a 12 month review of outcome data in the york & selby early intervention team; the monthly audit...
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A 12 month review of outcome data in the York & Selby Early Intervention Team; The Monthly Audit Tool (MAT)
Claire Robinson, Assistant Psychologist
Tracey Walker, Team Manager
EI General Overview
Specialist teams working with young people aged 14-35 (and their families) experiencing a first episode of psychosis, or who may be at risk of developing psychosis.
• Aims - to detect a persons psychosis as early as possible and offer evidence based interventions – reducing DUP.
• Assertive engagement over a three year period – bio-psycho-social approach.
• Team culture of providing a service which is enabling and empowering based on personal, social and occupational goals.
• The early evidence base-• 10 years of evidence in Australia • Early Psychosis Prevention and Intervention Centre,(EPPIC)- Patrick McGorry• In England - Birchwood et al (1997)
National Policy provided the impetus for the development of EIP in the UK
• Modernising Mental Health Services (DH 1998)• National Service Framework for Mental Health (DH 1999) • NHS Plan (DH 2000) • Policy Implementation Guide (DH 2001)
The Development of EI
“The early evidence base was not as robust as would have been desired”
(Appleby, 2006)
“EIP is the jewel in the crown of the NHS mental health reform” because……
Service users like itPeople get betterIt saves money Louis Appleby (National Clinical Director for Mental Health) Conference speech 29/04/09
There is now robust evidence to suggest that EI is clinically effective during the intervention period for first episode psychosis.
Peterson et al 2005 –OPUS 1 year follow up study – lower positive and negative symptoms, low admission rates
Cullberg 2006 – study of 3 year intervention – better symptomatic and functional outcomes, low admission rates
Fowler et al 2009 – comparison of EI model Vs. partial EI Vs. CMHT – partial EI did not produce the favourable outcomes seen with dedicated EI model.
Evidence Base
YES…. McCrone et al 2010- LEO 18 month
follow up – suggests EI is cost effective with QOL and vocational measures
Phase IV DOH report, McCrone et al 2010 in publication – DOH commissioned report – predicts much more saving due to reduced admissions, better employment outcomes, reduced suicides, and evidence for sustained outcomes post EI
Is early Intervention cost effective?
A move away from measuring activity in mental health services…
Favours measures of recovery and social achievement – employment and educational outcomes. This will place a demand on services to be effective and demonstrate effectiveness…
“a tougher challenge than demonstrating activity”…
Need a move to develop research and audit programmes…
NEW HORIZONS (DOH 2009)
EIP in North Yorkshire and York has developed research and audit programmes.
Measures have been produced to demonstrate effectiveness in relation to outcomes derived from policy and targets….
The early Intervention movement welcomes this shift
in focus…
Outcome measures for EI
Duration of Untreated Psychosis (DUP) PATHWAYS TO CARE ENGAGEMENT RATES OF FAMILIES AND INDIVIDUALS USE OF MENTAL HEALTH ACT READMISSION RATES OCCUPATION HOUSING STABILITY SUBSTANCE MISUSE RECOVERY RATES SELF HARM/SUICIDE OFFENDING RATES PHYSICAL HEALTH SATISFACTION
Introducing the Monthly Audit Tool…
The MAT Monthly Audit Tool
Please tick relevant boxes:
Cigarettes Problematic alcohol use Cannabis
Class A: Ecstasy, LSD, heroin, cocaine, crack, magic mushrooms, amphetamines (if
prepared for injection)
Class B: Amphetamines, Methylphenidate (Ritalin),
Pholcodine. Other
If Other, please specify:
DO NOT INCLUDE PRN Anti-psychotic Anti-depressant Anxiolytic
Mood stabilizer
Prescribed & taking
Prescribed & not taking
On depot
To be reviewed: Jan 2010
Engagement: 1. Good 2. With difficulties 3. Poor 4. Disengaged/discharged Relapse: 1. No 2. Non admission, increased support 3. Crisis (Joint working with crisis services) 4. Admission 5. MHA admission Death: 1. No 2. Suicide attempt 3. Suicide 4.Non-suicide Employment: 1. Unemployed – seeking work 4. P/T employed
2. Unemployed – not seeking work 5. Voluntary work (at least once a week) 3. F/T employed 6. Homemaker
7. Education/other Education: 1. F/T education/training 3. Home tutored 5. NA 2. P/T education/training 4.Not in education
In Receipt of DLA 1. Yes 2. No Perpetrator of crime reported to police 1. Violent 2. Non-violent 3. No Victim of crime reported to police 1. Violent 2. Non-violent 3. No
Housing Status: 1. Mainstream housing
1. Accommodation with mental health care support 2. Accommodation with other care support 3. Acute/hospital 4. Homeless 5. Unknown
Family Contact 1. No family
2. Offered to client & declined 3. Offered to family & declined 4. Engaged – structured 5. Engaged – informal 6. NA – Reason:_____________________________________________________
CLIENT NAME: DATE: EI KEY-WORKER:
ASSESSMENT EARLY DETECTION EARLY INTERVENTION DISCHARGED (see overleaf also)
Completed by:
Care Coordinators
Completed for:
Every Client
Every Month
One side of A4
What does it do?The MAT
Captures a “snapshot” of a client presentation for each month every month:
Client StatusEngagementRelapseDeath / SuicideEmploymentSubstance MisuseDLAVictim of CrimePerpetrator of CrimeHousing StatusFamily ContactMedicationDischarge Information
Detailed client data (even if client leaves before 3 years) Helps workers identify patterns of behaviours / stressors /
relapse signatures Informs formulation Helps evaluate individual care and service provision Provides information that is comparable for clients at key
points throughout recovery Promotes regular reflective practice within the team
Why Monthly?
The MAT – How does it help us?
Informs Accurate Service Evaluation and Quality Improvement
Integrates clinical governance activity into teams work, reduces pressure on evidence gathering
Monitoring of outcome objectives and targets for EI servicesEarly access to treatment ( reducing DUP)Access to full bio-psycho-social assessment by PSI trained practitioners Employment, education and occupational activityReturn to primary care
…how does it help us
Adherence to NICE guidelines NICE guidelines for Psychosis with coexisting
substance misuse (draft 2010) Nice Guidelines for Schizophrenia (2009) Standardises Information collected over 3
locality teams Supports the longitudinal research project
within the locality.
• 76% engaged without difficulty• 24% engaged with difficulties
• 95% of clients showing no signs of relapse
• 95% of clients were not experiencing suicidal ideation
• 38% of clients were in employment
19% in Full Time employment 19% in Part Time employment
• 62% not in employment
14% were not seeking work
14% were seeking work
14% were doing voluntary work
14% In Education / Training
5% Homemakers
The MAT - What does it show?• Data analysed of clients at an 18 month point with the team
• 21 clients
• 76% family members engaged informally
• 33% of clients receiving DLA
• 43% of clients were in education / training
19% Full Time education / training 24% Part Time education / training
• 0% of offending rates or victims of crime
• 95% of clients in stable housing
5% in accommodation with Mental Healthcare support
5% engaged in structured family work 10% clients declined family contact 5% no family 5% NA
At 18 months continued…
• 57% smoke cigarettes
• 38% problematic alcohol use
• 10% smoke cannabis
• 5% Class A• 5% Class B
• 19% Not prescribed any antipsychotic medication
• 5% Mood Stabilizer
• 5% Depot
62% prescribed and taking antipsychotic
10% prescribed and not – taking antipsychotic
• 72% were prescribed antipsychotic medication
At 18 months continued…
Apr-09
May-09
Jun-09
Jul-09 Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
Apr-10
F/T Employed
P/T Employed
Unemployed - Seeking
Unemployed - Not Seeking
Longitudinal progression of a clients employment status
Individual trends…..
Use reported
No use reported
Client engagement and substance use
Cigarettes
Alcohol
Canabis
Relationships…..
Discharge Destinations….Y & S Early Intervention discharges April 09 - April 2010
Other3%Forensic services
3%
Other EIP19%
AOT11%
CMHT36%
GP28%
36 Clients
Future developments
Recent evaluation of the MAT highlighted areas for development which included…
How to record data specific to activities of daily living
How to improve NICE concordance which would include, use of CBT and improved physical health monitoring.
How to collect data which allows for accurate DUP calculation.
A revised MAT will be agreed and implemented across the locality teams in the coming months to increase accuracy and usefulness of the data collected.
Questions and Comments.
ReferencesAppleby, L. (2006). Quoted in: Early Intervention in Psychosis in England – report from a day seminar on research
policy and practice. London: CSIP.
Birchwood, M. & McGorry, P. & Jackson, H. (1997). Early intervention in schizophrenia. British Journal of Psychiatry, 170, 2-5.
Cross-government strategy: Mental Health Division, 2009. New Horizons: A shared vision for mental health. HM Government
Cullberg, J. & Mattsonn, M. & Levander, S. & Holmqvist, R. & Tomsmark, L. & Ellingforsc, C. & Wieselgren, I. M. (2006). Treatment cost and clinical outcome for first episode schizophrenia patients; a 3 year follow up of the Swedish parachute project and two comparison groups. Acta Psychiatrica Scandinavica, 114, 274-281.
Department of Health (1999). National Service Framework for Mental Health. London: Department of Health.
Department of Health (2000). The NHS Plan – a plan for investment, a plan for action. London: Department of Health.
Department of Health (1998). Modernizing Mental Health Services. London: Department of Health.
Department of Health (2001). The Mental Health Policy Implementation Guide. London: Department of Health.
Department of Health (2008). NHS Next Stage Review. London: Department of Health.
Department of Health (2009). New Horizons: a shared vision for mental health. London: Department of Health.
References continued….
Fowler, D. & Hogdekins, J. & Howells, L. et al., (2009). Can targeted early intervention improve functional recovery in psychosis? a historical control evaluation of the effectiveness of different models of early intervention service provision in Norfolk 1998 – 2007. Early Intervention in Psychiatry, 3; 282 – 288.
McCrone, P. & Craig, T. K. J. & Power, P. & Garety, P. (2010) Cost effectiveness of an early intervention service for people with psychosis. British Journal Of Psychiatry. 196: 377-382.
National Institute for Health and Clinical Excellence. Psychosis with coexisting substance misuse: assessment and management in adults and young people. Draft for consultation, August 2010.
National Institute for Health and Clinical Excellence. (2009). Schizophrenia. Core interventions in the treatment and management of schizophrenia in adults in primary and secondary care. London, Holborn: National Institute for Health and Clinical Excellence
Petersen, L. & Jeppensen, P. & Thorup, A. et al., (2005). A randomized multicentre trial of integrated versus standard treatment for patients with first episode psychotic illness. British Medical Journal. 331, 602.