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Open access

An alternative to mental health ward admission for the over-65s

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In Edinburgh, a nurse-led team has changed the patient pathway for older people experiencing a mental health crisis. This initiative won the Nursing in Mental Health category in the 2018 Nursing Times Awards

Abstract

In Edinburgh, there used to be long waiting lists for beds in an older people’s mental health ward. In 2016, a new team of nurses, based in hospital but going out into the community, was set up to provide an alternative to hospital admission for older people experiencing a mental health crisis. This rapid-response team visits people at home up to three times a day, using specialist skills to assess and support them. Where possible, it works towards avoiding hospital admission and facilitating early discharge. In the team’s first two years of existence, waiting lists for mental health hospital beds occurred only occasionally or disappeared altogether.

Citation: Ritchie K (2019) An alternative to mental health ward admission for the over-65s. Nursing Times [online]; 115: 6, 48-49.

Author: Karen Ritchie is senior charge nurse, Royal Edinburgh Hospital, NHS Lothian.

  • This article is open access and can be freely distributed
  • Scroll down to read the article or download a print-friendly PDF here (if the PDF fails to fully download please try again using a different browser)
  • To contact Karen Ritchie about this project, please email: karen.ritchie@nhslothian.scot.nhs.uk
  • To find out more about the NT Awards click here
  • Award category sponsored by Northern Healthcare and Eirmed

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Introduction

The number of people aged ≥65 years in Edinburgh is expected to increase greatly in the next decade, and with it the number of older people with functional mental health issues or dementia. This will result in a higher demand for psychiatric services. In the summer of 2017, some wards from the Royal Edinburgh Hospital (REH) – the main mental health hospital in the city – moved to the new Royal Edinburgh Building; this reduced the number of beds for older people from 70 to 60.

In its 2020 vision for healthcare services, the Scottish Government emphasised recovery in the community as an alternative to hospital. Our nurse-led, hospital-based Older People’s Mental Health Rapid Response Team (known as the RRT) was established in December 2016 in Edinburgh to provide a community alternative to hospital admission in the context of increasing demand and a reduced number of beds.

I led the project to set up the RRT, working with stakeholders to ensure all agreed on its aims. An implementation group chaired by NHS Lothian’s psychiatry of old age clinical lead met every fortnight. It included representatives from REH inpatient wards, community mental health teams (CMHTs), psychology, occupational therapy, the Edinburgh Integration Joint Board and the voluntary sector.

Rationale

Before the creation of the RRT, Edinburgh had had a home treatment team for adults aged <65 years since 2008, but there was no equivalent for people aged ≥65. There was often a long waiting list for admission to older people’s mental health wards – the waiting time could be several weeks. In urgent cases, people often had to be admitted up to 70 miles away, which caused distress to patients and families.

The RRT aims to support older people in their own home when they are experiencing a mental health crisis. This way, they can receive intensive psychiatric assessment and treatment while maintaining their independence and preserving their quality of life. The RRT has three functions:

  • Provide a community alternative to admission to REH;
  • Triage admissions to mental health wards;
  • Facilitate early discharge from hospital.

How it works

The team visits people at home up to three times a day to provide specialist assessment and person-centred support. Referrals are accepted from a range of sources – GPs, general and community hospitals, old-age psychiatry inpatient wards, consultant psychiatrists, care homes and CMHTs – but come mostly from GPs and old-age psychiatrists. Calls to the team’s dedicated referral line are triaged by a band 6 nurse (or above). The main reasons for referral are:

  • People living with dementia experiencing high levels of stress and distress;
  • Psychotic and/or severe mood disorder;
  • Suicidal ideation with/without intent;
  • Anxiety;
  • Delirium;
  • Carer stress.

The team discusses all referrals for admission to mental health wards at REH with the referrers, considering whether intensive support at home would be a suitable alternative. There are, of course, circumstances when admission to hospital is required. If assessment shows a hospital admission is not warranted, the team supports people at home, providing respite to carers if required.

If a person is at risk of being admitted to a mental health hospital, they are suitable for RRT support and the RRT will assess them within 24 hrs of referral; if a response is required within five days, the referral is forwarded to CMHTs. The RRT also assesses patients in acute hospitals who are waiting for a bed at REH to establish whether admission can be prevented, either through intensive support at home or another pathway.

The RRT facilitates early discharge from hospital. A senior nurse visits the two older people’s functional assessment wards daily, working with ward teams to identify patients who could be discharged with intensive support. The team also visits the two dementia assessment wards, although less often as patient turnover is much lower. Early discharge only happens if certain criteria are met for safety. After discharge, the RRT provides home support to patients who need intensive input (contact with the team daily or most days); if they only need support once a week or less, they are referred to the CMHT.

Outcomes

In the RRT’s first two years (December 2016-December 2018) there was no waiting list for the functional assessment wards and rarely a waiting list for dementia assessment beds. Generally, older people who needed a hospital admission were able to get a bed at REH. Feedback from patients and carers has been very positive and:

  • 876 referrals were received for patients at risk of admission to a mental health ward, with 569 of these (65%) avoided;
  • The mean length of stay fell by 44% on functional assessment wards and 27% on dementia assessment wards;
  • The team supported 238 patients at home after early discharge.

In the same period, the number of emergency detention certificates issued for older people during RRT working hours fell by two-thirds, suggesting the team provides a viable but less-restrictive option than emergency detention.

Initially, referral rates were slow to pick up but they have been increasing. We visited general practices in Edinburgh to inform them of the new service and shared our work with our partners via information sessions and shadowing opportunities.

“The unique and authentic nature of this nurse-led initiative made this a worthy winner” (Judges’ feedback)

The team

The team started with seven staff: a senior charge nurse, three band 6 and two band 5 nurses, and a clinical support worker. It has now expanded to 19 staff: one senior charge nurse, six band 6 and six band 5 nurses, five clinical support workers and a full-time secretary. Initially, working hours were 8am-4pm Monday to Friday; it soon became apparent that a 4pm finish was too early for GP referrals so we extended this to 5pm. Since February 2017, the team is large enough to work seven days a week. We are now considering extending our hours to 8am-8pm.

Recruiting has been a challenge, particularly for the band 6 posts because of the skillset required. We have been unable to recruit a whole-time equivalent consultant psychiatrist as originally planned. Instead, the team liaises with sector consultant psychiatrists but this creates extra work for them. We are still planning to recruit a part-time consultant.

Another challenge has been to ensure senior nurses feel confident making complex clinical decisions, such as whether a person needs hospital admission. If we feel unsure about this, or if the person is to be detained, we seek advice from a consultant psychiatrist with whom we work.

The team uses reflective sessions and a positive enquiry approach to continue its development. Team cohesion and good morale are key, so we recently started using the FISH! Philosophy to reward good work and foster joy in the workplace. Every month, team members nominate a ‘fish of the month’ – a colleague who has made a difference to their day – who is celebrated at a team meeting.

Future steps

We want to develop our early-discharge work and are conducting a quality-improvement project. This will explore the benefits of having one of our nurses become a ward liaison nurse and working directly with ward staff to facilitate communication, expedite discharge and enhance the patient experience.

We also want to develop our nursing roles by having team members undergo training on non-medical prescribing, patient consent and mental capacity. We are looking to introduce advanced nurse practitioner role and social worker roles. Nurses on the team spend a lot of time liaising with social workers to arrange emergency respite, urgent care packages and care home placements, so a dedicated social worker would be invaluable.

Conclusion

The RRT has changed the patient pathway for older people experiencing a mental health crisis in Edinburgh, ensuring they have access to the right service at the right time. The project – the first of its kind in Scotland – has also promoted nursing leadership and autonomy in decision making. The key to our success has been our team of dedicated, enthusiastic, flexible and forward-thinking staff. 

Key points

  • Mental health issues in older people include dementia, psychosis, severe mood disorder, suicidal ideation, anxiety and delirium
  • Demand for psychiatric services for older people is likely to increase
  • Intensive support at home can be an alternative to admission to a mental health ward
  • In Edinburgh a nurse-led team provides home support to older people experiencing a mental health crisis
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