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TRANSCRIPT
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How Can a Mental Health Service be Good for Your Health?
Professor James V. LuceyMedical Director
St. Patrick’s University Hospital, Dublin
National Mental Health Conference – September 14th, 2011
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How Can a Mental Health Service be Good for Your Health?
• Can we solve the problems in our mental health care system.
• Is quality of service the answer? • Examples of a mental health service
dedicated to Quality?
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20th Century Mental Health Care
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21st Century Health Care
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In Health Care Politics the debate is still dominated by questions of location
Primary Care Vs Community Care Vs Residential Care Vs Secondary Vs Regional Centre of Excellence
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Hospital Care
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Home Care
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Community Care
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Residential Care in “Castlebeck”
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Primary Care
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What is Mental Health Care?
• A pseudo-science?• A craft informed by science?• A pill for all ills?• A social or political construct?• A myth?
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Mental Health Vs
Mental Health Disorder
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Home Work Balance
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The Existential Question?
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32% of OCD patients have depression
31% of SPpatients have
depressionGAD
59% of GAD patients have depression
50% of panic disorder patients have depression
49% of PTSD patients have depression
Source: National Comorbidity Survey 69,400 patients
34% of specific phobia patients have depression
PanicDisorderSpecific
Phobia PTSD
SocialPhobia
OCD
Depression
Complexity of Mental Health DiagnosisCo-morbidity of Anxiety and Depression
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Low High
Certainty
Consensus
High
Low
CHAOS
STANDARDISATION
ZONE OF COMPLEX JUDGEMENT
Consensus
Chaos
Standardize Zone of Complex Judgment
Low HighCertainty
High
Low
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Obsessive Compulsive Disorder
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“There's a very strong view with a lot of people that depression and mental illness is not a medical condition, that it's part of life's events that people get depressed or get unhappy. Years ago people were unhappy, they weren't depressed, they weren't given the name depressed…I was aware that unlike other areas of health like cholesterol, diabetes, or coronary care, where you can measure the results of taking medication, in mental health, it is impossible to measure, scientifically, the results”
Minister Tim O`Malley, Pharmacist and Minister for Mental HealthIrish Medical News, November 2006
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Dr. Steeven's Hospital 1901 Census
Mean Age 26.5 (23.5 women, 27.5 men)Female/Male 34/86 Religion C O I / COE: 17; Pres: 5, Refused: 1, RC: 97
Fully 50% of the 120 patients had infectiousdiseases readily curable now
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“Arguably by the standards of 1901, no-one outside of the Cancer Care Unit and ICU is sick. Modern infections or fractures are treated within a week. Myocardial infarcts are surveilled and thombolysed or stented. The age curve in hospital has changed dramatically and one century later our illnesses are completely different.
Modern illnesses were unseen in 1901, because these disorders were either already fatal, or like Diabetes, untreatable. No one who attends an Orthopaedic Surgeon with knee pain would be accused of malingering, if there is a demonstrable irregularity on MRI, but that same patient would not have been admitted in 1901. They would have been dismissed as a waste of time unless their leg was infected or broken off. Mental health suffering is exactly the same. Active treatment in all its professional and societal forms (Psychotherapy, Pharmacology, Milieu, a more tolerant welfare state) has enabled community care for Mental Disorder. We now witness service users with more subtle illnesses or illnesses at earlier stages, but that doesn’t mean mental health suffering is not real. These are not sicknesses if you judge them by the standards of 1901 or those who operate today within those standards”.
Dr Ross Dunne TCD/HRB Research Fellow
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Historical Fight for Mental Health
"He gave the little Wealth he had,To build a House for Fools and Mad:And shew'd by one satyric touch,No Nation wanted it so much:That Kingdom he hath left his Debtor,I wish it soon may have a Better.”
J Swift (1667-1745)
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National Cancer Strategy
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No New Drugs, No Silver Bullets and No More Money
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Team Work in Health Care
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The Ideal Mental Health Service
Model•Mission•Vision
•Strategy
Organisation•Structure
•Governanace •Rewards
•Responsibilities
Culture•Principles
•Ethos•Excellence
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Perfect Storm
• Perception of service as too medically driven
• Government policy driving a move to community care
• Hospital struggling to meet regulatory standards
• Occupancy dropping• Financial difficulties • Entering a domestic and
global recession
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MHM Phase 1
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MHM Phase 2
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Process of Strategy Development
• Consulted with service users and staff• Focused on the Mission and Culture not the
financials• Worked to obtain buy-in to the mission
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Key elements of strategy
• Highest quality mental health care• Promoting Mental Health• Advocating for the rights of those suffering
from mental illness
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Actions we took
• Quality Standards and strong Clinical Governance • Restructured and enhanced existing services• New services in community Dean Clinics and
Technology based supports• Invest in staff retention and training
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St Patrick's TCD- Evolution
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St. Patrick’s University Hospital Services
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Phone calls to Referral Line Administrator 2011
Month Total Average per Day
January 144 7.5 February 202 10.6 March 247 11.76 April 217 10.3 May 239 11.3 June 205 9.76 July 129 6.10
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No. Of Admissions
No of Admissions per Annum 2004-2011
2450
2500
2550
2600
2650
2700
2750
2800
2850
2900
2950
2004 2005 2006 2007 2008 2009 2010 2011
Year
No
Ad
mis
sio
ns
No. Admissionsper year
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Adolescent Service 2010 YTD 2011 New referrals 174 166 Multidisciplinary assessments 102 76 Consultant review 121 111 Registrar review 1 0 CBT 268 166 Nurse therapist review 148 148 Psychology 91 122 OT 4 9 Dietician 28 49 SW/Family Therapy 12 8
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Average Length of Stay
Average Length of InPatient Stay 2004-2011
313233
3435363738
394041
2004 2005 2006 2007 2008 2009 2010 2011
Year
Ave
rag
e L
eng
th o
f S
tay
(Day
s)
Average Length of Stay
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Occupancy and ReadmissionOccupancy and Readmission Rates 2004-2007
60.00%
65.00%
70.00%
75.00%
80.00%
85.00%
90.00%
95.00%
100.00%
2004 2005 2006 2007 2008 2009 2010 2011
Year
Occupancy
Re-admission rates
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The CGI Explained• Clinical global impression scale*• Baseline score – before
treatment – patients have often been in hospital for some time, refractory to medication
• Outcome score – after treatment
• Usually 3-4 weeks (average 7 treatments with ECT)
CGI OutcomeScale
*Despite seeming crude, this scale has good inter-rater reliability and good face validity
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Clinical Global impression scores for 83 patients
CGI OutcomeScale
Patients treated with ECT for 3-4 weeks (6-8 sessions)
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Clinical global impression scores for 83 patients
Very much better
Much better
Minimally better No change Minimally
worseMuch worse
Borderline ill 1Mildly ill 2
Moderately ill 11* 5 1Markedly ill 2 16 6 3Severely ill 3 15 8 5
Extremely ill 2 2 1
Patients treated with ECT for 3-4 weeks (6-8 sessions)
Outcome
Baseline
*For example 11 patients who started out moderately ill were judged “much better” after ECT
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Nothing acts faster than Anadin
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Service User Satisfaction
Service User Overall Experience Average ( 2006-2010).
30%40%
60%
49%
48%
37%
12%
10%
2%9% 3% 1%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2006 (n=46) 2007 (n=52) 2010(n=288)
YearVery Satisf ied Satisf ied Dissatisf ied Very Dissatisf ied
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Compliance with Mental Health Commission Regulations and Standards
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St Patrick's Dean Clinic Network
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2 weeks ending:
YTD
20/0
3/20
11
03/0
4/20
11
17/0
4/20
11
01/0
5/20
11
15/0
5/20
11
29/0
5/20
11
12/0
6/20
11
26/0
6/20
11
10/0
7/20
11
24/0
7/20
11
07/0
8/20
11
21/0
8/20
11
Number of assessments 409 26 30 30 31 24 34 19 18 28 17 21 27 Immediate admission following assessment 83 10 4 4 4 4 8 4 4 9 6 3 2
Referral back to GP or referrer 64 2 3 8 0 2 14 3 4 4 3 1 1 Referral to CBT 66 3 3 8 6 5 8 0 2 3 2 3 4 Day Services / WRC 31 4 6 1 3 3 3 1 1 2 0 0 2 On going Consultant review 110 12 8 6 7 4 8 6 4 13 7 0 15 Psychotherapy in Deans 53 1 2 4 3 4 1 4 4 4 2 8 2 OT 5 0 0 0 1 1 0 0 0 0 0 3 0 EDP referral 3 0 0 0 1 2 0 0 0 0 0 0 0 Other 46 0 4 0 7 3 0 1 1 1 2 6 4 Total admissions from Deans 2011 151 16 9 6 7 9 10 5 7 17 13 8 2
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18%
14%
14%
7%
24%
11%
1%
1% 10%
Immediate admission following assessment Referral back to GP or referrerReferral to CBT Day Services / WRCOn going Consultant review Psychotherapy in DeansOT EDP referralOther
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Wellness and Recovery Centre
Day Patient Referrals
WRC Activity 2010 January Feb March April May June July Aug Total Alcohol step down 8 14 11 14 9(1) 7 3 7 73(1) Anxiety prog 14(3) 10 (3) 14(6) 13(3) 6(3) 13(4) 12(5) 7(3) 89(30) Bi Polar Prog 10 12 15(1) 12 11 3 9(1) 6(1) 78(3) Nurturing Hope 2 1 (1) 2 5 5 1(1) 2(1) 18(3) Depression 2(1) 4(2) 6(5) 4(1) 1 1 3(2) 2(1) 23(12) EDP 1 1 5 2 3 2 3 17 Living T D 14(1) 21 (3) 21(3) 7(2) 11(2) 11(3) 14(5) 5(2) 104(21) LTD ACG 13 8 19 3 43 Mens Mental 1 7 5(2) 3(1) 3(2) 6(1) 5 30(6) Mindfulness 9 7 20(2) 5 8(1) 2(2) 10(6) 61(11) Psychosis Prog 2 2 (1) 3 3(1) 2(1) 3(1) 3(1) 18(5) Recovery Prog 26 27(1) 24(2) 17(2) 15(2) 14(2) 15(7) 21 (5) 159(21) Recovery refresher 3 5 3 11 Recovery evening 3(1) 1 1 5(1) St. Eds DS 46 12 28(5) 27(4) 15(2) 13(1) 14(1) 10(1) 165(14) Young Adult Prog 2 3(1) 6(5) 2(2) 3(1) 1 1(1) 1(1) 19(11) Totals 136 (5) 143(13) 155 (31) 122(15) 112(14) 94(13) 87(27) 82 (23) 930(141)
**Numbers in brackets denote referrals from Dean Clinics**
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Bed days used per year pre- and post- LTD particpation(Best 10 and Worst 10)
0
20
40
60
80
100
120
140
1 2 3 4 5 6 7 8 9 10 33 34 35 36 37 38 39 40 41 42
Particpants (Best 10 and Worst 10)
Bed
days
per
yea
r
Average No. of Bed days per year pre LTD No. of Bed days in the 12 months post LTD
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Distress Tolerance Scale - Lower Scores indicate a lower tolerance to distress
0
2
4
6
8
10
12
Mean Score Pre- LTD Mean Score Post- LTD
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Deliberate Self HarmDSH Inventory - 17 item self report questionnaire covering frequency, severity and types of self-harm
0
2
4
6
8
10
12
Mean Score Pre- LTD Mean Score Post- LTD
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Support and Information service Jan Feb Mar April May June July Aug
YTD Total
Total Number of calls 136 99 134 243 185 170 126 37 1130
Support Calls 10 3 4 3 17 6 6 1 50
Information Calls 126 96 130 240 167 164 120 36 1079
No of callers to Dean Clinic Ref No 47 25 39 89 45 57 44 14 360
Health Care professional callers 4 5 8 3 6 5 5 0 36
General public callers 115 81 116 230 152 158 113 34 999
Service user callers 17 12 10 10 27 7 8 3 94
Calls re: treatment under 18 years 6 4 1 3 3 15 5 0 37
Calls forwarded to admissions 29 22 28 18 25 15 13 4 154
e-mails at [email protected] 90 67 62 50 70 56 74 10 479
No of e-mail to admissions 4 2 1 1 4 3 3 1 19
No of e-mail to Dean Clinic Ref No 4 3 1 0 4 2 7 1 22
Callers given CBT referral procedure 10 7 12 21 8 25 13 6 102
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Financial Information 2004-2011
Financial Information 2004-2011
-4%
-2%
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
2004 2005 2006 2007 2008 2009 2010 2011
Year
EBITDA %
Surplus %
AnnualGrow th inrevenue %
Compoundannualgrow thrate %
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Cost per Treatment EpisodeAverage cost per treatment episode (€)
€0
€2,000
€4,000
€6,000
€8,000
€10,000
€12,000
€14,000
€16,000
€18,000
2004 2005 2006 2007 2008 2009 2010 2011
Average costper treatmentepisode
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St. Patrick`s University HospitalMental Health Service
Model•Mission Independent•Human rights based•Vision National MDT
•Strategy Not-for-profit
Organisation•Structure - Dedicated•Governance - Charter
•Rewards - Responsibilities
Culture•Principles – Recovery
•User-centred involvement•Ethos – Non-Denominational
•Academia - Excellence