Http://eastanglia.academia.edu/RichardGray Service evaluation of a well-being support programme for patients with severe mental illness Richard Gray RN.

http://eastanglia.academia.edu/RichardGray

Service evaluation of a well-being support programme for patients

with severe mental illness

Richard Gray RN PhDProfessor of Research Related to Nursing

e: [email protected]: http://eastanglia.academia.edu/RichardGray


How much younger will you die if you have schizophrenia?


What is the major cause of death for people with schizophrenia?


Literature review…


Physical health status of patients with schizophrenia

• People with schizophrenia die prematurely 20-25 years on average

• More than 60% of premature deaths are not directly related to suicide

• 50% of psychiatric patients have a co-morbid medical illness

• Many illnesses go undiagnosed• Patient group do not volunteer complaints readily

Robson D. and Gray R. (2006) Int J Nursing Studies


Metabolic screening is below recommended levels

Screening of 4 aspects of metabolic syndrome in the total national sample (n=1966)

Barnes et al. Schizophr Bull 2007;33:1397-403.

0

20

40

60

80

100

Bloodpressure

Obesity Glycaemiccontrol

Lipid profile

Test result/measurement recorded in casenotes

Some reference to screening, but no results

No evidence of screening

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Mean change in weightwith antipsychotics

*4–6 week pooled data (Marder et al. Schizophr Res. 2003;1;61:123-36; †6-week data

adapted from Jones et al. ACNP; 1999. Allison et al. Am J Psychiatry. 1999;156:1686-1696.

Estimated Weight Change at 10 Weeks on “Standard” Dose

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Olanza

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Zipra

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Weight Change (Kg)


Addressing physical health: the WellBeing support programme


The WellBeing support programme

• Two year programme• Six formal sessions with a nurse advisor• Nurse advisors trained by physical health experts• Performance managed• Funded by industry

– An add on to routine care


Wellbeing support

• Step 1: Generating a register of SMI patients and inviting them to participate in the WSP

• Step 2: First face-to-face Well-Being Session where physical health (blood pressure, pulse, weight and height) lifestyle factors (diet, physical activity, smoking status) and antipsychotic side effects (LUNSERS; Day et al 1995) were measured

• Step 3: Results of measures taken in session 1 were fed back to patients at a second face-to-face session. Blood tests (random blood glucose, thyroid function, liver function, serum prolactin, lipid screen) were performed during this meeting

• Step 4: Patients were referred by the practitioner to one or more of the following a weight management or physical activity group; primary care or specialist doctor for additional physical health care; medication review by prescribing clinician

• Step 5: Two follow-up face-to-face sessions to evaluate programme and complete follow-up measures (as in step 1 and 2)

1. Smith S. (2007) International Journal of Clinical practice


The WellBeing support programme

• 966 patients enrolled across seven demonstration sites• 80% completed the programme • Significant improvements in

– Physical activity– Smoking– Diet

• No change in patients BMI

• Programme recommended by English DH


WellBeing in the hands of the NHS

• Industry… ‘WelBeing no longer fits with our strategy’– Nurse advisors withdrawn from practice

• The NHS… ‘it works let’s change it’– One year (not two year) programme– Four (not six) formal sessions with mental health

practitioner• Practitioners attend a three day training course facilitated by a

‘WellBeing nurse advisor’– Part of routine care (not an add on service)

• Does it still benefit patients?


WellBeing in the hands of the NHS

• Enterprise and engagement…

• Invited to evaluate the WSP run by Kent and Medway NHS & Social Care Partnership Trust– Typical mental health service provider

• Provides services to a population of 1.6m• 25,000 open cases• 4,000 staff

– At the start of the project were providing minimal physical health input to their patients

– Implementation of WSP driven by clinicians in practice


WellBeing in Kent…

• Started in 2006• Evaluation undertaken at the end of 2008• 212 practitioners had attended training• 754 patients enrolled on the programme

• Baseline and one year follow-up data on– Cardiovascular risk factors– Laboratory tests (glucose, lipids)– Medication

• Face-to-face interviews with practitioners


The health of the population (n=754)

BMI n(%)25-29 (overweight) 303 (40%)>30 (obese) 198 (26%)Hypertension (>140/85) 260 (34%)Smoker 315 (48.5)Alcohol 143 (22%)Substance useCannabis use 69 (11%)Other reported substance use 38 (6%)No regular activity 284 (44%)Diet Unhealthy diet 104 (16%)Average diet 182 (28%)


A discrepancy

• Authors of epidemiological studies suggest rates of smoking, alcohol and substance use, quality of diet and levels of exercise worse than we observed…

• Why?– Interviewing skills of practitioners– Would an unknown practitioner (e.g. practice nurse in

primary care) elicit more accurate information


WellBeing in Kent…

• ‘Making a difference’ was an emergent theme from practitioner interviews– “…it has flagged up a massive deficit within out clients with some having not had

physical interventions for a number years. A lady I assessed hadn’t had a smear for 20 year!”

– “…I have welcomed the programme as it recognises the need to provide health promotion activity to a client group where this can be overlooked, falling between services of secondary and primary care”

– “I am pleased about running the group and working with others getting the project off the ground has been really enjoyable”

– “In fact we are cooking a healthy fry up this week! (i.e. Grilling not frying, including lots of veg and fresh fruit)…”

– “…high blood sugar, hypertension, obesity, polypharmacy and sexual health problems all of which I have been able to refer to appropriate services”.

– “…I have discovered a number of serious conditions including hypertension, raised cholesterol and recently two inpatients have been diagnosed with diabetes…”


Very compelling…


Outcomes of the programme

• Enrolled 754• Attended 1580 WellBeing session

– Mean of 2.1 sessions (half the programme)– 159 completed the programme– 79% of those who enrolled did not complete the

programme• 80% completed the two year WSP described by Smith et al (2007)• Practitioner motivation• Relevance of recording data• Patient motivation

• What was the effect of the package on those who did complete?


Entry Completion

BMI*

<24.9 (normal) 41 (28%) 33 (26%)25-29.9 (overweight) 29 (20%) 35 (28%)>30 (obese) 76 (52%) 59 (47%)Hypertension

Normal BP (<140/85) 103 (70%) 88 (69%)Hypertension (>140/85) 27 (30%) 39 (31%)Cigarette smoking

Smoker 65 (41%) 71 (45%)Non-smoker 94 (59%) 88 (55%)Alcohol

Alcohol 22 (14%) 35 (22%)No-alcohol 137 (86%) 124 (78%)Substance use

Cannabis use 5 (3%) 6 (4%)Other reported substance use 8 (5%) 7 (4%)Activity

No regular activity 72 (45%) 62 (39%)Diet

Unhealthy diet 100 (63%) 88 (55%)Average diet 35 (22%) 43 (27%)Health diet 24 (15%) 28 (18%)

WSP

out

com

es


Not very compelling…


Learning…

• Keep it simple• Set standards that can be performance managed• Communication skills of practitioners


A different model: the Health Improvement Profile (HIP)


The Health Improvement Profile (HIP)1

• Nurses can be trained to be competent in using the HIP is three hours

• The physical health of all patients can be profiled

• Enables [nudges] nurses to plan care/make appropriate referrals

• Bridges communication between primary and secondary care

1. White J. et al (2009) Journal of Psychiatric and Mental Health Nursing


HIP case series1

• 31 patients with schizophrenia• Nurses in routine care trained to use the HIP• 189 physical health issues

– 6.1 per patient• Individualised (evidence based) care and treatment

was planned based on individual profiles• 28 interventions were used

– Providing advice, promoting health behaviour change, performing an ECG, referral to professional colleague

1. Gray R. et al (in press) International Journal of Nursing Studies


The Health Improvement Profile

• Next step cluster RCT– NIHR (RFPB), England– HRB, Ireland


Key points

• Qualitative vs. Quantitative• E&E vs. Research• Ad hoc vs. Programmes


Service evaluation of a well-being support programme for patients

with severe mental illness

Richard Gray RN PhDProfessor of Research Related to Nursing

e: [email protected]: http://eastanglia.academia.edu/RichardGray

Http://eastanglia.academia.edu/RichardGray Service evaluation of a well-being support programme for patients with severe mental illness Richard Gray RN.

Documents

edurichardgray slide

wellbeing support programme

patients bmi programme

routine care slide

year programme

psychiatric patients

english dh slide

wellbeing support programme