Hospital Readmissions from Complex Mental Health Social Care Settings Thematic Reasons For Placement Breakdown and Implications for Commissioning
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Dr Andrew Hider, Clinical Director, Approved Clinician, September 2023
Overview
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• Outline of evaluation • Discussion of admission and destination data and costs • Thematic overview • Clinical Process – Supporting Complexity in the Community • Thoughts and Recommendations re: Commissioning and Cost
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Outline of Evaluation
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Examined all discharged residential social care placements over a 10-year period from Ocean Community Services N = 67 Diagnoses categorised: • Any Psychosis • Any ‘Personality Disorder’ • Any other (no psychosis group) Exploratory statistical analysis undertaken: • Is there any relationship between length of stay and final destination? • Does diagnosis predict destination on discharge? • Does level of service (prior and current) predict destination on discharge?.
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Results
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• Level of security prior to admission had no significant relationship with discharge destination. • Supported living was the most frequent discharge destination • People with a personality disorder diagnosis had shorter length of stay and were significantly more likely than people with a different non psychosis diagnosis or a psychosis diagnosis to be discharged to their own accommodation • A small but sizeable cohort (n=10) returned to inpatient secondary care. Of this cohort people with a personality disorder diagnosis were more likely than people with a different non-psychotic diagnosis to return to secondary care. • Nobody was discharged to secure services (although we could not track eventual destinations from secondary care for the secondary care discharged cohort)
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Results
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Discussion
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Positive outcomes for a small high demand previously inpatient population, but service costs are high: • Psychiatry • High grade clinical and forensic psychology • Bespoke social care support worker roles • Staff supervision, support • High governance demand – risk governance, legal (MHA, Part 3, Court of Protection) • High statutory liaison (MAPPA, NHS Commissioning, Emergency Care) Weekly cost inclusive of full MDT = c£3000 Weekly typical LS/Rehab inpatient cost = c£4000
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Thematic Overview
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For people with a diagnosis of personality disorder, degree of pre-existing coping affected placement stability. Many people arriving presented as clinically ‘untreated’ despite lengthy inpatient stays. Working within a clear psychological formulation, shared by both the people supported and staff, was seen more in people who transitioned to lower tier services. Perceived safety and ability to construct and work towards functional goals was associated with reduced risk of recall/readmission. Developing an identity other than that of patient, while also trusting that support would not be withdrawn was associated with better outcomes. MDT driven care and support from experienced clinicians who can tolerate risk, with dependable involvement of NHS care coordinator, resulted in less readmission. This is not cheap. For people with psychosis, the presence of threat-control override symptoms was associated with service decisions to recall / readmit. 7
Model of Care – Recovery in Supported Environments (RISE)
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Relationally/ socially focused. Explicit focus on hospital not being the right place to recover. Supports non-clinical staff to use basic evidence-based approaches to preventive and reactive care tailored to complex MH problems. Co-produced support planning Service user led MDT meetings wherever possible. Discipline naïve clinical leadership – focus on experience in clinical case management of high risk and complex needs cohorts. MPAC programme.
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Process
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Hospitals – Building the Right Environment.
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https://asylummagazine.org/2023/09/not-the-right-environment-by-rachel-rowan-olive/ • “There is significant debate over whether those of us with this dreaded diagnosis – the validity of which many of us dispute – should ever be admitted to hospital. NICE guidance and related reports stress that it should always be a last resort. In theory, this is because of the harm it causes us. I don’t want to pretend that this harm is insignificant, it isn’t. Hospitals are often the source of large-scale iatrogenic harm.” • “However, I have to wonder why the response to this harm is to say, ’we shouldn’t admit these people’ instead of ’how can we make wards less hellish for them?’. Given the wealth of evidence of how much clinicians frankly dislike us, I have my suspicions about the answer.” • “Who, then, do staff think these hospital wards, with their banging and beeping and total indifference to suffering, are right for? When I push this question, the answer I typically get is that they are for people in acute psychosis or mania who, it is heavily implied, mostly need medicating back into normality.” “ I don’t want to go into hospital, and I wish they didn’t exist (although I believe we have a long way to go in building alternatives before that is feasible). I want actual community care based on something other than restriction. But, in the meantime, I believe that harm is worth minimising.”
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Conclusions
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Despite many years of evidence we continue to treat people in hospital for too long for conditions that do not improve in hospital, However, commissioning frameworks for community placements need to be aligned to clinical need for this cohort - many have for years been routinely ‘risk managed’ via long term hospital stays, and that is often a variable in their presentation. Despite claims of psychological treatment adherents and pharmacological companies, the evidence base for most specific treatments for complex mental health problems is of poor quality and does not allow firm conclusions to be drawn about what works. But we do know that experiencing supportive and adequate relationships in a social context where we are both known and understood by others is associated with good mental health in the general population. These can be translated into general treatment and support principles, overseen by clinical expertise. This relatively small data sample of an ‘ultra high complexity’ cohort indicates that previous hospital level of security does not reduce the likelihood of good outcome, or improve it. People with a diagnosis of personality disorder after a period of community intervention using the RISE framework were more likely to move to lower tier supported living or to move to their own accommodation. 11
Iris Care Group
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Iris Care Group is the largest independent health and social care provider operating across the South West of England and South Wales. Iris Care Group launched in May 2023 through the merging of two companies, Holmleigh Care (since 1999) and Ludlow Street Healthcare (since 2005). Iris Care Group includes: • • • • •
Hospitals Supported Living Nursing Homes A Special Educational Needs College Ocean Community Services – 17 residential services with multidisciplinary teams across South Wales and Bristol 12
Thank You andrew.hider@iriscaregroup.co.uk @ahider
Unit 1, Castleton Court, Fortran Road, St Mellons, Cardiff CF3 0LT t: 03300 567 888
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