An integrated care model for mental health in diabetes: Recommendations for local implementation by the Diabetes and Mental Health Expert Working Group in England.

CONTEXT: In 2019, NHS England and Diabetes UK convened an Expert Working Group (EWG) in order to develop a Model and recommendations to guide commissioning and provision of mental health care in diabetes pathways and diabetes care in mental health pathways. The recommendations are based on a combination of evidence, national guidance, case studies and expert opinion from across the UK and form other long term conditions. THE CASE FOR INTEGRATION: There is good the evidence around the high prevalence of co-morbidity between diabetes and mental illness of all severities and, the poorer diabetes and mental health outcomes for patients when this co-morbidity exists. Detecting and managing the mental health co-morbidity improves these outcomes, but the evidence suggests that detection of mental illness is poor in the context of diabetes care in community and acute care settings and that when it is detected, the access to appropriate mental health resource is variable and generally inadequate. THE MODEL OF INTEGRATED CARE FOR DIABETES: The EWG developed a one-page Model with five core principles and five operational work-streams to support the delivery of integration, with examples of local case studies for local implementation. The five core principals are: Care for all-describing how care for all PWD needs to explore what matters to them and that emotional wellbeing is supported at diagnosis and beyond; Support and information-describing how HCPs should appropriately signpost to mental health support and the need for structured education programmes to include mental healthcare information; Needs identified-describing how PWD should have their mental health needs identified and acted on; Integrated care-describing how people with mental illness and diabetes should have their diabetes considered within their mental health care; Specialist care-describing how PWD should be able to access specialist diabetes mental health professionals. The five cross cutting work-streams for operationalising the principles are: Implementing training and upskilling of HCPs; Embedding mental health screening and assessment into diabetes pathways; Ensuring access to clear, integrated local pathways; Ensuring addressing health inequalities is incorporated at every stage of service development; Improving access to specialist mental health services through commissioning. DISCUSSION AND CONCLUSIONS: The Model can be implemented in part or completely, at an individual level, all the way up to system level. It can be adapted across the life span and the UK, and having learnt from other long term conditions, there is a lot of transferability across all long term conditions There is an opportunity for ICBs to consider economies of scale across multiple long term conditions for which there will be a significant overlap of patients within the local population. Any local implementation should be in co-production with experts by experience and third sector providers.

Achieving consensus on psychosocial and physical rehabilitation management for people living with kidney disease.

Background: People living with chronic kidney disease (CKD) need to be able to live well with their condition. The provision of psychosocial interventions (psychological, psychiatric and social care) and physical rehabilitation management is variable across England, as well as the rest of the UK. There is a need for clear recommendations for standards of psychosocial and physical rehabilitation care for people living with CKD, and guidance for the commissioning and measurement of these services. The National Health Service (NHS) England Renal Services Transformation Programme (RSTP) supported a programme of work and modified Delphi process to address the management of psychosocial and physical rehabilitation care as part of a larger body of work to formulate a comprehensive commissioning toolkit for renal care services across England. We sought to achieve expert consensus regarding the psychosocial and physical rehabilitation management of people living with CKD in England and the rest of the UK. Methods: A Delphi consensus method was used to gather and refine expert opinions of senior members of the kidney multi-disciplinary team (MDT) and other key stakeholders in the UK. An agreement was sought on 16 statements reflecting aspects of psychosocial and physical rehabilitation management for people living with CKD. Results: Twenty-six expert practitioners and other key stakeholders, including lived experience representatives, participated in the process. The consensus (>80% affirmative votes) amongst the respondents for all 16 statements was high. Nine recommendation statements were discussed and refined further to be included in the final iteration of the 'Systems' section of the NHS England RSTP commissioning toolkit. These priority recommendations reflect pragmatic solutions that can be implemented in renal care and include recommendations for a holistic wellbeing assessment for all people living with CKD who are approaching dialysis, or who are at listing for kidney transplantation, which includes the use of validated measurement tools to assess the need for further intervention in psychosocial and physical rehabilitation management. It is recommended that the scores from these measurement tools be included in the NHS England Renal Data Dashboard. There was also a recommendation for referral as appropriate to NHS Talking Therapies, psychology, counselling or psychotherapy, social work or liaison psychiatry for those with identified psychosocial needs. The use of digital resources was recommended to be used in addition to face-to-face care to provide physical rehabilitation, and all healthcare professionals should be educated to recognize psychosocial and physical rehabilitation needs and refer/sign-post people with CKD to appropriate services. Conclusion: There was high consensus amongst senior members of the kidney MDT and other key stakeholders, including those with lived experience, in the UK on all aspects of the psychosocial and physical rehabilitation management of people living with CKD. The results of this process will be used by NHS England to inform the 'Systems' section of the commissioning toolkit and data dashboard and to inform the National Standards of Care for people living with CKD.

Evaluating case studies of community-oriented integrated care.

This paper summarises a ten-year conversation within London Journal of Primary Care about the nature of community-oriented integrated care (COIC) and how to develop and evaluate it. COIC means integration of efforts for combined disease-treatment and health-enhancement at local, community level. COIC is similar to the World Health Organisation concept of a Community-Based Coordinating Hub - both require a local geographic area where different organisations align their activities for whole system integration and develop local communities for health. COIC is a necessary part of an integrated system for health and care because it enables multiple insights into 'wicked problems', and multiple services to integrate their activities for people with complex conditions, at the same time helping everyone to collaborate for the health of the local population. The conversation concludes seven aspects of COIC that warrant further attention.

The choking woman.

BACKGROUND: There is a small, but significant cohort of patients that receives inappropriate care, in the wrong setting, and that utilises a disproportionate amount of healthcare resources. People with multiple co-morbidities and often-undetected mental illness fare better with integrated care and case management approaches. SETTING: In North West London, we have been working in the 'Integrated Care Programme' for four years to try to improve the care this cohort receives. QUESTION: Can psychiatric intervention with case management improve outcomes for this cohort? METHODS: We describe the case of a 64-year-old woman who presented at an Emergency Department (ED) with functional dysphagia 25 times in the space of eight weeks. During that time, she was referred to numerous specialists, and had multiple invasive investigations even though her symptoms were not suggestive of organic pathology, and were in fact suggestive of anxiety. RESULTS: Her pre- and peri-psychiatric intervention healthcare costs were, on average, £3330/month. These reduced to an average of £276/month after three months of psychiatric intervention. CONCLUSIONS/DISCUSSION: We reflect on the possible reasons why the story unfolded in the way it did and suggest generalised implications for clinicians caring for this cohort and for service delivery in future.

Community-oriented integrated care and health promotion - views from the street.

On the 1st and 2nd May 2015, participants at the RCGP London City Health Conference debated practical ways to achieve integrated care at community level. In five connected workshops, participants reviewed current work and identified ways to overcome some of the problems that had become apparent. In this paper, we summarise the conclusions of each workshop, and provide an overall comment. There are layers of complexity in community-oriented integrated care that are not apparent at first sight. The difficult thing is not persuading people that it matters, but finding ways to do it that are practical and sustainable. The dynamic and complex nature of the territory is bewildering. The expectation of silo-operating and linear thinking, and the language and models that encourage it, pervade health and social care. Comprehensive integration is possible, but the theory and practice are unfamiliar to many. Images, theories and models are needed to help people from all parts of the system to see big pictures and focused detail at the same time and oscillate between them to envision-integrated whole systems. Infrastructure needs to enable this, with coordination hubs, locality-based multidisciplinary meetings and cycles of inter-organisational improvement to nurture relationships across organisational boundaries.

How important is mental health involvement in integrated diabetes care? The Inner North West London experience.

Supported self-management is key to good diabetes care, but the high rates of mental health difficulties in diabetes can hinder effective self-management. Depression, anxiety, eating disorders and cognitive impairment, as well as interpersonal difficulties and personality disorder are all known to have a detrimental effect on effective self-care and addressing these has been demonstrated to improve health and financial outcomes. We propose that integrating mental health into the core of diabetes care is vital to improve detection and effective treatment rates of these disorders as well as improving confidence of all professionals who support people living with diabetes. We found that in 81% of all cases brought to the multidisciplinary complex case conferences, mental health issues were discussed. The majority of these were regarding reasons for people not effectively self-managing their diabetes despite having education on diabetes. We found that there was a demand for our input in case conferences, educational sessions about self-management, cognition, capacity and mental illness, and a need and demand for a specialist mental health diabetes service.