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Discharge Pathway Project

Girish Kunigiri

Fabida Noushad

Mohammed Abbas

Colin Gell

Sarah Cassie

Ayesha Ahmed

Terri Eynon

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CMHT in Leicestershire

Town Hall Chambers

Melton

Rutland

Market Harborough

Cedars

Orchard

Hawthorne

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CMHT challenges in Leicestershire

Longstanding culture Variation in practices across localities Dependency on psychiatrist Overloaded outpatient clinics Waiting lists for first appointment (average 4-5

weeks; up to 13 weeks) Clinicians struggle when Service User need to be

seen urgently

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Mental Health Facilitator (MHF)in Leicestershire

MHF are mental health professions at Band 5/6/7 Managed in the primary care (along side the IAPT) Currently in the county (n=18 MHF)

Role• Help GP in assessment and management of SU with SMI

(mild to moderate)

• Ensure SU on SMI register are followed up and have annual health check

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Outpatient clinics Consultant case load – 350-600 (largely on their own) Average clinics by one community consultants

4-5/week; Junior doctors 2-3 clinics/week

No. of patients seen/week in outpatient clinics 4-5 new About 40-50 follow ups

Discharge range : 35-127 per year per consultant

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Outpatient clinics Leicestershire

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East Midlands MH Trusts benchmarking audit

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East Midlands MH Trusts benchmarking audit

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East Midlands MH Trusts benchmarking audit

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East Midlands MH Trusts benchmarking audit

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Limitations of clustering exercise

Audit done in May 2011- however training of clinicians in clustering completed only by September 2011

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Aim of discharge pathway project

To identify and discharge service users with SMI who have been stable back to primary care

To support the primary care in managing such patients

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Intended benefits of the project

To make efficient use of resources in secondary care services in managing service users with SMI

To reduce waiting time to see urgent and new referrals in CMHT

Clinicians to be able to provide more active psychological and crisis intervention to their SU

Smooth transition of SU between primary and secondary care

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Methodology

Set up a steering group Rolled as a pilot in NWL from Feb 2011-Jan 2012 Developed a tool to help identify SU who could be

potentially discharged back to GP• Those stable for one year or longer with no interventions• Advice to primary care included (medication, early signs of

relapse, risks and its intervention)• Consulted with all the clinicians and GP for their views on the tool• Clinician had option of using the tool at discharge or incorporate

the content of it in their clinic letter to GPs

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Methodology cont…

Educated the CMHT Educated the GP Encouraged clinicians to review patients who are

stable for discharge• During MDT/CPA meeting

• OPC Discussing with patients and carers regarding

discharge on their next appointment

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Methodology cont…

Joint decision to discharge to primary care• When necessary involved MHF/GP

Copy of the final care plan/clinic letter given to SU

Fast tract when necessary

Providing advice to primary care

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Evaluation of the project

Questionnaire sent at 6 months and 12 months post discharge• To SU

• To GP

Questionnaires identified• Care provided in primary care

• Increase in workload in primary care

• Satisfaction by SU and GP

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Results: Caseload

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Referrals (n=117)

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Discharges (n=143)

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Type of discharge (n=143)

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Diagnosis

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Results- Evaluation

So far responses from 5 GP’s• Discharge letter helpful

• Received help from secondary care when appropriate

• None of these patients had personalisation and advance directive

• No additional work

Patient responses- still awaited

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Challenges LPT Clinicians

• Reluctant discharging SU• Concerned that SU might not get the right care in primary care• Wary about providing advice to primary care when SU not

open to secondary care• Practicality of fast track

GP• Concerned about increase in case load• Expertise in managing when in relapse

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Challenges cont…

Service Users• Concerned that there may be no continuity of care

• Fear of delay in re-referral/acceptance by secondary care

• SU choice

• Issue with benefits

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The way forward

Integrating the discharge pathway project with care pathway development

Continue to review existing caseload on a regular basis

Openness with SU about reasons for discharge

Setting the goals and duration of treatment when SU are first referred to the services

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Integrating the discharge pathway results with care pathway development

Periodic review of care clusters• CPA

• Change in clinical status

• Set up maximum time frame

Defining possible time frame for each cluster

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Cluster pathway 11

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Conclusions Significant proportion of service users are in secondary care who

are relatively stable and could be managed in primary care. Service users should receive the right care at the right time and for

right period of time. This pilot has shown that 32 patients were stable enough to be

discharged. Service evaluation have shown satisfaction within GP’s. There

needs to be a cultural shift with clinicians and service users in bringing this change.

Integrating results with care pathway development is the way forward.

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Acknowledgements

Christine Green & Sue Scarborough Clinical staff GP’s Service users