Case Study Archive – Mental Health, Learning Disability and Dementia

Inpatient to Community Services

Project overview: A review and rationalisation of inpatient and community mental health services for adults across Devon.

DPT Community Services

 

My Way to Health

Project overview: During 2009 and into 2010, the Primary Care Trust has been working with local people with a learning disability to improve access to all health services, but also to focus on improving discharge planning from local acute hospitals. There are 2,189 people with a learning disability in  Cornwall.

NHS COIS My Way

 

Reducing falls in elderly care and across the hospital – Brighton and Sussex University Hospitals NHS Trust

The project aimed to reduce inpatient falls across eight elderly care and acute medical wards. Nationally over 200,000 falls are reported each year in the NHS and are a major issue in a range of health and social care settings, both NHS and non-NHS.

The initiative has focussed on what happens to patients for the first few days in hospital. With an increasing national focus on dementia and frailty the team believes that reducing falls will become a major challenge in delivering compassionate care.  The cost of failing to address the issue in terms of cost and reputation is an additional driver.

 Outcomes:

In the eight wards covered by the initial phase, falls were reduced by 32{79f878acaa41f375dcd804cc8c058b5459a5482f20a3b9f87269b26c8734749b} in twelve months.  Following this success a trust-wide initiative replicated the activity, achieving a reduction across the trust of 17{79f878acaa41f375dcd804cc8c058b5459a5482f20a3b9f87269b26c8734749b}. The original eight wards, with minimal additional input, are still improving at a faster rate than the rest of the trust and have reduced their rate by a further 31{79f878acaa41f375dcd804cc8c058b5459a5482f20a3b9f87269b26c8734749b}.  These results indicate that a focus on the behaviour and habits of individual practitioners is the way to make change sustainable and continuous.

In 2012 the trust was shortlisted for the BMJ Safety /Improvement Award.

Information, tools and techniques used:

The first phase, which took a conventional approach to service improvement (training, action plans, guidelines, meetings etc) was abandoned after 9 months as no improvements had been made.  Phase 2 focussed on the concepts of emergent design, followership and imitation, producing outstanding results.

Over the past 3 years the team has moved from a position of thinking that safety is a product of resilient processes to thinking that safety is something that emerges out of imitating safe behaviours.

Contact details and further information:

Mark Renshaw, Deputy Chief of Safety, Brighton and Sussex University Hospitals NHS Trust: Mark.Renshaw@bsuh.nhs.uk

Paula Tucker, Head of Nursing Patient Safety, Brighton and Sussex University Hospitals NHS Trust: Paula.tucker@bsuh.nhs.uk

 

Safe, Supportive and Therapeutic Care

Safe, Supportive and Therapeutic Care aimed to improve safety and care within acute inpatient mental health units by minimising risk while maximising therapeutic benefit. A secondary but related objective was to reduce length of stay in acute inpatient units.

Strands of work covered three key areas: clinical skills and interventions; policies, procedures and systems; and environmental security. Specific activities included a thorough review of clinical evidence and of policy and procedures; staff training and a ligature audit to identify and remove any environmental elements contributing to increased risk of patient suicide.

Outcomes:

The programme has achieved a wide range of improvements, including better clinical risk assessment and collaborative and patient focused care plans. Each acute inpatient environment has been assessed using an accredited ligature audit tool with high risk ligature points being addressed first and processes identified to modify medium and low risk points.

The programme has created a stronger identity and culture within Acute Care, as well as greater clarity among the different professions (psychology, nursing, occupational therapy and medical) about their role and contribution to providing high quality care.  There is now greater consistency of care across acute units and the programme has also achieved its overarching aim, which was to minimise risk while maximising the therapeutic benefit of inpatient care.

Information, tools and techniques used:

Whilst some general principles of change management underpinned the programme, it did not follow a formal change model. Different change management processes included a ligature audit which used a validated tool to assess environments as well as consulting nationally in order to learn from good practice elsewhere. The review of risk policy, training and redesign of risk tools was informed by a full consultation within the trust.

Geography:

The programme was run across the six acute inpatient units and six crisis teams working in the community across the Sussex Partnership NHS Foundation Trust.

Timescale:

The programme was initiated in March 2010, and by April 2012 most of its key elements had been implemented.

Contact details and further information:

Theresa Dorey, Nurse Consultant/Professional Lead, Acute Care. theresa.Dorey@sussexpartnership. nhs.uk

Sussex Dementia Partnership

The Sussex Dementia Partnership is a clinically-led collaboration between the health and social care commissioners and providers of Sussex involved in Dementia care. It aims to transform dementia services in line with the National Dementia Strategy (NDS) in order to improve the experience of people with dementia and their carers.

Dementia is a significant and increasing financial burden in Sussex. There are different commissioning and provider arrangements for dementia across Brighton & Hove, East Sussex and West Sussex. Evidence suggests that working collaboratively across organisational and geographical boundaries to implement the dementia transformation programme with a QIPP (quality, innovation, productivity and prevention) focus could enable Sussex to meet future challenges against a backdrop of financial constraint, and this has led to the formation of the Partnership.

The vision of the programme is to achieve improvements in the following areas:

  • The experience of people with dementia and their carers
  • Early diagnosis of dementia and access to information and support
  • Numbers of people treated (within existing resources) in order to meet significant demographic increases over the next 10 years
  • Improved care in the general hospitals, plus reductions in inappropriate admissions and length of stay
  • Improved care in care homes
  • Access to dementia crisis support at home services
  • Reduced inappropriate use of anti-psychotic medication
  • Reduced unwarranted variation in services across Sussex

Outcomes:

There has been significant progress in delivering the NDS. A full Memory Assessment Service with Dementia Advisors has started in West Sussex and procurement is also underway in the other localities meaning that full coverage will be achieved by April 2013.

The quality of care in general hospitals has improved notably; Older People’s Mental Health Liaison services have been extended across Sussex and the innovation of a Dementia Shared Care Ward is being spread to other hospitals. All four acute trusts have developed dementia strategies and are making progress in delivering improvements in education, environment and person-centred care. A Sussex wide dementia acute audit has provided the system with valuable information about the dementia profile in the hospitals and preventative approaches to admission.

In care homes, a Sussex-wide service has been developed to focus on medication review and non-pharmacological approaches to challenging behaviour. This has led to quality improvements and reductions in anti-psychotic prescribing. Achievements have also been made in dementia crisis support services at home.

Finally, work is in progress to improve services for people with dementia at end of life, to increase carer support and to provide education for the system in relation to reducing anti-psychotic prescribing.

Information, tools and techniques used:

The National Dementia Strategy was published in February 2009 and there was widespread belief that the strategy could not be implemented effectively by individual organisations in isolation. The concept of a partnership approach was initiated by CEOs and senior clinicians within Sussex, with the Director of Social Care and Partnerships South East acting as a catalyst to bring the different parts of the system together. The principles of the Academy for Large Scale Change model were utilised, focusing on mobilising, spreading and sustaining change. Whole system modelling was undertaken to understand the impact of implementing the NDS on demand and resources.

Contact details and further information:

Contact Charlotte Clow, Sussex Dementia Partnership. Email charlotte.clow@nhs.net

 

Rapid Assessment & Consultant Evaluation (RACE)

This programme established a new admissions unit, the Rapid Assessment & Consultant Evaluation (RACE) ward.  Here medical patients with geriatric needs (frailty, multiple co-morbidities, advanced age dementia) referred to hospital as emergencies, are assessed and cared for by a consultant-led multidisciplinary (MDT) team, including doctors, nurses, physiotherapists, occupational therapists and community support staff.

All patients receive comprehensive geriatric assessment (CGA) within 24 hours of admission and there is a daily multidisciplinary meeting attended by the ward team and representatives from Poole Intermediate Care Service, Poole Social Services and Dorset Social Services to facilitate discharge planning.

GPs can also refer patients to the daily emergency clinic held on the ward to access rapid diagnostics and CGA without admission to hospital.

The aim of the unit is rapid comprehensive assessment of older patients with complex needs. This facilitates early supported discharge and avoids unnecessary hospital stays which can be detrimental to older patients. The trust benefits from a reduced length of stay for older patients with concomitant savings.

Outcomes:

Within 3 months of the establishment of the RACE ward marked improvements were recorded. Patient discharge within 48 hours increased from 20{79f878acaa41f375dcd804cc8c058b5459a5482f20a3b9f87269b26c8734749b} to 40{79f878acaa41f375dcd804cc8c058b5459a5482f20a3b9f87269b26c8734749b}, and average length of stay decreased from 19 to 13 days. The quality of patient care also improved as a result of comprehensive geriatric assessment at the front door.

Information, tools and techniques used:

The original impetus for the change was managerial, but the change was driven bottom up: planned, led and implemented by clinicians.

Contact details and further information:

Prem Fade, Department Director: Prem.Fade@poole.nhs.uk

 

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