the first year as a demonstration site
TRANSCRIPT
IAPT SMI (for Personality Disorder):
the first year as a demonstration site
Dr. Janet Feigenbaum and Oliver English
North East London NHS Foundation Trust
Contact: [email protected]; 0300 555 1213
Improving Access to Psychological Therapies
for individuals with a Personality Disorder
Providing services for the treatment seeking population
Identifying strategies for engaging with the treatment reluctant population
Working within the current economic position
Improving Access means inclusivity
IMPART works with:
8 of the 10 DSM-IV Personality Disorders*
Older adults
mild learning disabilities
co-morbid substance abuse
high risk
* The clinical and business case for ASPD has been developed and
is being discussed with leadership and commissioners
Improving Access needs robust pathways
Mental
Health
Primary
Care
Local
Authority
Criminal
Justice
Weekly
Psychology
Referrals
Panels*
Psychology
Departments
IMPART
GP
Fewer assessments
Reduced waiting times CAMHS
IMPART Referrals Nov 2012 to Jan 2014
236 open cases on day of commencing IAPT SMI (1 Nov 2012)
830 new referrals
696 community (58/month)
134 Acute (11/ month)
Number offered steps 2/3 treatment: 511
Number started step 2 treatment: 389
235 cases open as of Jan 2014 (waiting list = 45)
27 – average caseload (current wte 8.6 – 3.0 vacant)
Demographics
OA: n=11
Gender
M 26%
F 74%
IAPT Stepped Care pathway
Step 1:
Screening assessment
Self help pack
Monthly phone call
Step 3:
Full assessment
Collaborative formulation
Motivational Interviewing
DBT or CBT (6m or 1y)
Step 2:
DBT or CBT
skills groups
Psychoeducational groups
MBCT Follow up:
Phone coaching
3 x follow up appointments
Top up sessions
Referral to
Appropriate
service
Not PD or risk
Supporters (carers) workshops and DBT skills training workshops
8-10 weeks
4-8 weeks
8-12 weeks
Activity by Type – 11/12-01/14
Activity Sessions
attended
Sessions DNA (%) Overall % activity
Assessments 907 223 (20) 15
Family meetings 32 0 0.4
CPA meetings 56 1 (2) 0 .7
CBT 1:1 1050 226 (18) 17
CBT group 271 63 (19) 4
CBT coaching (TC) 50 0.6
Crisis intervention 35 0 0.3
DBT 1:1 1777 331 (16) 28
DBT group 1805 403 (18) 29
DBT coaching (TC) 316 4
MBCT group 60 12 (20) 0.9
Motiv. Interv. 95 13 (12) 1.4
Psychoeduc. 25 3 (11) 0.3
Schema FT 68 7 (9) 1
Supportive Couns. 164 5 (3) 2.2
Indirect provision
• Training on working effectively with PD
Mental Health Services
Psychiatric Liaison and A&E staff
Housing workers
Social Services
Child protection services
Probation
Magistrates
GPs
Health visitors
Engaging with the treatment reluctant population
In-patient IMPART Therapist
assessments
facilitating pathways to community treatment
motivational enhancement
psychoeducation and coping skills
staff support groups
ward based DBT skills
What to measure - General Principles
The Five D’s:
• death
• disease
• disability
• discomfort
• dissatisfaction
Measuring Outcomes
IAPT Dataset
PHQ-9
IAPT employment status
WSAS (Work and Social Adjustment)
EQ-5D (Quality of Life)
WEMWBS (Warwick-Edinburgh Mental Well Being Scale)
SAPAS (Standardized Assessment of Personality)
Rates of self harm and suicide attempts
Service utilization
IMPART dataset
SCID I and II
Staxi (Speilberger Anger Scale)
Christo (modified drug/alcohol)
Treatment history (one year)
Outcomes (commissioning targets):
Amongst treatment completers (> 50% appts and agreed)
Q1 Q2 Q3
Bed days prior
to IMPART
233 82 95
Bed days
during IMPART
27 7 27
BED DAYS
reduced
206 75 68
Suicide
attempts
before
97 51 33
Suicide
attempts
during
5 10 7
% reduction in
self harm
frequency
89% 97% 94%
Challenges faced by IMPART
Demands to see individuals with ASPD
Care coordination – pressures on the system
Requests for more training /consultation/supervision
Continual restructuring – disrupted care pathways
Managing a wait list – high risk clients
Adopting a Dialectical Perspective
There is only one pie
and everyone wants it!
Trust Target Hierarchy
Risk
TIB
(Trust interfering behaviours)
Quality of Life
Will anyone die soon?
Interfere with management
Complaints
SUIs
Interfere with Targets
Contacts
Financial (e.g. bed days)
CQUINS
CQC/UQAT
NICE guideline compliance
Staff retention
Service User views
Fledgling IAPT SMI service
BPD with little comorbidity
Compliant with treatment
Out-patient
Good outcomes
Social network
Operational Manager
High risk
Revolving door
Long stay in-patient
High co-morbidity
High cost (e.g. ISA)
Isolated
Synthesize the dialectic
Issues relating to Cost Effectiveness / Health Economics:
• resources are limited
• decisions based on greatest outcome per unit of resource
employed
• economic burden of illness or psychological disorder
(without input/service)
• evaluate savings based on changes in service usage
• evaluate based on productivity
• may look at ‘dose dependent’ curve
i.e. number of sessions
• will need to examine initial severity as confounding factor