Posted by: ayrshirehealth | March 19, 2014

Clinical Informatics and service redesign, the HEAT is on by @markfleming1

The HEAT is on for Access to Psychological Therapies

Mental Health Services across Scotland are working hard on improving access to both mental health and psychological services. The approach being taken in NHS Ayrshire and Arran has included a complete rethink on how psychological therapies are provided within a multi-disciplinary mental health service. This approach has been particularly challenging piece of work as it has created a huge change in how staff work on a day-to-day basis.

Target2

The Health, Efficiency, Access, Treatment (HEAT) target ‘Deliver faster access to mental health services by delivering 18 weeks referral to treatment for Psychological therapies from December 2014‘, was approved by the Scottish Government in November 2010.

The HEAT target is also being developed in conjunction with the access to Child and Adolescent Mental Health Services (CAMHS) target ‘Deliver faster access to mental health services by delivering 26 weeks referral to treatment for specialist Child and Adolescent Mental Health Services (CAMHS) services from March 2013; reducing to 18 weeks from December 2014; and 18 weeks referral to treatment for Psychological Therapies within CAMHS from December 2014’  

Timely access to healthcare is a key measure of quality and that applies equally in respect of access to mental health services. Early action is more likely to result in full recovery and in the case of children and young people will also minimise the impact on other aspects of their development such as their education, so improving their wider social development outcomes.

Informatics – eHealth and meeting targets

This blog will explore how NHS Ayrshire and Arran have used a programme approach to explore and develop the following aspects to support them in moving towards achieving the target.

  • Mental Health/Psychological Service modelling
  • A Single point of access pathway to both mental health and psychological therapies
  • eHealth solutions to support data collection, HEAT waiting times information provision and the wider electronic clinical record.
  • Clinicians skills in psychological therapies and access to appropriate clinical supervision
  • Use of information to support improved access and quality of services.

The Blog will focus on the eHealth/Informatics aspects of the work however you will see from the discussion how these aspects are closely entwined with service management, pathway/service redesign and the broad development of clinical and informatics skills of staff.

RTT Wordle

Mental Health Service Modelling

An early decision was made to better integrate our psychology service into our multi-disciplinary community mental health services framework. This would allow for the development of a single point of access and the development of better referral pathways.

Some of the key problems identified before this included patients waiting for up to 18 months for some psychology interventions and patients referrals moving between services, as our referrers were not quite 100% sure where to send them. Because of this it was impossible to accurately collect true numbers of patients waiting and the times that they waited for as the total service was so fragmented. There was of course the lack of a dedicated Patient administration system to support the pathway and the collection of the appropriate waiting times data as the patient progressed along it.

 The Single Point of access

Referrers to our services were often unsure as to where to send the referrals and often were guided by where they perceived the shortest wait to be. A single point of access was created for each of our three locality areas.

Network

The SCI Gateway electronic referral system template was further developed to support the referral screeners in getting the patient’s referral to the most appropriate clinician ASAP.

The work done on developing our integrated care pathways allowed us to process map the clinical and business workflow to demonstrate how patients flow through our service and the points at which important data is collected. This intricate work, supported by Service improvement facilitators from our service futures department, also identified where the waiting times clocks should start and stop. Staff required some training to apply the 18 weeks waiting times rules as they had not collected this data in such a structured way previously.

Development of eHealth solutions to support HEAT target recording

NHS Ayrshire and Arran are still part of the way through this component of the programme.

  • The Trakcare PMS system will ultimately be the boards solution for monitoring waiting times using the 18 weeks Referral To Treatment module. However, this has not been readily available so in some areas we have had to develop local databases to mimic the recording and reporting of data until Trakcare is built and tested accordingly.
  • The development involves a new way in collecting waiting times. We are moving from collecting waiting times for clinicians to waiting times for the numerous interventions provided both within and outwith the NHS Education Scotland Matrix for psychological therapies.
  • A dedicated senior data analyst has been essential in the build of the databases to support the data collection prior to the Trakcare implementation. We are now in a position to accurately report on the waiting times for access to our Primary Care Mental Health Teams within one of our locality areas with a roll out programme quickly making them available in the other two.
  • Our FACE clinical information system has the capability to record the patient’s clinical outcome scores in the form of CORE 10 assessments, we are in the process of working with CORE and FACE to develop the reporting mechanisms. This will allow for better analysis of these outcomes in clinical and management supervision.Core

Analysis of Psychological Therapies clinical skills

In order to collect accurate information across all services we needed to clearly define what staff were trained to provide according to the psychological therapies matrix. This exercise also entails asking clinicians to clearly map out these interventions within their weekly schedules. This allows templates of care provision schedules to be built for recording within the Trakcare system. Only by having this detailed analysis can we create the schedules with the appropriate appointment slot types (approx. 21 of them) within Trakcare.  It also gives our managers the opportunity to see where the gaps lie in relation to the provision so they can enhance supervision models and further training plans.

Use of information to support improved access and quality of services

The development of the databases has allowed staff to apply stricter 18 weeks Referral to Treatment rules to their caseload management. This has created waiting times information which is much more accurate than the service has ever had. The knowledge and skills of staff to use this data is also improving the more that they use it. Graph 2It allows managers to identify trends in referral patterns so that they can manipulate their resources to reduce waiting times where possible. It also allows them to clearly identify where the capacity challenges are so that future training and recruitment can be tailored to support meeting the 18 weeks target.

Currently we are able to report in one of our localities a four week wait for initial assessment, followed by an 8-10 week wait for some of the matrix based interventions provided by nursing and self help workers. There is still a challenge to meet the 18 weeks target for more complex cognitive behavioural therapy and counselling interventions (current total wait is approx 28 weeks). However the information is allowing the managers the opportunity to explore what can be done to meet the target.

Conclusion

As you can see from the discussion above the use of eHealth systems and Informatics flows right through the middle of this piece of work. It is important to remember though the amount of service and pathway redesign that has gone on in redesigning how the services work. Clinical Informatics staff, service redesign, managers and clinicians working closely together to develop access to services.

This journey is not yet complete and over the next few months we will see more services using the databases, staff developing their Informatics skills and the final database transitions to our Trakcare PMS system. More exciting times ahead.

This week’s blog was by @markfleming1 (Mark Fleming), who is Clinical Information Manager in Mental Health Services in NHS Ayrshire and Arran.

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Responses

  1. Hi Mark,

    Thanks for your blog. Some really good work going on and a wealth of useful information generated by the smart use of technology.

    I remain deeply sceptical of the value of national quantitative targets as a means to drive improvement though. If they are used, they need to be used with great care and attention to other key quality indicators in other parts of the system.

    Admittedly, they are the thing that the system currently responds to – but at what cost? Effort substitution and failure demand manifested as pressure being squeezed into other parts of the system not in the glare of the HEAT target, can at best, reduce quality of care, and at worst cause physical and psychological harm.

    I worked in acute adult healthcare for many years and experienced first hand a deterioration in the quality of the service I was able to provide as a direct result of 4hr target for A&E and 18 weeks RTT.

    Would be interested to hear your thoughts on this or if you have some balancing measures around the HEAT targets to pick up any unintended consequences?

    All the best

    Shaun

  2. Hi Sean, thanks for your comments.
    I think for us this HEAT target has given us a focus and opportunity to redesign our services.
    Historically we had patients in need of psychological referred to the wrong services, waiting too long to be seen for assessment and then often having to wait up to 2 years for a service that they at that point often did not need as their presentation had changed.
    Evidence indicates the sooner people can be seen the better the outcome for them. Our new structure supports this and facilitates a wider choice of options for treatment. Often in the past patients waited long periods for highly specialist interventions that their GPs perceived that they needed but probably needed a different level of intervention.
    The redesign seems to allow us to better match interventions to level of need which has really improved pathways and waiting times.
    So although our target is to provide treatment in 18 weeks we are gradually seeing a more balanced approach to care provision across all levels of intervention intensity. It will take some time to clear backlogs and some cultural referral patterns but good clinical leadership can support change.
    Mark

  3. Sorry Shaun would help if I spelt your name correctly!! Many apologies

  4. All sounds good. Thanks for your response Mark.

    Shaun

  5. […] Clinical Informatics and service redesign, the HEAT is on by Mark Fleming on the Ayrshirehealth blog. […]


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