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: richard.gray@uea.ac.ukw: http://eastanglia.academia.edu/RichardGray

http://eastanglia.academia.edu/RichardGray

How much younger will you die if you have schizophrenia?

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

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Literature review…

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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

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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

% p

atie

nts

scr

een

ed

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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

Haloper

idol

Risper

idone

Olanza

pine

Cloza

pine

6

5

4

3

2

1

0

-1

-2

-3

Place

bo

Fluphen

azin

e

Zipra

sidone

Chlorp

rom

azin

e

Thiorid

azin

e

Quetia

pine

Aripip

razo

le

†

*

Weight Change (Kg)

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Addressing physical health: the WellBeing support programme

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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

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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

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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

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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?

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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

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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

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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%)

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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

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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…”

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Very compelling…

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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?

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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

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Not very compelling…

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Learning…

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

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A different model: the Health Improvement Profile (HIP)

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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

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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

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The Health Improvement Profile

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

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Key points

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

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Service evaluation of a well-being support programme for patients

with severe mental illness

Richard Gray RN PhDProfessor of Research Related to Nursing

e: richard.gray@uea.ac.ukw: http://eastanglia.academia.edu/RichardGray