Integrated Care Pathway for Bipolar Disorder. Seminar to the Westgate GP Practice, Lichfield,...
-
Upload
nick-stafford -
Category
Documents
-
view
158 -
download
2
description
Transcript of Integrated Care Pathway for Bipolar Disorder. Seminar to the Westgate GP Practice, Lichfield,...
From primary to tertiary care
An integrated care pathway for the improved screening, assessment and management of bipolar disorder
Dr. Nick Stafford, Consultant PsychiatristLichfield, SSSFT
DisclosuresPharmaceuticalsAstra Zenenca LtdOtsuka LtdBristol Myers Squibb LtdGlaxo Smith Kilne LtdPfizer LtdEli Lilly LtdLundbeck LtdServier Laboratories LtdGW Pharma Ltd
Private HealthcareNuffield HealthSutton Medical Consulting Rooms
Full list of business relationships at: www.uk.linkedin.com/pub/nick-stafford/17/7a4/54a/
Public Education/Professional Attitude
Praised by the public for going public Criticised by psychiatrists for going public
The management of bipolar disorder
Whole systems proble
m
Whole systems solution
s
Primary care
Secondary psychiatric
care
Inpatient care
Tertiarycare
CAPTURE MISSED BIPOLARBEGIN TREATMENT EARLY
SHARED CARE AGREEMENTS
IMPROVE DIAGNOSTIC ACCURACYBEGIN TREATMENT EARLY
ENHANCE SPECIALIST TREATMENT
Each element requires its own solutionsto improve overall outcomes
Aims of the bipolar care pathway
Project in Leicester
Health Care & Pharma
Mental Health Trust
AstraZenecaPCT/CCGs
Charitable
Bipolar UK
Depression AllianceRethink
Elements of the care pathway
Primary Care Secondary Care
Tertiary / Specialised
Care
Increase awareness
Screening
Enhanced assessment
Psychosocial interventions
Second opinions
Comprehensive management plans
Pilot sites:Lichfield (CMHT)
Stafford (IP)
Elements of the care pathway
Primary Care Secondary Care
Tertiary / Specialised
Care
Primary care red flags
Presenting complaint:
Breast lump
Blood on toilet paper
Persistent cough
Depression
Could it be
Breast cancer?
Bowel cancer?
Lung cancer?
Bipolar?
How do we fix it, practically?
Education Screening tool not diagnostic
Always be alert
A few extra questions is
effective
Low index of suspicion
History from someone
close
The goal in primary care
“If a GP sees Depressive Disorder they should have a reflex consideration of bipolar disorder every time and ask relevant questions to probe for it”
Primary care education in Staffs
Large group seminars (50+)
Individual practice seminars (3-15)
All Primary HCPs (not just GPs)
Internet e-Learning programme
Primary care screening options
• Ask more questions – But which? (e.g. BRIDGE)
• Collateral history encouraged• EMIS / Systm1 alerts (software templates)
– Surprisingly less popular with GPs• Formal screen HCL-32
– How useful is it in practice?– Frequency of use
• MDQ preferable?
HCL-32
• Most validated screen for hypomania• Available in a range of languages• Combines stem questions with screening
questions
• Distribute packs in primary care
Dimension and categories
BipolarDepression
Borderline Anxiety disorders
Addictions
HPA axis link?
Bipolar or unipolar depression
Borderline more likely if:
• Affective instability due to a marked reactivity of mood (e.g. intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and sometimes more than a few days)
• Identity disturbance: markedly and persistently unstable self-image or sense of self
• Chronic feelings of emptiness• Severe dissociative symptoms• Frantic efforts to avoid real or imagined abandonment• Recurrent suicidal threats, gestures or behaviour• Self mutilating behaviour
Others (not exclusive)
• Anxiety• ADHD• PTSD• Other personality disorders• ‘Behavioural’• Alcohol & substance misuse
If GP refers to the Clinic
• Standard GP letter (no forms to fill in)• HCL-32 if appropriate, not mandatory
– MDQ if preferred• Option to use the CPN• Patient educated about possible bipolar• Leaflets given (pre- and post-diagnosis)• Mood diary before OPC appointment
Elements of the care pathway
Primary Care Secondary Care
Tertiary / Specialised
Care
Specialised Bipolar Clinic
And supporting servicesPsychosocial interventions
Tertiary service
Specialist services NICE 2006DoH Guidelines 2007
• All trusts should provide:– Specialist Mental Health Services– Access to specialist advice from designated
experienced clinicians– Referral on to tertiary services
• This can be provided with a local specialised bipolar disorder clinic
Specialists within specialisms
• What does it mean?• Increasingly differentiated with medical progress
• In psychiatry– A need for generalists and specialists– ADHD, ASD, EDS, CFS / PIER, AOT / CAMHS, MHSOP
• Medicine and surgery– The norm in all areas
Nick Stafford, Allan Young, Tony Hale, Heinz Grunze, Daniel Smith, Francesc Colom
Pros and Cons of a Bipolar Clinic
Pros• Reduces readmissions• Increased satisfaction with
care• Better continuity of care• Improved education and
research
Cons• Greater cost (not always)• Not always more effective• Fragmentation of care• Tertiary setting distance• Gaps in overall care• Could focus less on functional
outcomes
• Need for greater peer support and expertise
Time to hospital readmission for patients treatedin the mood disorder clinic v. standard out-patient care.
Kessing L V et al. BJP 2013;202:212-219
©2013 by The Royal College of Psychiatrists
N=158Single manic episodeAfter 1st, 2nd or 3rd IP admissPOM = time to readmission
HR = 0.6095%CI = 0.37 – 0.97P=0.034
Kessing L V et al. BJP 2013;202:212-219
Economic analysis
Specialised Bipolar Clinic Model
Secondary care assessments and
management
Second opinions in tertiary service
Psychosocial interventions
Training and Research
MDT
Elements of the Clinic 1st Assessment
Pre-Interview Questionnaire• Lengthy
• Patients enjoy completing
• Structure similar to semi-structured interview
Semi-Structured Interview• Detailed focus on moods
• Predominant Polarity
• Bipolarity Index
• Detailed medication history
• Comorbidities identified
TO IMPROVE DIAGNOSTIC ACCURACY AND CARE PLAN COMPREHENSIVENESS
Semi structured assessment
• Face to face interview:– Questionnaire structure maintained– Clarify pre-interview questionnaire– Extra detail were needed– Are diagnostic criteria met? Listed in conclusion.– Bipolar I, II etc…– Predominant Polarity & Polarity Index– Review of comorbidity
• Axis I + addictions• Axis II – IPDE
Missed diagnosis of bipolar
• Variable figures: >15% RDD in primary care• Impact of untreated episodes are manifold• Relationship breakdown• Occupational breakdown• Increased use of CMHT services• Increased use of inpatient services• Kindling in the untreated worsens prognosis
MDT Approach
MDT Members• Consultants
• Higher ST trainees
• Non-medical prescribers
• Visiting clinicians
• CPN
• OT (BPE)
• Social Worker
Psychosocial interventions
• Training for all IP & CMHT staff– Psychoeducation– Functional remediation– IPSRT (Interpersonal Social Rhythm Therapy)– DBT (Dialectical Behavioural Therapy)– FFT (Family Focused Therapy)
Bipolar PsychoeducationSurvival curve on time to recurrence.
Colom F et al. BJP 2009;194:260-265
BPE group cf. Control group:
Fewer recurrences3.86 v. 8.37, F=23.6, P<0.0001
Less time acutely ill154 v. 586 days, F=31.66, P=0.0001
Less hospitalised days (median)45 v. 30, F=4.26, P=0.047
The philosophy of the pathway design
Apply what is known
Iterative designThe model can
be applied anywhere
Appliance of science
If GP/Psychiatrist refers to the Clinic
Standard summary letter
HCL-32 encouraged if appropriate
Patient educated about possible diagnosis
Leaflets given (pre- and post-diagnosis)
Mood diary from referral to OPC appointment
Elements of management
Comprehensive reportClarity of diagnosis &
management
Psychoeducation &Evidence-based
management plan
Multi-axial diagnoses& co-morbidities managed
Health adviceQuality information
Management with GP
Elements of the care pathway
Primary Care Secondary Care
Tertiary / Specialised
Care
Management algorithms
• International Guidelines for bipolar treatment– BAP– WFSBP
• Weekly OPC initially if necessary• Management of comorbidity• Lifestyle advice• Psychoeducation (online and face to face)
• MDT approach and enhanced capacity
Structure of South Leicestershire outpatient clinics now
CMHT Outpatient
Clinic Services
OPC services
Assessment clinic
Bipolar disorder specialised
clinic
Integrated depression
clinic(at a later date)
Generic Specialised
Training
In clinic experience
Psychiatry trainees
GP trainees
NMPs
Students
Psychosocial interventions
Psycho Education
IPSRT
DBT
FFT
Medication
Workshops
Forums
NMS skills
General training
Medical student
Psychiatric trainees
Nurses
Other CMHT/IP members
Research
Evaluation of
SSSFT bipolar services
Portfolio income
generating
external research
In development
• New Psychoeducation Course• Web based support• App development• New manuals for psychosocial interventions
• Research
Media attention & public education
Thank you