As part of the national Transforming Care agenda, the Care and Treatment Review (CTR) Policy (NHS England 2015) requested that commissioners hold a local database of people with a learning disability, autism or both who are at risk of an inpatient admission. As commissioners are tasked with holding the local database and keeping this information active and dynamic, they need support from clinicians in the community teams to know who is at risk of admission.
The DSD clinical support tool was developed within the Cheshire and Wirral NHS Foundation Trust to support the flow of information to commissioners in a standardised and consistent manner. The tool comprises of 19 items. The scores are weighted to reflect the extent to which each question is an indicator of increased risk of admission. It provides an overall RAG (red, amber, and green) rating which reflects current levels of risk of admission to inpatient services. Both child and adult versions of the tool are available.
As well as providing standardisation in relation to levels of risk of admission, the tool also provides support to clinicians and guidance on the structure of support. Those individuals rated as green are not deemed at risk of admission. The piece of work they were referred for would be completed with support plans and risk assessments completed as usual. Those rated as amber are individuals facing significant deterioration in the community who may need an inpatient admission if the deterioration continues.
These individuals would be started on Care Programme Approach (CPA) (where available) and additional support teams would be notified (for example intensive support teams). Multi-disciplinary team (MDT) meetings would aim to update the formulation, Positive Behaviour Support Plan (PBSP), care plans and risk assessments. For those individuals at immediate risk of admission (red), there would also be a CTR or CETR (Care, Education and Treatment Review) called to enable the MDT to discuss the situation with commissioners. Intensive support teams would be actively involved where possible/appropriate and locally commissioned inpatient services be made aware. The clinical tool rating would be reviewed regularly (weekly for those on amber and more frequently for those rated red). The updated information can then be communicated to local commissioners.
Evaluation of the DSD clinical support tool shows good face validity and strong inter-rater reliability. The tool also allows teams to collect information on the number of people rated as red in a team, the number of people rated amber, the number of people rated as red who were admitted to an inpatient unit and those where admission was avoided, the length of time people are rated as red prior to admission, the unit people were admitted to and whether a CTR/CETR was held. This information supports team pathways as well as future commissioning decisions.
Dr Ceri Woodrow, Clinical Psychologist, Cheshire and Wirral NHS Foundation Trust, DSD Lead for the North West Operational Delivery Network.
Editorial Lead: Centre for Autism Neurodevelopmental Disorders and Intellectual Disability (CANDDID)