Wexford/Waterford Mental Health Services:
Steve Lamb S.C.A.N Project Nurse
Suicide Crisis Assessment Nurse
Why SUICIDAL BEHAVIOURS? THE SCALE OF THE PROBLEM?
• According to WHO
around one million
people worldwide
currently die by suicide
each year and 10 to 20
times more attempt
suicide.
This represents on
average:
one suicide death every
40 seconds and
one attempt every 3
seconds
(WHO 1999).
Impact of Suicides:
‘Suicide is without doubt one of the saddest
events in human experience.
It leaves devastation in its wake as
relatives, friends and communities
struggle with feelings of shock, loss &
and rejection’
[Mary McAleese – President of Ireland 2005
[Extract of speech @ Forum for integration & partnership for Suicide Prevention]
S.C.A.N
Why Primary Care/GP services?
‘Primary care is the first point of contact that people have with health and personal social
services. Primary care is the appropriate care setting for 90-95 per cent of all health and social
service needs’
Primary Care: A New Direction DoHC 2001 p7.
‘In Ireland the vast majority (79%) see their family doctor/GP as their first point of
professional contact if they thought they had a mental health problem’
Mental Health in Ireland – Awareness & Attitudes. 2007 p 24 HSE. Dublin
‘Over 75% of suicide descendents had contact with Primary Care service providers in the year
before their death’
Luoma et al 2002
‘The Irish public identify suicide, alcoholism & depression as the most important mental health
related problems which require to be acted upon ‘
Mental Health in Ireland – Awareness & Attitudes. 2007 p 24 HSE. Dublin
S.C.A.N – Policy and Strategy
REACH OUT: Action Points 11.1 to 11.4
Recognise the unique opportunity for
primary care to be pro-active in matters of
early diagnosis, intervention, treatment and
enhanced suicide prevention for those
experiencing personal crises and distress.
S.C.A.N – The Project.
• Suicide Crisis Assessment Nurse
(SCAN)
Pilot Project intentions:
•
•
Development and deliver a ‘fast
track’ priority referral system from
primary care to community support
resources and/or community based
mental health services for individuals
experiencing a suicidal crisis, who
contact primary care services (GP) in
the Pilot locales.
SCAN Sites:
1. Dublin Cluain Mhuire (Urban)
2. Wexford (Rural).
•
•
Suicide Crisis Assessment
Nurse (SCAN)
The Research & Evaluation
intent:
To evaluate (quantitative and
qualitative outcomes) of the
introduction of the fast track
priority referral and
assessment system for
individuals experiencing a
suicidal crisis who contact
their GP/Primary Care Team.
Note: Project supported and
funded by the National Office
for Suicide Prevention
[NOSP: Reach Out Strategy]
So what is S.C.A.N. ?
SCAN is: New primary care approach to the assessment and care management for those
in suicide crisis.
SCAN Projects sought to :-Establish an expert mental health nursing resource that WOULD:
1.
Be available, accessible and speedy in providing a response to GP’s requests
for a timely assessment of those in DSH/Suicide Crisis
2.
Carry out a comprehensive (bio-psycho-social) needs & risk assessment of
the client within the GP surgery. (Ref: NICE 2004 & RCP 2010)
3.
Work collaboratively in partnership with the GP [& the wider specialist specialist
psychiatric services]– to institute a health/social care plan to meet the risks
and care needs of the client
SCAN POSTER
SCAN Wexford
- accomplishments
An Action Research Project
phased …from: Pilot Project to a Local Integrated Mental Health Service
Phase 1: SCAN: 2008
‘Preparation & research phase’
Actions: Pilot of SCAN estd - 1. MDT steering group estd- 2operational guidelines agreed 3 NOSP SLA, approval & support - and partnership approach with Cluain Mhuire agreed. 5GRASP
SCAN Operational Phase 1:
Piloted SCAN service within Wexford South sector ONLY (circa 70k pop.)
SCAN available: Mon – Fri to 20 GP Practices.
Nurse 1.0. wte (Project & Clinical Nurse)
_______________________________________________________________
Phase 2: SCAN: 2009 – 2010
‘Reflective and ‘going forward’ phase’
Reflections: Steering Group reflect upon low referrals rate (39 ref in 8 months) vs high
percentage uptake by GP’s (90% of GP’s utilised the service) + plus anecdotal positive feed
back from GP’s/Service Users.
SCAN Operational Phase 2:
SCAN operational across ALL Wexford North & South Locales (circa 130k pop.)
SCAN available:
Mon- Fri to 38 GP Practices.
Nurse resource 1.7. wte (Clinical Nurses).
SCAN Wexford - accomplishments:
A Phased Action Research Project
…from: Pilot Project to a Local Integrated Mental Health Service
Phase 3: SCAN 2010-to- presently: ‘Consolidation and evaluation phase’
SCAN Ongoing Operational Phase 3:
ACTIONS:
SCAN remains operational across BOTH Wexford North & South (circa 145k pop.)
Nurse resource 2.2. wte. (SCAN Nurses + Locum cover).
___________
In addition, SCAN Nurses further ‘integrated’ with the WGH Liaison Services enabling
the provision of:
- A clinically expanded (wider Liaison role) 7 day Wexford General LMHN service
- A SCAN/Liaison inter service acute hospital liaison cover rota
- Weekly case work/clinical supervision session with Consultant Psychiatrist/ADON.
- SCAN integrated with Locality CMHT’s operations & practice.
SCAN pilot projects accomplishments 2007-2012:
•
SCAN was made available to over 100
GP practices across South County
Dublin (population 180k) and County
Wexford (population 126k).
•
Over 90% GP’s used and re-used the
SCAN service.
•
Throughout the project period circa 660
people in self-harm / suicide distress
were seen and assessed by the SCAN
Nurse.
•
All client referrals were responded to in
a speedy/efficient manner and largely
all clients were seen and assessed
within the their own GP surgery,
reducing stigma, increasing uptake
(circa 3% failure to attend rate) and
achieving a GP/SCAN ‘shared care’
approach.
•
Identified client needs were met
through diverse statutory and
community care pathways of mental
health services, local counselling
services and locality social care
networks.
•
Psychiatric admission for those in
suicide crisis was significantly reduced
(admission rate to acute psychiatry inpatient services from a SCAN Nurse
assessment of less than 5%) and just
40% of SCAN assessed clients were
referred onto locality CMHT’s.
•
The majority of ‘next care’
management plans of SCAN assessed
clients involved the utilisation of
alternate primary care supports,
community counselling and voluntary
community care services.
SCAN Winner of the 2009 Aramark
Healthcare Professional Innovation
Award.
SCAN pilot projects accomplishments 2007-2012:
SCAN pilot project provider sites reflected that:
• SCAN is an effective and efficient solution to a long-standing
CMHT/Primary Care service gap.
• SCAN was seen to provide appropriate speedy response to those in selfharm/suicide distress.
• SCAN reduced clinical care inter-service acrimony and improved upon
service user and GP care response satisfaction ratings*.
• SCAN improved upon ‘needs led’ referrals to psychiatric services and other
community care agencies.
Research Evaluation
of the
Suicide Crisis
Assessment
Nurse (SCAN) Service
http://www.nosp.ie/scan-report-2012.pdf
SCAN EVALUATION Wexford & Cluain Mhuire:
•
•
Dr Stephen Bradley Lead Researcher
School of Nursing and Midwifery, NUIG.
Dr Brendan Kennelly Health Economist, NUIG
Evaluation Methods / Respondents
Qualitative:
•
Interview cohorts :
1.
former SCAN clients (face-to-face;
n=12)
2.
current and former SCAN nurses
(face-to-face; n=6),
3.
GPs with experience of utilising the
SCAN service (telephone; n=14).
Quantitative:
•
SCAN GPs and Non-SCAN GPs
of the 257 GPs invited, 127 completed
the questionnaire yielding a response
rate of 49.4%
•
Documentary Analysis of SCAN
records
•
Economic analysis utilising decisiontree modelling
Focus Groups cohorts:
1.
2.
SCAN CMHTs (face-to-face; n=5
teams (Wexford/Cluain Mhuire).
One non SCAN (TAU service) An
additional x1 face-to-face focus
group with a CMHT from an area
with no experience of a SCAN
service, so as to explore ‘usual
care’; On-line Questionnaire –
‘Skip logic’ – 46 items
SCAN Evaluation Outcomes
The NUIG focused literature review concluded
that:
A service like SCAN provides a fast-track referral system
to mental health services, supports the development of a
therapeutic alliance between healthcare professionals and
clients, represents a personalized approach to care, is
based in the community and fosters a collaborative
approach to care.
SCAN Evaluation Outcomes
– Without SCAN, all professionals recognised that
referral and/or admission to mental health services
was often a ‘default’ position, with the de facto
development of a possibly inappropriate
psychiatric history:
• Cluain Mhuire: 63% ‘social issues’ (n=159)
• Wexford: 62% ‘social issues’ (n=503)
“Before, I think we often as GPs felt we had very little resources other
than using a sledgehammer to crack a nut which was basically admit
patients’’ (DR06)
SCAN Evaluation Outcomes
Clinicians were frustrated by the delays and
uncertainty that regularly accompanied the
process of referral/admission:
“it would have involved a huge amount of telephoning and
not being able to get hold of people… the service… really
wasn’t very good for this sort of patient. It was very bad
actually and trying to get urgent appointments was a
complete disaster” (DR04)
SCAN Evaluation Outcomes
• As well as a gateway role, SCAN was found to have a therapeutic
value that was identified as pivotal by clients; apparently contributing
to the perception that they were being ‘taken seriously’:
“It was a very positive experience. It was emotional but she
helped me a lot. She helped me to say things, made me feel
comfortable enough to say things even though I'd never
met her before that “(CL08)
“I think it’s very therapeutic in itself… it’s not just the SCAN
nurse kind of gleaning the bits of information from them
and trying to assess their risk. I mean, it’s also quite
therapeutic… free of charge which is important for people
(DR01)”
SCAN was seen as accessible, efficient and prompt in responding to
referrals and undertaking timely assessment of those patients in suicide crisis
•
‘we always found it
fantastic in that… we
would just have numbers
that we could phone
directly… if the nurse
wasn’t available
immediately they would
always get back to us very
quickly’ (GP)
• ‘I couldn’t believe how quick it
all happened. I think the
response time was brilliant … I
think the response time is a
major factor in it’ (Service
User)
SCAN Evaluation Outcomes
• GPs interviewed described the support provided
by SCAN, both overt in terms of assessment / intervention and
‘hidden’ in terms of informal advice, as ‘empowering’:
“it empowered me to deal with suicide
and intervention of suicide crisis… I can
now feel as a GP I have resources to
deal with crisis and suicide crisis or the
expression of suicide ideation and it just
has revolutionised my management… (DR06)
SCAN Evaluation Outcomes
• Overall, GPs with access to SCAN services rated the service
significantly higher on its impact on identified patient
outcomes than those who had access to traditional mental
health services.
‘the provision of [a SCAN] service to people who
are acutely upset and who have declared that
they might actually harm themselves, has made
the management of that particular group of
patients much easier and much more satisfactory’
(GP)
Outcomes
GPs who had access to a SCAN service rated their overall
satisfaction with the service as significantly higher than those GPs
in the non-SCAN group:
GP's satisfaction with Mental Health
service (n= 57)
1.5%
1.5%
Extremely
satisfied
Satisfied
21.7%
34.8%
Neutral
Dissatisfied
40.6%
Extremely
disatisfied
Economic Analysis
• The effectiveness of programmes such as SCAN is
difficult to capture using traditional quantitative
economics or health services research methods
Under reasonable assumptions about the size of
effect, the SCAN service resulted in a reduction of
healthcare costs.
SCAN service would pay for itself if it resulted in 23
fewer people being admitted for an average ‘in
patient’ stay.
SCAN Evaluation Outcomes a final reflection
SCAN FORMER CLIENT:
‘I know for me it [SCAN] has been wonderful and
the help that I did get, it really brought me out. It
carried me over that period. I needed the help. ..
without that help, I don't know where I would be
today. I mightn't be sitting here talking to you’
SCAN in Summary:
SCAN: The aim:
• SCAN pilot projects were established to explore a primary care/community
mental health partnership response to adult primary care clients presenting
to their GP with self harm / suicide distress.
SCAN: The accomplishments (Subjective & Objective):
• SCAN has demonstrated that a client centred, rapid primary care focussed
response service to self-harm/suicide crisis clients is functional and
beneficial for those individuals in self-harm/suicide distress who present to
their GP.
Furthermore, outcomes indicate that similar SCAN services can be
introduced across Irish primary care/mental health healthcare systems to
the benefit of clients, GPs and psychiatric care providers.
SCAN – Post Pilot Projects & Research
Evaluation What Next?
= SCAN ‘Roll-Out’:
- NOSP achieved 2013 funding to support the roll-out of a
further circa 8 SCAN Services within new Mental Health
Locales across Ireland.
- In addition; Going forward, NOSP will seek future
budgetary allocation to support the provision of SCAN a
service within each Mental Health Locale across Ireland.
SCAN
•QUESTIONS?