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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
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
A) Pilot projects and their evaluation
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
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).
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
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
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
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
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
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
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
B) Results
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
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
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.
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.
• Smoking
• Weight
• Blood pressure
• Glucose
• Cholesterol
Audit data: screening and intervention
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
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
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
C) Discussion
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
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.
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
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
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?
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