People with Learning Disabilities often have an increased chance of physical or mental health problems, and may also display challenging behaviour. For some people care is needed in an inpatient setting to allow for effective assessment, formulation and intervention planning. This is not only relevant when someone’s behaviour is too risky to be safely managed in a community setting but also prior to a crisis situation when early assessment and intervention may reduce the likelihood of a crisis.
Since the broadcast of the BBC Panorama documentary “Undercover Care: the Abuse Exposed” (BBC, 2011) the role of learning disability inpatient services has been placed under scrutiny. In the years following the broadcast there have been a number of government documents published, which have questioned the use of inpatient beds.
They have concluded that for many people, they are in hospital for too long with no clear treatment plan. The most recent of these reports, Transforming Care – Next Steps (DoH, 2015), has reaffirmed the need to ensure all people with learning disabilities can live in their local community with the appropriate support and services, but also acknowledges that for some people a short-term inpatient admission is appropriate. However, a process of Care and Treatment Reviews is now in place, during which an independent panel review the need for admission and then, where care and treatment are required, ask why this cannot be provided in the community.
Although the current paper was published prior to the publication of Transforming Care, it seems that the authors suggestion of “A care pathway-based whole systems approach” could still be useful to investigate. Health-care pathways were introduced in the 1980s in the US (Bower, 2009) and in the 1990s in the UK (Johnson, 1997). Care pathways outline the essential steps and anticipated timeframes in a person’s journey through a healthcare service. This is a relatively new approach to working with adults with learning disabilities (Roy et al., 2003). In some learning disability services, care pathways have shown promising results in terms of risk assessment, monitoring, interdisciplinary communication and service satisfaction scores.
This paper describes the evaluation of a core care-pathway in a specialist inpatient unit which is part of a learning disability service in Leicester, Leicestershire and Rutland. At the same time the learning disability service was also developing a care pathways across all other parts of the service.
The study was conducted in an eight bedded specialist assessment and treatment inpatient unit for adults with learning disabilities. A multidisciplinary health team consisting of nurses, speech and language therapists, occupational therapists, psychologists and psychiatrists provides the service.
The inpatient team developed and implemented a core care pathway for referral, assessment, treatment and discharge. The approach was multi-agency and used a lean methodology. The lean methodology is a systematic process that aims to improve customer outcomes by making sure the right things are in the right place at the right time. This is done by focusing on what the customer values; any activity that is not contributing to this value is seen as waste and should be eliminated. By eliminating waste the customer will receive a more value added service. Lean methodology is based on the Toyota Production System and has been applied to healthcare to improve the patient’s journey through health systems in a more economical way.
The care pathway specified the journey and expected timeframes that someone using the service should expect when moving from referral to discharge. There was also funding and independent sector collaboration to develop the skill of the workforce to allow the delivery of the pathway-based approach (Described in Devapriam & Alexander, 2013). A nurse was employed as a pathway manager with the sole responsibility of ensuring the progress of the person along the pathway by working with the agencies and professionals involved.
The team evaluated the impact of the care pathway-based approach on length of stay and Health of the Nation Outcome Scale – Learning Disability (HoNOS-LD) scores. They used Statistical Package for Social Sciences version 20 to perform independent samples t-tests to compare the mean length of stay and change in HoNOS-LD scores.
Throughout the study period, the team had eight beds available for admission. The team report that in the five months prior to the introduction of the care pathway there were five admissions compared to 18 after the pathway was introduced. This is a threefold increase in the number of admissions. The team report that there were no differences in the profile of patients admitted during these two time period in terms of reasons for admission, legal status during admission or their diagnosis.
The team reported a significant reduction (p<0.000) in the length of admission from a mean of 11 weeks (SD = 4 weeks) to a mean of 3 weeks (SD= 3 weeks) and a significant reduction (p<0.000) in the length of admission for people whose discharge is delayed from a mean of 21 weeks (SD=25 weeks) to a mean of 4 weeks (SD=3.5 weeks).
They also reported that there was an increased difference in HoNOS-LD scores pre and post-admission.
The findings of this evaluation are promising and suggest that using a core care-pathway for admissions to an inpatient service may have a substantial and significant effect on treatment outcome and delayed discharge. This study also suggests that this increased throughput is not at the expense of service effectiveness as shown by the HoNOS-LD scores.
The authors note that a care pathway-approach may mitigate some of the concerns regarding variation in the quality and use of inpatient services. They also note in their discussion that the reduction in delayed discharge was due to good joint working with local authority and clinical commissioning groups. This they felt was achieved by having the dedicated pathway nurse and by holding monthly meetings with stakeholders to review the care and progress of the people in the unit.
Strengths and Limitations
It was good to read an article presenting evidence based on current practice and from the data presented, this was clearly a successful organisational intervention. However, the article left me wanting more information regarding the exact detail of the care pathway and the team experiences in implementing it.
During the statistical analysis, the authors compared the pre and post-pathway admission HoNOS-LD scores and the pre and post-pathway discharge scores, which did not differ significantly. It may have been beneficial for the authors to analyse if there was a significantly different change in the scores between admission and discharge pre and post-pathway.
The article summarised above presented compelling evidence to suggest that a core inpatient care pathway, along with a pathway manager, can improve outcomes for people admitted to a specialist learning disability inpatient assessment and treatment unit. Their data suggested that a care pathway approach can reduce admission length and delayed discharges, whilst maintaining the effectiveness of care.
Devapriam, J., Alexander, R., Gumber, R., Pither, J. & Gangadharan, S. (2014). Impact of care pathway-based approach on outcomes in a specialist intellectual disability inpatient unit. Journal of Intellectual Disabilities,18(3), 211-220 [abstract]
Department of Health. (2015). Transforming Care for People with Learning Disabilities – The Next Steps. London, UK: Author.
Devapriam, J. & Alexander, R. (2013). Tiered model of learning disability forensic service provision. Journal of Learning Disabilities and Offending Behaviour, 3(4), 175–185
Roy, A., Matthews, H., Clifford, P., Fowler, V. and Martin, D. M. (2002). Health of the Nation Outcome Scales for People with Learning Disabilities (HoNOS-LD). The British Journal of Psychiatry, 180(1), 67-70.
Lean. (n.d.). Retrieved August 18, 2015, from http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/lean.html
Kenyon, P. (2011). [Television broadcast]. London: BBC.