Children and Families
Lancashire Care
IAPT-SMI Demonstration
Site 3/9/15
James Kelly
Senior Clinical Psychologist
& IAPT-SMI
Project Manager
LCFT Demonstration Site
• Lancashire EIS – Laying the Foundations • Why we were chosen as a Demonstration Site • What we have done as a Demonstration Site • Interim Findings 1/10/12 - 31/12/14 • Learning Points
Children and Families
LCFT Demonstration Site
• Lancashire EIS – Laying the Foundations • Why we were chosen as a demonstration site • What we have done as a Demonstration Site • Interim Findings 1/10/12 - 31/12/14 • Learning Points
Children and Families
EIS Shared Learning Conference
Catchment area 1.5 million population – caseload 727 ( actual 760)
EIS Shared Learning Conference
Lancashire Care Overview • Large Geographical area – 1.5M population • 3 local authorities • Service caseload of 760
– Against target of 727 • Average care co-ordinator caseload under twenty (but
high teens) • Approx. 260 accepted into service against 500 referrals
assessed. • 5.4 wte therapists across this area.
Laying the Foundations
• From inception, service has had Senior Management buy-in
• Commissioner Support • Whole service commitment to psychosocial
interventions – 3 tier service model for PSI, CBT & FI. – In-house training in PSI
• Outcome measurement • Service User Involvement - ongoing
Children and Families
LCFT Demonstration Site
• Lancashire EIS – Laying the Foundations • Why we were chosen as a Demonstration Site
– The 3 tiered matched approach - PSI Training - REACH - Research
• What we have done as a Demonstration Site • Interim Findings 1/10/12 - 31/12/14 • Learning Points
Children and Families
A Matched-Care / Tiered Approach to Psychological Care
Psycho-social interventions
Case managers/
ST&R
Tier 2
Tier 3
Formal CBT or FI, Discrete Problems
Staff with:
Formal CBT training or COPE Msc
(under supervision)
Complex / multiple problems longer term CBT or FI
Tier 1 Specific PSI
Training Supervision/ Consultation
Cognitive Therapists
Clinical Psychologists
North Lancashire
East Lancashire
Central & West Lancashire
Aligned Therapist Aligned Therapist Aligned Therapist
Case Discussion and Formulation (Therapist and Case Manager)
Core PSI Tier 1
Formal CBT / FI (Tiers 2 and 3)
Supervision, consultation & ongoing support from
Therapist and Team Leader
Review Outcome and Effectiveness
Psychological Assessment including Case
Manager
Review Outcome
Tier 1
Tier 3
• Engagement (MI skills) • Normalising Approaches • Maintenance Formulation • Problem lists and Prioritisation • SMART Goals & Agenda Setting • Activity Scheduling • Relapse Prevention (+ Manual) • Recovery Approach • Measuring Change
Psycho-social interventions
Case managers/
ST&R
Tier 2
Tier 3
Staff with:
Formal CBT training or COPE Msc
(under supervision)
Formal CBT or FI, Discrete Problems
Routine Enquiry about Adversity in Childhood
(REACh)
What is it? Process by which we routinely ask individuals about Adverse Childhood Experiences (ACEs) during assessment process The intent being to respond appropriately and plan interventions which reduce the impact on adult health and wellbeing
Research Active
HELPER programme grant – Three streams 1. Healthy living 2. Cannabis use FEP intervention 3. Cognitive remediation
National EDEN SuperEDEN Benemine
NHS-E Goals for IAPT-SMI
• Increase choice by improving access to evidence based psychological therapies in existing services.
• Focus on barriers to implementation and how to overcome them (demonstration sites)
• Improve quality by specifying competenices to deliver therapies.
• National Training Syllabus for therapists and service leaders.
• Demonstrate impact of improved access to psychological therapies
• Outcome frameworks: service user experience at the core.
Children and Families
Why we became a Demonstration Site • Delivering evidence-based psychological
therapies. • Therapists with appropriate competencies. • Have strategic approach • Approach is replicable. • Collecting outcome data routinely and
effectively (access to historic data). • Access to training & supervision • Overcoming Barriers to Implementation: e.g.
Senior management ‘buy-in’; & ring fenced time.
Children and Families
LCFT Demonstration Site
• Lancashire EIS – Laying the Foundations • Why we were chosen as a Demonstration site • What we have done as a Demonstration Site • Interim Findings 1/10/12 - 31/12/14 • Learning Points
Children and Families
IAPT-SMI Dataset • Sessional Data:
• CHOICE Short Form
• Start/Middle/End • EQ-5D • Warwick & Edinburgh Well-Being Scale
(WEMWBS) • Work and Social Adjustment Scale (WSAS) • Psychosis Rating Scale (PSYRATS) • Patient Experience Questionnaire • Friends & Family
Children and Families
PROMS
• Data Collected in-session
• Developed mobile application for use on Samsung Galaxy tablets
• Feedback table for outcomes
Children and Families
Service Users
Therapists Informatics Technical Solutions
Person Centeredness Standardised measures ‘Imposing reality’ Use of the data Choice and ambivalence
Displaying the scores Accessibility
Data protection
Displaying the data What needs to happen next?
Delivering the IAPT Data Mobility and efficiency
Desktop App
Children and Families
66 - 10 9 30
60 - - - -
66 70 - - -
70 - 12 - -
70 - - - -
- - - - -
60 - 10 - -
- - - - -
Session one
Session Two
Session Three
Session Four
Session Five
Session Six
Session Seven
Session Eight
Choice
WEM WBS
WSAS
EQ 5D
PSYRATS
PROMS Paired Outcomes % Improved % Deteriorated
Outcomes Aims to contextualise data from individual Demonstration Sites whilst testing feasibility of measuring data across the following domains: • Service & Population • Workforce • Activity • Completion: Patterns of treatment and outcome:
PROMS • Health Utilisation Children and Families
Consent Form
Children and Families
Consent Form
Children and Families
LCFT Demonstration Site
• Lancashire EIS – Laying the Foundations • Why we were chosen as a Demonstration Site • What we have done as a Demonstration Site • Interim Findings 1/10/12 - 31/12/14 • Learning Points
Children and Families
Activity
Children and Families
• 1st October’12 to 31st December ’14 – 215 people referred – 151.2 offered treatment Context:
• referrals come after lots of informal work.
• 107 started and completed therapy in this period (85.6 per year) – 54 had 5 or more sessions (43.2) – 53 had 1 to 4 sessions. (42.4)
• 45 of completers had paired outcomes (83%)
CHOICE Scores
Children and Families
0
10
20
30
40
50
60
70
earliest latest
Mean = 46.61 S.D.= 19.12
Mean = 58.59 S.D.= 24.32
• ‘Completers’ with 5 sessions or more
• Data collected between 1/11/12 and 31/12/14
• Earliest measure and latest measure
• Significant improvement (P <0.001)
• Within group cohen’s d = 0.54 (moderate)
EIS Shared Learning Conference
Sessional Measurement Advantages
– Allowed therapist and client to see progression and alter therapy accordingly.
– Positive change was viewed as very rewarding
– A drop in scores provided focus for session – Could serve to ground clients when
unwell/distressed.
EIS Shared Learning Conference
Sessional Measurement Disadvantages
– Not always suitable when client unwell/distressed
– Clients did not always feel measurement was relevant
– Measurement as part of therapy: reduced time to speak about issues concerning client.
– Sometimes led to reduction of use of specific measures, e.g. BDI-II, BAI, ISS, HAPPI, Padau Inventory for OCD.
– Culture change
0
0.1
0.2
0.3
0.4
0.5
0.6
pre-treatment(n=54)
duringtreatment
(n=54)
Follow up(n=9)
Contacts with CRHTT • Completers (5 or more) • Contacts with
crisis/home treatment teams per month per patient
• Data collected between 1/11/12 and 31/12/14
0
0.005
0.01
0.015
0.02
0.025
0.03
0.035
0.04
pre-treatment(n=54) during treatment(n=54)
follow up (n=9)
• People with more than 5 sessions
• MH acute admissions per month per patient for total cohort
• Data collected between 1/11/12 and 31/12/14
Mental Health Acute Admissions
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
pre-treatment(n=54) during treatment(n=54)
follow up (n=9)
Mental Health Acute Bed Days
• People with more than 5 sessions.
• Data collected between 1/11/12 and 31/12/14
Service User Feedback • ‘[Therapist]’s the only one I can be 100% open with, and I still
tailor things with my social worker and it’s like…there’s still bits I’m scared to tell them, but with [therapist] I can tell [him/her] everything, yes.’
• ‘I think I’ve become a lot more optimistic.’ • ‘I’ve not self-harmed as much anymore.’ • ‘I feel a lot happier, like I’m doing something with my life, and
I’m not staying at home getting isolated. I haven’t been ill now in over a year or so…’
From evaluation carried out by The McPin Foundation.
Children and Families
LCFT Demonstration Site
• Lancashire EIS – Laying the Foundations • Why we were chosen as a Demonstration Site • What we have done as a Demonstration Site • Interim Findings 1/10/12 - 31/12/14 • Learning Points
Children and Families
Outcomes • Regular Outcome Measurement seems feasible and
acceptable as part of CBTp delivered in EIS. • This can be done in-session, using a mobile application and
with paper data. • Data for people receiving 5 sessions or more of CBTp and
EIS TAU shows improvement on Recovery Scores (p<0.001, cohen’s d = 0.54 (moderate)
• Heath Utilisation data shows reduced service use over this period.
• FI much more difficult to measure – Helen Lockett will look at this in presentation/workshop.
• Note on interpretation: CBT + EIS + Natural recovery Children and Families
Challenges • Some EIS clients do not wish to provide sessional measures • Sessional measurement a culture change to therapists.
– Weekly monitoring improved rates. • Developing IT systems:
– Service user, clinician & software developer perspectives. • Developing systems for collating and reporting data regularly:
complex and requires cross departmental buy-in. • To transform service whilst continuing to deliver high quality
service. • Difficulty in recruiting therapists to 1 year posts. • Service pressures meant we were unable to continue SUDW
pilot.
Conclusions • Lessons learned as a Demonstration Site
are valuable and transferable. • Routine assessment of outcomes is
possible in this client group with high paired completion.
• Innovative use of technology can enhance efficiency and SU engagement
• This involves a culture change for therapists – key point.
Conclusions • Executive level support and cross Trust Buy-In is
essential. • With more resources, therapists could provide
more CBTp and FI, as well as support PSI culture as part of Lancashire Care’s 3 tier EIS model;
• Initial Data suggests improved recovery and reduced service usage.
• Improving Service User Involvement and measurement of FI are key issues.
Considerations
• New EIS Access and Waiting Time Standards (AB, SW)
• Training the workforce (MF and CB) • Service User Involvement (HL& McPin
Foundation) • Symptom Focussed Best Practice
Clinical Pathways (Trauma Informed Care JWB & DK)
• Family Interventions (HL)
Children and Families
