the needs of the locality but also meets the core service features and clinical interventions that evidence shows are required for successful EI.EIP has to be value for money therefore promised outcomes must be achievedRisks in alternative service models are that outcomes are not achieved
20A key challenge for us all is delivery of EIP, not just in urban inner city areas but also in rural settings
22EIP Service Delivery Best practice principles Evidence base and Early Psychosis DeclarationButDemography, geography, resources, financial pressures mean compromise.What principles of EI are non negotiable?Practical and effective
23Minimum Fidelity Standards for New EIP Services (NIMHE 2005) Involvement of all stakeholders including CAMHS in service planningOptimally a discrete specialist team or hub & spoke that meets minimum standards for team definitionA coherent group of specialist practitioners whose sole/main responsibility is EIP with common aims and objectives, philosophy of care and agreed care standardsExplicit leadership that provides specialist supervision, work allocation,fidelity monitoring, service & staff development and performance managementAssertive outreach to those who require itClarified medical responsibility for patientsInterventions: as per policy implementation guideCapacity: sufficient capacity to meet the actual level of local need Capacity to be based on care-coordinator caseloads of and an intention to see clients for 3 yearsAudit and Information: local information gathered to enable audit including evaluations of outcomes
24Essential clinical components of EI Staff trained in EI approach and interventionsICP to guide and ensure fidelityTrue MDT work incorporating all disciplines including dedicated Consultant Psychiatrist and PsychologistComprehensive MDT assessmentDevelopmental history from family membersAssessment of family functioningFormulation driven care planHighlights potential barriers and risks and directs specific interventionsOngoing family work including formal therapy where indicatedIntensive support and outreach to engageCrisis function
25Discussion Delivering EI in Rural locations: which model? What is your expected caseload of 1st Episode Psychosis?(For every 250,000 (depending on populationcharacteristics), one team ; Total caseload 120 to 150)Is EI currently being delivered?What are the current resources?What skills training would be required?Scottish Government Remote & Rural Healthcare Report Mental Health (2008)Specific arrangements for the management of mental health crisis in remote and rural areas to be included in NHS Boards’ Psychiatric Emergency Plans (PEPs);The requirement to review the need for the extension of current mental health service provision to cover out of hours;The development of networks with specialist psychiatric centres, including communication across the system involving case management and critical incident reviews;Responsive retrieval systems for patients experiencing mental health crisis;The need to establish robust e-health links between remote and rural healthcare settings and larger psychiatric centres.Guaranteed access to expert opinion to inform clinical decision-making.Peer group support, training and education.Rotation for skills maintenance.Development of shared protocols and patient pathways.Transfer debriefs.Increased practitioner confidence.Clinical Audit.Good e-health links.Improved discharge planning.