A mental health trust in Birmingham has developed a new model for patient assessment and discharge that helps address the full spectrum of patient needs in one assessment. Professor George Tadros explains how this award-winning service works - and the difference it makes to mental health awareness.
The Birmingham and Solihull Mental Health Foundation Trust Rapid Assessment, Interface and Discharge (RAID) model, the first of its kind in the UK, ensures patients get help for mental and physical health at the same time – delivering all the care that people need, when they need it – in one of Birmingham’s busiest acute hospitals.
The government’s mental health strategy, No Health Without Mental Health, recognises that mental wellbeing is closely linked to physical health – and the need for mental health awareness to be raised in primary care and acute hospital settings.
Recent research and guidance highlights how important it is for acute hospitals to address the needs of patients who self harm or misuse substances, recognise the impact of conditions like depression and dementia, and those who present as complex cases with both physical and mental illness, which often result in repeat admissions to acute care.
RAID is a great example of how this new strategy works in Birmingham. The RAID team assesses and treats patients aged over 16, who present at A&E or are already inpatients at Birmingham’s City Hospital, getting them the help they need, regardless of age, locality, complaint, severity or time of presentation.
This award-winning service – which was launched at City Hospital in December 2009 and receives around 250 referrals a month – is accredited the Royal College of Psychiatry’s Psychiatric Liaison Accreditation Network.
In November 2010, less than a year after the service was launched, the RAID team won the HSJ Award for Innovation in Mental Health.
On the right path
The key to RAID’s model is to see everyone referred from A&E within an hour, and all others within 24 hours. This means care for people with mental health problems is initiated early and problems are dealt with swiftly.
Staff in the RAID team provide tailored interventions, signposting, follow-up clinic appointments and onward referrals to GPs, Aquarius and third sector organisations that have been set up to provide on-going help in the community.
Staff at City Hospital also received training on mental health awareness and interventions. Staff reported this was highly relevant and has led to improvements in their practice, which in turn improves patient experience, with better detection, diagnosis and therefore earlier treatment.
In the ten months between December 2009 and September 2010, the team received more than 2,500 referrals. The most common reasons for referral were deliberate self harm, depression, confusion/dementia, alcohol misuse, suicidal thoughts, and psychosis.
Before RAID was introduced at City Hospital, patients who presented to A&E or on one of their inpatient wards with a mental health difficulty had to wait to be referred to the trust for assessment, before they could be put on the appropriate care pathway. This created delays and the patient experience could become disjointed and frustrating.
Now when a patient arrives at the hospital, the RAID team are alerted to provide an assessment prior to admission. The model has shown clear benefits in service delivery, increasing staff and patient satisfaction, rapid response times and delivering high cost savings while improving the overall quality of care.
Discharge and support in the community
RAID’s primary aim was to streamline the patient journey. In achieving this aim, RAID has also had a beneficial effect on traditional winter pressures, by reducing length of stay and the number of readmissions.
A sample study conducted by the RAID team revealed that patients seen by our service were discharged quicker than those who were not seen by a member of the team – with 75 per cent discharged within a week, and 65 per cent within three days, of seeing RAID. This prevented unnecessary long stays in hospital, enabling safe and early discharge.
The number of older adults seen by RAID, who had come from their own home and returned there, almost doubled with 80 per cent returning home compared to 47 per cent pre-RAID.
The team specialists in working with older people with mental health problems, who are embedded in the acute hospital through RAID, can support other professionals to jointly manage the potential risks of discharge and facilitate rapid access to specialist community support.
Avoiding acute hospital admissions – and saving money
To assess the financial impact of our RAID model at City Hospital, data on three key areas was independently collected and analysed to identify cost savings. This information focused on reduced length of stay, reduced readmissions and admission avoidance at the medical assessment unit (MAU).
- Length of stay: RAID saved 21,509 bed days over 12 months (58.9 beds per day), with an associated cost saving of around £4.5m.
- Reduced readmissions: RAID saved 1,800 admissions over 12 months, saving approximately £5.4m. This amounts to 8,100 saved bed days (22 beds per day).
- Admission avoidance: By avoiding admissions at the point of MAU, RAID saved £454,500 through 202 patients receiving a reduced tariff of £750, rather than the £3,000 an admission would have cost.
In total, the combined savings are estimated at £10m (ranging between £7m and £12m).
RAID’s innovative model has shown it is possible to improve patient experience and quality of care while delivering significant cost savings within the service.
Training acute staff at City Hospital to improve mental health awareness was well received and reported to have a beneficial impact on practice. The presence of RAID within the hospital has also resulted in more patients being diagnosed with mental health difficulties, compared to pre-RAID levels of diagnosis.
Referrals received reflect a wide range of mental health issues and ages. By combining specialities, the RAID team were able to respond to complex cases providing skilled assessment, intervention and onward referral for patients. The number of referrals made to home treatment teams fell, to show that RAID can handle some patients who previously would have been referred on to these services.
An audit of mental health related four hour breaches revealed these have been reduced since RAID was introduced. The team were also to meet one hour response targets in A&E and 24-hour targets for inpatient wards in most cases.
A large percentage (80 per cent) of older adults who came from their home, and were seen by RAID, went back there compared to pre-RAID levels, which highlights benefits in terms of service usage and patient experience.
The close working relationship between staff at City Hospital’s A&E, the RAID team and the trust’s community-based teams, ensures the patient’s journey from assessment to treatment is a smooth, straight-forward one.
Finally, the savings our RAID service has made during its pilot phase – and the projections for what it can save the NHS over longer periods, cannot be ignored. Investing in the RAID model can reduce bed days and readmissions, as well as avoiding admissions at point of care, usually within an MAU.