Integrated Care Pathways in Mental Health Sean Doherty NHS Quality Improvement Scotland

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Integrated Care Pathways in Mental Health Sean
DohertyNHS Quality Improvement Scotland
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What is an ICP

• Integrated care pathway
• A system of continuous quality improvement
• Focuses on recording, analysing and acting on
  variances
• Put simply - a tool to compare planned care with
  care actually given

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The policy context

• Commitment 6 - Delivering for Mental Health
  (2006)
• NHS QIS will develop the standards for ICPs for
  schizophrenia, bipolar disorder, depression,
  dementia and personality disorder by the end of
  2007.
• NHS board areas will develop and implement ICPs
  and these will be accredited from 2008 onwards.

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Links to performance management

• HEAT targets
• Benchmarking
• Single Outcome Agreements

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Standards for integrated care pathways for mental
health

• Developed collaboratively
• Consulted on widely
• Evidence based
• Published December 2007

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• Process
• the essential foundations for development of ICPs
• Care generic
• the framework for all mental health care
• Care specific
• five mental health conditions
• Service improvement
• Ensuring that ICPs are making a positive impact
  on care

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Condition specific care

• Bipolar disorder
• Borderline personality disorder
• Dementia
• Schizophrenia
• Depression

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What now? - baseline scoping

• All NHS boards visited during April June 2008
• Local factual reports NHS QIS
• Degree of development and implementation of ICPs
  variable across NHS board areas
• Local action plans NHS boards

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What now? - ICP toolkit

• ICP resources available online now
• Focus group sessions what do you want from the
  ICP toolkit?
• All NHS boards invited to participate
• External web design company to be commissioned
• Piloting and launch

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Crerar Review

• Looked at audit inspection and regulation of
  public services
• 42 recommendations to improve the role of
  scrutiny within the public sector

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What now? - accreditation

• Complex
• System under development - but - this is NOT a
  barrier to ongoing local ICP development and
  implementation
• Facility for ongoing data collection
• Supportive and developmental
• The products of a functioning ICP will provide
  the evidence for accreditation

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Our approach

• All NHS boards developing and implementing
• Continued support from NHS QIS
• ICP national co-ordinators
• Measuring and acting on variance

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Mental Health Collaborative

• A brief overview

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Collaborative Approach

• Providing the capacity (time) and capability
  (skills) to learn to see our systems afresh
• Experiential understanding how it feels to
  those on the receiving end of services
• Factual - using data to focus our attention
• Informed - using the evidence base and learning
  from experience

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Systems Approach

• 95 variance is caused by the system
• We need to give front line staff the skills to
  understand why the system is failing and how to
  fix it
• Instead we have become self-taught experts in
  working around broken systems

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Mental Health Collaborative 3 Workstreams 4
HEAT Targets

• Better treatment for depression
• Improved inpatient processes and community mental
  health services
• Timely diagnosis of Dementia and appropriate
  follow-up support
• Each underpinned by
• Improvements in the quality of the experience

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Mental Health Collaborative

• We dont have all the answers in advance
• We do have tools and techniques to help us find
  the answers together

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Results delivered by

• Developing links across other national programmes
  and organisations
• Allocating funding to NHS Boards for Improvement
  Infrastructures
• Providing training on improvement tools and
  techniques
• Generic Core Skills Training
• Customised to Mental Health and Local Needs

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Results delivered by.

• Providing toolkits for local use
• Generic Improvement Toolkits
• Customised to Mental Health (Simulation process
  improvement game and Demand Capacity Model)
• Identifying High Impact Changes and Measures for
  Improvement
• Reference Group

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Results delivered by.

• Developing mechanisms for sharing learning and
  knowledge
• Web based resources
• Newsletters
• Networking events

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• To change an organisation, the more people you
  can involve, and the faster you can help them
  understand how the system works and how to take
  responsibility for making it work better, the
  faster will be the change.
• Marvin Weisbord,Training and Development Journal

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Why do we need measurement in mental health?

• Information about delivery and outcomes of
  clinical and social care can make a vital
  contribution to facilitating the safety,
  efficiency and effectiveness of health care.

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Who is the information for?

• Three Ps (in America 6 Ps)
• Patients
• Providers
• Policy makers

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What do we need to measure?

• Our challenge is to select measures that matter
  in terms of
• Clinical outcomes
• Strategy
• Legislation

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• What are the key aspects of performance?

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Key Aspects of Performance

• QUALITY patient experience and health outcomes
• EFFICIENCY How resources are managed and used
• SUSTAINABILITY Whether the functions provided
  by services are sufficiently sized and
  appropriately positioned to meet needs of local
  communities
• COST resources are limited so best value must
  be achieved from current investment

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What are appropriate performance tools to measure
the data?

• Benchmarking/Balanced score cards
  (indicators/definitions)
• HEAT (targets)
• ISD
• LDPs
• Review visits (templates)
• Joint Futures Outcomes (indicators)
• DoH compendium of clinical outcomes

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What do these tools measure?

• Benchmarking measures - Responsibility
• Benchmarking template reports annually try to
  achieve consistent definitions across the system
• Costing project relates costs to definitions
• Balanced scorecard

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What do these tools measure?

• Balanced Scorecards
• National
• Local
• Subspecialities

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What do these tools measure

• HEAT measures Accountability

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What do these tools measure?

• ISD mental health information programme
• Inpatient returns SMR4, SMR1 (SPARRA)
• Outpatients returns SMR00
• Prescribing information (monthly)
• Practice team information (GP plus nurse
  individual contacts)
• QOF

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Performance tools not used

• MMI (monthly management Information)
• 18 week wait

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Asprational PerformanceTools

• Data system (eHealth) data sets
• IPACC versus PMS versus others
• eHealth supporting ICP data set
• IPACC core data set operating in some areas

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What are the challenges?

• Robust, meaningful data sets and collection
  (definitions, IT, software, core data)
• Using the data appropriately

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• How it all fits together

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DRAFT V3
NQIS ICP Programme
Mental Health Collaborative Programme
NES Psychological Therapies Programme
Mental Health Benchmarking Programme
Setting National Standards for ICP Development
Are we doing the right things
Identifying High Impact Changes that if
implemented will make a significant difference
to outcomes
What therapies should we be delivering to which
diagnostic groups?
Provide benchmarking comparisons to help to
identify which services/functions may be less
effective than others
Supporting systems to process redesign to ensure
evidence based care is being delivered
in the most efficient way
Competency Framework Agree model - stepped or
matched care Review cost-effectiveness of
therapies
Providing evidence for most efficient pathway of
care
Provide benchmarking comparisons to help to
identify where there may be inefficiencies
Supporting systems to process redesign to ensure
reduction of duplication and waste, removal of
bottlenecks and efficient flow of work through
system
Modelling the demand for psychological therapies
and capacity needed to respond Reviewing no of
staff at different levels needed to meet demand
Funding Improvement Infrastructures in NHS
Boards Developing knowledge and skills of
frontline staff in improvement methodologies Suppo
rting staff to put these into practice
with appropriately skilled staff
Developing knowledge and skills of staff to
develop and implement ICPs
Developing a competency framework Providing
training on psychological therapies and training
for supervisors Funding NHS Boards to put in
place governance arrangements Advice to boards
on commissioning local training
Provide benchmarking comparisons to help to
identify where there may be skill mix issues
Reporting on variance analysis and using this to
inform further service development
and using information to review
Setting standard definitions to enable
comparison Providing reports which show how
health boards compare
Developing the ability to collect and analyse
information to inform service improvement
Accreditation of ICPs
Using variance analysis, outcome and impact
assessment data to inform commissioning of
psychological therapies training programme
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