Shaping a service

Colin HughesConsultant Nurse - Older People

(Mental Health)

Chesterfield Primary Care Trust

Chesterfield Royal Hospital NHS Foundation Trust:

570 acute beds

Walton Hospital

Chesterfield PCT:

104 general intermediate care beds

Total beds = 674

Do the

‘Who Cares Wins’

calculation:

129 will have depression

89 will have delerium

138 will have dementia

Consultant Nurse-Older People (Mental Health)

Chesterfield Primary Care Trust 1st December 2004

Clinical and developmental role:to develop a mental health liaison service

for older people with mental health problems in Chesterfield

NSF for Older People (2001) Standard Four:

Develop clear guidelines for involving specialist mental health services in the care of older people in hospital

Staff should be trained to recognise and manage behavioural problems appropriately

Health and Social Care Change Agent Team (2004):

Early identification of the mental health problems

Check if already known to the specialist mental health services

Responsive multi-disciplinary liaison services that do not solely rely on consultant-to-consultant referral

Benefits of providing mental health services into the general hospital setting:

•shortened hospital stays and reduced costs•improved physical functioning•fewer nursing home transfers•increased recognition of depression•increased use of community services after discharge•positive effects on outcomes for the treatment of depression and delirium, and for the prevention of delirium

Consultation Liaison

General hospital staff refer a patient to the mental health service; a member of the service (usually a doctor) provides an assessment and advice, then leaves. Patients may be reviewed.

Direct patient work involves more intensive involvement.The liaison service is more accessible, can respond quickly and review patients more often.Liaison is more proactive involving:awareness raising of the profile of mental health issues,collaborating in shared care through joint meetings,developing education and training programmes.

Advantages for the liaison model over the traditional consultation models:

•referrals being more appropriate•more accurate diagnosis by referrers•increased referrals•more referrals for depression•reduced waiting time for assessment leading to increased satisfaction for the referrer•more patient contact•better adherence to recommendations•better outcomes in some circumstances

Benefits in providing mental health services along the lines of a liaison model:

•to referrers (e.g. increased satisfaction)

•to patients (e.g. treatment of depression) •to hospitals (e.g. shortened hospital stays and reduced costs)

Who does mental health

consultation-liaison in Chesterfield?

• psychiatrists

• clinical psychologists

• mental health nurses

• occupational therapists

• community mental health teams

Some ideas to start with:

• build on current provision

• add something

• don’t disrupt current processes

• current activity should continue

Fully multidisciplinary team,all with designated sessions to liaison:The Hospital Mental Health Team

Partly multidisciplinary team, some with dedicated sessions to liaison: an enhanced sector model

Nursing liaison service, dedicated sessions

Medical liaison service, dedicated sessions

Standard sector based consultation service: no dedicated sessions

Option 1

Develop a nursing liaison service

• Consultant Nurse expertise

• dedicated time, rapid response

• demonstrate nurse led services

BUT

• replacing ‘like with like’

• need medical support

• isolation

Option 2

Start to develop the idea of a multidisciplinary mental health liaison

service

• partnership with Mental Health Trust

• enhanced sector model but Consultant Nurse is different

• change from the current consultation model to a liaison model

But where to start?

• work in partnership as a team with the medical psychiatric staff of Derbyshire Mental Health Services NHS Trust

• single point of entry for referrals to enhanced service

• same telephone numbers as previously

• Consultant Nurse leads change:

consultation to liaison

REFERRALS IN 1 YEAR BY SPECIALTY AT CRH

142

1629

5 20

20

40

60

80

100

120

140

160

Medical Surgical Orthopaedic EMU Gynaecology

T = 194

REFERRALS IN 1 YEAR BY WARD AT WALTON

28

23

14

22

0

5

10

15

20

25

30

Amber Derwent Haddon Hardwick

T = 87

Referral and allocation

Referral from general ward phoned through to Barwise

Administration staff at Barwise take referral information and complete referral form

Consultant Nurse (or consultant psychiatrist in his/her absence) triages referrals daily

For urgent referrals administration staff will contact most appropriate and available member of service for action

Consultant Nurse allocates referrals to members of the service following discussion with the consultant psychiatrist as needed

Liaison activities

• awareness raising of the profile of mental health issues

• undertaking training needs analysis• developing education and training programmes• collaborating in shared care through joint

development meetings or participation in ward rounds

• development of protocols for detection, management and referral of mental health problems in older people

• follow up and tracking of particular patients as indicated

Evaluation

• the development of a case register database• audit of referrals before and after Consultant Nurse

clinical involvement by number, source and reason for referral

• tracking of a sample of patients to record: where discharged to; re-admissions and reason for re-admissions; physical and mental state

• examination of the views of nursing, therapy and medical staff

• development of patient and relative satisfaction measures

• examination of the operationalisation of the structure and processes of the service