Summary Background Individuals with a history of recurrent depression have a high risk of repeated depressive relapse or recurrence. Maintenance antidepressants for at least 2 years is the current ...recommended treatment, but many individuals are interested in alternatives to medication. Mindfulness-based cognitive therapy (MBCT) has been shown to reduce risk of relapse or recurrence compared with usual care, but has not yet been compared with maintenance antidepressant treatment in a definitive trial. We aimed to see whether MBCT with support to taper or discontinue antidepressant treatment (MBCT-TS) was superior to maintenance antidepressants for prevention of depressive relapse or recurrence over 24 months. Methods In this single-blind, parallel, group randomised controlled trial (PREVENT), we recruited adult patients with three or more previous major depressive episodes and on a therapeutic dose of maintenance antidepressants, from primary care general practices in urban and rural settings in the UK. Participants were randomly assigned to either MBCT-TS or maintenance antidepressants (in a 1:1 ratio) with a computer-generated random number sequence with stratification by centre and symptomatic status. Participants were aware of treatment allocation and research assessors were masked to treatment allocation. The primary outcome was time to relapse or recurrence of depression, with patients followed up at five separate intervals during the 24-month study period. The primary analysis was based on the principle of intention to treat. The trial is registered with Current Controlled Trials, ISRCTN26666654. Findings Between March 23, 2010, and Oct 21, 2011, we assessed 2188 participants for eligibility and recruited 424 patients from 95 general practices. 212 patients were randomly assigned to MBCT-TS and 212 to maintenance antidepressants. The time to relapse or recurrence of depression did not differ between MBCT-TS and maintenance antidepressants over 24 months (hazard ratio 0·89, 95% CI 0·67–1·18; p=0·43), nor did the number of serious adverse events. Five adverse events were reported, including two deaths, in each of the MBCT-TS and maintenance antidepressants groups. No adverse events were attributable to the interventions or the trial. Interpretation We found no evidence that MBCT-TS is superior to maintenance antidepressant treatment for the prevention of depressive relapse in individuals at risk for depressive relapse or recurrence. Both treatments were associated with enduring positive outcomes in terms of relapse or recurrence, residual depressive symptoms, and quality of life. Funding National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme, and NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula.
Abstract
Background
This study evaluates the effectiveness of a targeted telephone-based case management service that aimed to reduce ED attendance amongst frequent attenders, known to ...disproportionately contribute to demand. Evidence on the effectiveness of these services varies.
Methods
A 24-month controlled before-and-after study, following 808 patients (128 cases and 680 controls (41 were non-compliant)) who were offered the service in the first four months of operation within a UK ED department. Patients stratified as high-risk of reattending ED within 6 months by a predictive model were manually screened. Those positively reviewed were offered a non-clinical, nurse-led, telephone-based health coaching, consisting of care planning, coordination and goal setting for up to 9 months. Service effectiveness was estimated using a difference-in-differences (DiD) analysis. Incident rate of ED and Minor Injury Unit (MIU) attendances and average length of stay in intervention recipients and controls over 12 months after receiving their service offer following ED attendance were compared, adjusting for the prior 12-month period, sex and age, to give an incidence rate ratio (IRR).
Results
Intervention recipients were more likely to be female (63.3% versus 55.4%), younger (mean of 69 years versus 76 years), and have higher levels of ED activity (except for MIU) than controls. Mean rates fell between periods for all outcomes (except for MIU attendance). The Intention-to-Treat analysis indicated non-statistically significant effect of the intervention in reducing all outcomes, except for MIU attendances, with IRRs: ED attendances, 0.856 (95% CI: 0.631, 1.160); ED admissions, 0.871 (95% CI: 0.628, 1.208); length of stay for emergency and elective admissions: 0.844 (95% CI: 0.619, 1.151) and 0.781 (95% CI: 0.420, 1.454). MIU attendance increased with an IRR: 2.638 (95% CI: 1.041, 6.680).
Conclusions
Telephone-based health coaching appears to be effective in reducing ED attendances and admissions, with shorter lengths of stay, in intervention recipients over controls. Future studies need to capture outcomes beyond acute activity, and better understand how services like this provide added value.
Background
Although there is growing utilisation of intermediate care to improve the health and well-being of older adults with complex care needs, there is no international agreement on how it is ...defined, limiting comparability between studies and reducing the ability to scale effective interventions.
Aim
To identify and define the characteristics of intermediate care models.
Methods
A scoping review, a modified two-round electronic Delphi study involving 27 multi-professional experts from 13 countries, and a virtual consensus meeting were conducted.
Results
Sixty-six records were included in the scoping review, which identified four main themes: transitions, components, benefits and interchangeability. These formed the basis of the first round of the Delphi survey. After Round 2, 16 statements were agreed, refined and collapsed further. Consensus was established for 10 statements addressing the definitions, purpose, target populations, approach to care and organisation of intermediate care models.
Discussion
There was agreement that intermediate care represents time-limited services which ensure continuity and quality of care, promote recovery, restore independence and confidence at the interface between home and acute services, with transitional care representing a subset of intermediate care. Models are best delivered by an interdisciplinary team within an integrated health and social care system where a single contact point optimises service access, communication and coordination.
Conclusions
This study identified key defining features of intermediate care to improve understanding and to support comparisons between models and studies evaluating them. More research is required to develop operational definitions for use in different healthcare systems.
ObjectivesThis study aimed to describe the recovery journeys of people with a history of recurrent depression who took part in a psychosocial programme designed to teach skills to prevent depressive ...relapse (mindfulness-based cognitive therapy (MBCT)), alongside maintenance antidepressant medication (ADM).DesignA qualitative study embedded within a multicentre, single blind, randomised controlled trial (the PREVENT trial).SettingPrimary care urban and rural settings in the UK.Participants42 people who participated in the MBCT arm of the parent trial were purposively sampled to represent a range of recovery journeys.InterventionsMBCT involves eight weekly group sessions, with four refresher sessions offered in the year following the end of the programme. It was adapted to offer bespoke support around ADM tapering and discontinuation.MethodsWritten feedback and structured in-depth interviews were collected in the 2 years after participants undertook MBCT. Data were analysed using thematic analysis and case studies constructed to illustrate the findings.ResultsPeople with recurrent depression have unique recovery journeys that shape and are shaped by their pharmacological and psychological treatment choices. Their journeys typically include several over-arching themes: (1) beliefs about the causes of depression, both biological and psychosocial; (2) personal agency, including expectations about their role in recovery and treatment; (3) acceptance, both of depression itself and the recovery journey; (4) quality of life; (5) experiences and perspectives on ADM and ADM tapering-discontinuation; and (6) the role of general practitioners, both positive and negative.ConclusionsPeople with recurrent depression describe unique, complex recovery journeys shaped by their experiences of depression, treatment and interactions with health professionals. Understanding how several themes coalesce for each individual can both support their recovery and treatment choices as well as health professionals in providing more accessible, collaborative, individualised and empowering care.Trial registration numberClinical trial number ISRCTN26666654; post results.
Intermediate care (IC) was redesigned to manage more complex, older patients in the community, avoid admissions and facilitate earlier hospital discharge. The service was 'enhanced' by employing GPs, ...pharmacists and the voluntary sector to be part of a daily interdisciplinary team meeting, working alongside social workers and community staff (the traditional model).
A controlled before-and-after study, using mixed methods and a nested case study. Enhanced IC in one locality (Coastal) is compared with four other localities where IC was not enhanced until the following year (controls), using system-wide performance data (N = 4,048) together with
data collected on referral-type, staff inputs and patient experience (N = 72).
Coastal showed statistically significant increase in EIC referrals to 11.6% (95%CI: 10.8%-12.4%), with a growing proportion from GPs (2.9%, 95%CI: 2.5%-3.3%); more people being cared for at home (10.5%, 95%CI: 9.8%-11.2%), shorter episode lengths (9.0 days, CI 95%: 7.6-10.4 days) and lower bed-day rates in ≥70 year-olds (0.17, 95%CI: 0.179-0.161). The nested case study showed medical, pharmacist and voluntary sector input into cases, a more holistic, coordinated service focused on patient priorities and reduced acute hospital admissions (5.5%).
Enhancing IC through greater acute, primary care and voluntary sector integration can lead to more complex, older patients being managed in the community, with modest impacts on service efficiency, system activity, and notional costs off-set by perceived benefits.
If integrated care approaches are to be properly adapted to local contexts, a better understanding is required of key determinants of implementation and how these might be appropriately supported.
...This study applied the Canadian Context and Capabilities for Integrating Care (CCIC) Framework to investigate factors influencing the implementation and outcomes of a complex integrated care change programme in Torbay and South Devon (TSD) and, more specifically, in one of five sub-localities, Coastal.
A case study method using embedded 'Researchers in Residence' to conduct action-based participatory research and deploying mixed qualitative methods.
The relative importance of some domains differ between the English and Canadian studies. In this case study, physical features (structural and geographic) were found to be very pertinent to the relative success of the Coastal Locality, as were empowered clinical leadership, with readiness for change being expressed through processes and cultures that were risk-enabling, strengths-based, person-/outcome-focused.
The CCIC Framework provided a useful tool capturing key elements of complex system change with key domains being transferable across settings, while also finding local variation in the UK. This would encourage its wider application so that further comparisons can be made of the ways in which different contextual and implementation properties impact upon delivery and outcomes.
Background: Experience and evidence from the Integrated Care Organisation (ICO) in Torbay and South Devon, UK show that implementation of fully integrated systems (comprising acute, community, ...primary, social, and voluntary services) require, amongst others, leadership and a co-produced engagement approach to foster a shared culture. Aims and Objectives: This is an interactive workshop to explore with participants through plenary and small group, flipcharts, and a prioritisation exercise relevant elements of the ‘Context and Capabilities for Integrated Care’ (CCIC) implementation framework for integration. The outcome is to identify with participants the elements which are most salient and critical (both as facilitator and barriers), how they interact with key processes and outcomes of system transformation, and to discuss emerging best practice and potential solutions. Format (timing, speakers, discussion, group work, etc): The workshop is facilitated by key leaders, representative of the wider system: Dawn Butler - Deputy Director of Strategy, Performance and Planning, Torbay and South Devon NHS Foundation Trust TSDFT; Dr Matthew Fox –GP, Locality Clinical Director TSDFT, Governing Body Locality GP (Coastal) South Devon and Torbay Clinical Commissioning Group CCG, Chloe Myers - Manager, Volunteering In Health @ Coastal Information Centre. Researchers-in-Residence Dr Felix Gradinger, and Dr Julian Elston (University of Plymouth). If participants are consenting to do so, researchers would aim to capture and record the content of the workshop for co-production of research, learning and dissemination. Timing: 90minutes required 10mins: Introductions, co-production aim, overview Clarify and manage expectations, consent 25mins Introducing speakers and 5mins pitch each, RIRs to introduce CCIC framework and relevant domains; Brainstorming exercise (depending on numbers split into 3 or 4 groups each allocated to key elements), Showcase Torbay story; Highlight leadership domains/approaches and interdependence at system level, explain method and highlighted main elements 5mins Individual exercise, prioritising and thinking of examples for key elements; think about how most important elements link to others in the framework in own context; Get people to think about examples from their own practice 25mins Collectively rank around table/group and make links to other elements, consider solutions of how challenges were overcome; and discuss examples for feedback to the plenary (using flip charts); Get people to share why and how links start emerging; reach consensus around feedback from group and prepare to share in plenary 20mins Plenary and live feedback populating domains on whiteboard tying up most important connections and solutions; Start making connections between key elements across domains, formulate best practice elements 5mins End; summary and next steps; Encourage people to think about how to apply this personally or through conference networks Target audience: Managers, Practitioners, Researchers, and Public Representatives. Learnings/Take away: To illustrate system transformation, leadership and approach To introduce an implementation framework for integrated working Prioritise and identify key elements relevant to attendants Share and note experiences of how elements play out Identify solutions (facilitators and barriers) Record and feedback notes from workshop (co-produced leagacy)
Social prescribing is the topic of the moment. Many national organisations and individuals from policy, practice, and academia (such as NHS England, the RCGP, the Mayor of London, and National ...Institute for Health Research) are rightly advocating social prescriptions as an important way to expand the options available for GPs and other community-based practitioners to provide individualised care for people’s physical and mental health through social interventions. No robust figures exist but it is thought that around 20% of patients consult their GP for primarily social issues, given this and the driving forces of an ageing population, increased complex health and social needs, and increasing demand on services, social prescribing is rapidly gaining popularity.
Introduction: Torbay and South Devon NHS Foundation Trust, an Integrated Care Organisation, re-designed its Intermediate Care (IC) service to manage more complex, older patients in the community and ...facilitate earlier hospital discharge and reduce admissions from the community. The “Enhanced” IC service (EIC) employed GPs, pharmacists and the voluntary sector to work with social and community services (the traditional model) in locality ‘hubs’. It was assumed that EIC would deliver a more strengths-based, person-centred, coordinated care (PCCC) ‘closer to home’, whilst reducing system demand and costs. Methods: A mixed-methods case study, using embedded Researchers-in-Residence (RiR), compared the first established service (Coastal EIC) with four other localities, over time (natural experiment). Quantitative data: service input data (n=72); two ad-hoc validated surveys (n=672 and n=17) of PCCC in staff and patients; assessment of service use prevented (n=1001), including a ‘cost-offset’ analysis, calculating ‘notional’ annualised cost-saving; and routine data used to calculate rates in over 70 year-olds for referrals (acute and GP), bed-capacity, admissions and length of stay (LOS). Findings were co-produced with stakeholders to drive change and to explore explanations for differences in outcomes. Results: Service data showed GPs inputted into 36% of cases (not including GP contacts), pharmacists 15% and the voluntary sector 13%. Moderately high need service users reported fairly high levels of PCCC, with an average score of 66%. The PCCC practitioner survey (response rate 39%) showed higher levels of PCCC in 19/27 questions, compared to an Australian benchmark. PCCC was strongest in the domains of ‘treating people holistically’, ‘supporting activation’, ‘feeling joined-up’ and ‘involving the family’. ‘Care planning’, ‘single point of contact’ and ‘telling your story once’ required improvement. EIC prevented 1,940 incidences of service use (1.9 per referral). Most of this fell outside the ICO (Out of Hour GP and nursing services (45.1%), a GP telephone consultation (13.6%), Residential nursing (4.0%) and social services (3.2%)). Prevention of ICO service use equated to 2-3% of emergency attendances. The notional average cost saving was £149.17 per person, mostly due to secondary care avoided. Coastal EIC had persistently shorter LOS, lower bed-day and emergency attendance rates and more care at home than other localities, but fluctuations over time weaken attribution solely to EIC. Discussion: Coastal EIC was managing more complex patients in the community. Greater clinical and pharmaceutical input and personal information at the daily MDT, record sharing and pro-active links with GPs and the hospital, enabled more PCCC, impacting on LOS and demand. Conclusion: EIC has the potential to deliver better patient experience for complex, older patients, whilst reducing demand and costs. Lessons learned: Implementing EIC consistently across localities presented challenges for leadership, GP engagement, record sharing, and links with community and acute services. RiRs can help facilitate relationships, learning and service development. Limitations: Implementing complex integrated interventions often precludes rigorous study designs. Although case studies and participatory research are prone to bias, they can provide rich insights and support change. Suggestions for future research: How can the RiR model support implementation of other complex integrated care initiatives?
Introduction: International policy is encouraging a re-design of health and social care services, including the use of social prescribing. Torbay and South Devon NHS Foundation Trust, an Integrated ...Care Organisation in the UK, commissioned a voluntary sector ‘Wellbeing Coordination’ service as a key element of the wider care model. This case study seeks to understand how primary, acute, social, community and voluntary services are working together in a locality hub and the impact of wellbeing coordinators on service users’ well-being, use and cost of health and social care services Methods: A before-and-after study, supplemented with qualitative case studies, practitioner interviews/surveys, observations of multidisciplinary team (MDT) meetings and service user/caregiver interactions. Applying an action-based participatory approach, findings were co-produced with stakeholders and members of the public by embedded researchers-in-residence. Quantitative service user data were collected on health and social well-being outcomes and frailty on referral and 12 weeks. Comprehensive activity and cost data were collected at 12 months pre- and post-referral. Results: Health outcomes and service activity data were collected on 49 participants receiving the wellbeing coordination programme. All person-reported outcomes showed statistically significant increases in mean change scores (Warwick-Edinburgh Mental Well-being Scale, Well-being Star™, Patient Activation Measure, Rockwood Clinical Frailty Scale, Living well goals met). Qualitative case studies and observations highlighted key mechanisms of the intervention and the hub working. The impact on health and social care use and cost was more nuanced, with mean activity and cost increasing overall. Referrals from the Enhanced Intermediate Care MDTs (20/49) showed higher levels of use and cost. At locality hub level, the practitioner survey, observations and interview findings show an increase in vertical and horizontal organisational integration and high levels of staff-reported person-centeredness while embodying a strengths-based approach. Discussion: The study shows a positive impact on outcomes and mixed patterns regarding activity and cost. The findings indicate potential for more ‘down-stream’ and preventative work. The close links with the wider voluntary sector add to the hub offer in holding more complexity, providing access and continuity of care, and delivering holistic and personalised care in the right place and at the right time. Conclusion: Key elements of how the hub works indicate the importance of leadership, co-ordination, communication, colocation, and contracting that allows the nourishing of trusting relationships and crossing of organisational and professional boundaries. Lessons learned: Challenges included pooling resources, record sharing, information governance and engaging all stakeholders in a shared vision for a strengths-based, person-centred culture. Ownership and bottom up dynamics and formal and informal relationships between practitioners at all levels, including the community they work with, were key features for overcoming these. Limitations: Case studies and participatory research approaches may be considered lesser to experimental study designs. However, context is crucial to integrated care and extrapolating generalizable findings. Co-production and triangulating varying data sources helps studying and implementing complex system wide transformation. Suggestions for future research: The Researcher-in-Residence model could be rolled out across systems to facilitate learning, and to increase robustness of insights.
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