York integration seminar [5.4.12] (c brand et al)

PSSRUPersonal Social Services Research Unitat the University of Manchester

Community mental health teams for older people: the outcomes and costs of different ways of working

Christian Brand, Michele Abendstern, Sue Tucker, Mark Wilberforce, Rowan Jasper, David Challis


Disclaimer: This presentation presents independentresearch funded by the National Institute for HealthResearch (NIHR) under its Programme Grants forApplied Research Programme (Grant ReferenceNumber RP-PG-0606-1109). The views expressed arethose of the author(s) and not necessarily those of theNHS, the NIHR or the Department of Health.


B ackground and aim s

Background and aims

• Part of a larger study: ‘National trends and local delivery in old age mental health services: towards an evidence base’

• 3 strands (I. ‘balance of care’, II. community mental health teams for older people, III. care home liaison)

• Focus on CMHT strand today: Integration and its effectiveness


From a national survey of all CMHTsOP in England we selected 4 ‘high’ integration teams and 5 ‘low’ integration teams

We interviewed 42 staff members on their views on integration (covering all staff groups, approx. 60 minutes per interview)

From the teams’ caseloads, we collected data on socio-demographic and clinical profiles as well as service receipt details for 948 CMHT clients (193 clients were also interviewed in person)

We conducted a work satisfaction survey of all CMHTOP staff in the chosen NHS trust areas (295 participants in 38 teams)

M ixed m ethods approach

Mixed methods approach


D efin ition of in tegration

Definition of integration

Integrated team = A multidisciplinary team which • Had at least one social worker

Plus at least 6 of the following features:

• A single manager between health and social care• Accepted referrals directly from non-medical sources; • A single point of access; • Used the same or at least shared assessment document • A single client database or two that were accessible to all staff • Allocated a single care coordinator across health and social care • Used a single care plan which included both health and social care

information• Could access both health and social care resources.


In itia l concept: h igh vs. low integration

Initial concept: high vs. low integration

Teams Team type Team characteristics

5 examples* Low-integration

Co-located multidisciplinary health team with single manager located within the team

4 examples* High integration

Co-located health and social care team with single manager located within the team

* Teams were purposefully chosen as typical examples of ‘different ways of working’ as identified in our national survey (n=376)


Revised concept: high vs. low integration vs. ‘network team’ or ‘nominally’ integrated team

Revised concept: high vs. low integration vs. ‘network team’ or ‘nominally’ integrated team

Teams Team type Team characteristics

1 example Network Like low integration, but with separate managers for individual disciplines

4 examples Low-integration

Co-located multidisciplinary health team with single manager located within the team

1 example Nominal integration

Like high integration, but with separate health and social care managers

3 examples High integration

Co-located health and social care team with single manager located within the team

Degree of Integration


Findings I: the voice of practitioners

Findings I: the voice of practitioners

How does the nature and extent of

integration within the team help or

hinder your ability to provide an

effective service?


Findings I: overview

Findings I: overview

1. Features of working in integrated teams found to be beneficial to practice by staff (emphasis on social work membership)

2. Features of working in non-integrated teams found to impede practice by staff(emphasis on social work membership)

3. Complexities of working in an integrated team

4. Summary findings


B enefits of a m ultid iscip linary team

Benefits of a multidisciplinary team

• A wide range of easily accessible skills and expertise to support service users

• The potential to enhance the skills of all individual members by the informal learning between colleagues that this fostered

It widens your knowledge and we’re not there for anybody else other than the Client, so it is

beneficial

Team manager


Benefits of an integrated team: social work membership


It is a huge benefit…They are …very skilled and they have a good

knowledge of the Mental Health Act and

they have good knowledge of

safeguarding … they just bring a different

dimension really

Consultant, integrated team

• Specific mental health expertise

• Knowledge of social services procedures and funding

• The ability to access social care resources directly

• Direct access to social care information

• Wider perspective




• Shared case ownership

• Shared goals

• Informal

joint working

• Intra-referring

I can dip into my colleagues case load where there’s a social care need identified

without them having to … go through the process of

referring to …[social services]

Social worker, integrated team

you are sitting alongside them, you can have a chat and discussion about the patients beforehand…So you are not referring them blind … you are

referring to a colleague, which is a lot quicker because you are not sending it

out of the office, onto a waiting list

Team manager, nominally integrated team




• A single point of access

– leading to a holistic

approach and input…all the referrals are going to

one place…and then as a team they will discuss the medical/social component

and respond together…otherwise I feel the

multidisciplinary part of the work will take place but in

stages

Consultant, integrated team


Features found to impede practice in non-integrated teams: lack of social work membership


• Slow response and lack of communication

• Lack of shared understanding and goals

• Limited joint working

we make the referral to [a central number] … and then that tends to sit on a waiting list …we don’t

even know when it happens unless we

actually keep checking

Nurse, non-integrated team

...they are interested, but …just…in their bit and … they are just

thinking, well if it is open to that CPN…they want to look for a care

provision … and get [out]

Team manager, non-integrated team


Features found to im pede practice in non-integrated

team s: lack of social work m em bership


• Loss of data in case

transfer

• Support breakdown due to limited understanding of mental health work by generic social workers

they …ring the person and … say, - ‘I’ve had a referral from the OT, I’m coming out to see you’. … I might have had a discussion with that person and taken a long time to get them to agree, and because of the dementia they might

have already forgotten. They would get a phone call and

then say, - “no I didn’t ask for anybody”, so then… [the

social worker] wouldn’t go out

OT, non-integrated team


Features found to impede practice in non-integrated teams

Features found to impede practice in non-integrated teams

• Lack of single

manager

• Difficulty of access

to information

what one organisation sees as the higher priority.., the other

might not …. and if you had one who has an understanding of our service then that might

be better

OT, non-integrated team

[We]’ve got..5 IT systems, none of which talk to each other….I can’t get on the social workers site…if

you just opened those lines of communication a little… that

would be a huge improvement.

Team manager, non-integrated team


O bstacles to effective w orking in integrated team s

Obstacles to effective working in integrated teams

• Where social workers were expected to complete two sets of

records, one for health and one for social care

• Formal internal referral systems

• Complexities of managing and supervising across disciplines

and agencies

• Use of ‘specialists’ for generic work….OTs and Psychologists….

(all multidisciplinary teams?)

Perhaps evidence of integration not having gone far enough


Sum m ary of F indings I

Summary of Findings I

Non-integrated team

Limited understanding of

service user needs & each other’s

pressures

Difficulties in accessing social

services

Limited joint work

Social worker in team or not

Key attribute Integrated team

Shared responsibility and goals

Ease of access to specialist skills and

resources

Joint work and holistic approach


Findings II: c lient outcom es and costs of services

Findings II: client outcomes and costs of services

Multiple outcomes

Risk of mental health inpatient admission

Time to inpatient admission

Risk of care home admission

Quality of life score (interview)

Satisfaction with services and key worker (interview)

Multiple cost types

Service receipt/cost* of community mental health support

Service receipt/cost* of social care package

Total costs*

* Calculated as monthly costs at baseline


Findings II: statistical m odelling

Findings II: statistical modelling

All outcomes and costs were analysed with

various forms of regression models: i.e. predicting

the variable while controlling for other known

characteristics (principally socio-demographic

and clinical profile)

The main aim: comparing different team types


Findings II: outcom es

Findings II: outcomes

Possible effect of high integration

(vs. low)

Other group effects (‘nominal’

and ‘network’)Other team effectsOutcome variable

Risk of mental health inpatient

admission

Time to inpatient admission

Risk of care home admission

Quality of life score

Satisfaction with services/key

worker

Higher risk (x5)Network team

resembling high integration (x4)

Higher risk and slightly later

(timing)

Network team resembling high

integrationMuch higher risk in one team only (high integration)

No systematic group effects, but one team (low integration) scoring consistently above average and another (also low

integration) scoring consistently below average

But: sample size was limited!


Findings II: service receipt and costs

Findings II: service receipt and costs

Possible effect of high integration

(vs. low)

Other group effects (‘nominal’

and ‘network’)Other team effectsOutcome variable

Cost of community MH support

Care package receipt

Cost of social care packages

Total service cost

Higher expenditure

(+80%)

Both have higher expenditure

(+50%)More likely to receive (x1.6); lower needs!

Conditional upon receipt, no systematic differences; but high integration teams reach more service users (hence

higher total expenditure) Higher

expenditure (+50%)

Both have higher expenditure

(+50%)


Findings III: Exploring the impact of integration on staff outcomes


Measures

Satisfaction

Intention to quit

Job characteristics related to stress (autonomy, demands, control)

DataPostal survey

N=295Face-to-face interviews

(n=42)




Survey dataPoorer outcomes in integrated teams

But mainly due to social work membership and greater job insecurity

Being managed by different profession reduced outcomes (tested on nurses only)

Interview dataOutweighed by

frustrations of working in non-integrated team

Evidence of mix of social worker

dis/satisfaction


C onclusions and other observations

Conclusions and other observations

Findings I: • Non-integrated teams have to work harder to implement good practice (not

supported by structures)• But: other types of integration (setting/sector) are equally important

Findings II:• Integrated services associated with more service use whilst not preventing

acute inpatient and care home admissions relative to low integration teams• But: methodological and data limitations confound the findings

Findings III: • Lack of clear evidence that integration either improves or reduces staff

outcomes• Interestingly: support workers have more positive outcomes in both team

types

York integration seminar [5.4.12] (c brand et al)

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