Analysis

Community learning disabilities and autism team halves inpatient admissions

An overhaul of care for people in the West Midlands with learning disabilities and autism has more than halved inpatient admissions and cut hospital length of stay.

An overhaul of care for people in the West Midlands with learning disabilities and autism has more than halved inpatient admissions and cut hospital length of stay.


Members of the multidisciplinary team (L-R) Jade Waterfield, Aimee Cross, Zoe Owens,
Amy Holton, Chanel Rose, Jason Harrison, David Pidduck, Jodie Cassidy,
Jess Jenkinson, Leanne Coupe, Heather Sullivan, Paul Yarnold,
Mark Baxter and Samantha Cope. Picture: Tim George

The introduction of the community-based intensive support team in Coventry has led to more care being delivered swiftly in service users’ homes.

Winterbourne effect

The team was introduced as part of a review of care following the Winterbourne View scandal in South Gloucestershire, which uncovered abuse in a hospital for people with learning disabilities and autism.

In partnership with four clinical commissioning groups (CCGs) – including lead commissioner, Coventry and Rugby CCG, local authorities, providers and service users – NHS Arden and Greater East Midlands Commissioning Support Unit took an in-depth look at how services for people with learning disabilities and autism were being commissioned and delivered.

More than 50%

of admissions cut from 2014-15 to April 2016

This resulted in an ambitious programme to improve services as a fast-track site for NHS England’s Transforming Care agenda.

Transformation partner at the commissioning support unit Sally Eason, says they were keen to support individuals with often complex needs in the community. Once someone was admitted in hospital, they could be in for a long time, often with uncertain plans for their care or discharge.

The decision was taken to close a nine-bed inpatient unit, which meant a reduction of beds in the area for people with learning disabilities by one third.

Instead, a rapid response multidisciplinary team including specialist nurses, occupational therapists, physiotherapists and psychologists was set up to work closely with people at risk of being admitted to hospital and keep them in their homes.

Personalised support

The intensive support team, which operates seven days a week from a health centre in Coventry, generally works with a cohort of about 35 to 40 individuals on ‘at risk’ register.

‘It is about personalised support packages for complex individuals’, Ms Eason says. ‘They mobilise quickly to provide intensive input to stabilise someone.’

Staff can see a patient swiftly, and visit frequently if necessary, to provide the necessary support. This involves assessing the patient, and often includes modelling positive behaviour change, developing a new care plan and training carers at the service user’s home.

The team has found that a frequent problem is that the non-verbal patients may start displaying  behaviour that challenges because health problems, such as toothache or infections, were not being recognised and treated. People were then ending up in hospital needlessly.

379

Average monthly occupied bed days in 2015-16

Close working

Working closely with the staff at the individual’s home to prevent a service user reaching crisis point is a key part of the team’s job.  

General manager for children’s complex health services Karen James, who was involved with setting up the team, says: ‘We do a thorough assessment of someone’s behaviour which might take in direct observations of how staff are working with that particular person, and how that could be done to the best effect.

'We have nurses and care assistants who get out and model an intervention with a provider. Our nurses work intensively one on one with that person to avoid unnecessary admission to hospital.'

Liaison nurse for people with learning disability and mental health services David Pidduck moved to the team after working for three decades in an acute setting. He says they can move quickly to provide intensive support in the way that many community teams with bigger caseloads cannot.

'Our nurses work intensively one on one with that person to avoid unnecessary admission to hospital'

Karen James

‘If individuals need a daily input, we can do that,’ he says. ‘We collaborate with all the existing services to avoid inappropriate admissions. Where people do end up being admitted we keep in contact with them and help them transfer out as quickly as possible.'

Since the team’s introduction, admissions and the average number of beds filled with their patients has fallen. Admissions have more than halved since 2014-15, when the average acute admissions for people with a learning disability and/or autism, to a mental health or a specialised learning disability setting was three. From April 2016 the mean number of admissions to those settings has dropped to 1.3.

At the beginning of 2015-16, the average monthly occupied bed days for people with a learning disability and/or autism in hospital was 379. From April 2016, this had dropped to 169.

Feedback

The team, which has been running for 18 months, has received high rates of positive feedback from service users and their families.


Liason nurse David Pidduck. Picture: Tim George

‘We are not a crisis team, although we work with people in crisis,’ Mr Pidduck says. ‘While we provide a rapid and intensive response, we are not just there for crisis management. We do assessment and observational work with the person in their environment to try and identify what intervention may help and what is causing the change in behaviour. That involves a lot of collaboration with their support staff working alongside them, developing a positive behavioral support package for that person.’

The team holds care and treatment reviews, which are also part of the Transforming Care agenda. Mr Pidduck says these are enhanced multidisciplinary team meetings where concerns, such as a risk of being admitted, a residential placement breaking down or a health concern, can be discussed.

169

Average monthly occupied bed days from April 2016

In one case, the team worked with a patient who had been in an institution for many years because of fears of what would happen to him if he left. Through carefully planned support, which concentrates on activities to reduce his anxiety levels, he is now living a ‘fulfilling’ life in the community, according to the commissioning support unit.

Holistic philosophy

The way the team works suits the person-centred approach of learning disability nurses. ‘Learning disability nurses are good at looking at a person holistically for a change in their behaviour and look at their physical health,’ Mr Pidduck says. ‘This overarching philosophy is the same for us and we are able to respond more quickly, more intensively, and take the time to look beyond the initial information we are given. It is kind of detective work.’

The programme, which has been running for 18 months, has now widened to include children and young people.

Mr Pidduck says they are focused on what is best for the patient: ‘We are working in their best interest so they are able to maintain and hopefully improve their quality of life.’

Transforming Care

Transforming Care is the national programme in England to improve services for people with learning disabilities, who may also have autism and mental health problems, and who display behaviour that challenges.

The programme, led jointly by NHS England, the Association of Adult Social Services, Care Quality Commission, Local Government Association, Health Education England and the Department of Health, was established after the abuse of patients was uncovered at Winterbourne View.

It seeks to provide more choice for people and their families about their care, more care in the community with personalised support from multidisciplinary teams, and ensure that any people admitted to hospital are only kept in for as long as they need to be.


Erin Dean is a health writer

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