Showcases the Overall Winner at this year’s PEN National Awards

Leicestershire Partnership NHS Trust (LPT) provides integrated community health, mental health and learning disability services for a population of a million people in Leicester, Leicestershire and Rutland. We have more than 5,000 staff and a passion for quality, integration and excellence. LPT’s division of Families, Young People and Children’s Services (FYPC) provides the School Nursing Service across the area.

1INTRODUCTION
ChatHealth is new texting software that safeguards vulnerable teenagers. It keeps messaging conversations safe/secure to provide timely, confidential access to help from qualified clinicians. Our initiative is improving experiences for patients and staff – who co-developed the system uniquely for the NHS.
AMBITION
Our ambition was to transform access to healthcare for young people. They are leading communications change – almost 100% own mobiles, 80% have advanced phones used to administrate every aspect life. If we fail to provide age-appropriate care in this landscape, they will disengage further.
IMPACT
Our ChatHealth school nurse messaging service is now available to 65,000 students aged 11-19 in 90 mainstream schools in Leicester, Leicestershire and Rutland. They no longer have to wait for a clinic appointment or ask a teacher’s permission to attend – they just send a discreet SMS text message at any time and get 1:1 support from a clinician.
INNOVATION
Our software proves technology can have large scale, cost-effective impact on improving patient experience – whilst our team is influencing national best practice and actively promoting transfer/dissemination.

PROBLEM
Teens are high risk. In the last 10 years depression/self-harming in this demographic has doubled. Texting provides them with timely, age-appropriate, confidential access to help. It’s widespread technology, offering a far-reaching solution for improving patient experience. Yet it’s rarely adopted in the frontline because staff/managers are risk adverse. The risk of messages going unanswered out-of-hours, losing audit trails and holding sensitive info on handsets, seems to outweigh vulnerable young people crying-out for help.
SOLUTION
School nurses and young people solved this problem. They co-designed ChatHealth. They imagined pupils in school sending texts from phones as normal, but texts arriving with nurses in a computer-based risk management system that:

  • Ensures no message received ever goes un-answered
  • Sends automated safety bounce-backs out-of-hours signposting alternative help
  • Is fully auditable and reportable
  • Notifies staff when action is needed
  • Allows nurses to manage messages as a team without giving out numbers for personal handsets

No off-the-shelf product met this specification. So, the Trust employed a software developer to build ChatHealth.

LEADERSHIP
The plan was supported from the outset by senior management, ensuring high quality leadership. This enabled tech development to begin – bringing to life the system patients and nurses had co-designed:

  • Chief Executive injected initial funding/created dedicated project lead post
  • Director of FYPC chaired project board to ensure robustly governed approach
  • Commissioners, impressed with initial achievements, contributed £150K funding to widen impact.


OBJECTIVES

Project lead was appointed from marketing/communications background, to engage patients/staff and communicate objectives. Aims were clear:

  • Improve patient access to school nurses
  • Enable patients/staff to lead transformation
  • Pilot in 3 schools (4,500 students) until at least 10% contact was delivered by text messaging
  • Assess impact on patient/staff experience, with a view to rolling-out

IMPACT
IMPROVED TEENS’ EXPERIENCES
Staff capacity’s stretched; sometimes students can’t get to see a school nurse. But, some choose not to see a school nurse. They feel more comfortable talking about sensitive issues without meeting face to face (F2F). Because of emotional/cultural stigma they feel more self-confident speaking remotely/anonymously from “behind the screen” (of their mobile device). ChatHealth gives patients a better experience on both fronts.
IMPROVED OUTCOMES

  • Increased reach/access – 100 additional monthly contacts
  • Overcomes stigma of F2F access – half of contacts begin anonymously
  • Reaches underserved teens, 1/5 male users compared to 1/10 in F2F clinics
  • More 1st time users, broader range of enquiries, earlier intervention compared with F2F clinics
  • Improved safety for staff and service users
  • Improved interagency working with police/social-care

MEASUREMENT/VERIFICATION
To better understand the impact we examined/discussed patient/staff experiences in a number of ways:
Focus groups (30 students)

  • Student survey (2,000 respondents)
  • Staff reference group
  • “Mystery shopper” anonymous test by appointed service user
  • Patient/staff satisfaction video interviews
  • Peer review; 150 conversation transcripts reviewed by school nurses/managers
    Reviewers described a thorough, timely, instant, informative, succinct, safe, non-judgmental, sensitive and reassuring service.

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TESTAMONIALS

See short exert from patient/staff satisfaction interviews: Young People and Staff Feedback
Read more feedback in “Additional Supporting Evidence”.

WHAT MAKES THIS INITIATIVE SPECIAL?
CHALLENGING CLIMATE
With 1,200 school nurses nationwide looking after 20,000 schools, there aren’t enough staff. ChatHealth is the kind of sustainable solution needed to improve experiences more young people with fewer resources.
EFFICIENCY SAVING
School nurses can now provide an industrial-scale messaging enquiries service. We introduced a single point of access triage model, so just one duty nurse handles all enquiries from 65,000 patients across Leicestershire. If all Trusts adopted a similar model, as few as around 30 nurses could handle all messaging enquiries from all UK teens.
COST SAVING
We’re delivering 100 additional monthly contacts within existing capacity. Achieving the same in a traditional F2F way would require two additional nurses costing £70K p.a. Low-cost messaging contacts eliminate unnecessary resource-intensive F2F contacts, saving taxpayers’ money. Furthermore, our duty nurse responds to two thirds of enquiries through messaging; only one third is escalated to F2F colleagues. This releases capacity so more F2F care can be delivered where it’s most needed.
TRANSFERABILITY/DISSEMINATION
The capacity for transferability is infinite – ChatHealth is configurable to multiple services/organizations. We’ve already engaged widely with other Trusts and identified a healthy appetite to adopt the culture/behaviour.
AGE-APPROPRIATE
ChatHealth improves the patient experience for teenagers because it’s age-appropriate. Techy young people will become increasingly isolated if healthcare fails to keep up with them – ChatHealth turns that on its head by changing the primary way we interact with patients.
SAFELY IMPROVES ACCESS FOR UNDERSERVED TEENS
This would be impossible without our unique technology and guidance which ensures safety. Nurses say they speak with more new young people than ever before across a broader range of issues. We get more contact from vulnerable/underserved adolescents who might not otherwise engage with healthcare, particularly boys, for whom we are significantly improving outcomes.
SCALABLE
ChatHealth is significantly scalable, which we are actively catalysing. This could benefit high numbers of patients.
KEY ELEMENTS

  • Improves access – an open channel, available to patients 24/7
  • Innovative – more efficient, but simple and safer
  • Age appropriate – empowers patients
  • Earlier intervention – discreet and timely, removes barriers for patients

LEARNING POINTS
CHALLENGING TIMESCALES

  • We learned software development takes much longer than expected, but results are outstanding if patients/staff are involved from the conceptualisation stage.
  • PATIENT CHOICE

  • We haven’t set out to replace face to face care – but we learned some young people prefer an alternative. They say they feel more self-confident, less judged, less exposed speaking anonymously/remotely.
  • SAFEGUARDING/CONFIDENTIALITY

  • We learned young patients are interested in what we mean by “confidential”. We are clear – we won’t tell parents, teachers, etc. if a student makes contact, unless we have concerns about safety. If a message suggests a young person is at significant risk, we ask the police to help ensure they’re safe. Is this a breach of confidentiality? One patient told us they were just pleased someone cared.
  • MANAGEABLE MESSAGING

  • Widening service access has improved our patients’ experiences. We were unsure what would be the impact of this on our already busy nurses, but they say messaging as quick, efficient and manageable. We learned messaging helps them reach more patients within existing capacity.
  • CENTRALISED WORKING

  • Our new single point of access improves timeliness for patients. We thought changing the traditional locality based service model would be challenging. We learned that it flourished. Young people value having direct access and duty nurses say it’s gratifying to support more patients from across the County.
  • CHAMPIONS CREATE CHAMPIONS

  • Patients wanted messaging access and many staff were keen to pioneer it. These confident champions were critical to the success of the project, supporting less confident colleagues to engage. The champions approach was so valuable we made it central to the service roll-out.

Let the Children be heard

Let the Children be heard

Setting: NHS (National Health Service) Leicester City, Leicestershire County and Rutland (LLR) is a public organisation responsible for commissioning health services in the Leicestershire County Region including the Leicester City and Rutland areas. NHS LLR Commissions health services for 955,300 residents and has more than 700 staff. NHS LLR aims to improve the quality of life, health outcomes and the life expectancy of the residents (customers) it serves. The main focus for the organisation is to target the causes of premature death and reduce health inequalities between its residents and the national average.

Introduction: We believe that children and young people should be given a clear voice to help improve the health services they access and need. When NHS Leicester City needed to redesign its strategy for Child and Adolescent Mental Health Services (CAMHS), it turned to its Engagement team to discover how young people felt about the existing service and where improvements could be made. The engagement work that followed resulted in a new service specification that better meets patients’ expectations, based on young people’s feelings about using the service.

To design the most appropriate service, a public consultation took place over four months. The aim was to listen to what young people:

  • think of the service
  • want from the service
  • want to be prioritised regarding treatment
  • think are major issues that need addressing.

The engagement team then wrote a strategy to reflect the findings from the public consultation, reflecting the priorities and service changes that were fed back.

Summary of Outcomes

By carrying out such a robust process with the full involvement of children, young people, their families and carers alongside experienced and knowledgeable health professionals, From the results a new strategy was written, and service changes made, with principles chosen to reflect the children’s views. NHS Leicester City feels confident that the CAMHS strategy developed will ensure continuous involvement and service improvement. The young people involved have had their voices heard and their thoughts acted on, which has proved to be an overwhelmingly positive experience for them. And, as well as meeting the needs of patients, the efficiency of the service locally has improved dramatically.

Let the Children be heard

How Was It Achieved?

In order to design the most appropriate and effective consultation, we used the insight and knowledge of young people. The consultation was designed by a young person who joined the engagement team on the Takeover Leicester Day, with input from other young people and supported by YoungMinds, a charity for children’s and young person’s mental health promotion. The young people suggested who should be approached for comments, the style of language to be used and advised on incentives they would trigger the best response. This knowledge and information proved invaluable in creating a genuine engagement process. The resulting questionnaire design was simple to understand and complete, asking children for their thoughts on the rules of the service and what the priorities should be.

We then evaluated the existing service and developed the engagement plan with children and young people, identifying the priorities and guidelines by involving stakeholders at every key stage of the process.

There are two elements of this project which have been very unique; the integration and influence of patient feedback into the project and strategy as a whole, and the engagement design itself.

From project initiation to the strategy design through to the final documentation, the patient has been placed at the heart of the service and includes objectives that are viewed as real and will improve the patient experience. Throughout the process there has been real influence from patients, carers and local children and young people which has been a rewarding experience, creating a completely accessible strategy.

The engagement design used experience-based patient involvement from the very beginning. The look, feel, tone and method of engagement was all influenced by the end user – children and young people all played an integral role in the design, language, communication channels, questionnaire and presentation design which made it easier for communication and made the strategic process understandable for people involved. This allowed the engagement team to collect excellent, beneficial feedback that was meaningful to the organisation and the strategy design.

The strategy itself has outlined the future progression of CAMHS and has laid the foundations to continually improve patient experience. We ensured the plans developed were fed back to interested stakeholders and complied with the standards of engagement for all partnership organisations of CAMHS. An agreed priority was for CAMHS staff to continually gather patient feedback on service delivery. A real success is that there is now on-going engagement by the service itself as part of the delivery strategy. Taking a ‘whole family approach’ to treatment involves including carers and family members in future care and this approach was highly supported by the consultation and by CAMHS staff.

The feedback has also had an influence on the future action plan for CAMHS. This is to be fulfilled by 2014 when the strategy is to be reviewed. By this point the future GP lead Clinical Commissioning Groups – CCGs – will be responsible for the review, and they are being made aware of how successful this process has been.

Learning Points and Tools

There were many learning points from this particular project. They included very small factors and some overarching principles which our organisation has used on projects since the project debriefing.

The most valuable learning experiences which were key to the project’s success are:

  • Ask questions; do not be afraid to ask service users for advice on what they want.
  • Use best practice; the design phase was made easy and was quick and simple by using best practice materials such as artistic pathway design (NHS Leicester City), experience based design (Institute of Innovation), and easy read (LDICN).
  • Test and test again; using the questionnaire as an example, the first questionnaire was not the final one. We used practice questionnaires to develop a final questionnaire which could be delivered by people who may not have known CAMHS well.
  • Hear what people say; we didn’t just listen to what patients were saying, we heard what their problems were. Some issues raised were not necessarily the problem itself, but an underlying cause. We explored these using a focus group which proved successful.
  • Take time; this was a long process, allow the project time and remind people that it is happening. This removes the tokenistic approach and allows the organisation to gather meaningful feedback.

Living Our Values

Summary – A key aim of this programme is to nurture a values-led culture within teams: through team development sessions, facilitated by trained in house facilitators, to build the skills to deliver a great patient experience, and to be receptive to, and act on patient feedback. We wanted to inspire staff to want to make changes and improvements; in their behaviour, for their teams and for their patients.

Organisation

Ashford and St. Peter’s Hospitals were authorised as a Foundation Trust (FT) in December 2010. The Trust is a medium sized district general hospital working across two sites, St Peter’s Hospital in Chertsey, Surrey and Ashford Hospital in Middlesex. The Trust employs over 3,200 staff, serving a population of 450,000 including a broad socio-economic and ethnic mix. The Trust provides a wide range of medical, surgical, diagnostic and emergency services as well as a full range of medical outpatient specialties. Ashford and St Peter’s have a combined bed allocation of over 600 beds.

Background

Our values are:

  • We put patients first;
  • We take personal responsibility for our role and the responsibilities we have every working day;
  • We have a passion for excellence in everything that we do; and
  • We take pride in our team, looking out for each other and celebrating our successes and supporting each other through the challenges we may face.

We believe that to succeed in improving patient and staff experience a vital starting point is the alignment of core values to the patient and staff pathways around our core values. We have been and will continue to work closely with our employees to inspire and enable them to listen to what patients say and to make improvements to the clinical and non-clinical services they provide to them.

A key aim of this programme is to nurture a values-led culture within teams: through team development sessions, facilitated by trained in house facilitators, to build the skills to deliver a great patient experience, and to be receptive to, and act on patient feedback. We wanted to inspire staff to want to make changes and improvements; in their behaviour, for their teams and for their patients.

Our aim was that all Trust staff – from ward to Board would have the opportunity to attend a workshop within 6 months.

Approach

  1. Diagnostic review; programme plan and messaging
    Identify a plan to create a clear vision for improving patient and staff experience, based on a good understanding of what is already in place:
    • Diagnostic sessions were held to create a vision for aligning patient and staff experience pathways, we identified what was already in place and agreed improvement priorities with our Project Board.
    • Established objectives and measures of success.
    • Developed a plan for roll out of team sessions and feedback
  2. Team development

    The aim was that every team would take part in a workshop to raise awareness the importance of values and feedback in delivering a great patient experience, to practice service and communication skills and to put in place an improvement loop of listening to and acting on patient feedback by providing a:
    • Team workshops which included presentation materials and a facilitator guide
    • Tailored delegate workbook which was brought to life with real patient and staff feedback.
    • We trained 16 members of staff to deliver the training across the Trust

Before workshops staff were provided with “graffiti boards” in their areas to write comments, below with some examples:

The compliment I’d most like to hear from patients:

  • Knowledge & confidence/caring in their care.
  • Trust.
  • You seem cheerful.

Within our Team we can help each other to live our values by:

  • Team building.
  • Working as a team and all chip in!
  • Listening & supporting each other.

I’d like my colleagues to describe me as the kind of person who:

  • Is a good team player.
  • Listens and assists their concerns
  • Communicator and team worker – happy to help.

The organisation can support me to live our values everyday by:

  • More communication!
  • Listening to our concerns.
  • To show appreciation on a personal level & to understand the concerns we have!

The sessions in the workshop focused on:

  1. 1. “We get what we give” – the experience exchange cycle, helps us understand the impact of what we say and do on others and how this can in turn affect us.
  2. 2. Confident communication
  3. 3. Challenging behaviours
  4. 4. Patient stories – staff met with our patients, carers and relatives or watched a video of one of our patients. They then worked together to think about what they would want to differently.
  5. 5. Putting our values into action – inspired by the patient story and what they had learned from each other and the graffiti boards.
  6. 6. Listening and improving
  7. 7. Personal Commitments

This was a true ward to Board venture. Where possible staff attended in their team groups. Where this was not possible staff attended in specialty groups. All levels of staff took part including: Executive and Non-Executive Board members, consultants, nurses of all grades, administrative staff, allied health care professionals, managers, registrars, housekeeping staff. We achieved 86% attendance. The Project Team reported to a Steering Group, whose Executive members were the Director of Workforce and Organisational Development, the Chief Nurse and the Medical Director.

To support the involvement of Clinicians we set up a “Medical Advisory Group” who helped us design bespoke sessions for doctors, which were well attended.

Outcomes

The key measurement of success was attendance of staff at workshops. Early on in project delivery we found that levels of attendance were low, we explored this from feedback and a significant barrier to attendance was the level of time commitment. We therefore worked with April Strategy and our facilitator colleagues to redesign workshops, providing a high quality half day option. We then re-launched this and attendance dramatically increased.

There was also an initial resistance to attending workshops, or staff who did attend did so reluctantly. However word got out that the workshops were not only interesting and helpful – they were also fun! Bookings increased dramatically.

We wanted to see evidence that staff were engaging with patient stories:

Whether face to face, with one of our patient story videos and also with patient feedback and that they intended to make changes as a result.
Each team developed a set of Team Standards and these demonstrated that they had been inspired by the patient story and the workshop to think about what they and their teams could do differently to improve both staff and patient experience.

A suggestion was that we develop a patient diary and this has been commenced – it is currently under a second stage of development, following feedback from patients and following pilot a final version will be rolled out across the Trust.

We wanted to see more interest in patient feedback taken by senior staff:

One Matron responded to patient feedback about frustration they experienced in Out Patient Clinic where they did not receive timely updates about waiting times – the action was to introduce monitors, which give real time updates to patients and Matron is monitoring this.
Another Matron interrogated patient feedback to understand why the Net Promoter Score had dropped during a particular period and discovered that communication had been affected by a Ward move. This has been shared with the staff on the Wards, who were able to associate their behaviours with patient satisfaction – the NPS has improved.

The facilitators received excellent feedback from the majority of staff and often made inspiring comments:

“It’s not about the number of staff, it never will be. It’s about your individual attitude with that patient, at that time – you have a choice”.

“That moment you have with the patient is their moment – it’s not your moment to be stressed or huffy and cross – it’s your moment to be with them”.

Evidence that staff are living our values are reflected in The WOW! Awards submissions – the Trust introduced the national recognition scheme in July 2012 to capture positive staff and patient feedback relating to when staff get it right!

Derek Williams, Chief Executive of The WOW! Awards, said: “Running The WOW! Awards across a broad variety of sectors, we are truly surprised and delighted by the enthusiasm of patients for catching people doing things right. It’s clear to see the impact this has on employees and management are getting a whole new line of communication which will help to underpin their teams’ standards.”

Here are some examples of those award submissions:

Passion for Excellence

  • “At one stage I was seeing [the nurse] 3 times a week, and she has always been so kind, gentle and patient. She really goes that extra mile to put patients at ease, and shows that she enjoys her job. She is always there if I need her advice, and will always make time to see me if need be. [She] is a REAL nurse – kind and caring, something sadly missing in the world of today.”

  • Patients First

  • “The staff were very kind and considerate to all [my mum’s] needs”
  • “My daughter, who has multiple food allergies, has been admitted to Ash Ward 3 times in the past 2 months and on every admission [the Housekeeping Assistant] has gone above and beyond to ensure that she gets everything that she needs, pre ordering her allergy friendly meals ahead of time, and following up with us to make sure everything arrives as expected. This is a huge weight off our minds during a difficult time”
  • “[The physiotherapist] always has time to help you understand why you have pain and how you need to help yourself.”

Pride in our Team

  • “The day staff on [the Ward] are gentle, compassionate and thoughtful in every way. Their calm, gentle manner is most re-assuring. Also, attention to detail is outstanding; one significant example was cutting food without being asked (as, due to an injury, I am unable to do anything myself). This is just one example of the help that has meant so much to me. I could go on. The overall efficiency is exemplary.”
  • “All the staff are always jolly and willing to help her help herself! My mother can be very difficult at times, yet they manage to get her to improve on a daily basis. Nothing has been too much trouble when I have asked.”

Personal Responsibility

  • “[The nurse] showed so much dignity and supported me when I needed it most.”
  • “I was very nervous today, but [the nurse] was wonderfully reassuring, explaining every detail, and even holding my hand.”
  • “[The physiotherapist] has been so encouraging, helping me with my ongoing hip problem. He explains things so well, which helps with understanding why I need to do the exercises and overall has given me a new confidence, which has been lacking previously.
  • “[The doctor] is simply fabulous! She puts you at ease and has a very engaging nature. It is so easy to speak to her. I consider my visits a social call!”

“I am due to come in for an operation soon, which I am very nervous about. I came in today and was dreading just seeing someone asking *me* general questions and not actually reassuring me and answering *my* questions! [The nurse] was such a lovely lady – she could see I was upset and she took the time to explain exactly what I wanted to know, even without me asking.”

The Future

We have incorporated the Living our Values programme into Trust induction. In association with the Chief Executive’s welcome message about the organisation’s vision and values, inductees participate in a Living Our Values session when we explore the key elements of the original workshop (as outlined above): the communication model; a patient story via DVD; what patients tell us about their experience and inductees are invited to explore what they will contribute to the Trust and what associated support they require from the Trust. The Non-Clinical staff attend a further workshop during induction to explore that contribution as experience from the projects suggests it may be more difficult to appreciate one’s contribution if you do not care for patients directly every day. Feedback from these sessions has been very positive.

We have commenced our “Valuing Frontline Feedback” project, which we have started following a funding award from the NHS Institute’s Patient Feedback Challenge. This project will include activity with two other healthcare providers to share learning from the Living our Values programme. It will also build on what is already in place to develop a replicable approach to continuous engagement with patients and making improvements as a result of their feedback.

We will look at how we gather, report and act on frontline feedback; celebrating success and sharing good practice amongst teams.

Key Elements & Learning Points

The key contributor to success has been the engagement and involvement of staff at all levels as well as patients, carers and relatives.

Our Chaplain and a housekeeper were members of our fantastic team of facilitators. Our Chief Executive really inspired staff to attend after he attended a workshop and gave some positive feedback.

Above all, many patients took part in this programme and some even agreed to be filmed so that their experiences, both negative and positive, could be used to improve services and the experience of patients in the future.

Patients consistently told us how helpful the experience was for them and staff now ask patients to come and tell their story when they want to improve a service or respond to a complaint.

This programme has led to other values-based initiatives, including an invitation to the Tutu Foundation to look at the humanity aspects of the care we deliver. We were honoured by a visit by Archbishop Desmond Tutu to the Trust as part of his recent UK health and education tour.

  • Culture change does not happen overnight, so think about the pace. Be realistic, if it is possible to deliver a large programme over a longer period, you can then also focus on work to embed.
  • If you want to engage a particular staff group (e.g. doctors) make sure you involve them from the outset. It is important to consider how you might tailor workshops according to the audience.
  • Champions are really important –champions from all staff groups actively encouraged involvement in their areas/disciplines.
  • Be flexible! Listen continuously to feedback, adjust plans and comms accordingly.

Northumbria Healthcare NHS Foundation Trust – North Tyneside General Hospital

Multidisciplinary Review of Medication in Nursing Homes – A Clinico-ethical Framework

Northumbria covers one of the largest geographical areas of any health trust in England and provides integrated health and social care to over 500,000 people living in Northumberland and North Tyneside and employs 9000 staff.
Medicines use in care homes is an area of concern. Problems include:

  • Excess medicines (sometimes inappropriate)
  • Lack of structured review of medicines
  • Patients unaware of what treatment they are on and why

It is estimated that between 10% and 71% of elderly patients take medicines that are not suitable or have the potential to cause harm. Some patients experience minor side effects from medicines that have a profound effect on their quality of life.

Case study: 85 year old lady in a care home was bedbound (strokes & dementia) and unable to communicate or make decisions for herself. She was prescribed 11 regular medicines, including medicines to prevent a fracture, and medicines to prevent cardiovascular disease. Each day nursing staff would administer these medicines by lifting her head and pouring the solution into her mouth. This lady was also taking antidepressant, hypnotic and antipsychotic medicines for agitation. On stopping her preventative medicines her agitation resolved and in time her clinicians were able to stop medication for her agitation.

This case study demonstrates that residents are prescribed excess, inappropriate medication and they or their families (advocates) are not given any say in what medicines they are given.

The aim of this project was to develop a patient involvement framework for medication reviews in care homes.

Funding from The Health Foundation Shine 2012 award was used to set up a series of medication reviews in care homes. A team involving psychiatry of old age, pharmacy, care home nurses, general practitioners and the Trust’s patient experience expert led the project. Care home and general practices from North Tyneside were invited to participate. The stages of the reviews were as follows:

  1. 1. Detailed medication review by clinical pharmacist
  2. 2. Multidisciplinary team (MDT) meeting to discuss review
  3. 3. Meeting with resident or representative (e.g. family) to discuss medicines, MDT discussions and patient’s preferences
  4. 4. Proposed changes (e.g. stop or start medicines) take into consideration the MDT and resident (or representative) discussions

As not all residents had the mental capacity to participate in the reviews, the team developed a four level patient involvement framework, with all reviews starting at level one and moving down to level four (least desired option).

  1. 1. Resident involved in review and makes decisions regarding medicines
  2. 2. Resident has no capacity: Family or representative makes decisions on behalf of the patient
  3. 3. Family not actively involved in resident’s care: A letter sent to family outlining the discussions from the MDT. The family are encouraged to contact the pharmacist to discuss or challenge any proposed changes
  4. 4. No family or other representation: Formal advocacy

The residents are followed up periodically following any changes to monitor for any adverse events. The project’s patient experience lead has been interviewing a sample of patients and family members to capture their experiences on being involved in this project. We used a mixture of quantitative data and qualitative data to measure the success.

Quantitative Data
To date we have completely reviewed 105 residents in 5 care homes.

Quantitative data was collected prospectively at the end of the review process. Our primary data sources are GP records, MDT data collection form and care home records. In some cases we have requested hospital notes.

In 105 residents we made 364 interventions with 14 different types of interventions being made. The most common intervention was to stop medicines; 195 medicines (23.6% of all medicines prescribed) in 81 residents (77%). The 105 residents were taking 825 medicines (average of 8 per resident) compared with 630 medicines (average of 6 per resident) following the review; a 23.6% reduction in medicines burden. The main reason for stopping medicines was lack of indication for the treatment; 108 (55.3%) residents. In 16 cases (8.2%), patient safety was the primary reason for stopping the medicine.

Resident Involvement Framework
Figure 3 shows our current resident involvement mapped against the framework. In most cases the residents or their family representative were involved in decisions. We have used advocates for two residents.
Figure 3: Resident Involvement Framework

case-study

Qualitative findings
The main themes emerging from care home staff are:

  • Non-compliance, inability to take tablets, residents’ lack of awareness and understanding of current medication.
  • Staff reported varying involvements from family members
  • Suggestions to improve their residents’ experience of medication and medication reviews included regular medication reviews prompted by the medical practice, forgetting the cost implications of liquid medication when a resident requires it, protected medication rounds and prevent wastage of drugs that have not been removed from repeat prescriptions.

Family members valued getting a voice:
“There is no point in people being on things unnecessarily. You don’t need to be on them, why be on them”
“I think we should be notified if something was going to be stopped. [pharmacist] discussed about taking her off a Statin. Erm…. but at the minute I think she is happy and has really good quality of life, I don’t think she should be taken off things without consulting the family…”

General practitioners agreed with involving patients in decisions about medicines:
“I think involving the family is a really good idea……………it is a positive thing to try and involve them”
The project has attracted interest from primary care and locally there is a desire for it to continue post-Shine funding. A number of initaives are underway to ensure this happens:

  1. 1. North Tyneside Clinical Commissioning Group (CCG) were informed of the project and have received regular updates from the Trust’s communications team. We are curently working with the CCG on a business case to expand this review service from April 2014, when funding ends.
  2. 2. Northumberland CCG have met with the project team and negotiations to set up a similar service in Northumberland are ongoing.
  3. 3. Northumberland medical practices have shown interest in this project. One practice has commissioned services from the Trust to run reviews for their care home residents and we are about finalise a commission from a second practice to provide a similar service.

The learning from this project has been used to shape a local service suppporting older patients in their own homes.
This initiative has the potential to be applied to other patients in care homes. We have already shared our findings with a team in another CCG who are planning a similar initiative. We have developed a model of patient involvement that other individuals working with care home residents can use.

Our work has the potential to be transferred to housebound elderly patients who live in their own homes. Many of these patients have the same medicines issues as residents in care homes, taking multiple medicines with little involvement in decisions. We have been sharing our work with a local team of health and social care professionals (North Tyneside High Risk Patient Programme) so that learning from this care home project can be transferred to patients in their own homes.

The novel aspect of this project is the patient involvement framework. Too often patients in later life or those who lack capacity to make decisions do not get a say in what medicines they take or don’t take. This project allows patients or their representatives to make informed decisions by being supported by a team of health care professionals.

An example of this in practice is a case of a 92 year old lady who was prescribed simvastatin tablets at night. She was unsure what this was for. After the indication (prevention of cardiovascular disease) and the risks/ benefits had been explained, she made a decision to stop taking this medicine; a decision that her GP and other health professionals supported.

An important learning point from this project has been not to assume that as a health professional, one knows what is best for one’s frail older patients. Patients (and their families) have a desire to be involved in decisions about them.

We have used shared decision making tools to help supports residents and their families with decisions about starting, changing or stopping medicines.

Cate’s plots: http://www.nntonline.net/visualrx/cates_plot/
NHS Right Care: http://www.rightcare.nhs.uk/index.php/shared-decision-making/
Health Foundation’s MAGIC programme: http://www.health.org.uk/areas-of-work/programmes/shared-decision-making/
The team have a number of flyers, research posters, data collection tools (including database), patient/family/professional questionnaires that we will be happy to share with anyone wishing to undertake similar work.

Integrated Community Support Team – NHS Lanarkshire

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East Kilbride and Strathaven is a locality within the South Partnership of NHS Lanarkshire and South Lanarkshire Council. Population is approximately 90,000 in both urban and rural locations with an over 65 population of approximately 24, 000 and rising annually.

The Integrated Community Support Teams (East Kilbride & Strathaven pilot) started on 14th May 2013. They provide inter agency support, especially for frail older adults, requiring coordinated care in their homes. This includes Social Care, Nursing, Physiotherapy (PT) and Occupational Therapy (OT) with palliative or rehabilitation/re enablement programmes as appropriate. Proactive links have been made with other services e.g. Carers Development Officer, Specialist Health Services and the Acute Health Sector.

Working in partnership is fundamental to achieving progress in each of the priority areas as set out in the 2020 Vision (2011) and the Quality Ambitions in the Quality Strategy (2010). This pilot was initiated in response to the Scottish Government Re Shaping Care programme by the NHS Lanarkshire, South Lanarkshire Council and partners.

The Integrated Community Support Teams Model has demonstrated that partnership working across health and social care and with third sector organisations provides person centred, effective, efficient and safe supports to allow older people to remain at home wherever possible.

Crucial to all of this were the consultations with, not only all the social work, nursing, allied health professionals and medical staff, but with their partners in the 3rd sector and independent providers and absolutely, not least, the people themselves and their families and carers.

The key issues identified were:

  • Join staff into one team and provide 24 hr community nursing, therapy and home care.
  • Make it a neighbourhood model
  • Use existing knowledge, skills and practices.
  • Build in confidence and resilience within the local workforce
  • Retain GPs as the responsible medical officer

The overall aims were:

  • Provide effective, person centred support to enable people to remain safely at home for as long as possible
  • Support the person to return home as soon as possible if admitted to hospital
  • Support older people with complex health and social care needs to have their community care assessments carried out in their own home if possible

All of this required to be delivered within existing organisational and management structures and within separate bases as available accommodation was limited.

Once the model was agreed and with continued consultation with all the staff and partners pilot teams in the East Kilbride and Strathaven locality were implemented. The ICST comprises both health and social care staff. The social care element includes home carers, community support coordinators, occupational therapists (OTs) and social workers. The health element is made up of community staff nurses, clinical support workers, district nurses (DNs), physiotherapists, occupational therapists, generic support workers and administration staff.

Each team provides coordinated support to a geographic locality area. The desire is to focus on a neighbourhood model, building on the assets within a locally defined geographic area which allowed the flexibility to evolve in a dynamic way.

There had been a recent major realignment within Social Work with the introduction of the Supporting Your Independence (SYI) approach. While home care has been the main focus of SYI activity, the approach permeates all social work practice.

Health care staff are co-located in the three Health Centres, with social care staff in the Civic Centre. In view of accommodation restrictions staff were unable to be co-located together however organisational arrangements have been put in place to maximise opportunities for joint working. Hot-desking with access to both NHS and South Lanarkshire Council IT systems have been put in place on all sites to enable integrated practice. Accommodation was made available within Hairmyres Hospital to provide a secure and central base for both health and social care ICST staff working at weekends, evenings and overnight.

A fundamental ambition of the workstream was to offer a 24 hour, 7 day a week Nursing and Home Care service, closing the 8-9 am and 5-6 pm gaps for Nursing services and the overnight gap for scheduled Home Care – a 24 hour emergency response was already in place. Additional Nursing and Home Care staff were recruited to achieve this.

The Managers and staff from Health and Social Work and the Integrated Community Support Teams have shown what can be achieved when agencies are willing to work together with respect and understanding of each others’ roles, responsibilities and professional cultures but with the single aim of improving care for the local population. Allowing practitioners to inform the development of joint processes has proved effective in building confidence and improving communication. The “lead professional” role enables the continuity of care and the coordinated approach which is vital to this team’s aims.

Prior to the commencement of the pilot a number of qualitative and quantitive measures were identified to be measured against and have demonstrated that:

  1. ICSTs have supported the avoidance of admission to hospital and lengths of stay for older people
  2. ICSTs have supported the reduction in delayed discharges from hospital and allowed people to have complex care assessments carried out at home.
  3. 89% of people referred to the teams in the community have remained at home at 30 days
    Integrated practice is now embedded within the teams.
  4. Nursing caseload complexity is greater in East Kilbride than other localities across Lanarkshire
  5. ICST staff have evaluated the pilot positively

The South Partnership view the work carried out in this pilot of ICSTs as having made a valuable contribution towards informing future arrangements for integration of health and social care.

Not least the independent evaluation and continued feedback from our older people, carers and partner organisations e.g. Carers network, Seniors forums , Public Partnership forums etc has been outstandingly positive.

The evaluation has now resulted in the pilot being continued and is rolling out in the next few months to all other South Lanarkshire areas.

Lessons being learned include the essential consultation with all stakeholders, the involvement of staff and stakeholders in developing the service processes and sufficient flexibility to make adjustments as required.

The use of IT by all staff and links with other agencies together has been a major achievement and is continuing to develop. This has been crucial in delivering the continuity e.g. during out of hours periods.

The single access telephone system has been an undoubted bonus to the patients/service users and their carers – 24 hr access to someone who knows or can quickly access information to support them is seen as the fastest “quick win!! This, coupled with a continuous nursing service and associated home care has provided this 24 hr support across the locality.

Plans are in hand to replicate these important elements within the other areas in South Lanarkshire.
Learning Points / Unique Angles

  • The merging of teams and not another “bolt on” team.
  • Staff feel they are all part of the team – not separate services.
  • We used our existing resources in a different way and listened to what patients, service users, carers and staff all had been saying for many years – bring us together and talk to each other!
  • Consultation
  • Use of existing resources- get the right management leadership and staff involvement
  • Look for solutions not barriers- encourage staff and their patients/service users to provide them