2nd Hertfordshire Diabetes Conference The Fielder Centre, Hatfield HOW CAN INTEGRATING MENTAL & PHYSICAL HEALTH IMPROVE PATIENT OUTCOME & EXPERIENCE? 2nd Hertfordshire Diabetes Conference The Fielder Centre, Hatfield Thursday, 1st October 2015 Dr. Nikki Scheiner Dr. Sarah Cohen Lead Psychologist Consultant Psychiatrist Watford & Stevenage RAID Watford RAID

AIMS OF PRESENTATION To increase knowledge about mental health services in Hertfordshire To understand how psychological and mental health interact and impact on Diabetes To look at some case examples

RAID Rapid Assessment Interface and Discharge Service Watford General Lister Psychiatric Liaison Emergency Department Ward based Teaching and training Multidisciplinary Psychiatrists Psychologist Nurses Social worker

Examples of Co-morbidity 47 year old man with chronic and difficult to control Schizophrenia since age 22. Has been on various antipsychotics over the years including olanzapine and clozapine. Has developed Type 2 Diabetes, which is difficult to control 17 year old girl with Type 1 Diabetes since age 9. Lives with mother and step father who is a very controlling character. High demands on her academically. Has developed an eating disorder, with bingeing and purging by vomiting. Also runs sugars high to lose weight

RAID Frequent Attenders Programme Distributed to all involved professionals, to Service User and family/carer Therapeutic care plan drawn up – Aims to meet true needs and stop reinforcement of inappropriate behaviours Multi system (or multi agency) meeting; Biopsychosocial assessment with RAID psychologist to map out stressors impacting upon physical health Referred by Ward, ED, and now increasingly by specialist consultants; Patients with numerous inappropriate attendances to ED or ward

JP Referral: Ward-based Diabetes Registrar; Reason: District Nurses withdrew their service because of JP’s non-compliance and their view that she was not being honest about her medication adherence; Initial ward-based ax by RAID CPN: did not elicit mental illness. Reported that JP stated she would benefit from being busier

FIRST PSYCHOLOGICAL ASSESSMENT JP assessed in RAID offices in a wheel-chair, accompanied by a nurse Presentation: frail – impression quickly dispelled when she started to talk; mood: euthymic. Patient report: fully compliant with medication; good diet – cannot understand reason for hypos and admissions. Social: grandchildren visit everyday; daughter visits regularly; but still needs more to occupy herself.

CONTACT WITH GP GP: ‘we haven’t got a handle on her.’ RAID organised a meeting at GP surgery, attended by all GP partners and DNs: most expensive patient c. £350,000 in 4 years; Agreed that there was a psychological component to presentation; queried cognitive functioning

Cognitive assessment OPA: attended with daughter. Daughter: stressed +++ and has given up work to be main carer. JP completed the ACE-III and score suggested that she has very mild cognitive impairment; some memory loss, but not sufficient to explain. Language task: asked to write about her Christmas, wrote about hospital admission!

MDT meeting RAID Psychologist and Psychiatrist; Diabetes Consultant and Specialist nurse; Community Navigator; A&E JP’s behaviour on the ward: limits food triggering further hypos; seeks social interaction with nurses, e.g. helping making beds. Information also provided from GP and District Nurses

CARE PLAN Diabetes team reviewed her insulin regime to optimise it Bed manager asked to admit – if possible only to Heronsgate Ward at WGH (Diabetes ward) where JP is well-known to nursing staff; Referral to Age UK Active Living Club once weekly – transport and lunch included, and to Age UK Friendship Tea twice monthly; JP to be allocated a befriender under Age UK befriending scheme: one hour weekly; Community Navigator explored activities that take place on Fridays as JP’s hospital admissions tended to be just before the weekend; Carer’s assessment offered to daughter.

OUTCOMES Patient’s experience: positive; Patient’s control of Diabetes: improved; Number of admissions: reduced; Length of Stay: reduced; Daughter’s anxiety: reduced; Cost to GP and Health Care budget: reduced

Psychosocial factors & Diabetic control Personal identity (forms in teenage years / early adult years, at same time as Type 1 diabetes Sense of self control / being controlled Peer influence and need to fit in Depression: poor motivation, loss of interest, sleep dysregulation; poor or increased appetite Psychotic illnesses: self neglect; delusions and hallucinations; thought disorder; chaotic lifestyles; antipsychotics Eating disorders : altered body image; enmeshed relationships; disordered relationship with food Drug and alcohol use Cognitive impairment Attachment issues

Integration You can not deal with physical illness in isolation. If you don’t deal with psychological factors concurrently treatment will fail

THANK YOU sarah.cohen@hpft.nhs.uk nikki.scheiner@hpft.nhs.uk