A recent report by the Royal College of Psychiatrists attempted to set out the range of in-patient service provision for adults with learning disabilities and set the role of assessment and treatment beds in the context of a broader range of services. They stated very clearly in that report that in-patient services should form part of a care pathway which complements the work of community teams to achieve good outcomes for people.
Assessment and treatment units have been described as a new form of institutional care and certainly it has been the case that people have often stayed for too long, been in units where they were receiving no active treatment and had poor planning for the future and return to their own homes.
The authors suggest that a care pathway-based whole systems approach might be a response to address some of the issues identified with assessment and treatment units. A care pathway sets out the essential steps in the care and treatment delivered for a patient, sets out timeframes and milestones and introduces standards and expectations for outcomes.
The current study took place in Leicester, Leicestershire and Rutland, where since 2011, the service has developed and implemented a core care pathway for community and inpatient services as well as eight clinical pathways for autism, challenging behaviour, complex physical disability, dementia, eating and drinking, mental health, forensic and epilepsy.
The researchers in this study were interested in looking at the impact of the introduction of a care pathways approach on outcomes for people using a specialist inpatient unit for adults with learning disabilities.
The unit itself had eight acute assessment and treatment beds and the service was delivered by a multidisciplinary health team of includes nurses, speech therapists, occupational therapists, psychologist and psychiatrist.
The care pathway developed was for referral, assessment, treatment and discharge. They developed a referral checklist, clear admission procedures, decided appropriate timeframes for assessment and the delivery of interventions and an approach to discharge planning. Overarching this was an agreement on outcome measures and approaches to measurement.
A senior nurse acted as a pathway coordinator with responsibility for ensuring progress and working with other agencies and professionals.
The team evaluated outcomes by looking at length of stay and Health of the Nation Outcome scale–learning disability (HoNOS-LD) scores, a set of outcome scales used to measure changes in people with learning disabilities who have additional mental health needs.
The team had eight beds available for admission during the period of the study. There were six admissions in the 5-month period before the implementation of the pathway compared to 18 admissions in the same period after the implementation of the pathway approach – a threefold rise.
They found that this rise could not be accounted for by differences in patient profiles as there were no major differences found between those admitted before and after the implementation of the pathway approach.
One of the key findings they draw attention to is the difference in average length of stay. The group who were admitted after the introduction of the pathway approach had considerably less time in hospital for assessment and treatment than those admitted before.
The measures taken on the HoNOS-LD were also better for those admitted after the pathway approach was introduced.
Conclusion and Comment
There appear to be some significant advantages of introducing a care pathway approach to an assessment and treatment unit service that have been identified in this study. Throughput increased with a threefold increase in admissions. Although not covered in the study protocol, the authors do draw on anecdotal evidence that suggests that before the introduction of the pathway approach, delayed discharge from hospital had resulted in patients needing inpatient admission, sometimes having to use out-of-area placements due to a lack of local beds.
Given that there were also better outcomes measures post pathway on the HoNOS-LD scores, it would seem to suggest that the approach focused on expediting the patient journey and coordinating inputs from professionals had an impact on patient outcomes as well.
The authors suggest that this finding also adds weight to the view that treatment by “specialists in the mental health of people with intellectual disability, within settings that are particularly suitable for those with intellectual or developmental disadvantage, allows people with intellectual disability to achieve the same equity of outcome as people without intellectual disability who have the same mental disorders.”
It is difficult to draw a firm conclusion on this point however from a study of this nature that is not comparing this approach with an alternative intervention.
It certainly appears from the findings that improved communication within teams as a result of the introduction of the pathway approach enabled the delivery of care in a more coordinated and standardised way. The authors have also commented in other papers on the views of staff about working in this coordinated and focused way.
The authors suggest that their findings add weight to the view that the introduction of a care pathway-based approach to the delivery of inpatient services to adults with learning disabilities contributes to good outcomes through timely assessments, treatments, continuity of care and reduced lengths of stay.
However, it must be pointed out that this is a small study, in one eight bedded unit in a single trust, where there had been a good deal of investment of time and resources into working in this new way. The authors themselves point out that in addition to the care pathweay approach itself, there could be a range of factors like skills, morale, environment etc that could have impacted on the outcome. It would seem to me that the role of the senior nurse as a pathway coordinator was possibly key in driving the programme as well.
The authors suggest the need for “controlled trial research with multiple centres with different models of inpatient services and community service provision” to improve the quality of evidence.
John Devapriam, Regi Alexander, Rohit Gumber, Judith Pither, and Satheesh Gangadharan, Impact of care pathway-based approach on outcomes in a specialist intellectual disability inpatient unit, in Journal of Intellectual Disabilities, 18: 211-220 [abstract]