Better outcomes, better value: integrating physical and mental health into clinical practice and commissioning Tuesday 24 June 2014: 15Hatfields, Chadwick Court, London

1. Are our models of care truly integrated? -
psychological, social and diabetes care
www.kcl.ac.uk 1
Dr Carol Gayle
Dr Anne Doherty

2. BMJ Awards
3DFD: Diabetes Team of the Year 2014

3. 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.

4. Depression is common in diabetes and associated
with worse health outcomes
.65.7.75.8.85.9.951
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)
Cumulativesurvival
4
0

5. Social problems are common in diabetes
poor
housing
debt
social
isolation
inequities in
access to
healthcare
ethnicity
family roles &
responsibilities
employment

6. Psychological
care
Diabetes care
Social care
Parallel versus integrated services
Diabetes care
Psychological
care
Social care

7. Necessary ingredients
Mental
Health
Diabetes &
physical
health
Social
interventions
Patient

8. Diabetes care only
Psychiatry
Diabetes &
physical
health
Social
interventions
Patient
Pros:
• nil
Cons:
• No integration
• Poorer outcomes – glycaemic
control, morbidity, mortality

9. IAPT
Mental
Health
Diabetes &
physical
health
Social
interventions
Patient
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

10. 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

11. Liaison psychiatry model
Mental
Health
Diabetes &
physical
health
Social
interventions
Patient
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

12. Active ingredients of 3DFD
• debt management
• housing support
• occupational rehab
• literacy
• Advocacy
• patient-led MDT meeting
• increase self efficacy for
diabetes
• HbA1c
• medication support
• biomedical monitoring
• diabetes education
• technology
• complications
• diagnostic assessment
• risk management
• psychotropics
• brief psychological
treatments
• family work
Mental
Health
Diabetes &
physical
health
Social
interventions
Patient

13. Integrated across the sectors
Diabetes care
Psychological
care
Social care
secondary
community
primary

14. 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)
129, 40%196
60%
Gender
Male Female
102
31%223
69%
Type of Diabetes
Type 1 Type 2
121
40%
127
41%
59
19%
Ethnicity
Caucasian African/Caribbean Asian/Other

15. Social Needs
0
5
10
15
20
25
Social supportneeds

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

17. Psychiatric morbidity
0
20
40
60
80
100
120
Nil Known
diagnosis
New diagnosis New relapse
N
Psychiatric Diagnosis
Psychiatric diagnosis: new, known or relapse

18. Main 3DFD outcomes
Pre 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

19. Improvements maintained at 2y

20. Comparisons
0
2
4
6
8
10
12
14
16
18
Glicazide Gliptin Dapagliflozin Lamb/Swk DICT
(n=472)
3DFD (n=185)
ImprovementinHbA1c,mmol/mol
Agents producing improved glycaemic control
Improvement in Hba1c, mmol/mol

21. Cost benefit analysis
Costs £94k/borough/year
• 0.5WTE 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

22. 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%

23. 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

24. 3DFD
Translation
of research
Cross
sector
integration
Health
inequalities
Cost
effective
Dissemination
3DFD

25. Contact us
– kch-tr.3DFD@nhs.net
– 0203 299 1350
– annedoherty1@nhs.net
– carol.gayle@nhs.net Mental
Health
Diabetes
Social
interventions
Patient