Optimising community C(E)TRs through understanding the experience of people with intellectual disability and autistic people and investigating their impact on care

Research Questions 1. Do Community Care (Education) and Treatment reviews (C(E)TRs) reduce hospital admissions and improve outcomes? 2. What are stakeholder perspectives of the C(E)TR process? 3. Do high quality C(E)TR action plans improve patient outcomes? Background

Over 2,000 patients with learning disability or autism are in psychiatric hospital; over 50% stay for more than 2-years. C(E)TRs were introduced in 2015 as part of Transforming Care and are conducted in patients at high risk of admission. They generate actions to enable patients and carers to access timely support in the community to avoid admissions.

Wide variations in the use of Dynamic Support Registers (DSRs) to monitor patients at risk of admission, and subjectivity in stratifying risk, have led to differences in the implementation of C(E)TRs. Consequently, 75% of patients do not have a C(E)TR prior to admission, and only a small reduction in admission rates (19%) has been achieved (target 30-50%).

There is scant research on whether C(E)TRs reduce admissions and produce positive outcomes and on the experience of stakeholders about the C(E)TR process. Aims and objectives

To compare psychiatric hospital admission rates and other outcomes (e.g. length of stay, behaviour, quality of life, costs) in children and adults with learning disability and/or autism who have and have not received a C(E)TR; explore stakeholder perspectives of the C(E)TR process; and examine the association between the quality of C(E)TR action plans and outcomes.

Methods

1. Retrospective cohort study of electronic patient records using the Clinical Record Interactive Search system to identify C(E)TRs, examine the clinical profile of patients who have and have not had a community C(E)TR and the association between having a C(E)TR and clinical outcomes (e.g. hospital admission, length of stay). We will also identify patients who were admitted and examine their C(E)TR status prior to their admission.

2. Prospective study of 300 patients, rated red or amber on the DSR, to compare clinical (e.g. hospital admissions), social and cost outcomes in patients who have and have not had a community C(E)TR over 12 months.

3. Qualitative study with interviews of patients, carers and clinicians to identify aspects of the C(E)TR process that is working well and needs improvement.

4. Delphi Panel exercise using an online survey with clinicians, patients and carers to obtain consensus on what makes a high quality C(E)TR action plan. A rating checklist will be developed and used to rate C(E)TR plans from the prospective study to examine the association between the quality of C(E)TR plans and patient outcomes.

Anticipated impact and delivery

The project will be over 42 months. The study will provide information on the effectiveness of community C(E)TRs in preventing admissions and improving clinical and social outcomes; which patients receive or do not receive community C(E)TRs; and which groups are most likely to benefit from them. This will inform targeting/tailoring of C(E)TRs and optimise resource use.

We will develop guidelines on how the C(E)TR process should be improved. Our lived experience PPI groups will be involved throughout and will develop lay summaries, blogs and videos, targeted to specific audiences via social media, professional forums, charities and engagement with NHS England. Findings will be published in journals and will shape policy, commissioning and clinical guidelines.