The project is based on inter-agency collaboration, utilising public health, pharmacists, service users and carers, health and wellbeing practitioners, primary and secondary care agencies working together in an aim to develop a database with the objective of reducing the mortality rates of service users with a diagnosed severe mental illness through a structured physical health screening, monitoring and intervening process. The project offers a physical health intervention framework for service users who have been prescribed antipsychotic medication. Additional contributors: Dr Javed Latoo; Jane Neve, Amanda Derbyshire and Rachael Kane.
Aims and objectives
2. To promote a more integrated approach to the physical health care of people with a SMI.
3. To focus on improvements in the following areas: screening and monitoring, targeted (early) prevention, interventions, collaborative care between primary and secondary care.
4. Shared decision making between primary and secondary care.
Reasons for implementing your project
Before the initiative physical health was not perceived as a priority within the team. Physical health screenings were unsystematic as were referrals to support such as Fresh Start, Recipe for Health, smoking cessation, drug and alcohol services, carers centres were also ad hoc. Physical checks were not consistent and only at the request of the doctor prior to the commencement of medication. Service user's often refused or lacked interest to attend physical health screenings. The team's links with primary care and wellbeing nurses were poor. Early intervention (EI) letters to GP's did not always highlight physical health concerns. In Patient Units physical health screenings needed to improve as did the recording systems. Furthermore SMI registers were not up to date in GP surgeries). We were also involved in on-going discussions in respect of whose responsibility it was for carrying out the physical health checks - primary or secondary care.
In order to improve efficiency and quality we needed to find a comprehensive assessment tool that was Trust approved. We required a documentation system and a formalised system of highlighting when people where due a physical health assessment. This required a more robust approach to ensure service users attended for screening and any health concerns identified were followed-up. Links with primary care needed to improve with regards to communication and the unnecessary obstacles, which were making it difficult to access test results. The links within secondary care agencies needed to be improved such as the community to in-patient and vice versa. We also identified additional skills needed within the team such as, venepuncture and ECG training.
How did you implement the project
We established a local project group, which met on a monthly basis, which included: business manager, nurse consultant, team manager, occupational therapist, support, time and recovery (STR) worker, pharmacist, social services, public health leads, wellbeing nurses, consultant psychiatrist and service user representatives. To keep costs to a minimum we used existing Trust material, the starting point of which was the 5BP Comprehensive Physical Health Assessment. This included areas such as: smoking, diet, exercise, sexual health, sleep, dental, optical, ECG, and bloods. We also devised and implemented an in-house database in which results could be recorded using Microsoft Outlook.
In order to maximise the impact of the project we contacted all relevant GP?s and wellbeing nurses within the localities and passed on the initial baseline results. We saw a further opportunity to publicise the project through the creation of a GP DVD and information booklet for inclusion on the Trust's GP website and Clinical Commissiong Group (CCG) newsletter. We were fortunate to establish and develop wellbeing nurse led clinics in Halton and physical health clinics in Warrington which were STR led at no additional cost.
We established access to test results from the pathology labs for both localities. We made links with both the Medical Director and CCG leads within our Trust. We also saw an opportunity to utilise the role of the relationship managers within 5BP to reinforce links with local GP surgeries. We used the care programme approach to highlight physical health/wellbeing issues, and reinforced the need for annual physical checks.
-4 weeks November 2012: 4 (7.4%) May 2013: 19 (66%)
-3 months November 2012: 3 (5.5%) May 2013: 18 (72%)
-12 months November 2012: 4 (7.4%) May 2013: 21 (77%)
-24 months November 2012: 2 (3.7%) May 2013: 15 (95%)
The results show a significant increase in people having 6 physical health screenings in the dates specified above.
Quantitative evidence via our recording systems shows that people are receiving screenings and this is demonstrated by the increase in figures shown above. The recording system in-house has proven to be robust and comprehensive. We are looking to incorporate this or something very similar in our new electronic recording system.
Awareness of the importance of physical health screenings has risen among professionals, carers and service users. We've established better links and working relationships with primary care. We also feel that secondary care agencies are now more aware of the requirements for physical health screenings, which is reflected in the discharge letters that we are receiving from inpatient units. In terms of cost efficiency and productivity we believe we have demonstrated short-term savings in financial terms in respect of increased attendance at GP screening clinics and our own physical health clinics. We expect this will produce longer-term savings in the wider health economy. In summary we believe the project has been successful, especially in monitoring the effects of medication on physical health and in identifying, dealing and managing identified health issues such as smoking, BMI and exercise regimes - ultimately decreasing the morbidity rate of people with a SMI.
Key learning points
- To have the support of the senior management team in house, and encourage the involvement throughout in order to deal with the wider issues such as involvement with primary care partners, social care and health promotion.
- To get the basics rights in terms of meeting on a regular basis with the desired membership of the project group. Utilise the PDSA (Plan, Do, Study, Act) model and make sure targets are set and achieved efficiently.
- Do a scope of what is already available in terms of physical health screening clinics via help promotion and the health and wellbeing nurses. Often we found that services were duplicated and we were able to streamline not only secondary care but primary care also, therefore, saving money for both sectors.
- We struggled to engage GPs across both localities as our project aims were not included in QOF targets. This continues to be an issue although engagement has appeared to increase in the last couple of months.
- It is necessary to contact and engage local commissioners from CCGs as soon as possible in order to utilise their skills in dealing with primary care agencies.
- To accept that physical health screenings are an on-going concern and as such the process will need continued investment in both physical and financial resources.