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HOW CAN INTEGRATING MENTAL & PHYSICAL HEALTH IMPROVE PATIENT
OUTCOME & EXPERIENCE?
2nd Hertfordshire Diabetes Conference
The Fielder Centre, HatfieldThursday, 1st October 2015
Dr. Nikki Scheiner Dr. Sarah CohenLead Psychologist Consultant Psychiatrist Watford & Stevenage RAID Watford RAID
AIMS OF PRESENTATION
To increase knowledge about mental health services in Hertfordshire
To understand how psychological and mental health interact and impact on Diabetes
To look at some case examples
RAIDRapid Assessment Interface and Discharge Service• Watford General• Lister
Psychiatric Liaison• Emergency Department• Ward based• Teaching and training
Multidisciplinary• Psychiatrists • Psychologist• Nurses• Social worker
Examples of Co-morbidity
47 year old man with chronic and difficult to control Schizophrenia since age 22. Has been on various antipsychotics over the years including olanzapine and clozapine. Has developed Type 2 Diabetes, which is difficult to control
17 year old girl with Type 1 Diabetes since age 9. Lives with mother and step father who is a very controlling character. High demands on her academically. Has developed an eating disorder, with bingeing and purging by vomiting. Also runs sugars high to lose weight
RAID Frequent Attenders Programme
Distributed to all involved professionals, to Service User and family/carer
Therapeutic care plan drawn up – Aims to meet true needs and stop reinforcement of inappropriate behaviours
Multi system (or multi agency) meeting;
Biopsychosocial assessment with RAID psychologist to map out stressors impacting upon physical health
Referred by Ward, ED, and now increasingly by specialist consultants;
Patients with numerous inappropriate attendances to ED or ward
JP
• Referral: Ward-based Diabetes Registrar;
• Reason: District Nurses withdrew their service because of JP’s non-compliance and their view that she was not being honest about her medication adherence;
• Initial ward-based ax by RAID CPN: did not elicit mental illness. Reported that JP stated she would benefit from being busier
FIRST PSYCHOLOGICAL ASSESSMENT
• JP assessed in RAID offices in a wheel-chair, accompanied by a nurse
• Presentation: frail – impression quickly dispelled when she started to talk; mood: euthymic.
• Patient report: fully compliant with medication; good diet – cannot understand reason for hypos and admissions.
• Social: grandchildren visit everyday; daughter visits regularly; but still needs more to occupy herself.
CONTACT WITH GP
• GP: ‘we haven’t got a handle on her.’
• RAID organised a meeting at GP surgery, attended by all GP partners and DNs: most expensive patient c. £350,000 in 4 years;
• Agreed that there was a psychological component to presentation; queried cognitive functioning
Cognitive assessment• OPA: attended with daughter.
• Daughter: stressed +++ and has given up work to be main carer.
• JP completed the ACE-III and score suggested that she has very mild cognitive impairment; some memory loss, but not sufficient to explain.
• Language task: asked to write about her Christmas, wrote about hospital admission!
MDT meeting
• RAID Psychologist and Psychiatrist; Diabetes Consultant and Specialist nurse; Community Navigator; A&E
• JP’s behaviour on the ward:– limits food triggering further hypos;– seeks social interaction with nurses, e.g. helping making
beds.
• Information also provided from GP and District Nurses
CARE PLAN
• Diabetes team reviewed her insulin regime to optimise it
• Bed manager asked to admit – if possible only to Heronsgate Ward at WGH (Diabetes ward) where JP is well-known to nursing staff;
• Referral to Age UK Active Living Club once weekly – transport and lunch included, and to Age UK Friendship Tea twice monthly;
• JP to be allocated a befriender under Age UK befriending scheme: one hour weekly;
• Community Navigator explored activities that take place on Fridays as JP’s hospital admissions tended to be just before the weekend;
• Carer’s assessment offered to daughter.
OUTCOMES
• Patient’s experience: positive;
• Patient’s control of Diabetes: improved;
• Number of admissions: reduced;
• Length of Stay: reduced;
• Daughter’s anxiety: reduced;
• Cost to GP and Health Care budget: reduced
Psychosocial factors & Diabetic controlPersonal identity (forms in teenage years / early adult years, at same time as Type 1 diabetes
Sense of self control / being controlled
Peer influence and need to fit in
Depression: poor motivation, loss of interest, sleep dysregulation; poor or increased appetite
Psychotic illnesses: self neglect; delusions and hallucinations; thought disorder; chaotic lifestyles; antipsychotics
Eating disorders : altered body image; enmeshed relationships; disordered relationship with food
Drug and alcohol use
Cognitive impairment
Attachment issues
IntegrationYou can not deal with physical illness in
isolation. If you don’t deal with psychological factors concurrently treatment will fail
