3DLC - Service Development 3 Dimensions for Long Term Conditions (3DLC) is a service that provides integrated medical, psychological and social care for people across Lambeth and Southwark who have either heart failure, chronic obstructive pulmonary disease (COPD) or resistant hypertension, in addition to a mental health and/or social concern. Currently funded by King’s Health Partners, 3DLC is hosted by King’s College Hospital in collaboration with Guy’s and St Thomas’s and South London and Maudsley NHS Foundation Trusts.
Please briefly describe your project, group, team or service, outlining what you do and why it makes a difference.
3DLC – Service Development 3 Dimensions for Long Term Conditions (3DLC) is a service that provides integrated medical, psychological and social care for people across Lambeth and Southwark who have either heart failure, chronic obstructive pulmonary disease (COPD) or resistant hypertension, in addition to a mental health and/or social concern. Currently funded by King’s Health Partners, 3DLC is hosted by King’s College Hospital in collaboration with Guy’s and St Thomas’s and South London and Maudsley NHS Foundation Trusts. The 3DLC clinical team includes a psychiatrist, psychologist and social support worker, and they have three main roles: 1. Development of mind and body pathways, and supporting staff within acute trusts to better navigate available mental health services. This includes embedding a routine psychosocial screening and referral system; 2. Provision of education and training to upskill physical health teams to feel confident and competent in responding to co-occurring mind and body needs; and 3. Direct clinical care for the most complex patients. In the first 18 months of the project, approximately 2000 patients have been screened for anxiety and depression. Of these, approximately 850 patients were referred on to the appropriate services as necessary (for example to local Improving Access to Psychological Therapies (IAPT) services, and the 3DLC directly treated around 595 (70%) of patients. The 3DLC project also places a strong emphasis on learning and development. Multi-disciplinary learning sessions have been provided to over 750 staff across primary and secondary care, and the community. From an interim evaluation performed in 2018, it has been shown that the 3DLC approach to care can improve patient experience, physical functioning, psychological outcomes, quality of life, and lead to the more appropriate use of healthcare services. The value of this work is also reflected in a change of attitudes and confidence, with over 95% of staff now stating that they consider their patients’ mental health and social needs as a vital component of their care.
What makes your service stand out from others? Please provide an example of this.
3DLC – Service Delivery Common mental health disorders are more prevalent in people with long-term conditions, such as diabetes, cardiovascular disease (CVD) and chronic obstructive pulmonary disease (COPD). The co-existence of mental and physical health conditions can lead to poor self-management and reduce adherence to medication, which in turn can negatively impacts on a person’s quality of life. Further still, patients with both mental and physical health concerns often have reduced ability to participate across wider society and increased morbidity and mortality. There are also substantial impacts on healthcare usage and costs. The 3DLC service is an innovative service in that it aims to address these concerns by offering patients an integrated service that brings together clinical and research expertise in medical care, mental health and social support to deliver a mind and body, or holistic, approached to their care. 3DLC creates value by improving outcomes that matter to patients – such as coordinated ‘whole-person’ care, functional status, and quality of life. An interim evaluation suggests the programme is also likely to reduce healthcare and societal costs (e.g. through treatment adherence, reducing inappropriate healthcare usage, and improved ability of patients and carers). Patients benefit from the integrated nature of the psycho-social support and view it as a core part of their care – much like physio is a core part of an older adult’s recovery from a fall. The benefit of the programme is clear from patient testimonials. For example, one 3DLC patient, Anna* has COPD, severe depression and anxiety, and through engagement with the service has progressed from being extremely breathless, homebound, and needing a package of care to being able to drive again to see her grandchild every other day and living independently. Her care is more coordinated, and her health was improved by joint professional working led by outcomes important to her.
A video outlining the experiences of another patient, Shawn, is available on our website: https://www.kingshealthpartners.org/our-work/mind-and-body/our-projects/3dlc In the video, Shawn talks about the fact that any kind of health condition can impact on mental health, and as such he appreciates that the 3DLC team are able to ‘look at all my conditions together’ and ‘talk about my mental state and how it was all linked in to one’. Notably, the value of 3DLC also extends beyond patients by improving staff confidence and wellbeing. 3DLC offers weekly support and supervision to staff to help them manage patients’ anxiety, set boundaries and expectations. Of particular value are reports from the 3DLC team who have observed the impact of screening and feel that it is contributing to a shift in clinicians’ thinking. One staff member reported: “As well as allowing some clinicians increased confidence to have those conversations because not only is the information there, that also helps direct you towards a plan…so I think it’s helping to give people the language to do that. But I think also showing that ‘oh, actually 40% of the people who came to your clinic in the past month had scores that are suggestive of major depressive disorder or generalised anxiety disorder. I think that is really powerful because a co-morbidity that is that common, people will do something about. Although we had shared the national figures I think being able to share the local figures feels different – ‘these are my actual patients’. “
How do you ensure an effective, safe, compassionate and sustainable workforce?
3DLC (Service Delivery) As noted above, a key component of the 3DLC service is the provision of frequent multi-disciplinary learning sessions which aim to upskill staff across secondary, and community care, and increase their confidence to talk to patients about their mental health. Furthermore, we created an education and training curriculum and a series of online educational materials for easier dissemination. As a result, staff have reported reduced stigma and improved skills in making appropriate referrals to mental health support. Survey data has been collected which demonstrate the impact on clinical teams’ confidence and awareness of identifying patients for mental health issues and where to direct them when screening is positive. Results showed an increase in confidence in identifying the best course of action in working with people with mental health needs and an increase in feeling supported in looking after the psychological needs of patients. On the national level, 3DLC has previously been invited to present at professional conferences and learning networks spanning across disciplines such as health economics, cardiology, gerontology, psychiatry, and the King’s Fund. We have also shared blogs and staff and patient videos on social media and the KHP website. Supporting the clinical teams to develop their skills and confidence expands beyond formal training opportunities. The 3DLC provide informal and ad hoc advice and guidance on a regular basis, through MDT conversations and opportunistic meetings.
Who is in your team?
1 1WTE Consultant Psychiatrist 1 8a 1WTE Principal Clinical Psychologist 1 WTE External Social Support Worker (Thames Reach) 1 Band 5 1WTE KCL Researcher
How do you work with the wider system?
Collaborative working across the three NHS organisations, our social support provider, and local commissioners is key to our success and is consolidated via bimonthly steering groups. There is also strong support at a senior level from across King’s Health Partners and local CCGs for better integration of physical and mental health care which we have drawn on to support sustained change. Developing stronger partnerships with other organisations providing psychosocial care – such as Improving Access to Psychological Therapies (IAPT), Living Well Hubs, Thames Reach and other 3rd sector organisations (e.g. pumping marvellous) – as well as our local CCGs has been essential in establishing an efficient and sustainable care pathway. We also work with the University of York and King’s College London to collect data for external evaluation and economic analysis and report regularly to key stakeholders.
Do you use co-production approaches?
The 3DLC service is under-pinned by co-production with patients, families and carers. Service user involvement has been integral to service development. Bi-annual patient involvement groups have been held and following an additional stakeholder event (attended by >50 services users and staff), a person with lived experience has joined the steering group. As noted above, patient-reported outcome measures have also been used for the evaluation process. Services users are also very much involved in the direction of the care they use. As an illustration, patients receiving social support use the ‘making every adult matter’ outcomes and all have a support plan where individual goals and risks are identified.
Do you share your work with others? If so, please tell us how.
3DLC receives considerable attention through word of mouth from champions and boundary spanners. Other subspecialties in cardiology, respiratory and gerontology followed our model and arranged to set up routine mental health screening in their clinics. The service falls under the oversight of the Mind & Body programme at King’s Health Partners (KHP), which facilitates executive level support and access to the wider Mind & Body Champions network across KHP. Mind & Body clinical skills training days are offered for this larger network of staff who then bring their knowledge and skills to their respective medical, mental health or research teams. In addition, we hold patient engagement events and are connected to our local care network and the health innovation network who are supportive of our work. Our initiative is shared in primary care through GP education days and virtual clinics. On the national level, 3DLC has previously been invited to present at professional conferences and learning networks spanning across disciplines such as health economics, cardiology, gerontology, psychiatry, and the King’s Fund. We have also shared blogs and staff and patient videos on social media and the KHP website: https://www.kingshealthpartners.org/our-work/mind-and-body/our-projects/3dlc
What outcome measures are collected, how do you use them and how do they demonstrate improvement?
Screening for depression and anxiety is now routine in 14 outpatient clinics and in all 4 community teams, with over 1600 patients screened (30% positive). Over 750 members of staff have received 3DLC education on psychosocial care and LTCs, including all staff in the LTC teams that we work with. Training includes inter-professional stand-alone workshops and lectures as well as continuous educations delivered during MDMs, CPD programmes and case based discussions. Feedback from these events show increased knowledge and confidence. Qualitative evaluation also suggests culture change within teams is happening with increased interest and confidence displayed. This is supported by referral numbers to 3DLC, with over 850 referrals made to 3DLC, with a significant increase in monthly referrals noted during the initial stages. Importantly, the intervention has also been welcomes by service users as demonstrated by engagement with care and through formal qualitative work. Condition specific measures and rating scales, depression, anxiety and quality of life measures and service use is being collected at baseline, 6 and 12 months for external evaluation. Formal economic analysis is pending but case studies illustrate probable savings in reduced service use. Early findings from the full service evaluation indicate that despite the complexities of this patient group, the service has demonstrated improvements in psychological, physical, and social outcomes. The full dataset will be available later in the summer.
Has your service been evaluated (by peer or academic review)?
In early 2018, the 3DLC service underwent an interim evaluation process by external qualitative researchers at the University of York. This process was predominantly a qualitative process evaluation using face to face interviews and non-participatory observations. A thematic analysis showed a clear consensus, from staff, that 3DLC raised awareness of psychosocial issues, improved good working relationships with teams, and also changed the way care was delivered. Some additional internal qualitative evaluation has shown that 3DLC has led to improvements in patient outcomes – such as physical functioning, mood, and quality of life – and led to positive reports of perception of care. Currently the project is undergoing a second more comprehensive evaluation process, again from external researchers based at the University of York. In addition to revisiting the qualitative aspects, this valuation will include a quantitative evaluation of the effectiveness of 3DLC in improving health outcome and cost savings. Early indications show that the service is effective at avoiding unnecessary healthcare use, and so contributes to greater service efficiency.
How will you ensure that your service continues to deliver good mental health care?
The 3DLC service has been funded by the Health Foundation from January 2017 – March 2019. In March, King’s Health Partners agreed to fund the service on a short term basis whilst business cases were submitted to the trusts to mainstream the service and agreeing funding on a rolling basis, with full support of our local Directors of Integrated Commissioning. The intention is to make all posts substantive by end 2019/2020. The service is now well established within the long-term conditions clinical teams and the team has been able to develop and maintain effective communication for the continuation of screening and referrals of patients. There has also been interest from other services in adopting the 3DLC stepped care model and approach.
What aspects of your service would you share with people who want to learn from you?
Scaling up the original 3DFD model to work across more than one specialty has brought challenges for the 3DLC team, notably ensuring a presence across four MDMs and becoming familiar with three different patient populations. However, both the medical teams (and patients) are increasingly seeing 3DLC as part of the wider team supporting patients, in recognition that culture change is possible within relatively short timeframes. There were a number of early implementation challenges: lack of space for to hold co-located clinics reduced opportunities for joint working and shared learning; busy and crowded clinics are a barrier to collecting screening data; clinicians had concerns about professional accountability for ensuring that high risk patients identified through screening are appropriately referred/cared for. However, protected time has given the 3DLC team space to develop as a team and reflect on the new approaches and systems being put in place. Furthermore, the referral pathway is working well; flexibility was important for this as clinicians were becoming more confident about making judgements about where to refer; and the idea of having access to telephone advice from 3DLC team was welcomed.
How many people do you see?
In the first 18 months of the project, approximately 2000 patients have been screened for anxiety and depression. Of these, approximately 850 patients were referred on to the appropriate services as necessary (for example to local Improving Access to Psychological Therapies (IAPT) services, and the 3DLC directly treated around 595 (70%) of patients. Multi-disciplinary learning sessions have been provided to over 750 staff across primary and secondary care, and the community.
How do people access the service?
They are referred into it by the medical team in Heart Failure or COPD across each of the three Trusts.
How long do people wait to start receiving care?
The referrals are under a week – there are no national standards.
How do you ensure you provide timely access?
Timely access is managed through continual reviewing of screening data as this is embedded within the Electronic Patient Record. The team review all referrals and current caseload on a weekly basis.
What is your service doing to identify mental health inequalities that exist in your local area?
The screening includes data on demographics and this filters through (with consent) into a research database. This enables us to look at the impact of demographics, such as socio-economic status and if the patient is BAME, on prevalence of mental health and mental health inequalities. Furthermore, the team also offer home visits in order to ensure those typically “hard to reach” populations have an equal access to the service.
What inequalities have you identified regarding access to, and receipt and experience of, mental health care?
We have identified that there are certain hard to reach populations who may find it harder to present to the hospital for various reasons eg transport and physical mobility or lack of engagement and trust. The team have done home visits and follow up with patients over the phone to combat this.
What is your service doing to address and advance equality?
3DLC, through its bio-psycho-social model, is in itself a developed service aimed at improving access and experience for people who are at risk of experiencing physical and mental health inequalities as it is mobile and multidisciplinary. It raises awareness of mental health with people who interact and come to know about the 3DLC programme, which reached a high profile after the previous 3 dimensions for diabetes programme won an award (3DLC is an upscaled version). 3DLC is a flagship programme of the Mind & Body programme and is held up as an example of good practice at workshops and conferences. As it is across three hospital Trusts and part of King’s Health Partner’s, there is institutional knowledge about our local population needs and a common goal to reduce stigma and advance equality.
How do you identify the needs of a person using the service (such as their physical, psychological and social needs)?
Our screening tool for 3DLC is a tool called IMPARTS. (IMPARTS) is an initiative funded by King’s Health Partners to integrate mental and physical healthcare in research, training and clinical services at Guy’s and St Thomas’, King’s College Hospital, and South London and Maudsley NHS Foundation Trusts. IMPARTS collects patient reported outcome measures through an iPad that the patient self report, which in real time, flows through to the Electronic Patient Record.
How do you meet the needs of people using the service and how could you improve on this?
Our bio-psycho-social model (the 3 dimensions for long term conditions) meets the needs of patients holistically. It conforms to NICE guidelines which say that people with long term conditions should have access to psychological support. IMPARTS also uses measures recommended by NICE to screen for depression and anxiety. 3DLC could be improved with more psychology time and spread to other long term conditions.
Commissioner and providers
Commissioned by : The King’s Health Partner’s are King’s College Hospital Trust, Guy’s and St Thomas’ Hospital Trust, South London and Maudsley Hospital Trust and Kings College London
Provided by: The King’s Health Partner’s are King’s College Hospital Trust, Guy’s and St Thomas’ Hospital Trust, South London and Maudsley Hospital Trust
Brief description of population (e.g. urban, age, socioeconomic status):
The population of Southwark, Lambeth have very diverse, socio-economically deprived and majority younger and growing populations. Whilst progress has been made over the last 50 years, health inequalities remain across the boroughs. Southwark is an inner London Borough on the south of the Thames. Its poverty rate is 31%, above the London average of 27%, and the unemployment ratio is 6.5% – the 4th highest rate in London. Infant mortality and premature mortality are also above the London average. It is estimated that almost one in five adults in Southwark are experiencing a common mental disorder, equating to approximately 47,000 individuals. The prevalence of severe mental illness in Southwark is 1.4% (approximately 3,800 patients) and severe mental illness disproportionately affects male, older and black ethnic population groups. Suicide is seen as a proxy for underlying rates of mental ill-health; in 2013/15 Southwark was one of five London boroughs to report higher suicide rates than the national average. Lambeth is an inner London borough with a mixed picture on poverty and inequality. The poverty rate of almost 30% is above the London average of 27%. Lambeth has a high rate of infant mortality and premature mortality as well. 59% of Lambeth homeless households who the borough places in temporary accommodation are moved outside the borough, which is the second highest rate in London.
Size of population and localities covered: Our Health and Wellbeing toolkit, and Champions programme covers Lambeth, Southwark, Lewisham and Croydon which is a population of roughly 1.3 million. Our 3DLC programme covers Lambeth and Southwark, which is a population of roughly 638,000. Figures from 2017 census estimates: • Southwark 314,232 • Lambeth 324,048 (2017)
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