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Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Setting

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Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Settings Alan Quirk and Sonya Chee CVD SMI Pilot Project Second National Learning Network Event Wednesday 27 th January 2016
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Page 1: Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Setting

Evaluation of the implementation of Lester tool 2014 in

Psychiatric Inpatient SettingsAlan Quirk and Sonya Chee

CVD SMI Pilot Project Second National Learning Network Event

Wednesday 27th January 2016

Page 2: Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Setting

Introduction

• Lester Tool developed to provide simple guidance on cardiovascular health to MH services

• Based on screening for well-known determinants of CVD

• Brings together advice in various NICE guidelines• Offers an intervention framework:

Smoking, weight, BP, glucose, cholesterol domains• NHSE funded 4 sites to implement the Lester• Our job - to evaluate process and impact of this work

Page 3: Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Setting

A) Pilot projects and their evaluation

Page 4: Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Setting

Goals• Design and implement simple and sustainable process for

monitoring CVD risk factors• Enhance the communication of physical healthcare information

between secondary and primary care

Plan• Employ a dedicated nurse to champion and lead this project

Page 5: Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Setting

Two key strands to project delivery

Phase 1 – Development of Network of Link Workers96 link workers have been identified in each inpatient and community area to build capacity for, and promote development of, knowledge and skills in physical health and intervention.

Link workers will facilitate the local implementation of the Lester tool and embed this in clinical practice.

Phase 2 – Development of clinical pathwaysDevelop robust systems and processes to ensure consistency of access to clinical services (such as cardiology).

Page 6: Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Setting

TEWV Goal: To improve cardiovascular health of our service users

Project to be piloted initially in 2 inpatient areas, one acute admission, one rehabilitation

To implement an electronic physical health monitoring system based on the Lester Tool

To improve recording and data quality in respect of physical health monitoring within pilot areas

To increase service user awareness and understanding of the importance of physical wellbeing and afford them opportunities to adopt a healthy lifestyle

Page 7: Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Setting

Mersey Care NHS Trust

• This project aims to use funded pilot to improve current systems and practices for monitoring and addressing cardiovascular health

• Full implementation on one acute ward will allow further understanding of how to affect behaviours that will impact on physical health & wellbeing, and thus inform roll out across the trust

• Project objectives include: To identify the level of staff training required to effectively

embed the Lester Tool in practice To identify where care pathways need to be developed

Page 8: Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Setting

Evaluation Aims

To evaluate:

1. The impact of pilot initiatives on levels of physical health screening and interventions for inpatients

2. How pilot sites achieved improvements (or not) and the factors associated with this

Page 9: Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Setting

Study Design

• Mixed methods approach informed by ‘realistic evaluation’

• Four case studies of Lester implementation were written-up and compared

• Data for case studies: Outcome Audit – to measure impact of implementation Qualitative Investigation – to understand how outcomes

were achieved• Inpatient survey – views on physical healthcare

Page 10: Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Setting

Outcome AuditData collection • Case note audit before and after pilot initiatives:

Baseline – av. 82 per site (range 30 – 100)Follow-up – av. 65 per site (range 29 - 100)

• 6 – 9 month gap between baseline & follow-up

Data analysis• Number and characteristics of patients receiving

Lester screens/ interventions before and after pilot interventions were compared to assess change

Page 11: Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Setting

Qualitative Investigation

Data collection• In depth interviews (n=82)• Focused participant observation• Most data collected during site visits

Data analysis• Data coded and analysed to provide account of:– Trust context; what was planned; what happened; impact

& outcome of implementation; process and context factors associated with impact

Page 12: Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Setting

Service User Survey

Data collection• Focus group with service users to inform

questionnaire design• All pilot sites distributed questionnaires• 195 completed by inpatients and analysed

Data analysis • Focus on what physical health means to service users

and what types of screening/ intervention they want

Page 13: Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Setting

B) Results

Page 14: Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Setting

Inpatient survey results • Inpatients’ views on CVD screening and intervention when in MH hospital vs. community

• 195 questionnaires were completed across the 4 sites

• 31% reported substantial concern about their physical health

• 84% at least ‘somewhat’ confident that their mental health team takes their physical health concerns seriously

• Care coordinators most commonly identified source of information about how to

be physically fit and healthy

• 89% wanted ≥1 tests/support when in MH hospital. However, ~60% wanted weight monitoring vs. ≤16% who wanted cholesterol monitoring

 

Page 15: Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Setting

Weight Diet and exercise BP Diabetes Smoking Cholesterol Other None0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

62% 59%55%

48%

34%

16% 16%

10%

59% 59%

46% 46%

33%

13% 13%15%

in mental health hospital in the community

Proportion of respondents wanting assessment of physical health problems in hospital and in the community

Page 16: Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Setting

 

  

 

As meals are healthy and you are encouraged to have your

meals when you live on your own you have no-one to keep an eye

on eating healthily.

When in community I eat junk food and hospital provides veg,

salads and gym.

The OT staff are very open and receptive. I have almost had a

personal trainer and all the staff have helped me feel better about

myself.

Being in mental health hospital means opportunities can be

found to get into the gym and monitor my physical health

while I’m exercising.

Page 17: Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Setting

 

Set mealtimes aren't good (and set meals). Limited to when and what you can eat. Should be able to buy own food and keep in kitchen.

Gym or exercise time is limited to certain times in the day and I can't always attend. Being depressed and on medication makes the motivation suffer.

If I was in the community I could do more activities for example long walks and bike rides.

I feel that it's not uncommon for me to be physically healthy but I find it hard motivating myself and sometimes feel that a psychiatric hospital isn't always the best place to keep fit - mainly based on the equipment and/or facilities that are offered up to me.

Page 18: Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Setting

• Smoking

• Weight

• Blood pressure

• Glucose

• Cholesterol

Audit data: screening and intervention

Page 19: Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Setting

Key impact audit findings from across 4 sites

1% 1% 4%

21%

27%

46%

0 screenings

1 screening

2 screenings

3 screenings

4 screenings

5 screenings

1% 4%

12%

83%

0 screenings

1 screening

2 screenings

3 screenings

4 screenings

5 screenings

Baseline Follow up

Page 20: Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Setting

Base

line

(n =

350

)Fo

llow

up (n

= 2

80)

Base

line

(n =

350

)Fo

llow

up (n

= 2

80)

Base

line

(n =

350

)Fo

llow

up (n

= 2

80)

Base

line

(n =

350

)Fo

llow

up (n

= 2

80)

Base

line

(n =

350

)Fo

llow

up (n

= 2

80)

Smoking Weight Hypertension Glucose Cholesterol

0%

20%

40%

60%

80%

100%

120%

97%98%94%98% 96%100%

73%

94%

52%

88%

Screening not documented

Screening refused

Screened - intervention not needed

Screened - intervention needed (Lester 'RED ZONE')

Screening offered

Screening

Page 21: Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Setting

Interventions

Base

line

(n=2

18)

Follo

w u

p (n

=189

)

Base

line

(n=1

90)

Follo

w u

p (n

=161

)

Base

line

(n=8

5)

Follo

w u

p (n

=44)

Base

line

(n=6

6)

Follo

w u

p (n

=21)

Base

line

(n=1

0)

Follo

w u

p (n

=5)

Smoking Weight Hypertension Glucose Cholesterol

0%

20%

40%

60%

80%

100%

120%

72%

97%

63%

87%

39%

59%

36%

67%

90%

Intervention not documentedIntervention refusedIntervention receivedIntervention offered

Page 22: Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Setting

C) Discussion

Page 23: Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Setting

Influences on CVD

screening and

intervention

Perceived influences on CVD screening

and intervention*

Clinical skills and confidence to use

them

Recording physical health data

Perceived appropriateness, motivation and

engagement by staff

Interface with primary care and other specialist

services (e.g. cardiology)

Availability of necessary equipment

Effective communication with service users about their physical health

Clarity over roles and responsibilities

*As identified in the Project Initiation Documents produced by the four pilot projects for NHS England.

Page 24: Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Setting

Making a difference

1: Improving recording of physical health data

Potential change mechanisms

Electronic tools make it easier for staff to know if and when they

should be checking CVD risk factors.

The integration of physical health screening in routine assessment.

All physical health information is stored in one place.

Easier retrieval of data.

Page 25: Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Setting

Examples: Improving recording of physical health data

 Incorporation of the Lester tool into the Essence of Care

& incorporation of Lester tool care plan onto RiO.

A standalone spreadsheet on secure trust shared drive

for recording screenings and interventions in line with

the Lester tool.

Page 26: Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Setting

Making a difference

2: Improving clinical skills and confidence to use them

• ‘Back to basics’ training in screening, to more advanced

training in interventions.

• Physical health link workers/champions to cascade learning

Potential change mechanism

• Staff are better able to undertake screenings and

interventions prompted by Lester tool.

Page 27: Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Setting

Examples: Improving clinical skills and confidence to

use them

1. TEWV ran a series of training sessions for

staff in the two pilot wards.

2. NTW development of a network

of 96 Band 6 Physical Health Link Nurses already

working across the trust, using a ‘train-the-

trainer’ approach. 

Page 28: Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Setting

Making a difference

3: Improving interface with primary care and other specialist

services

Pilot sites undertook mapping and development of clinical

pathways, to identify gaps in patient access to appropriate care.

Potential change mechanism

Equal access to appropriate interventions is

ensured across the trust.

Page 29: Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Setting

Example: Improving interface with primary care and other specialist services

NTW reviewed their

cardiometabolic care and pathways. They also

mapped diabetic and COPD pathways and made

recommendations to the trust’s Physical Health and

Wellbeing Group with regard to service

improvements and gaps in access to specialist

services. 

Page 30: Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Setting

Making a difference

4: Clarifying roles and responsibilities

Trust-wide policies specifying which type of staff were responsible for

which physical health screenings and interventions.

Potential change mechanisms

Senior management commitment to &

endorsement of physical healthcare.

Clarity of responsibility and timeframe for staff for physical health

screenings and interventions.

Page 31: Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Setting

Example: Clarifying roles and responsibilities

2gether produced a clear, concise policy on

‘Physical Examinations in Inpatient Settings’. It included a

table summarising admission and review procedures and

specified:

(a) the healthcare professional (e.g. admitting doctor)

responsible for each assessment (e.g. routine bloods)

(b) the timescale for completing the assessment. 

Page 32: Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Setting

Making a difference5. Improving communication with service users about

their physical health

Inpatient survey undertaken;

Lester Postcard used

Potential change mechanisms

• Survey results can inform communication approaches

• Lester Postcard, designed for service users by service users,

can encourage discussion & raise awareness

Page 33: Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Setting

Examples: Improving communication with service users

about their physical health

Mersey Care initiated the inpatient survey. All sites took part

and received individual reports with feedback from their trust’s

service users.

TEWV ordered 2000+ postcards – distributed

to meet their pilot objective of improving service user awareness

and understanding around physical health.

Page 34: Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Setting

Context – importance of CQUIN & other contextual factors

• Policy & commissioning context – national CQUIN, NAS, Lester - has created favourable conditions for local QI

• Practice variable at beginning of pilot, e.g. NTW much better at screening overall

• Strong support in each trust for national ‘agenda’• Variation in how high level policy is translated into

practice• One trust provided an esp. challenging context for QI

Page 35: Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Setting

Barriers to improvement

• Concerns about the applicability and usefulness of the Lester Tool in improving outcomes

• Setting in which screening and intervention should be undertaken

• Acceptability of CVD screening and interventions to service users

• Complex IT systems • Governance and data sharing• Absence of joined-up working

Page 36: Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Setting

Limitations of evaluation

1. Short gap between baseline and follow-up (6-9m)2. Insufficient resources to collect patient outcomes

data3. Sample for inpatient survey not randomly selected4. Improvements result of better recording or real

changes to practice?

Page 37: Evaluation of the implementation of Lester tool 2014 in Psychiatric Inpatient Setting

Conclusions

• Pilot activities had positive impact on recording and practice of CVD screening and intervention

• Lester Tool is suitable for further roll out• Inpatient survey results and case studies offer

important lessons• Lessons will be distilled in upcoming resources from

NHSE• Transferability to LD services addressed separately


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