Are our models of care truly integrated? - psychological, social and

diabetes care

www.kcl.ac.uk 1

Dr Carol GayleDr Anne Doherty

BMJ Awards3DFD: Diabetes Team of the Year 2014

3DFD

Translation of research

Cross sector

integration

Health inequalities

Cost effective

Dissemination Parsonage M, Fossey M, Tutty C. Liaison Psychiatry in the Modern NHS. Centre for mental Health, London. 2012, p35.

Depression is common in diabetes and associated with worse health outcomes

.65

.7.7

5.8

.85

.9.9

51

3 6 9 12 15 18

Observation time (months)

Major depressive disorder

Minor depressive disorder

No/minimal depression

A cohort study of people with diabetes and their first foot ulcer: the role of depression on mortality. Ismail et al Diabetes Care 2007

Adjusted hazard ratio 3.23 (1.39 to 7.5)

Adjusted hazard ratio 2.73 (1.38 to 5.40)

Cum

ulat

ive

surv

ival

4

0

Social problems are common in diabetes

poor housingdebt

social isolation

inequities in access to

healthcare

ethnicityfamily roles & responsibilities

employment

Psychological care

Diabetes care

Social care

Parallel versus integrated services

Diabetes care

Psychological care

Social care

Necessary ingredients

Mental Health

Diabetes & physical health

Social interventionsPatient

Diabetes care only

PsychiatryDiabetes &

physical health

Social interventionsPatient

Pros:• nil

Cons:• No integration• Poorer outcomes – glycaemic

control, morbidity, mortality

IAPT

Mental Health Diabetes & physical health

Social interventionsPatient

Pros:• Psychological input

Cons:• Not integrated• No social component• No evidence of improved

biological outcomes• Uni-dimensional – cannot

accommodate complex patients with comorbidities, requiring medications, risk issues

CMHT

Mental Health Diabetes & physical health

Social interventions

Pros:• Full mental health input –

psychiatry & MDT

Cons:• Not integrated• No evidence of improved

biological outcomes• High threshold for service

Liaison psychiatry model

Mental Health Diabetes & physical health

Social interventionsPatient

Pros:• Full integrated mental health

input – psychiatry & MDT• Integration to varying degrees

with teams in secondary care

Cons:• Secondary care only• Limited social component –

usually only psychiatry/ psychology for outpatients

• General, not disease specific

Active ingredients of 3DFD• diagnostic assessment• risk management• psychotropics • brief psychological

treatments• family work

• medication support• biomedical monitoring• diabetes education• technology• complications

• debt management• housing support• occupational rehab• literacy• Advocacy

• patient-led MDT meeting

• increase self efficacy for diabetes

• HbA1c

Mental Health Diabetes & physical health

Social interventionsPatient

Integrated across the sectors

Diabetes care

Psychological care

Social care

secondary

community

primary

Characteristic Mean (SD)/Proportion (%)

Age (years) 47.4 (14.7)

Gender male 129 (39.7)

female 196 (60.3)

Ethnic group white 121 (39.4)

African/Caribbean 127 (41.4)

Asian 59 (19.2)

Postcode deprivation 35.2 (9.9)

Type of DM type 1 102 (31.4)

type 2 223 (66.8)

HbA1c (mmol/mol) 95 (21)

Characteristics of 3DFD referrals, n=325 (Oct 2012- Dec 2013)

12940%196

60%

Gender

Male Female

10231%

22369%

Type of Diabetes

Type 1 Type 2

12139%

12741%

5919%

Ethnicity

Caucasian African/Caribbean Asian/Other

Social Needs

05

10152025

Social support needs

Support worker assisting patient with type 2 diabetes with her housing situation

Psychiatric morbidity

Nil Known diagnosis New diagnosis New relapse0

20

40

60

80

100

120

Psychiatric diagnosis: new, known or relapse

Psychiatric Diagnosis

N

Main 3DFD outcomesPre 3DFD Post 3DFD Change score p-value

Mean (SD) IFCC HbA1c mmol/mol (n=185) 100 (23) 83 (22) 17 (17) <0.001

Mean (SD) Diabetes Distress Scale (n=54) 48.9 (16.2) 39.5 (19.9) -9.4 (19.3) <0.001

Mean (SD) anxiety score on GAD-7 (n=54) 9.1 (5.1) 5.8 (5.9) -3.3 (3.2) <0.001

Mean (SD) Outcomes Star score (n=54) 53.4 (11.5) 59.0 (15.9) +5.6 (9.4) <0.001

No of admissions to A&E/previous year (n=119) 141 77 -64 <0.001

No of bed days/previous year (n=119) 381 300 -81 0.08

No of recurrent admissions (days)/previous year (n=119) 10 (73) 4 (14) -6 (-59) 0.012

Improvements maintained at 2y

Comparisons

Glicazide Gliptin Dapagliflozin Lamb/Swk DICT (n=472) 3DFD (n=185)0

2

4

6

8

10

12

14

16

18

Improvement in Hba1c, mmol/mol

Agents producing improved glycaemic control

Impr

ovem

ent i

n H

bA1c

, mm

ol/m

ol

Cost benefit analysisCosts £94k/borough/year• 0.5

WTE Consultant liaison psychiatrist

• Community outreach worker

• Admin support and infrastructure

Savings £127k/borough/year (-on-year)• Short term:

reduction in unscheduled care

• Long term: reduction in developing diabetes complications

3DFD net saving £33K/borough/year

Patient testimonials

My name is Rochelle, I am a single parent with two children. I had difficulties controlling my diabetes. I became very depressed. 3DFD has managed to help me to overcome my fears of dealing with diabetes. I now use my insulins better.....Rochelle:(T1DM) HbA1c 15.2 to 8.7%

Conclusions

Psychiatric morbidity is a poor prognostic factor for diabetes outcomes (and other long term conditions)

Patients do not prioritise their diabetes care if they have social, psychological or psychiatric problems

Integrating mental health and social welfare directly into the diabetes team is a simple solution that integrates everything from the patient’s perspective

3DFD

Translation of research

Cross sector integration

Health inequalities

Cost effective

Dissemination

3DFD

Contact us

– kch-tr.3DFD@nhs.net – 0203 299 1350

– annedoherty1@nhs.net– carol.gayle@nhs.net

Mental Health Diabetes

Social interventio

nsPatient