Christian Brand et al

1. Community mental health teams for older
people: the outcomes and costs of different
ways of working
Christian Brand, Michele Abendstern, Sue
Tucker, Mark Wilberforce, Rowan Jasper, David
Challis
PSSRU
Personal Social Services Research Unit
at the University of Manchester

2. Disclaimer: This presentation presents independent
research funded by the National Institute for Health
Research (NIHR) under its Programme Grants for
Applied Research Programme (Grant Reference
Number RP-PG-0606-1109). The views expressed are
those of the author(s) and not necessarily those of the
NHS, the NIHR or the Department of Health.
PSSRU
Personal Social Services Research Unit
at the University of Manchester

3. Background and aims
• Part of a larger study: ‘National trends
and local delivery in old age mental health
services: towards an evidence base’
• 3 strands (I. „balance of care‟, II.
community mental health teams for older
people, III. care home liaison)
• Focus on CMHT strand today:
Integration and its effectiveness
PSSRU
Personal Social Services Research Unit
at the University of Manchester

4. Mixed methods approach
From a national survey of all CMHTsOP in England
we selected 4 „high‟ integration teams and 5 „low‟
integration teams
We interviewed 42 staff members on their views on
integration (covering all staff groups, approx. 60
minutes per interview)
From the teams‟ caseloads, we collected data on
socio-demographic and clinical profiles as well as
service receipt details for 948 CMHT clients (193
clients were also interviewed in person)
We conducted a work satisfaction survey of all
CMHTOP staff in the chosen NHS trust areas (295
participants in 38 teams)
PSSRU
Personal Social Services Research Unit
at the University of Manchester

5. Definition of integration
Integrated team = A multidisciplinary team which
• Had at least one social worker
Plus at least 6 of the following features:
• A single manager between health and social care
• Accepted referrals directly from non-medical sources;
• A single point of access;
• Used the same or at least shared assessment document
• A single client database or two that were accessible to all staff
• Allocated a single care coordinator across health and social care
• Used a single care plan which included both health and social care
information
• Could access both health and social care resources.
PSSRU
Personal Social Services Research Unit
at the University of Manchester

6. Initial concept: high vs. low integration
Teams Team Team characteristics
type
5 examples* Low- Co-located multidisciplinary health team
integration with single manager located within the
team
4 examples* High Co-located health and social care
integration team with single manager located within
the team
* Teams were purposefully chosen as typical examples of „different ways of
working‟ as identified in our national survey (n=376)
PSSRU
Personal Social Services Research Unit
at the University of Manchester

7. Revised concept: high vs. low integration vs. ‘network
team’ or ‘nominally’ integrated team
Teams Team Team characteristics
type
1 example Network Like low integration, but with separate
Degree of Integration
managers for individual disciplines
4 examples Low- Co-located multidisciplinary health team
integration with single manager located within the
team
1 example Nominal Like high integration, but with separate
integration health and social care managers
3 examples High Co-located health and social care team
integration with single manager located within the
team
PSSRU
Personal Social Services Research Unit
at the University of Manchester

8. Findings I: the voice of practitioners
How does the nature and extent of
integration within the team help or
hinder your ability to provide an
effective service?
PSSRU
Personal Social Services Research Unit
at the University of Manchester

9. Findings I: overview
1. Features of working in integrated teams found to be
beneficial to practice by staff
(emphasis on social work membership)
2. Features of working in non-integrated teams found to
impede practice by staff
(emphasis on social work membership)
3. Complexities of working in an integrated team
4. Summary findings
PSSRU
Personal Social Services Research Unit
at the University of Manchester

10. Benefits of a multidisciplinary team
• A wide range of easily accessible skills
and expertise to support service users
It widens your
knowledge and
• The potential to enhance the skills of we’re not there
all individual members by the informal for anybody else
learning between colleagues that this other than the
fostered Client, so it is
beneficial
Team manager
PSSRU
Personal Social Services Research Unit
at the University of Manchester

11. Benefits of an integrated team: social work membership
It is a huge
• Specific mental health expertise benefit…They are
…very skilled and they
• Knowledge of social services have a good knowledge
procedures and funding
of the Mental Health
• The ability to access social care Act and they have good
resources directly knowledge of
• Direct access to social care safeguarding … they
information just bring a different
• Wider perspective dimension really
Consultant,
integrated team
PSSRU
Personal Social Services Research Unit
at the University of Manchester

12. Benefits of an integrated team: social work membership
• Shared case ownership I can dip into my colleagues
case load where there’s a
• Shared goals social care need identified
• Informal Social worker, without them having to … go
integrated team through the process of
joint working
referring to …[social services]
• Intra-referring
you are sitting alongside them, you
can have a chat and discussion about
the patients beforehand…So you are
Team manager, not referring them blind … you are
nominally referring to a colleague, which is a lot
integrated team
quicker because you are not sending it
out of the office, onto a waiting list
PSSRU
Personal Social Services Research Unit
at the University of Manchester

13. Benefits of an integrated team: social work membership
• A single point of access
– leading to a holistic …all the referrals are going to
approach and input one place…and then as a
team they will discuss the
medical/social component
Consultant, and respond
integrated team together…otherwise I feel
the multidisciplinary part of
the work will take place but
in stages
PSSRU
Personal Social Services Research Unit
at the University of Manchester

14. Features found to impede practice in non-integrated
teams: lack of social work membership
we make the referral to
• Slow response and lack of [a central number] … and
communication then that tends to sit on
Nurse, non-integrated a waiting list …we don’t
team
even know when it
• Lack of shared understanding happens unless we
and goals actually keep checking
...they are interested, but …just…in
• Limited joint working their bit and … they are just
thinking, well if it is open to that
Team manager, CPN…they want to look for a care
non-integrated
team provision … and get [out]
PSSRU
Personal Social Services Research Unit
at the University of Manchester

15. Features found to impede practice in non-integrated
teams: lack of social work membership
• Loss of data in case they …ring the person and …
transfer say, - „I‟ve had a referral from
the OT, I‟m coming out to see
you‟. … I might have had a
• Support breakdown due to discussion with that person
limited understanding of and taken a long time to get
mental health work by them to agree, and because
generic social workers of the dementia they might
have already forgotten. They
would get a phone call and
then say, - “no I didn‟t ask for
anybody”, so then… [the
OT, non-integrated
social worker] wouldn‟t go
team
out
PSSRU
Personal Social Services Research Unit
at the University of Manchester

16. Features found to impede practice in non-integrated teams
what one organisation sees as
• Lack of single the higher priority.., the other
manager might not …. and if you had
OT, non-integrated one who has an understanding
team of our service then that might
be better
• Difficulty of access
to information [We]’ve got..5 IT systems, none of
which talk to each other….I can’t
get on the social workers site…if
you just opened those lines of
Team manager,
non-integrated communication a little… that
team would be a huge improvement.
PSSRU
Personal Social Services Research Unit
at the University of Manchester

17. Obstacles to effective working in integrated teams
• Where social workers were expected to complete two sets
of records, one for health and one for social care
• Formal internal referral systems
• Complexities of managing and supervising across
disciplines and agencies
• Use of ‘specialists’ for generic work….OTs and
Psychologists….(all multidisciplinary teams?)
Perhaps evidence of integration not having gone far enough
PSSRU
Personal Social Services Research Unit
at the University of Manchester

18. Summary of Findings I
Key attribute Integrated team Non-integrated team
Limited
understanding of
Shared responsibility
service user needs
and goals
& each other‟s
pressures
Social worker in team Ease of access to Difficulties in
or not specialist skills and accessing social
resources services
Joint work and Limited joint work
holistic approach
PSSRU
Personal Social Services Research Unit
at the University of Manchester

19. Findings II: client outcomes and costs of services
Multiple outcomes Multiple cost types
Risk of mental health inpatient Service receipt/cost* of
admission community mental health support
Service receipt/cost* of social
Time to inpatient admission
care package
Risk of care home admission Total costs*
Quality of life score (interview) * Calculated as monthly
costs at baseline
Satisfaction with services and key
worker (interview)
PSSRU
Personal Social Services Research Unit
at the University of Manchester

20. Findings II: statistical modelling
All outcomes and costs were analysed with
various forms of regression models: i.e. predicting
the variable while controlling for other known
characteristics (principally socio-demographic
and clinical profile)
The main aim: comparing different team types
PSSRU
Personal Social Services Research Unit
at the University of Manchester

21. Findings II: outcomes
Possible effect of Other group
Outcome variable high integration effects („nominal‟ Other team effects
(vs. low) and „network‟)
Risk of mental Network team
health inpatient Higher risk (x5) resembling high
admission integration (x4)
Higher risk and Network team
Time to inpatient
slightly later resembling high
admission
(timing) integration
Much higher risk
Risk of care home
in one team only
admission
(high integration)
Quality of life No systematic group effects, but one team (low integration)
score scoring consistently above average and another (also low
integration) scoring consistently below average
Satisfaction with
services/key
But: sample size was limited!
worker
PSSRU
Personal Social Services Research Unit
at the University of Manchester

22. Findings II: service receipt and costs
Possible effect of Other group
Outcome variable high integration effects („nominal‟ Other team effects
(vs. low) and „network‟)
Higher Both have higher
Cost of community
expenditure expenditure
MH support
(+80%) (+50%)
More likely to
Care package
receive (x1.6);
receipt
lower needs!
Conditional upon receipt, no systematic differences; but
Cost of social care
high integration teams reach more service users (hence
packages
higher total expenditure)
Higher Both have higher
Total service cost expenditure expenditure
(+50%) (+50%)
PSSRU
Personal Social Services Research Unit
at the University of Manchester

23. Findings III: Exploring the impact of integration on staff outcomes
Satisfaction
Measures Intention to quit
Job characteristics related to stress
(autonomy, demands, control)
Postal survey Face-to-face interviews
Data
N=295 (n=42)
PSSRU
Personal Social Services Research Unit
at the University of Manchester

24. Findings III: Exploring the impact of integration on staff outcomes
Poorer outcomes in integrated teams
Survey data
But mainly due to social work membership
and greater job insecurity
Being managed by different profession
reduced outcomes (tested on nurses only)
Evidence of mix of Outweighed by
Interview data social worker frustrations of working in
dis/satisfaction non-integrated team
PSSRU
Personal Social Services Research Unit
at the University of Manchester

25. Conclusions and other observations
Findings I:
• Non-integrated teams have to work harder to implement good practice
(not supported by structures)
• But: other types of integration (setting/sector) are equally important
Findings II:
• Integrated services associated with more service use whilst not
preventing acute inpatient and care home admissions relative to low
integration teams
• But: methodological and data limitations confound the findings
Findings III:
• Lack of clear evidence that integration either improves or reduces staff
outcomes
• Interestingly: support workers have more positive outcomes in both
team types
PSSRU
Personal Social Services Research Unit
at the University of Manchester