Transforming Care for people with Learning Disabilities (LD) is about getting the right care in the right environment, least restrictive and close to home, preventing unnecessary inpatient admissions.
In Lincolnshire an integrated service model was built on the principles of Transforming Care using NICE Guidance for Mental health problems in people with learning disabilities: prevention, assessment and management (NG54) and the guidance for challenging behaviour and learning disabilities (NG11) to develop comprehensive care pathways.
This has enabled professionals to provide more structured outcome focussed support with more partnership working between clinicians making the service more accessible efficient and seamless.
Proactive positive behavioural support and psycho social interventions reduce the reliance on pharmacological and inpatient treatment. Experts by experience who have previously received services are now an integral part of the workforce.
Aims and objectives
The aim of the service redesign was to implement a proactive, local, person centred model of care which supports access to mainstream services wherever possible, enabling other services to make reasonable adjustments and to assist in destigmatising people with learning disabilities.
Specific objectives included:
- Implementation of Learning Disability (LD) liaison support for physical healthcare,
- Autism Spectrum Disorders (ASD) and Mental Health (MH) services in line with NICE guidance. CG142, NG54.
- Proactive support for people with LD who present with behaviours which challenge, in line with NIGE guidance NG11.
The new integrated teams have a range of professionals including nursing, psychiatry, psychology and allied health professionals who are all trained in the principles of Positive Behavioural Support (PBS) and are able to draw on each other’s expertise to provide a seamless consistent service to service users and carers.
To prevent inpatient admission, a further county-wide 'Community Home Assessment and Treatment team' was established to provide intensive 24/7 support to individuals in their home environment, (whether this be a family home, supported living or a care home) thus preventing admission to hospital or extended periods away from their home environment. This team is an integral part of the wider service and works to the same principles of PBS and care in the least restrictive environment.
Reasons for implementing your project
Transforming Care is the national drive to implement a community based learning disability model of care with a significant reduction in inpatient admissions, and increased access to mainstream services. Prior to the implementation of Transforming Care in Lincolnshire, Lincolnshire Partnership NHS Foundation Trust (LPFT) provided a range of health provision for adults with learning disabilities including eight assessment and treatment and eight rehabilitation beds.
Community services included outpatient psychiatry, psychology, OT, SaLT, physiotherapy, behavioural nursing support and physical healthcare liaison. In the spring of 2015, working with partners to implement the Care and Treatment Review process, LPFT recognised that care and support for adults with learning disabilities with behaviour which challenges was outdated and overly restrictive. A bold decision was taken, jointly with the CCG commissioner, to temporarily close the inpatient service and invest all the resource into a proactive integrated person centred model of care.
Engagement events were held across the county. Invitations were sent in accessible format, resulting in over 80 percent of attendees being service users and their carers, who indicated that they felt that the invitations were specifically for them and that their opinion was wanted. Consistently they fed back that although, happy with each element, services were disjointed and difficult to access with long waits between each element. There was previously no Autism Spectrum Disorder (ASD) service, with diagnosis only provided by LPFT on a spot purchase basis and undertaken by clinicians in addition to their day to day work.
The service had evolved over years and in-spite of some excellent clinical practice from professionals there was no consistent approach. It was therefore fortuitous that there was related NICE guidance in the pipeline. This enabled the Trust, working in partnership with the commissioner, employed experts by experience, and carers, to develop a structured integrated model based on best practice NICE guidance.
As the guidance was in development the team were working to consider the implications and integrate the themes into the development of the model. When the guidance was published comprehensive pathways were developed to ensure best practice for those adults with LD who present with behaviours which challenge, and for those who have additional MH needs.
How did you implement the project
Working in collaboration with the commissioner representing the 4 Lincolnshire CCG’s, a plan for remodelling services was presented to the relevant Boards based on the principles of Transforming Care. The views shared at stakeholder and staff engagement events were built on and incorporated to the new model.
The Challenging Behaviour and Learning Disability guidance (NG11) was published and was key to the integrity of the model. The lead psychologist trained as an accredited trainer for PBS and prior to implementation the whole service. Almost 100 staff were given a full week’s training in line with guidance. The lead psychologist worked collaboratively with staff and carers to develop a comprehensive Care Pathway for Behaviours of Concern. At this point all parties were aware of the forthcoming MH guidance due to be issued by NICE, (NG54) and the principles from the draft were incorporated into the model.
An audit of use of antipsychotic medication was undertaken and changes were made embed the consultant psychiatrists into the integrated team. A lead LD/MH liaison nurse was appointed with a LD/MH liaison nurse appointed to each team. Since the publication of the LD/MH guidance in September, a care pathway has been developed (currently in draft) by the Lead Psychologist, MH Liaison Nurse and the lead psychiatrist, with involvement from the peer experts by experience who are currently now employed as an integral part of the service provision.
Since the implementation of the model, the inpatient facility has remained closed and plans are being put in place to consult on permanent closure. An outcome measure tool has been designed and is being piloted by the service to enable evaluation of clinical interventions. A further service away day is planned to review progress on all elements of the model.
Prior to closure of the inpatient service there were 27 adults with learning disabilities from Lincolnshire in specialist Learning Disability inpatient care, today there are 8. Furthermore, since the implementation of the new model there have only been 2 new admissions into specialist LD inpatient hospital care.
The implementation of the NICE guidance has enabled LPFT learning disability services to provide a structured model of care with comprehensive care pathways. The teams have supported service users to remain in their home environment by providing consistent proactive support to them and their carers, and where necessary the CHAT team have provided intensive round the clock support.
Numbers of services users at risk of admission are monitored through the Care and Treatment Review (CTR) process. By implementing early CTR’s and using them to identify an integrated support plan using the care pathways service users otherwise flagged up for admission are being kept out of hospital. One clear example of a patient experience can be illustrated by the following: the individual had an emergency "blue Light" CTR called with a view to admission for inpatient care, due to presenting with behaviours of concern, a plan was implemented, and following a period of intensive support from the team she remained in her own home and is now a paid expert by experience working for the Trust.
Further work is being undertaken to evaluate the cost savings to the whole health and care community. Additionally implementation of the newly developed outcome measure will give us a measurable quality indicator.
Key learning points
- The service redesign could not have been achieved without full collaboration between commissioner and provider.
- Service user involvement was essential to the project.
- Closing an inpatient unit prior to implementation was challenging, however without additional pump prime funds it would have been impossible to implement without releasing the cash from the inpatient provision.
- New ways of working involve cultural change and it is essential to be aware that it takes time for some staff to adapt.
- Review, evaluate and adjust, taking account of service user carer and clinician feedback.