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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
http://eastanglia.academia.edu/RichardGray
How much younger will you die if you have schizophrenia?
http://eastanglia.academia.edu/RichardGray
What is the major cause of death for people with schizophrenia?
http://eastanglia.academia.edu/RichardGray
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
http://eastanglia.academia.edu/RichardGray
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)
http://eastanglia.academia.edu/RichardGray
Addressing physical health: the WellBeing support programme
http://eastanglia.academia.edu/RichardGray
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
http://eastanglia.academia.edu/RichardGray
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?
http://eastanglia.academia.edu/RichardGray
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
http://eastanglia.academia.edu/RichardGray
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
http://eastanglia.academia.edu/RichardGray
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?
http://eastanglia.academia.edu/RichardGray
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
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