1 SEPT Clinical Health Psychology Service SOUTH ESSEX QIPP PROJECT Clinical Lead: Dr Greg Wood, Consultant Clinical Psychologist
2 Clinical Health Psychology Initiatives Proposals posited locally: identified needs in Stroke provision and LTCs in South Essex EoE SHA support for investigating QoL, efficiency and cost savings through psychological provision Funding for Stroke (acute and community) and COPD (acute and community) identified 132k for Stroke QIPP project 97.5k for COPD QIPP project CCG leads, CSU staff, SEPT community and MH staff and Southend managers engaged
3 COPD PROJECT DR HANNAH OSBORNE DR HANNAH OSBORNE PRINCIPLE CLINICAL PSYCHOLOGIST
4 QUIPP COPD Psychology Aims Decrease service use: Reduce number of inpatient admissions Reduce number of repeat admissions i Increase period of being well at home Increase quality of life Increase adjustment & self coping. Decrease anxiety/depression Increase self management and completion of PR.
5 Prevalence of mental health in COPD 3 times more likely to have emotional difficulties than the general population p (NICE, 2009). Rates of anxiety disorders much higher than in the general population: GAD 3x greater; panic 5x higher (Brenes, 2003) Rates of anxiety higher than in patients with cancer, heart failure and other medical conditions (Brenes, 2003) Higher rates of depression (42%) than in other medical patients (Light et al., 1985) 50% prevalence of anxiety and depression in COPD (Mikkelsen et al., 2004) High prevalence rates found in western and developing countries (Mikkelsen et al., 2004) These people have poorer outcomes, lower quality of life and These people have poorer outcomes, lower quality of life and reduced ability to manage their symptoms (Felker et al., 2010).
6 Impact on social and emotional functioning Patients experience: Reduced quality of life Reduced uptake of therapeutic activities Increased admission rates and duration Delayed discharge Decreased functional status Increased pain Increased disability Marital problems Increased mortality Increased non-compliance with medication/treatments Increased exacerbations 59-62% increase in medical costs (Brenes, 2003; Mikkelsen et al. 2004; Sage et al., 2008)
7 COPD and anxiety/depression: why such high prevalence? Impact and experience of physical symptoms (breathlessness, fatigue, weight loss, mobility); Overlap of somatic and psychiatric symptoms; Symptoms can be very frightening; Side effects of medications (steroids); Loss: changes in social, peer and gender relationships; employment status; Smoking: elevated lifetime rates of anxiety in smokers; more difficult to quit if anxious or depressed; only got myself to blame ; Shame: disability, oxygen; No cure/terminal.
8 COPD & BREATHLESSNESS Anxiety Panic Frustration Acceptance Depression Coping STRESS IMMUNE SYSTEM IMMUNE SYSTEM ADRENALIN RESPONSE LONGER HOSPITILISATION POORER RECOVERY LOWER ACTIVITY SLEEP PROBLEMS TENSION NON-COMPLIANCE POOR QoL
9 The Evidence for clinical psychology input The impact of pulmonary rehabilitation ti programmes for COPD can be increased by adding a psychological component, improving completion rates and reducing re-admission for COPD (Abell et al 2008). CBT-based interventions can improve treatment adherence, psychosocial adjustment, coping skills and quality of life for people with co-morbid longterm conditions, as well as reducing use of health care services (Thompson et al 2011; Spurgeon et al 2005). Including a psychological component in a breathlessness clinic for COPD in Hillingdon Hospital led to 1.17 fewer A&E presentations and 1.93 fewer hospital bed days per person in the six months after intervention i (Howard et al 2010). This translated into savings of 837 per person around four times the upfront cost. An RCT of CBT based Guided Self Help for breathlessness resulted in a total saving of 450 per person based on A&E attendance and admission rates (63 % reduction) (Howard et al., 2010)
10 The South East Essex COPD Service Prior to Specialist Clinical Psychology input there was: No reliable means of recognising or detecting mental health difficulties in COPD. No clear pathway for the treatment of psychological distress in COPD. No specialist psychology treatment for acute or community care Limited staff knowledge/training in managing emotional difficulty A reliance on IAPT or anti-depressant/benzodiazepine treatment for complex emotional difficulty in COPD.
11 The Psychology COPD Project Oct 2012 Jan 2013 Preparation & engagement Preliminary MDT acute and community staff training Engagement with community & hospital; clinical engagement group Recruitment of senior Clinical Psychologist Feb 2013 April 2013 April 2013 current
12 The Psychology COPD Project Oct 2012 Jan 2013 Feb 2013 April 2013 Preparation & engagement Preliminary MDT acute and community staff training Engagement with community & hospital; clinical engagement group Recruitment of senior Clinical Psychologist Development Qualified clinician in post Servicepathway and referral process development Screening & outcome tools: Staff training & psychology champions training Pulmonary rehab input commences Feb 25 th Service open to referrals, clinic and inpatient service. Self help manual (anxiety and depression) developed April 2013 current
13 The Psychology COPD Project Oct 2012 Jan 2013 Feb 2013 April 2013 April 2013 current Preparation & engagement Preliminary MDT acute and community staff training Engagement with community & hospital; clinical engagement group Recruitment of senior Clinical Psychologist Development Qualified clinician in post Servicepathway and referral process development Screening & outcome tools: Staff training & psychology champions training Pulmonary rehab input commences Feb 25 th Service open to referrals, clinic and inpatient service. Self help manual (anxiety and depression) developed Action CBT groupand ACT community group program commence Community matron CBT supervision (once every 2 weeks) Guided self help and self help available A&E/care home/ RRT training in panic symptom management Depression and low mood CBT training, ward based self help developed Psychological guidance for smoking cessation service
14 Our model of psychological l support All available on both an inpatient, outpatient and home basis. Tier 1: Individual Sessions (up to 12 sessions) 936 Tier 2: Group therapies tailored to COPD (6-8 sessions) ACT/CBT Tier 3: Psychology + pulmonary rehab Tier 4: Self help/guided self help tailored to COPD
15 Direct Interventions The Interventions Indirect Interventions 1:1 evidence based Consultation with MDT therapy with specialist Guided d self help delivered d Clinical Psychologist (up to by Nursing staff in 12 sessions) community and hospital (4 CBT group (6 sessions) sessions) Acceptance and Psychological input and Commitment Therapy joint work in Hospital Group (8 sessions) Pulmonary Rehab Assessment only program. Inpatient sessions Basic psychological l Self help
16 Case Examples Case 1 Case 1: Mrs Y, 75 yrs of age, COPD for 8 yrs, anxiety and memory problems. Pre: 7 admissions in 6 months, 47 bed days, Intervention: 1:1 sessions during admission and following discharge at home, focus on panic management and involved close work with daughter. Liaison and attendance at pulmonary rehab ensured Mrs Y did not drop out due to health anxiety. Post: No admissions since May 2013, successfully completed pulmonary rehab, continues to live at home.
17 Case example case 2 Case 2: Mr X, 61yrs, diagnosis i of v. severe COPD. Long history of poor engagement and compliance with services and medication. Severe, untreated life-long depression, self-medicated through drugs and alcohol. Pre: 2 admissions in 2 months, 11 bed days, 7, Intervention: Seen in hospital, T/C appointments every week and clinic appointments every 3 weeks. Post: No further admissions since April 2013, now reliably attending clinic once a week off own volition and preparing p to engage g in physio, mental health support and pulmonary rehab programme.
18 Treatment t overview Treatment Overview Treatment Type Number of Patients 1:1 clinic 24 1:1 Home Visit 22 CBT Group 38 ACT Group 6 Pulmonary Rehab 54 Guided self help 10 Self help 31 Assessment Only 7 Inpatient Only 4 Referred on 3 waiting 14 Patient Referral Sources Referred From Number of Patients Pulmonary Rehab 72 Consultants 32 Community Matrons 55 Ward 18 Rapid Response Team 6 Other 16 Total 199 Total 213 Nb. Higher number reflects clients in multiple treatments * 47.8% of people receiving 1:1 therapy seen at home due to nature of disease and hospital transport issues.
19 Clinical Outcomes Direct Interventions * HV = home visit
20 Clinical i l Outcomes - Recovery Dimension % % No % Improv reliable deteriorat ed change ed n Perceived Health Change Overall psychological og ca disorder Mood Anxiety Disease Impact (CAT) Breathlessne ss (MRC)
21 Recovered indicates likely below caseness and improved is reliable improvement. Overall improvement % combine these scores (e.g. those no longer distressed = 51%, those less distressed = 61%)
22 Clinical Outcomes- 3 month follow up
23 Clinical Outcomes - satisfaction Average response* Strongly Agree Satisfaction Questionnaire Question 9: Would you recommend this service to a friend or family member? 2 Agree 3 Neither 4 Disagree Agree Nor Disagree 91% of patients either agreed or strongly agreed *n = 57 91% of patients would recommend the service to a friend or family member 5 Strongly Disagree Patient written feedback This service is something that has been needed for a long time. I have felt much more positive and able to cope I have a better understanding of the nature of my illness and the many ways it can affect me. I truly believe that you gave me the tools to hold on to what is important to me and to let go and face the things that aren t. I will always be eternally grateful for giving me back my life. I feel really lucky to have had this help. X really puts me at ease and understands how I feel. I have not had to call the ambulance since these visits started.
24 Admission/A&E cost data: Overall 1st Appointment Admissions Position Admissions Costs 6 months Prior , months Post 46 59, * NB Weather variations may account for approximately max 20% of reduction estimated based on COPD admission variance. Equates to approximately 50, * 3% of people deceased post intervention * July cost data unavailable Monthly Averages Position Admissions Costs Prior , Post ,
25 Admission/A&E i cost data: Direct vs Indirect intervention 1st Appointment Admissions Position Admissions Costs 6 months Prior , months Post 41 55, st Appointment Admissions Position Admissions Costs 6 months Prior 29 37, months Post 3 3, Monthly Averages Position Admissions Costs Prior , Post , Monthly Averages Position Admissions Costs Prior 4.8 6, Post * NB Interventions show cost savings across the board. Direct Interventions treat more complex, more severe difficulties and continue to show equal cost savings
26 Summary of project cost/savings 6 month project cost 6 month saving Total project saving (6 months) 48, , ,432.23
27 Successes Close liaison i with MDT, particularly l community matrons, ward and pulmonary rehab. Skilling staff (psychology as part of their day-to-day practice). Multi-disciplinary working and joint working Flexibility; COPD is very unpredictable and can mean missed appointments and difficulty attending. Initial i inpatient i assessments with follow up in the community (intervention across the pathway) Tailored, specialist approaches to COPD. Longer contracts for those with lower motivation. Home visits and community work Group therapies.
28 Streamlining referrals Looking forward Maintenance CBT/Mindfulness sessions for completers. Carer education course Community based clinics Training RRT, A&E, AMU Exploring co-morbidity boundaries of care e.g. psychology for cardiology, diabetes etc (* 90% of people p with COPD have co-morbid LTC).
29 Why commission? QIPP Project Challenge Met? Demonstrating Financial Benefit Yes Adhering to COPD Quality Standards (NICE 2011) and high quality care and support as set out in the DH (2011) outcomes strategy for COPD Producing Positive Clinical Outcomes in Local lservice User Data Yes Yes Meeting patient satisfaction standards and patient need Yes