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Service evaluation of a well-being support programme for patients with severe mental illness Richard Gray RN.

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Presentation on theme: "Service evaluation of a well-being support programme for patients with severe mental illness Richard Gray RN."— Presentation transcript:

1 Service evaluation of a well-being support programme for patients with severe mental illness Richard Gray RN PhD Professor of Research Related to Nursing e: w:

2 How much younger will you die if you have schizophrenia?

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

4 Literature review…

5 Physical health status of patients with schizophrenia People with schizophrenia die prematurely 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

6 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: % patients screened

7 Mean change in weight with 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; Allison et al. Am J Psychiatry. 1999;156: Estimated Weight Change at 10 Weeks on Standard Dose Haloperidol Risperidone Olanzapine Clozapine Placebo Fluphenazine Ziprasidone Chlorpromazine Thioridazine Quetiapine Aripiprazole * Weight Change (Kg)

8 Addressing physical health: the WellBeing support programme

9 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

10 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

11 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

12 WellBeing in the hands of the NHS Industry… WelBeing no longer fits with our strategy –Nurse advisors withdrawn from practice The NHS… it works lets 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?

13 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

14 WellBeing in Kent… Started in 2006 Evaluation undertaken at the end of 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

15 The health of the population (n=754) BMIn(%) (overweight)303 (40%) >30 (obese)198 (26%) Hypertension (>140/85)260 (34%) Smoker315 (48.5) Alcohol143 (22%) Substance use Cannabis use69 (11%) Other reported substance use38 (6%) No regular activity284 (44%) Diet Unhealthy diet104 (16%) Average diet182 (28%)

16 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

17 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 hadnt 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…

18 Very compelling…

19 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?

20 Entry Completion BMI* <24.9 (normal)41 (28%)33 (26%) (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 Smoker65 (41%)71 (45%) Non-smoker94 (59%)88 (55%) Alcohol 22 (14%)35 (22%) No-alcohol137 (86%)124 (78%) Substance use Cannabis use5 (3%)6 (4%) Other reported substance use8 (5%)7 (4%) Activity No regular activity72 (45%)62 (39%) Diet Unhealthy diet100 (63%)88 (55%) Average diet35 (22%)43 (27%) Health diet24 (15%)28 (18%) WSP outcomes

21 Not very compelling…

22 Learning… Keep it simple Set standards that can be performance managed Communication skills of practitioners

23 A different model: the Health Improvement Profile (HIP)

24 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

25 HIP case series 1 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

26 The Health Improvement Profile Next step cluster RCT –NIHR (RFPB), England –HRB, Ireland

27 Key points Qualitative vs. Quantitative E&E vs. Research Ad hoc vs. Programmes

28 Service evaluation of a well-being support programme for patients with severe mental illness Richard Gray RN PhD Professor of Research Related to Nursing e: w:

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