Trust establishes a team to provide assessment and treatment for individuals with personality disorder and upskill staff to deliver better care within in-patient settings, reducing hospital days and out-of-area placements

Outline:

The Personality Disorder Hub Team was initially commissioned by the Trust’s six clinical commissioning groups to provide direct care co-ordination, case management and treatment* for up to 84 clients who are diagnosed with Emotionally Unstable Personality Disorder (EUPD) in combination with high degrees of complexity, co-morbidity and risk to self.

The rationale for this team came from a series of Serious Incidents (SI’s) where 4 patients died within ward settings. The Trust, as well as clinicians, were extremely anxious about how to best improve patient safety in this area. They were in many respects “risk averse”, and had sent many patients to “Out of area” (OAT) placements for care and treatment.

There was also a tendency for patients to have overly long admissions to hospital, where they may not improve their safety or functioning, and were felt as posing too great a risk to discharge safely. The Trust at the time was developing good patient and carer involvement with service planning, development and delivery, so this was utilised further as the business case for the team took shape. The challenge was working with a system that was extremely anxious and averse to positive risk approaches.

Ambition:

The goals of the team were multiple:

1. To provide better patient care and treatment

2. To provide better patient clinical outcomes and experience of care

3. To strengthen the system of care, including staff support, across the whole pathway of care

4. To improve meaningful patient, carer and partner involvement in the pathway and team development

5. To reduce iatrogenic harm within the system of care

6. To make financial savings in costs of care and treatment

7. To reduce stigma, increase choice and promote meaningful recovery-based care and treatment.

The team considered these goals were based on an understanding of current best practice guidance (NICE), advice received from other specialist teams in the UK and feedback from patient and carer networks on what is necessary to improve patient care and treatment. The Local Clinical Commissioning Groups attached to the Trust share commissioning intentions regarding whole systems of care, including care pathways and integrated team working focusing on long-term conditions.

Outcome:

The team have demonstrated improved outcomes in terms of:

1. Patient care and treatment. Approximately 60 patients have now received, or are continuing to received evidence-based psychological treatment. We have had 0 suicides within 4 years of operation.

2. Better outcomes and patient experience. Patients reported reduced symptoms (e.g. self-harm episodes), improved well-being and social functioning, and less days in hospital or in an out of area placement.

3. Stronger system of care. Staff report valuing the scaffolding support, training delivered, reflective practice and supervision.

4. Better involvement. Recovery Colleges across the Trust developed, peer support workers employed within the team, close collaborative working with other organisations within the statutory and 3rd sector, including service user and carer involvement networks.

5. Financial savings. Substantial reductions in bed usage has occurred.

Now, over 98% of patients have brief hospital admissions for crises, 25 patients have been repatriated from out of area treatments, saving the Trust around £2M pa and pharmacological interventions are now being reduced as alternative treatments are being provided.

Main difficulties were around pressure from the Trust to repatriate OATs patients. These were dealt with through open dialogue and honest appraisal of the team’s focus.

Spread:

The pathway and team have an overall framework that applies across the Trust, and system of care. We have worked closely with and enabled Trust wards and community teams, Police and Street triage teams, housing and 3rd sector organisations to benefit from shared ways of working and training the team has provided.

This has also included emergency departments, psychiatric liaison, crisis and home treatment teams, patient and care involvement teams and Recovery Colleges. The team are embedded within community services, and so work closely with other staff, teams and organisations.

We have held engagement events with other teams and services, and shared our pathway and model with them through collaborative working. In the past year, we have shared our pathway evaluation at national Conferences (e.g. DCP, BIGSPD). Recently, we have received visits from several other Trusts to share our pathway model and team operational functioning. This has been well received. We are arranging to provide evidence-based training to other Trusts on psychological approaches to care and treatment.

A Therapist Manual for evidence-based care and treatment is being prepared for publication this year after being field tested during 2016-18. Other organisations are using our model to inform their local service developments.

Value:

The team has contributed to considerable financial savings in inpatient bed usage and repatriation (N=25) and prevention (N=0) of OATS placements. Savings at around £2 pa.

The wards no longer have most patients in hospital for more than a few days and there is much more “flow” across services and teams. Patient and carer improved experiences are reported during and after treatment, such as: “I have always been listened to.

I have felt safe. I have been kept as calm as possible. I have a better understanding of my mental health problems; thank you so much for all the care and support you’ve given me.

You’ve changed my life; I wouldn’t still be alive without the help you’ve provided; Excellent service and good care; I felt like the service helped my transition from hospital to community much easier; Feel like I’m finally on the right treatment with the right people”.

Involvement:

Our stakeholders are various and include primary care, local authority, Police, liaison psychiatry, housing and residential providers, 3rd sector organisations and patient and carer networks, including Recovery Colleges.

We engaged with them through a strategic pathway development group embedded into the Trusts management structure. We also visited our partners and mutually developed the pathway model.

There was considerable “buy-in”, as most people felt the need for improving services and the pathway, but didn’t have the resources to integrate strategic thinking at a systemic level.

Their contribution was crucial to the outcome of the team and pathway so that the system could become more integrated and seamless for patients. Without a pathway strategic development group and operational management support from the Trust, the team would not have developed.

Strong and collective leadership, including the appointment of Trust wide Lead for Personality Disorder and a Clinical Lead for the team has been essential to the team developing and embedding a coherent model of care across the pathway.

Patient involvement and co-production was maintained through the process of design, planning and implementation. We have learned the value of employing peers support workers within the team and wider pathway.