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Out-of-area placements in acute mental health care: the outcomes
Abstract
Out‐of‐area placements (OAPs) are heavily relied upon by the NHS to meet growing demand but they are expensive, disruptive for patients, and may reduce quality of care and outcomes for patients. Here, the authors compared 50 patients who used acute OAPs with 50 patients admitted to an acute bed locally as regards length of stay, readmission rates, contact with services and levels of self‐harm in the following 12 months. The results were substantially worse in key respects for patients who go to OAPs, raising further questions about their quality and the economic impact to the NHS.
... As of September 2019, the National Health Service (NHS) spent 11.3 million (NHS Digital 2019) on out-of-area placements, which, an outcomes study found, when compared to patients admitted locally, -OAPs are expensive, inefficient, distressing for patients, and may increase risk. We found that there were significantly increased lengths of stay, more subsequent contacts with services, and more self-harm in this group‖ (Galante et al. 2019).The study concludes that -The results were substantially worse in key respects for patients who go to OAPs, raising further questions about their quality and the economic impact to the NHS‖ (Galante et al. 2019). ...
... As of September 2019, the National Health Service (NHS) spent 11.3 million (NHS Digital 2019) on out-of-area placements, which, an outcomes study found, when compared to patients admitted locally, -OAPs are expensive, inefficient, distressing for patients, and may increase risk. We found that there were significantly increased lengths of stay, more subsequent contacts with services, and more self-harm in this group‖ (Galante et al. 2019).The study concludes that -The results were substantially worse in key respects for patients who go to OAPs, raising further questions about their quality and the economic impact to the NHS‖ (Galante et al. 2019). ...
Schizophrenia is a relapsing disease. Repeated relapses have detrimental effects on the patient and strains care delivery. Non-compliance with medication is the most common reason for relapse. This questionnaire-based study surveyed the knowledge and attitudes of all groups of staff towards relapse prevention within a single organisation. It finds significant deficits in knowledge, with variations across different classes of care professionals. There was limited evidence of long-term planning and analysis of the evolving risk of relapse due to non-compliance over time These knowledge deficits are associated with negative cognitive constructs about evidence-basedtreatment options such as the use of Long-Acting Antipsychotics (LAI's) to minimise the risk of relapse. These attitudes mediate compromised clinical decision making that could be contributing to sub-optimal care delivery. Given the crisis in care delivery affecting psychiatric services, the study calls for education of patients, carers and staff regarding the evidence-based therapeutic options available to anticipate manage and minimise the incidence of relapse in schizophrenia.
... There are growing concerns about the impact of out-of-area placements on mental health service users, both clinically and financially [5]. In addition to being costly to the NHS and local social care authorities, individuals placed out-of-area can become socially dislocated, achieve poorer outcomes [6], experience disruptions to their lives [7] and in some cases, be over-supported [5]. The issue of distance can also cause complications for the 'home' services who made the referral, which are services generally provided in the locality of a patient's home, as it can be difficult to maintain contact regarding the suitability of the placement and the person's care, which can also hinder their rehabilitation and eventual reintegration into their home community [4,8]. ...
Background:
Mental health services for adults, as they are currently configured, have been designed to provide predominantly community-based interventions. It has long been recognised that some patients have such significant clinical and/or risk needs that those needs cannot be adequately met within standard service delivery models, resulting in a pressing need to consider the best models for this group of people. This paper shares a protocol for a mixed methods study that aims to understand: the profile and history of service users described as having complex needs; the decision-making processes by clinicians that lead to complex needs categorisation; service users and carers experience of service use; and, associated economic impact. This protocol describes a comprehensive evaluation that aims to inform an evidence-based service delivery model for people with complex needs.
Methods:
We will use a mixed methods design, combining quantitative and qualitative methods using in-depth descriptive and inferential analysis of patient records, written medical notes and in-depth interviews with service users, carers, and clinicians. The study will include five components: (1) a quantitative description and analysis of the demographic clinical characteristics of the patient group; (2) an economic evaluation of alternative patient pathways; (3) semi-structured interviews about service user and carer experiences; (4) using data from components 1-3 to co-produce vignettes jointly with relevant stakeholders involved in the care of service users with complex mental health needs; and, (5) semi-structured interviews about clinical decision-making by clinicians in relation to this patient group, using the vignettes as example case studies.
Discussion:
The study's key outcomes will be to: examine the resource use and cost-impact associated with alternative care pathways to the NHS and other sectors of the economy (including social care); explore patient health and non-health outcomes associated with alternative care pathways; and, gain an understanding of a complex service user group and how treatment decisions are made to inform consistent and person-centred future service delivery.
... There are growing concerns about the impact of out-of-area placements on mental health service users, both clinically and financially (5). In addition to being costly to the NHS and local social care authorities, individuals placed out-of-area can become socially dislocated, achieve poorer outcomes (6), experience disruptions to their lives (7) and in some cases, be over-supported (5). The issue of distance can also cause complications for the 'home' services who made the referral, which are services generally provided in the locality of a patient's home, as it can be difficult to maintain contact regarding the suitability of the placement and the person's care, which can also hinder their rehabilitation and eventual reintegration into their home community (4,8). ...
Background
Mental health services for adults, as they are currently configured, have been designed to provide predominantly community-based interventions. It has long been recognised that some patients have such significant clinical and/or risk needs that those needs cannot be adequately met within standard service delivery models, resulting in a pressing need to consider the best models for this group of people. This paper shares a protocol for a mixed methods study that aims to understand: the profile and history of service users described as having complex needs; the decision-making processes by clinicians that lead to complex needs categorisation; service users and carers experience of service use; and, associated economic impact. This protocol describes a comprehensive evaluation that aims to inform an evidence-based service delivery model for people with complex needs.
Methods
We will use a mixed methods design, combining quantitative and qualitative methods using in-depth descriptive and inferential analysis of patient records, written medical notes and in-depth interviews with service users, carers, and clinicians. The study will include five components: (1) a quantitative description and analysis of the demographic clinical characteristics of the patient group; (2) an economic evaluation of alternative patient pathways; (3) semi-structured interviews about service user and carer experiences; (4) using data from components 1-3 to co-produce vignettes jointly with relevant stakeholders involved in the care of service users with complex mental health needs; and, (5) semi-structured interviews about clinical decision-making by clinicians in relation to this patient group, using the vignettes as example case studies.
Discussion
The studys key outcomes will be to: examine the resource use and cost-impact associated with alternative care pathways to the NHS and other sectors of the economy (including social care); explore patient health and non-health outcomes associated with alternative care pathways; and, gain an understanding of a complex service user group and how treatment decisions are made to inform consistent and person-centred future service delivery.
... Out of area admissions have already been shown to increase length of stay [18] and our findings support this conclusion. Additionally, within-Trust continuity of care appears to be an important factor in length of stay. ...
Background:
The NHS Mental Health Implementation Plan aims to reduce length of inpatient psychiatric stays to a maximum of 32 days, yet provides little guidance on how to achieve this. Previous studies have attempted to analyse factors influencing length of stay in mental health units, focussing mostly on patient factors. These models fail to sufficiently explain the variation in duration of inpatient stay. We assess how the type of service delivered by a trust, in addition to patient factors, influences length of stay.
Methods:
We conducted a retrospective case cohort study in a large inner-city NHS mental health trust for all admissions in a 1 month period. Data was gathered from electronic notes of 105 patients. Descriptive univariate and bivariate analyses were conducted on the data, with multiple regression analysis conducted on statistically significant data.
Results:
Short-stay assessment ward admission significantly reduced length of stay. Patients under outpatients or under care co-ordination, admitted through Mental Health Act assessment and formally detained all had longer length of stay. Out of area admissions, locum Consultant care, changing Responsible Clinician and ward transfers all led to longer length of stay. Factors indicating more severe illness such as increased observation level and polypharmacy, as well as diagnoses of psychosis or bipolar disorder were associated with longer duration of stay. Discharges requiring referral to accommodation or rehabilitation led to longer stays. The most significant factors that influenced length of stay were higher observation levels, diagnosis of psychotic illness or bipolar, and discharge to rehabilitation placement. The final model, taking into account all these factors, was able to account for 59.6% of the variability in length of stay.
Conclusions:
The study backs up existing literature which shows patient-factors have an influence on length of stay. The study also demonstrates that service-level factors have an impact on the duration of stay. This data may be used to inform further studies which may aid provision of inpatient and community services in the future.
... Out of area admissions have already been shown to increase length of stay [16] and our ndings support this conclusion. Additionally, within-Trust continuity of care appears to be an important factor in length of stay. ...
Background: The NHS Mental Health Implementation Plan aims to reduce length of inpatient psychiatric stays to a maximum of 32 days, yet provides little guidance on how to achieve this.
Previous studies have attempted to analyse factors influencing length of stay in mental health units, focussing mostly on patient factors. These models fail to sufficiently explain the variation in duration of inpatient stay. We assess how the type of service delivered by a trust, in addition to patient factors, influences length of stay.
Methods: We conducted a retrospective case cohort study in a large inner-city NHS mental health trust for all admissions in a one month period. Data was gathered from electronic notes of 105 patients. Descriptive univariate and bivariate analyses were conducted on the data, with multiple regression analysis conducted on statistically significant data.
Results: Short-stay assessment ward admission significantly reduced length of stay. Patients under outpatients or under care co-ordination, admitted through Mental Health Act assessment and formally detained all had longer length of stay. Out of area admissions, locum Consultant care, changing Responsible Clinician and ward transfers all led to longer length of stay. Factors indicating more severe illness such as increased observation level and polypharmacy, as well as diagnoses of psychosis or bipolar disorder were associated with longer duration of stay. Discharges requiring referral to accommodation or rehabilitation led to longer stays. The most significant factors that influenced length of stay were higher observation levels, diagnosis of psychotic illness or bipolar, and discharge to rehabilitation placement. The final model, taking into account all these factors, was able to account for 59.6% of the variability in length of stay.
Conclusions: The study backs up existing literature which shows patient-factors have an influence on length of stay. The study also demonstrates that service-level factors have an impact on the duration of stay. This data may be used to inform further studies which may aid provision of inpatient and community services in the future.
... Out of area admissions have already been shown to increase length of stay [16] and our ndings support this conclusion. Additionally, within-Trust continuity of care appears to be an important factor in length of stay. ...
Background:
Despite the focus on community-based care, demand for inpatient psychiatric care still remains high. Trusts strive for safe, efficient patient throughput with reduced length of stay.
Previous studies have attempted to analyse factors influencing length of stay in mental health units, focussing mostly on patient factors. These models fail to sufficiently explain the variation in duration of inpatient stay. We assess how the type of service delivered by a trust, in addition to patient factors, influences length of stay.
Methods:
We conducted a retrospective case cohort study in a large inner-city NHS mental health trust for all admissions in a one month period. Data was gathered from electronic notes of 105 patients and analysed using IBM SPSS version 26. Descriptive univariate and bivariate analyses were conducted on the data, with multiple regression analysis conducted on statistically significant data.
Results:
Short-stay assessment ward admission significantly reduced length of stay. Patients under outpatients or under care co-ordination, admitted through Mental Health Act assessment and formally detained all had longer length of stay. Out of area admissions, locum Consultant care, changing Responsible Clinician and ward transfers all led to longer length of stay. Factors indicating more severe illness such as increased observation level and polypharmacy, as well as diagnoses of psychosis or bipolar disorder were associated with longer duration of stay. Discharges requiring referral to accommodation or rehabilitation led to longer stays. The most significant factors that influenced length of stay were higher observation levels, diagnosis of psychotic illness or bipolar, and discharge to rehabilitation placement.
The final model, taking into account all these factors, was able to account for 59.6% of the variability in length of stay.
Conclusions:
The study backs up existing literature which shows patient-factors have an influence on length of stay. The study also demonstrates that service-level factors have an impact on the duration of stay. This data may be used to inform further studies which may aid provision of inpatient and community services in the future.
... Mental health services nationally have already suffered under austerity (Reeves et al., 2013), as has the wider social care safety net. In many places, care has not been what it used to be or should be for some time, with excessively long waits (especially for psychological therapy) and the regular shipping of acutely unwell patients, including children, around the country due to bed shortages (Galante et al., 2019). Given this backdrop, it is of real concern that mental health services have been partially stepped down over recent weeks, leading to growing waiting lists. ...
... It is known that patient outcomes when admitted out of area are significantly worse than for those admitted locally. 2 The Five Year Forward plan, however, set targets without acknowledging that many mental health trusts were already 'under-bedded' in relation to their population size and level of social adversity and under-resourced in terms of community provision. Also, critical indicators for admission/discharge and estimated discharge dates were being underutilised by crisis teams and ward staff, leading to unnecessarily prolonged in-patient stays. ...
Aims and method
In three localities in a mental health trust in England, an enhanced bed management team was established to improve patient flow and reduce out-of-area placements. Trusted assessments were provided to support risk management and conflict resolution. Two measures of flow were compared before and after the team was established.
Results
The trusted assessment recommendation was for discharge in 70% of cases. The number of out-of-area placements was significantly reduced ( P < 0.05), saving £616 876 over a 12-month period. Patient flow was significantly improved in one of the three localities as measured by patients/bed/6-month period ( P < 0.05). In one of the other localities increased use of trusted assessment input and reduced numbers of patients being transferred in are recommended to improve flow.
Clinical implications
Mental health trusts should consider the establishment of an enhanced bed management team, including trusted assessment, as a safe and cost-effective approach to improving patient flow and reducing the need for out-of-area placement.
Background:
Transferring individuals for treatment outside their geographic area occurs when healthcare demand exceeds local supply. This can result in significant financial cost while impacting patient outcomes and experience.
Aims:
The aim of this study was to assess initiatives to reduce psychiatric intensive care unit (PICU) out-of-area bed placements within a major healthcare system in South West England.
Methods:
Discrete event computer simulation was used to model patient flow across the healthcare system's three PICUs. A scenario analysis was performed to estimate the impact of management plans to decrease admissions and length of stay. The amount of capacity required to minimise total cost was also considered.
Results:
Without increasing in-area capacity, mean out-of-area bed requirement can be reduced by 25.6% and 19.1% respectively through plausible initiatives to decrease admissions and length of stay. Reductions of 34.7% are possible if both initiatives are employed. Adjusting the in-area bed capacity can also lead to aggregate cost savings.
Conclusions:
This study supports the likely effectiveness of particular initiatives in reducing out-of-area placements for high-acuity bedded psychiatric care. This study also demonstrates the value of computer simulation in an area that has seen little such attention to date.
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