Improving Multidisciplinary Team Working to Support Integrated Care for People with Frailty Amidst the COVID-19 Pandemic.

Multidisciplinary team (MDT) working is essential to optimise and integrate services for people who are frail. MDTs require collaboration. Many health and social care professionals have not received formal training in collaborative working. This study investigated MDT training designed to help participants deliver integrated care for frail individuals during the Covid-19 pandemic. Researchers utilised a semi-structured analytical framework to support observations of the training sessions and analyse the results of two surveys designed to assess the training process and its impact on participants knowledge and skills. 115 participants from 5 Primary Care Networks in London attended the training. Trainers utilised a video of a patient pathway, encouraged discussion of it, and demonstrated the use of evidence-based tools for patient needs assessment and care planning. Participants were encouraged to critique the patient pathway, reflect on their own experiences of planning and providing patient care. 38% of participants completed a pre-training survey, 47% a post-training survey. Significant improvement in knowledge and skills were reported including understanding roles in contributing to MDT working, confidence to speak in MDT meetings, using a range of evidence-based clinical tools for comprehensive assessment and care planning. Greater levels of autonomy, resilience, and support for MDT working were reported. Training proved effective; it could be scaled up and adopted to other settings.

Evaluating the implementation and impact of a new model of care for integrating children and young people's acute mental healthcare in a paediatric setting: a protocol for a realist, mixed-methods approach.

INTRODUCTION: The mental health of children and young people in the UK has been declining and has continued to worsen throughout the pandemic, leading to an increase in mental health-related emergencies. In response, the Best for You programme was developed as a new service designed to integrate mental healthcare for children and young people between acute hospital and community services. The programme is comprised of four new services: a rapid assessment young people's centre with dual-trained staff, a co-located day service offering family-based care,a digital hub, designed to integrate with the fourth element of the model, namely community support and mental health services. This evaluation protocol aims to assess the development, implementation and outcomes of the Best for You programme and develops a scalable model that could be implemented in other parts of the National Health Service (NHS). METHODS AND ANALYSIS: This mixed-methods realist evaluation aims to delineate the components of the system to assess their interdependent relationships within a wider context. Data collection will include interviews, participant observations, focus groups and the collection of local quantitative healthcare data. The research will be conducted across four phases. Phase 1-captures the development of the underlying programme theory. Phase 2-a process evaluation testing the programme theory. Phase 3- an outcome and economic evaluation. Phase 4-consolidation of learning from phases 1-3 to identify barriers, facilitators and wider contextual factors that have shaped implementation drawing on the Consolidated Framework for Implementation Research. ETHICS AND DISSEMINATION: Ethical approval for the evaluation was received from the NHS local ethics committee. Embedded within the evaluation is a formative review to feedback and share learning with stakeholders to scale-up the programme. Findings from this study will be disseminated in peer-reviewed journals as well as presentations to be useful to service user organisations and networks.

Models of integrated care for young people experiencing medical emergencies related to mental illness: a realist systematic review.

Mental illness heightens risk of medical emergencies, emergency hospitalisation, and readmissions. Innovations for integrated medical-psychiatric care within paediatric emergency settings may help adolescents with acute mental disorders to get well quicker and stay well enough to remain out of hospital. We assessed models of integrated acute care for adolescents experiencing medical emergencies related to mental illness (MHR). We conducted a systematic review by searching MEDLINE, PsychINFO, Embase, and Web of Science for quantitative studies within paediatric emergency medicine, internationally. We included populations aged 8-25 years. Our outcomes were length of hospital stay (LOS), emergency hospital admissions, and rehospitalisation. Limits were imposed on dates: 1990 to June 2021. We present a narrative synthesis. This study is registered on PROSPERO: 254,359. 1667 studies were screened, 22 met eligibility, comprising 39,346 patients. Emergency triage innovations reduced admissions between 4 and 16%, including multidisciplinary staffing and training for psychiatric assessment (F(3,42) = 4.6, P < 0.05, N = 682), and telepsychiatry consultations (aOR = 0.41, 95% CI 0.28-0.58; P < 0.001, N = 597). Psychological therapies delivered in emergency departments reduced admissions 8-40%, including psychoeducation (aOR = 0.35, 95% CI 0.17-0.71, P < 0.01, N = 212), risk-reduction counselling for suicide prevention (OR = 2.78, 95% CI 0.55-14.10, N = 348), and telephone follow-up (OR = 0.45, 95% CI 0.33-0.60, P < 0.001, N = 980). Innovations on acute wards reduced readmissions, including guided meal supervision for eating disorders (P = 0.27), therapeutic skills for anxiety disorders, and a dedicated psychiatric crisis unit (22.2 vs 8.5% (P = 0.008). Integrated pathway innovations reduced readmissions between 8 and 37% including family-based therapy (FBT) for eating disorders (X2(1,326) = 8.40, P = 0.004, N = 326), and risk-targeted telephone follow-up or outpatients for all mental disorders (29.5 vs. 5%, P = 0.03, N = 1316). Studies occurred in the USA, Canada, or Australia. Integrated care pathways to psychiatric consultations, psychological therapies, and multidisciplinary follow-up within emergency paediatric services prevented lengthy and repeat hospitalisation for MHR emergencies. Only six of 22 studies adjusted for illness severity and clinical history between before- and after-intervention cohorts and only one reported socio-demographic intervention effects.

A Systematic Review of Interventions that Use Multidisciplinary Team Meetings to Manage Multimorbidity in Primary Care.

Introduction: Multidisciplinary team (MDT) meetings could facilitate coordination of care for individuals living with multimorbidity, yet there is limited evidence on their effectiveness. We hence explored the common characteristics of MDT meetings in primary care and assessed the effectiveness of interventions that include such meetings, designed to improve outcomes for adults living with multimorbidity. Methods: A systematic review of literature was conducted using MEDLINE and EMBASE. A narrative synthesis was performed, extracting study and MDT meeting characteristics, in addition to any outcomes reported. Results: Four randomised controlled trials that were conducted in the United States of America were identified as eligible, recruiting a total of 3,509 adults living with multimorbidity. Common MDT meeting themes include regular frequency of discussion, the absence of patient involvement and the participation of three or four multiprofessionals. Significant improvements were observed in response to interventions with an MDT component across most measures, yet this trend did not extend to physical health outcomes. Discussion: It is unclear if the results in this review are sufficient to support the widespread implementation of MDT meetings in primary care, for adults living with multimorbidity. Due to the paucity of studies collated, further research is required to inform widespread implementation.

Conceptualising interventions to enhance spread in complex systems: a multisite comprehensive medication review case study.

BACKGROUND: Advancing the description and conceptualisation of interventions in complex systems is necessary to support spread, evaluation, attribution and reproducibility. Improvement teams can provide unique insight into how interventions are operationalised in practice. Capturing this 'insider knowledge' has the potential to enhance intervention descriptions. OBJECTIVES: This exploratory study investigated the spread of a comprehensive medication review (CMR) intervention to (1) describe the work required from the improvement team perspective, (2) identify what stays the same and what changes between the different sites and why, and (3) critically appraise the 'hard core' and 'soft periphery' (HC/SP) construct as a way of conceptualising interventions. DESIGN: A prospective case study of a CMR initiative across five sites. Data collection included: observations, document analysis and semistructured interviews. A facilitated workshop triangulated findings and measured perceived effort invested in activities. A qualitative database was developed to conduct thematic analysis. RESULTS: Sites identified 16 intervention components. All were considered essential due to their interdependency. The function of components remained the same, but adaptations were made between and within sites. Components were categorised under four 'spheres of operation': Accessibility of evidence base; Process of enactment; Dependent processes and Dependent sociocultural issues. Participants reported most effort was invested on 'dependent sociocultural issues'. None of the existing HC/SP definitions fit well with the empirical data, with inconsistent classifications of components as HC or SP. CONCLUSIONS: This study advances the conceptualisation of interventions by explicitly considering how evidence-based practices are operationalised in complex systems. We propose a new conceptualisation of 'interventions-in-systems' which describes intervention components in relation to their: proximity to the evidence base; component interdependence; component function; component adaptation and effort.

Stratification of inflammatory bowel disease outpatients by disease activity and risk of complications to guide out-of-hospital monitoring: a patient-centred quality improvement project.

BACKGROUND: Inflammatory bowel disease (IBD) is a chronic relapsing-remitting condition affecting 600 000 people in the UK. Traditionally, patients attend outpatient clinics for monitoring regardless of their symptoms or risk of developing complications. This can lead to a mismatch between need and access: patients in remission given elective appointments displace those in need of urgent specialist attention. Novel initiatives implemented in the UK to improve outpatient monitoring have often required a well-maintained patient registry, empowered patients and significant information technology support. DESIGN AND STRATEGY: In this large-scale quality improvement project at St Mark's Hospital, a tertiary centre for IBD, we stratified over 1000 patients attending three non-complex IBD clinics over 12 months according to disease activity and risk profile. The aim was to offer a choice and subsequently transfer 50% of eligible patients to specialist nurse-led telephone clinics and demonstrate non-inferior satisfaction levels to existing outpatient follow-up. We also sought to ensure there was timely access to a newly established rapid access clinic for patients requiring urgent specialist attention.A core project team consisting of healthcare professionals, patients and quality improvement scientists met regularly. The team tested and scaled up interventions using 'Plan-Do-Study-Act' cycles within the 'Model for Improvement' framework and analysed data continuously using statistical process charts. RESULTS: Over 12 months, the average number of eligible patients transferred to telephone clinics rose from 17.6% (42/239) using a questionnaire method to 59.3% (73/123) using active discussion in clinic. Patient satisfaction scores remained high and non-inferior to baseline scores in face-to-face clinics. The median waiting time to be seen in the rapid access clinic was 6.5 days. CONCLUSION: This is the first published study to report on the successful stratification of patients with IBD based on disease activity and risk of complications to create a more responsive, sustainable and patient-centred model for IBD monitoring.

The role of patients and carers in diffusing a health-care innovation: A case study of "My Medication Passport".

BACKGROUND: Patients are increasingly recognized as playing important roles in improving health services. Little is known about the mechanisms by which patients develop and diffuse local innovations in a complex health-care system. OBJECTIVE: To ascertain how diffusion of an innovation, My Medication Passport, occurred and roles played by patients in it. DESIGN: Case study: quantitative mapping of innovation's diffusion and analysis of the routes and occupations of those through whom the innovation spread; documentary analysis; reflective assessment of patient's roles. SETTING AND PARTICIPANTS: NHS Trusts, third sector organizations, patients and health-care professionals. INTERVENTIONS STUDIED: Co-produced action to raise awareness and influence use of the innovation; order database which enabled ease of access to the innovation. MAIN OUTCOME MEASURES: Geographical spread of innovation; occupations of individuals; types of organizations using the innovation. RESULTS: The innovation spread from initial development and use in Northwest London across the UK and beyond. Key roles played by patients were as follows: co-producer; advocate; relationship builder; relationship broker; planner; presenter; awareness raiser; trainer; networker. Patients identified and introduced potential audiences and users to MMP, using social, organizational, sectoral, lay and professional networks to do so. They organized a range of awareness-raising and communication activities, monitored feedback, evaluated the impact and responded to new interest. DISCUSSION AND CONCLUSIONS: The roles of patients in diffusing innovations are under-recognized. Collaborative working between patients, carers and health-care professionals in planning and progressing the use and supporting diffusion of the innovation was important. Principles described in this study are relevant to progressing other patient-led ideas for innovative changes relating to health service development.

Evaluation of My Medication Passport: a patient-completed aide-memoire designed by patients, for patients, to help towards medicines optimisation.

OBJECTIVES: A passport-sized booklet, designed by patients for patients to record details about their medicines, has been developed as part of a wider project focusing on improving prescribing in the elderly ('ImPE'). We undertook an evaluation of 'My Medication Passport' to gain an understanding of its value to patients and how it may be used in communications about medicines. SETTING: The Passport was launched in secondary care with the initial users being older people discharged home after an admission to one of the four North West London participating Trusts. The uptake subsequently spread to other (community) locations and other age groups. PARTICIPANTS: We recruited more than 200 patients from a cohort who had been given a passport as part of the improvement projects at one of four sites. Of them, 63% (133) completed the structured telephone questionnaire including 27% for whom English was not their first language. Approximately half of the respondents were male and 40% were over 70 years of age. RESULTS: More than half of the respondents had found their medication passport useful or helpful in some way; 42% through sharing details from it with others (most frequently family, carer or doctor) or using it as a platform for conversations with healthcare professionals. One-third of those questioned carried the passport with them at all times. CONCLUSIONS: My Medication Passport has been positively evaluated; we have a better understanding of how it is used by patients, what they are recording and how it can be an aid to dialogue about medicines with family, carers and healthcare professionals. Further development and spread is underway including an App for smartphones that will be subject to wider evaluation to include feedback from clinicians.