Mental Health Care for Emergency Department Frequent Attenders: a Regional Collaborative
- Winning idea
The final straight or just the beginning?
Leading up to the Q-event in September we have been working hard to engage with the Q-Community and build your ideas into our project development. Thank you for all those commenting and supporting! Of course we hope to go on with the Q Exchange project but even if we don’t, the feedback we received confirmed what we believed all along – this project is essential for both patients and professionals!
So what have we done and what are the next steps?
– Networking in our region: We now have representatives at all the major Trusts who recognise this as a project that can deliver real outcomes.
– Brainstorming with diverse stakeholders: We have invited ED and mental health teams, lay representatives and non-ED clinicians (GPs are key!) to join us in a dedicated session at an upcoming ED Collaborative Event next week. Based on previous events this forum has been a melting pot of ideas where shared learning can be transformed into true QI.
– Engaging with patients: Building on feedback from lay representatives we have acknowledged the need to have hands-on active involvement from the word go. Their involvement will enhance the outcomes of our project. We anticipate real change in how we design this model and believe our patients will benefit directly. It will also be an example of how to give a voice to a group of patients who have been previously underrepresented.
– Aligning our goals with the future of the NHS: We have examined the resources and visions expressed by national organisations like NHS Improvement and the NHS Five Year Forward View. Our systemic goals have been adopted to provide immediate outputs to these (and similar) organisations. In real terms we believe it will add value in the future planning of Sustainability and Transformation Partnerships throughout the country.
– From regional to national: We have made contact with individuals with a shared interest beyond the Thames Valley. The results of our project will be a replicable model that can be adopted elsewhere. In addition, once we have learnt from this project we will be able to face challenges (e.g. Information Governance) and expand the network to a much wider region. The Thames Valley Regional Collaborative can indeed become a nation-wide ED mental health network!
In summary – this is truly just the beginning and we have laid the foundations for a value-driven and meaningful project. Support from the Q-Community will significantly boost our chances of success in the short and near-term. We hope to see you at our stand in a few weeks.
Best wishes from our team. And remember – the more we work together in QI the more beautiful (and bigger) the starling murmuration of the modern NHS becomes!
Another week on and we continue to learn from Q-member comments. Thank you!
So far we have received a lot of questions on how we plan to work with other stakeholders, especially patients and primary carers. The answer is twofold. First of all, our idea remains above all a collaborative approach. So working with others is written into the essence of the project. More specifically, we are hosting a dedicated session at an upcoming ED Collaborative event being held in Milton Keynes. It will act as a brainstorming session and we have invited local Q-members to present (or join via teleconferencing). This includes representatives from peer support experts and GPs.
Keep the comments coming fellow Q-Members. The more you question and criticize, the more opportunity we have to improve our project in line with what you think!
Wonderful to be shortlisted!! Please support us, leave comments, get in touch, etc…Regular conversations on recently set up twitter account @mental_ED. Much of what we aim to do is share experiences and learning. Patient involvement essential!
Conceptually there is no group more in need of a collaborative approach than patients frequently attending the Emergency Department. Of particular significance is the fact that mental health conditions are more prevalent in this population. This is acknowledged in the design of CQUIN 4 for 2017/19, which is aimed at ‘improving services for people with mental health problems presenting to Emergency Departments’. The CQUIN specifically focuses on reducing the Emergency Department use by frequent attenders .
A few issues underlie this topic. Firstly, frequent attenders typically have unmet psychological needs. Secondly, as stated in the CQC report on patients in mental health crises (Right here, Right now, 2015), frequency of attendances may be a sign that local services are failing to provide comprehensive support.
However, the problem is potentially much bigger.
Evidence shows that while researchers acknowledge the likelihood that patients may be visiting multiple emergency departments, studies on frequent attenders are regularly limited by a lack of data on service-use beyond single hospitals. Not knowing how patients access services, impacts directly on the quality and safety of the care we provide. For example, patients who frequently attend various emergency departments may do so because of unhealthy drivers such as drug-seeking behaviour. Instead of addressing the underlying problem, inconsistencies between individual emergency departments may accentuate it.
Similarly, patients with somatoform disorders regularly attend hospitals with physical complaints. These patients are known to be at significant risk of healthcare induced harm due to over-investigation or over-medicalisation, made more substantial by different emergency departments repeating the same interventions.
The idea behind the Thames Valley Starling Collaborative is symbolised by the flawless murmurations of the birds we share our name with. To effectively provide care for frequent attenders requires an acute awareness and relationship between a large number of stakeholders.
The Thames Valley Starling Collaborative is aimed at peer support of teams across the Thames Valley and has two goals:
Goal 1 Sharing of Frequent Attenders Programme models across the Thames Valley region aiming to identify and implement best practice
Goal 2 Using existing data our project will be able to categorise groups of frequent attenders (e.g. based on presenting complaints) and evaluate the outcomes of specific interventions. We hope to identify which frequent attenders are more receptive to particular interventions, thereby allowing trusts to work together in optimising their efforts of influencing patient flow into the emergency department.
These goals are based on the analysis of data across the region which will inform the investigation of patterns of attendance and unwarranted variation between emergency departments.
Matching data across the Thames valley will not only help us comprehend the scope of the problem, but also enable us to identify if we have high regional users. Building a region- wide network of stakeholders and services will enable us to coordinate the consistent and safe delivery of care. These are very practical steps with real outcomes for individual patients.
Our second goal is to categorise and then analyse already-collected anonymised detailed data sets within our emergency departments and to use clinical knowledge and experience to determine which interventions produce the best outcomes thus helping us to design interventions to help stop these individuals from developing healthcare -seeking behaviour.
Emergency Department clinicians at the Oxford University Hospitals NHS Foundation Trust have worked closely with their local mental health liaison team, known as the Emergency Department Psychiatric Service (EDPS) to create the Oxfordshire Frequent Attenders Programme. The Frequent Attenders Programme team has had remarkable results, not least in outperforming what was believed to be the almost unattainable CQUIN indicators. The Year 1 targets included a 20% reduction of attendances in a selected cohort of patients. After being enrolled into the Frequent Attenders Programme, the Oxfordshire patient cohort steadily decreased their Emergency Department use, with a 63% reduction in monthly attendances achieved by Quarter 4. In acknowledgement, NHS England has distributed a write-up of the Frequent Attenders Programme (attached) to the wider ‘CQUIN community’ for other Trusts to learn from the model.
The Oxfordshire Frequent Attenders Programme has a diverse core team representing Emergency Departments, Emergency Department Psychiatric Service, South Central Ambulance Service, community psychiatric services, the hospital psychological medicine department, and an Emergency Department-based community safety officer. The variety within the group means they have much expertise to draw on and also facilitates the sharing of accurate and up-to-date data. By positioning Emergency Departments as the central stakeholder in this collaborative network of professionals, they continue to steer patients to the most appropriate services. This collaborative project will enable best practice for frequent attenders which has been developed across the Thames Valley to be shared and adopted as appropriate.
Funding from Q exchange would pay for time for an emergency department consultant and nurse to lead the project, and three stakeholder workshops to identify and report on two improvement cycles and a dissemination phase.
The timescale of the project is one year, allowing for stakeholder ownership of the project, the development of detailed plans followed by two improvement cycles
How you can contribute
- A big part of our project is built around the idea of collaboration and networks (hence the name). We believe that members of the Q- community will be able to enrich and promote our project by tapping into their own networks.
- Involving patients in the case management and care planning process is usually not complicated when dealing with individuals and has been a key component of the Oxfordshire model.However, we want patient representatives to inform the the strategic side of our project,we are hoping that the Q-community will be able to help us explore how this can be achieved.
- Of particular benefit is the technical expertise we hope can be offered by the Q-community. While we have experience in working with data sets, experience of this particular topic analysis will enable us to build efficiency into the project from the outset.
- On the strategic side, technical expertise will also be useful to inform the process of 'profiling' the patient at risk of becoming a FA.
- Local knowledge of relevant stakeholders in and beyond our region, or insight into similar projects elsewhere will be valuable in building a relevant professional network.
FAP write-up (PDF, 927KB)
This is a great project because…
The team are planning to start their project by analysing and understand the groups of patients that they might be able to support. By starting with a clear understanding of patient groups and developing and testing interventions that might have most impact for those groups we think there is real potential for impact and future further spread.
By the time of the event we encourage the project team to think more about…
The project would be strengthened with further thought about how patients and carers can be involved in the design and delivery of the project. Also, we think the project could produce good generalisable learning so would like to see a more developed plan for sharing that learning with the Q community.