Geraldine Strathdee and Jen Hyatt: Technology innovation for supporting patients at home
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Transcript of Geraldine Strathdee and Jen Hyatt: Technology innovation for supporting patients at home
Delivering the Five Year Forward View for Mental HealthWhole systems approach to Mental Health Informatics, Information, Intelligence and Improvement Science (4Is)
#5YFV #MentalHealthDr Geraldine Strathdee @DrG_NHS
& Dr James Wollard
January 2015 v1
The 4 ‘Is’ is route map to better mental health services in England
Information & data
What are the national policies and priorities that
direct our work
What are the quality standards we need to
implement for evidence based best clinical
How do we agree what data to gather to assess baseline & to ensure we are making
progress
Informatics
How do we gather the data in a low burden way to free up time to care and improve
data quality
How do we achieve integrated care through
interoperability's & increased functionalities
Intelligence
How do interpret the data & turn it into intelligence for choice and improvement support for the public,
patients and clinical teams
Where do we find and share ‘What Good Looks Like’ to tackle the big problem of variation in standards and
17 year science to front line gap
Improvement
Implementation How do we create a Learning
Organization Model of leadership & improvement
NHS England’s The Five Year Forward View – Mental Health
• INVESTING IN MENTAL HEALTH NEEDS TO HAPPEN TO BENEFIT ALL OF US:
– Mental illness is the single largest cause of disability in the UK and each year about one in four people suffer from a mental health problem. The cost to the economy is estimated to be around £100 billion annually – roughly the cost of the entire NHS. Physical and mental health are closely linked – people with severe and prolonged mental illness die on average 15 to 20 years earlier than other people – one of the greatest health inequalities in England. However only around a quarter of those with mental health conditions are in treatment, and only 13 per cent of the NHS budget goes on such treatments when mental illness accounts for almost a quarter of the total burden of disease. Over the next five years the NHS must drive towards an equal response to mental and physical health, and towards the two being treated together.
• WE ARE ALREADY ON OUR WAY, BUT IT IS ONLY A START:
– We have already made a start, through the Improving Access to Psychological Therapies Programme – double the number of people got such treatment last year compared with four years ago. Next year, for the first time, there will be waiting standards for mental health. Investment in new beds for young people with the most intensive needs to prevent them being admitted miles away from where they live, or into adult wards, is already under way, along with more money for better case management and early intervention. This, however, is only a start.
• BEGINNING WITH TIMELY ACCESS TO THE RIGHT CARE:
– We have a much wider ambition to achieve genuine parity of esteem between physical and mental health by 2020. Provided new funding can be made available, by then we want the new waiting time standards to have improved so that 95 rather than 75 per cent of people referred for psychological therapies start treatment within six weeks and those experiencing a first episode of psychosis do so within a fortnight.
• CRITICAL STANDARDISATION OF CARE
– We also want to expand access standards to cover a comprehensive range of mental health services, including children’s services, eating disorders, and those with bipolar conditions. We need new commissioning approaches to help ensure that happens, and extra staff to coordinate such care. Getting there will require further investment.
January 2015 v1
The “I’ statements in 2014 for people who use mental health services – what they experience now and what they want
‘I cannot find good information on how to build my resilience for
whatever life throws at me
I look on NHS choices and i can’t see what services I can access
locally or on line
I am not sure if its safe to speak to peers on line in digital support
I have to tell my story over and over again in
every settings.
I am not sure my clinicians know what
each other has recommended
I don’t get any text reminders for
appointment or for my blood tests like I do
from the dentist & my physio
I don’t know what treatments will help me or how to judge
them
One of my psychiatrists uses an app to help me to do
mindfulness exercises as part of my therapy and its really helpful
I use crisis service often because i can’t seem to
get them all to work together to share my
crisis care plan
I can’t have my treatment at home although it is a struggle for me to get out because my CPN’s trust will not let her use
video-calls or skype
I wish I could have my physical health monitored at home, so I don’t have to travel to be told my blood pressure is normal
and to carry on with the same treatment
My mother has dementia and she is not safe as she wanders at night and we dont have technology to
keep her safe at home
I am psychological resilient and use on line
tools to help have a better quality of life
I use a series of on line self assessment and
management tools as part of my ‘mental health
‘reading
I can safely use an on line peer support platform to
get support when a bit shaky
I can access psychological therapy for my conditions
on line
I can have my treatment as a combination of on
line, face to face, groups, by skype
I get text reminders to remind me to go for blood tests, see my
doctor for monitoring, take my medication,
inspirational lines
I love to hold my own records and get my blood
tests and track my own improvement and self
monitoring
I feel more in control as I am more knowledgeable
My doctors and professionals all get the test results so I feel safe
that treatment is not interacting badly
I feel safe that when my records are shared, the very confidential issues
are well safeguarded
I can get most of my treatment at home
I now get my blood tests at home
I can monitor my blood pressure and weights on
my iPhones the trust gave me
The ambition for 2020:“I’ statements for people who use mental health services in the future
The 4I’s behind meeting the #5YFV:
Intelligence
Information
Informatics
Improvement Science informed
change
January 2015 v1
In order to meet the vision of the five year forward view we need to engage in a whole systems approach that makes the best use of the Informatics, Information, Intelligence and Improvement Science available and being developed. These 4 “I’s” form a reinforcing cycle that will drive the system towards better more effective care, for more people, in more communities, in more personalised, technology enabled ways.
4I’s sit at the centre of delivering effective policies that lead to better commissioning and better, personalised care
January 2015 v1
Activity and Outcome Based Tariff Models
Effective Patient Choice
Access and Waiting Time Standards to Evidence-Base Care
Information,
Intelligence,
Informatics &
Improvement
Science
Quadri-lingual Leadership
At the heart of the strategy to meet the five year forward view for Mental Health, we need four areas of co-ordinated leadership brought together in effective forum:
– Policy and Healthcare Economics
– Patient/Person using services
– Technology and Data
– Clinical and Improvement Science Evidence
• Identifying and bring together the core leadership in these areas will be critical
• Maintaining and developing the right skills and knowledge in emerging leaders will also be critical to continuing progress through to 2020
January 2015 v1
Aims of a 4I strategy for Mental Health
January 2015 v1
• To implement the “No health without mental health”, Better Access & Crisis Concordat policies, and support the implementation of the CYP taskforce recommendations & dementia
• To determine & develop the transparent metrics to inform Ministers, policy makers, the public, patients, commissioners & clinicians of the levels of access, standards, outcomes & Value of the NHS, Las, & wider system collaborative communities functioning
• To inform the development of an information, informatics, intelligence & improvement highway to support the implementation of the 5YFV aims
• To steer the development of digital maturity in the mental health sector to• a) ensure the commissioning of electronic care records systems that maximise the functionalities &
interdependencies of Electronic care record across primary & specialist sectors & social care sectors, • b) enables modern integrated, safe, NICE/SCIE concordant effective treatment & care, & routine
outcome measurement, fed back to front line clinicians and teams to drive improvement & transformations in care,c) improves data quality through reduced burden of data collection for clinicians &, delivers a digital revolution in data access, decision support systems for patients & clinicians,
• To identify through our mental health networks, SCNs , AHSNs, CLARCs, ‘What Good looks like’ in commissioning, provision & empowered patient self care & disseminate through improvement programmes & to ensure sustainability through establishing an independent, robustly funded mental health intelligence network collaborative ( like cancer IN)
10
Policy• 5 Year Forward View • No health without MH’• Cross Govt Commission • Better Access & Choice• Crisis Concordat• Care pathways & CFV• PHE prevention agenda • Workforce modernisation• Generational ambition• Tariff & economic
modelling• Funding allocation
formula
Better, safer, modern care• NICE /SCIE HTAS, PH &
care guidelines, quality stds
• Generational • Outcome measurement• Research programme• CPRD• Prevalence project• CFV design • RCPsych/BPS Better
/MIND better formulation
• ICD/ smowmedintroduction
Systems Programs• SOS transparency prog.• Jon Rouse T & F & PID• MHSB sub group• 13 agency programme• HSCIC, MHMDS spec.
for ICD, bed+ team types,
effective interventions, Oats + coding alignment with A/E, ambulance, CEM, MH
• NHS Choices information
Fingertips pathways• Prevention, Social care
Primary care • Workforce data • New NHSE+ CQC, CCQUI
• Website dev’t
NCD team work • JSNAs• Psychosis reports etc• Atlas of variation • Outcome metrics • Quality metrics urgent• Crisis concordat
metrics• Crisis Concordat
assurance checklist• CQUIN
Governance WGLL programmes
Digital maturity optimization • Electronic records
(interdependency &
functionality
• Digital data collection • Empowered self
managing patients• Use of NHS number,
ODS 5 digits, ICDs• SPN notifications for
111 frequent attenders • Clinician decision
systems • Bradford SMI template• Capacity man’t system • 111 clinical pathways
Information sharing Caldicott protocols crisis
Digital governance• Digital Apps
accreditation• Digital therapies
accreditin• London platform
Current programs
• SCN manuals
• AHSN programmes
• CCG leaders programmes
Key products to commission
• Model JSNA + LGA/PHE
• Aligned coding for UEA
• Data demand & capacity modelling
• Economic modelling
• Workforce modelling
• In vivo live for every clinical team data set
• LCCG commissioner data set
Leadership & improvement programmes
1. What Good Looks Like Repository
2. BBC & journals comms• Timetable of products
• Slide share packs
3. MHIN funding
• Improvement offer 2 pager for 5 funders
• Establish blind trust
5. NCCCH access and waits programme + MHIN ERGs
6. AHSN & Education
• JSNAs
• AHSN psychosis pathway
• East London course
• Educational products e.g. slide share
• Commissioning for value
• Newsletter to CCGs/ SCNs
What directs our work Getting & sharing good data
How to agree & assure the data indicators & analysis
Turning data into intelligence and improvement programs
How do we develop leaders with literacy to drive sustainable transformation & improvement
Policy & clinical best practice developments Digital developments
Governance &Innovation
An overview of the 4I programs in place or being developed to meet the #FYFV
Why we need a 4I’s strategy group to deliver it
• There are already multiple programs internally and externally to NHS England that are trying to achieve the same ends, leading to partial and incomplete solutions being reached
• The number of existing and potential data streams is expanding and will continue to expand. There needs to be an agreed, structured approach to organising and analysing those streams of data – this is critical in closing the loop of: data – information – intelligence –transformative change
• The increasing use and desire to use technology in self-care and care co-produced with Healthcare serviced must be backed by co-ordinated, effective and safe policy – this cannot be achieved if the relevant experts and stakeholders and not brought together in a sustained and organised way.
• Specifically to Mental Health services: There is wide recognition that they are not meeting the needs of the population, both in terms of the level of services available, but also in their current models of delivery. However evidence for effective model of service and care exist and need to be implemented in an intelligence driven way to bring about the changes desired by all parties.
January 2015 v1
The Critical 5 W’s of data that will drive the 4I’s
• To accurate describe the pathways of care we need to collect data about 5 critical aspects of the processes involved at every stage:– Who - Patient and HCP - NHS number and National Staff codes
– Why - Diagnosis Codes – ICD-10, SnoMed
– What - Intervention codes
– Where - ODS codes, standardised taxonomy of services across data streams
– What Happened - Outcome measurements
• Many of the W’s are already collected but need greater coordination across data sets.
– The NHS number provides a key part of this and hence the importance of it as a “Primary Identifier”
– Intervention codes are the least developed area of data
– Use of Outcome measures needs to become embedded in clinical practice beyond IAPT services.
– There is no current standardised taxonomy of services to define “where” care took place
January 2015 v1
“Global” Mental health Taxonomy of service types and accurate
Directory of Service based on it
Tariff ModelsOutcome or Acitivity
based models require clear evidence of
where care took place
Enabling Choice through choose and book – services
registered appropriately
Standardised information for patients to make informed choice and access services appropriate
Transparency and comparability of services – drives service improvement
Allowing standardised collection of data and aggregation of data across sources
Where? – A standardised taxonomy and maintained Directory of Service are a critical part of delivering other policy areas
Access and Waits – Clarity and standardisation about what these mean
Admission/Attendance
Referral
Assessment
Care Planning
Investigations Treatments
Discharge
I can only receive information by fax or over the phone and then have to transcribe this into an electronic record system
I have to write duplicate entries in the medical records, often still paper based, and the mental health records system
I cannot use technology based interventions and monitoring routinely in
care planning
I have to rely on colleagues in acute trusts to access pathology results otherwise I have to call the pathology lab and receive the results manually over the phone
I have to rely on paper systems to transfer results of investigations between acute settings and mental health outpatient and community clinics
I cannot routinely contributed to an integrated discharge summary that is electronically distributed.
I can only use technology in a limited way to keep patients up-to-date with follow-up arrangements
There is no place for an collaborative shared care plan between the medical team, mental health team and the patient/their carers
Information about attendance or admission is not automatically sent to mental health trusts systems
The current use of technology in Mental Health Care is far from what it could or needs to be to meet the vision of the #5YFVLiaison Services – example “I statements” for professionals now
Admission/Attendance
Referral
Assessment
Care Planning
Investigations Treatments
Discharge
I can receive referral electronically that integrate into the electronic records system reducing duplication of work
I can write one entry in one record system and it is shared with other linked records systems, or there is one record systems across trusts
I can recommend technology-enabled care that integrates well with
other IT systems – e.gApps or remote sessions
using videocalling.
I have access to pathology systems within the electronic patient record for mental health service. I can order investigations online and remotely
Information about t physical health investigations is shared with primary care and community services electronically
I can contribute to an electronically integrated discharge summary
Discharge plans (eg. appointment times) are routine shared and updated through an electronic system . Notifications are sent about changes to staff who will see the patient
Care plans are shared in real time across systems and can be updated and) accessed by all involved (including patients.
My team are able to receive timely alerts through an integrated system that enable us to respond quick and triage our work more effectively
In to the future...Liaison Services – “I statements” for professionals in 5 years
Wider Consensus Needed On Difficult Issues:
• Who own’s data generated by individuals – how do we agree policies that ensure we can make the best use of this for the individual, communities and the whole healthcare system
• How do we manage (both in terms of policy and technically) the balance between confidentiality of data and the need to share information (such as care plans) to ensure better care, particularly in urgent or emergency care and working with other agencies. Not addressing these will lead to barriers in making progress. Allowing local decision to be made on this will lead to a myriad of solutions that will continue that post-code lottery of care
• Due to the sensitive nature of many narratives in mental health, potential vulnerability for those suffering from mental health difficulties in negotiating these issues, and the relevants laws, these issues required specialist consideration beyond that which may agreed for other areas of healthcare
January 2015 v1
AppendicesMapping the Complexity in the system
• The following slides illustrate the complexity of the systems we are working with and the need for a consistent 4I’s strategy across the mental health care system.
• That the systems we are trying to influence and change are complex only underlines the need for a co-ordinated national mental health strategy around informatics, information, intelligence and improvement science.
January 2015 v1
Local/FrontlineP
ub
lic S
ecto
rIn
du
stry/Private Secto
r
National/International
NHS England
Tim KelseyBeverly BryantMonitor
PHEGregor
HendersonCQC
Paul Lelliot
Benchmarking Club
NHS Trusts
Private Health Care
Providers
CCIOs
RCPSYCH
Simon Wessley
CCGs
Informatics CommitteeJonathon
Richardson
MHINJames Seward
Transparency – Emma
Doyle
CCG Leadership Program –Data and
Tech Themes
Apps Library Kite Marking Technology –Simon Dixon
DHKathy
SmethurstPeter Burke
Charlotte Lilliford
Wildman
HSCICAndy
Williams
EHI CCIO NETWORK
EHI
Digital Maturity Index
Technology Strategy –Paul Rice
TDA
Pathways –Jackie Shears
NHS Choice
s –Nicola
Gill
AHSNs
CSUs
NICE
The 4Is Organisational Map – there is more to go on this!!
Electronic Patient Record
Providers
British Computing Society –Specialist
Interest GroupDigital Maturity
Model For Mental
Health –Jackqui
McBurnie
Patient Information/Technology – Helen Rowntree
Oxford AHSN
– Sarah Amani
Composite indicators – Karina G
Data CataloguePaul Gavin
January 2015 v1
Health Foundation –Improvemen
t Expertise
Awareness/Acknowledgement of health related problem
Initial healthcare seeking activityEffective Choice is Enabled
Public Health/Preventative
Programs
Consultation and management in Primary care
Referral for further assessment/careby outpatient secondary care provider
Effective Choice is Enabled
Pre-consultation “wait” period
Specialist Consultation
Post consultation Wait/communication period
Further consultation/Investigations/
Interventions started
Individual generated data eg. From Fitness Tracker
Web searches results from Google etc
NHS Choices and its information and Data
“Quantified Communities” – Mental Health Intelligence Network (with participatory model)
Analysed by Geography
Accesses Urgent or Emergency Care Services (via 999/111)
Primary care record systems and generated data sets
Episode of Secondary Care Inpatient Treatment
Access and Waits standards data -monitoring
NHS Pathways systems data
Outcome Data
Data from self-management tools/technology and programs
KeyGreen –Information flowing away from the person using services
Blue –Information and Intelligence flowing back to the person using service
Secondary Record Systems
Secondary Record Systems
Initial 4I Flow Map – How Choice, A&W and Outcome link across the pathways
Awareness/Acknowledgement of health related problem
Initial healthcare seeking activity
Public Health/Preventative
Programs
Consultation and management in Primary care
Referral for further assessment/careby outpatient secondary care provider
Specialist Consultation
Accesses via Urgent or Emergency Care Services (via 999/111)
Episode of Secondary Care Inpatient Treatment
Continuation and modification of care package
Discharge from Secondary Care
Outpatient Care Package agreed and implemented
CPA Discharge from Secondary inpatient care
Community DischargesClinical Outcome Measure (e.g Honos)
7 day follow up
Inpatient Measures Admissions by bed type DischargesLength of StayBed Occupancy RateSeclusion RatesMedication ErrorsRestraintDeath RatesMedication AdherenceRates of Detention of MHAOutcomes of Detention
Community “In treatment” measuresGoals MonitoringInterventions CodesAttendance rates/missed appointmentsPrescription Changes
Medication Adherence
Outcome/RecoveryClinical Severity Measurese.G PHQ9Honos/HonosRates of EmploymentPrimary Care Data
Diagnosis rates in Primary Care by ICD-10 codeUse of psychotropic medications – prescription rates Use of Legal Right to ChoiceAccess to Primary Care
MH assessment in secondary care setting (e.g A&E, 136 suite)
Initial measures and dataAccess and Waiting timesClinical Severity ratingsICD Diagnosis ratesComplexity Measures – Social deprivation, rates of co-morbid conditionsInterventions codes Prescription Rates
Outcome and Activity Measures along the pathway
Awareness/Acknowledgement of health related problem
Initial healthcare seeking activity
Public Health/Preventative
Initial consultation with primary care professional
Referral for further assessment ?by secondary care provider
Pre-consultation “wait” period
Specialist Consultation
Post consultation Wait/communication period
Further consultation/Investigations/Interventions started
empowered self-monitoring
And data gathering
“Portal” website/app facilitating self triage – structured assessment tools
System that generate Co-constructed referrals
Online toolsthat inform consultation Apps, Websites, text message
Paper diaries
Preparing for consultation
Information websites/apps/videos
Comms systems around referral progress
ServicesVideos on YouTube
, Twitter, Virutal Wards
Text message acknowledgementsAnd updates
Good Guiding Systems Principles
• Every interaction is an intervention – “design” this in.• There should be no such things as “waiting time” • Processes should be adaptable to overcome barriers• Shared ownership of information where possible
Specific sites/Apps. E.g. “Docready”
Ongoing self-monitoringand data gathering
Co-Constructed and recorded outcomes
NHS Choices and other curatedinformation sites
The Potential of Technology to enhance person-centred care and pathway effectiveness
Technology delivered or enhanced
Therapy