Physical health interventions – the patient journey from a physical health perspective through our services.

Aims • Give an overview of 2gether’s project including its

achievements and challenges.• To describe the assessment and intervention processes

that are undertaken within Wotton Lawn Hospital and how the Lester tool is implemented.

2gether NHS Foundation Trust-• Who we are and what we do• 2gether NHS Foundation Trust (2gether) provides specialist mental health

and learning disability services to the people of Gloucestershire and Herefordshire.

• We serve a combined population of 761,000 people who live within 1900 square miles of rural and urban landscape. 96% of our services are provided within the community

• At any one time, we are deliver services to around 18,500 individuals while offering education and support to their carers and family.

Why so important? •Severe mental Illness reduces life expectancy by 15-20 years•Deaths among people with Schizophrenia occur at three times the rate expected in the general population – due to poor physical health.•People with Severe mental Illness are at higher risk of specific physical health conditions

Where we started : • In 2014/15 National CQUIN for National Physical Health• 2gether NHS Foundation Trust also successful in

application to be involved in NHS Improving Quality (IQ) pilot site – 2 year project .

Goal – to embed the use of the Lester Tool for all patients with a SMI and then to extend to all patients at increased risk of poor physical health outcomes

Achievements and Challenges

Physical Health at 2gether what was in place• Physical Health Expert Reference Group• NEWs embedded• LESTER Tool• Open RiO• Willingness from key teams groups

What helped to achieve implementation• Physical Health CQUIN’s• NHS IQ project• Health Facilitator post • Essence of Care tool & LESTER care plan system• Physical Health Policy – full re-write• Training programme - Multi disciplinary

Challenges for implementation • RiO – our electronic patient record .• Numbers of professions involved in physical health

screening and implementation – whose responsibility was it ? Who should do what, when and where to record it• Consistency in application • Change of culture for mental health staff

How we are overcoming Challenges • Engagement and Training : On going training in Lester tool , Care plans and

Physical Health to Teams and Groups

• Identification of roles : Nursing, Medical, Physiotherapy/Health and Exercise

• Improving Systems: Rio working group to stream line Physical Health Screening and Intervention. Reviewing and improving care plan templates.

• Governance : Audit and follow up/ support where Lester tool or Care plans fall short of expectations . Implementation of Physical Health Policy. Reporting to Physical Health Expert Reference Group

•

Results and Progress to Date Trust Wide – LESTER Tool Screening

Wotton Lawn Hospital• 76 bed unit plus a 12 bed low secure unit for working age

adult patients.

• Approximately 730 (725 acute ward) admissions over the 2015 period.

Physical Health at Wotton Lawn Hospital (WLH)

• Staff recognise increase in co morbidities.• The Trust has recognised and adapted.• Attempts to identify roles in the LESTER tool.

Physiotherapy and the Exercise and Health Team and OT Team at WLH• 3.0 WTE Exercise and Health Practitioners (Band 7 and Band 5).

• 3.5 WTE Physiotherapists (Band 6 and Band 5).

• 1.0 WTE Physiotherapy Assistant (Band 4).

• 8.5 WTE OT (Band 7, Band 6 and Band 5)

• 2.0 WTE OT Technicians (Band 4)

• 1.0 WTE OT Assistant (Band 3)

Offering a seven day service including evenings

Engagement, Activity and Physical Health TeamsEach PICU and Low Secure Unit has an EAP team of:•1.0 WTE Exercise and health practitioner (Band 6)•1.0 WTE OT (Band 5)•0.5 WTE Physiotherapist (Band 5)•3.0 WTE EAP Technicians (Band 4)

“Working together to reduce mental health inequalities and improve opportunities by engaging individuals in decisions that will improve their quality of life. This is achieved by adopting the principles of recovery.”

Medical intervention as part of the initial patient journey• Dr physical examination• Blood on admission to include cholesterol and HbA1c• Further examination and investigations as needed

Nursing intervention as part of the initial patient journey• Essence of Care on admission and every 28 days• ECG on admission and as indicated• To commence elements of the LESTER: BP; Cholesterol; Diabetes; Alcohol use; Substance misuse• NEWS once a week and as clinically indicated• Physical health discussed at the MDT meeting each week for all

service users• Activity coordinator and activities program• Urine Drug Screen/ Alco-meter as indicated• Dipstick Urinalysis as indicated

Physiotherapy intervention as part of the initial patient journey• Falls assessment, which may include additional assessment

e.g. POAM, Berg Balance.

• VTE assessment.

• Further specific assessment. For example; neurological, musculo-skeletal, respiratory.

• Development of specific treatment and intervention programmes.

Exercise and Health intervention as part of the initial patient journey

• MUST assessment (Malnutrition Universal Screening Tool)• LESTER tool: Smoking; BMI; Lifestyles and life skills• PAR-Q• Development of specific treatment and intervention

programmes/care plans

How we prevent/reduce the risk factors• A gym within the hospital, swimming and walking groups, hydrotherapy, 1:1 running

session, circuits, pilates, dance, box fit.

• Healthy living sessions to include a designated nutrition group.

• Smoking cessation advisors within the physiotherapy/exercise and health department

• 1:1 health education

• Liaison and joint working with OT’s, nursing staff, dietician’s, doctors, kitchen staff, turning point, external government led organisations e.g. change4life

• Offer healthy meal options and food diaries

• Physical health monitoring including weekly weight, BP, pulse, BM’s.

• Address motivation and mental health

• Team are often considered the physical health leads/champions

• Healthy social activities

• Inclusion for all

Case studyMs B –

54 years old, diagnosed with bipolar disorder as a teenager.Never married and lives alone. Ms B has one friend who she goes on holiday with yearly and will

meet for coffee once a week. Other than this, Ms B leads a secluded life

Ms B used to be admitted to Wotton Lawn approximately 3 times per year.

On this admission, Ms B had presented with low mood and low levels of motivation which resulted in her spending prolonged periods of time in bed and self neglect.

Problems identified:- Assessments completed:-

Actions taken:-• Turning rota and provision of specialist equipment• OT intervention for daily living tasks• VTE monitoring• Circulatory exercise• Mobility work and Extend sessions• Timetabled physical activity to provide structureGym x3 per week (as able); Swimming once per week; Daily walking for 30 minutes• Healthy eating advice/food shopping• Well being advice – sleep hygiene, breast cancer awareness• Weekly weighing• Food diaries• Dr medication review for HTN and diabetes• Offered support when going to follow up appointments at the breast clinic• Outpatient walk4life every Wednesday morning

Results • Has not been admitted to Wotton Lawn Hospital for over 2 year and half

• Weight loss of 5kg during 2 month admission

• Continues to attend community walking group every Wednesday and carers an

community staff also help with maintaining a healthy diet

• Continues to lose weight in the community and has more structure to her week

• Able to identify signs or concerns regarding breast care

• Regular visits to GP for diabetes and HTN control

• Also seen by the community recovery team physiotherapist and has asked that

she goes for walks with the team rather than going for coffee

Thank you

Any Questions?