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Learning from managed care in mental health
Dr Richard Ford
Director
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Managed care system
• Care programme approach for all people in contact with specialist mental health services – originally called case or care management (1991 onwards)– Key worker, care plan and reviews
• National Service Framework/NHS Plan/LDP Targets
– Assertive outreach teams for the most severely ill 20,000 people
– Crisis resolution and home treatment for 100,000 people per annum
– Early intervention in psychosis for 7,500 people per annum
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Care programme approach/case management
• May be necessary component of other models but ineffective on its own
• Can help to keep people in contact with services
• Increases use of hospital beds
• No outcome benefits – clinical or quality of life
• Unpopular with clinicians and therefore difficult to implement
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Assertive outreach/assertive community treatment
• Well validated model (Cochrane review)
• Can help to keep people in contact with services
• Decreases use of hospital beds if targeted at high users
• Clinical and patient satisfaction outcome benefits
• Popular with clinicians and relatively easy to establish
• Can be difficult to sustain effective service
• Lesson – hit target group + assertive + community + treatment
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Crisis resolution and home treatment• Well validated model (Cochrane review)
• Decreases use of hospital beds if targeted at people at risk of hospital admission
• Clinical, patient and carer satisfaction outcome benefits
• Initially unpopular with clinicians and complex to establish
• Must be multi-disciplinary including medical input, emphasis on intensive home treatment for several weeks and not just assessment, must act as the filter to all potential admissions
• Lesson – fidelity to model or opposite to intended impact
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Early intervention in psychosis• Similar to assertive outreach but for young people
• Evidence base for minimising duration of untreated psychosis – better long term prognosis
• Limited evidence base for service models
• Popular service but numbers small and difficult to establish to rural and low prevalence areas
• Lessons – too early
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Conclusions
• Case management may be necessary but is not sufficient
• It is not the model but the effective interventions within it that have impact
• Must hit the target group – all too easy to miss
• Fidelity to evidence based models important, but makes implementation more difficult
• You don’t get it right first time and things change all the time – continual review for people and services