Doing the right things right...

Transcription

1 Doing the right things right... Building the evaluation findings of Keep Well into our future anticipatory care planning Wednesday 27th October 2010, 9.30am pm

2 Building the findings of Keep Well into our future anticipatory care planning Dr Linda de Caestecker, Director of Public Health On behalf of NHS Greater Glasgow & Clyde I am delighted to welcome you to our Doing the right things right meeting, the primary purpose of which is to share the key evaluation findings of Keep Well and to ensure that they fully inform our future planning of anticipatory care. As everyone participating today will be all too aware, health inequalities in Greater Glasgow & Clyde are some of the most extreme in Europe and much of this burden of poor health is preventable. In these turbulent financial times, we will need concerted action from individuals, communities and public and private sector organisations to address the problems that confront us. As we negotiate our way through this current recession, it is absolutely essential that we make the best possible decisions on how to deploy the limited resources we have available for health improvement. We know that there are opportunities to change the drivers of poor health in our most deprived communities, if we do the right things right, as the theme of this conference will explore. Since its inception in 2006, the Keep Well programme in NHS Greater Glasgow & Clyde has been strongly committed to improving the health of people living in areas affected by intense, multiple deprivation. One of its notable achievements has been the rich diversity of approaches that have emerged to deliver this fundamental aim, all seeking to increase access to a wider range of health improvement services in close partnership with primary care. Today s presentations and workshops will allow us to critically examine some of these approaches in their respective local contexts and will help us to better understand the overall impact and achievements of Keep Well over the last four years. I hope that you will take the opportunity of reading the abstracts contained in this portfolio, which represent a selection of the many approaches tested within Keep Well, think critically and contribute actively to the workshops. This will enable us to apply the learning from Keep Well to the health and healthcare challenges of the future by genuinely doing the right things right. 1

3 2

4 PROGRAMME 8:45...Registration 9:30...Welcome 9:35...Opening plenary 10:00...Key findings from the national external evaluation of Keep well Wave 1 10:20...From input to impact: the impact of Keep well at a population level 10:40...What did Keep well deliver - and to whom? 10:50...Did we do the right things right? 11:15...Break 11:30...Parallel sessions 1:00...Lunch 1:45...Introduction to afternoon session Economic Evaluation of Keep well in North and East Glasgow 2:15...Putting it all together: combining Keep well and ASSIGN in sustainable anticipatory care 3:15...Parallel sessions & the way forward Close 3

5 PROGRAMME am Plenary WELCOME Dr Linda de Caestecker, Director of Public Health, NHS Greater Glasgow & Clyde OPENING PLENARY: DOING THE RIGHT THINGS RIGHT : THE TRANSFORMATORY POTENTIAL OF KEEP WELL IN SCOTLAND Professor Harry Burns, Chief Medical Officer for Scotland KEY FINDINGS FROM THE NATIONAL EXTERNAL EVALUATION OF KEEP WELL WAVE 1 Dr Kate O Donnell, Professor of Primary Care R&D, University of Glasgow FROM INPUT TO IMPACT: THE IMPACT OF KEEP WELL AT A POPULATION LEVEL Dr Jim Lewsey, Senior Lecturer in Medical Statistics, University of Glasgow WHAT DID KEEP WELL DELIVER - AND TO WHOM? Ms Heather Jarvie, Keep Well Planning Manager, NHS Greater Glasgow & Clyde DID WE DO THE RIGHT THINGS RIGHT? Dr Anne Scoular, Consultant in Public Health, NHS Greater Glasgow & Clyde 11.30am pm Parallel session Option 1: Engagement/ consultation Coordinator: Heather Jarvie Room: Arcoona - A EVALUATING OUTREACH TECHNIQUES Mhairi Mackenzie WHAT CAN WE LEARN FROM PATIENTS WHO DID NOT ENGAGE? Richard Lowrie WHAT ARE THE COMPETENCIES REQUIRED TO DELIVER KEEP WELL CONSULTATIONS AND DO WE HAVE THEM? Susan Kennedy DETERMINANTS OF PRACTICE NURSE BUY IN IN INVERCLYDE Sandra Moore EVALUATION OF THE KEEP WELL LONG TERM MEDICINES SERVICE Joan Miller 4

6 PROGRAMME 11.30am pm Parallel session Option 2: Health improvement outcomes Coordinator: Julie Truman Room: Arcoona - A EVALUATION OF SMOKEFREE ENHANCED SERVICES IN NORTH, EAST AND SOUTH WEST GLASGOW Liz Grant EVALUATION OF THE HEALTH COUNSELLOR ENHANCEMENT TO LIVE ACTIVE PROGRAMME Chris Kelly EXPLORATION OF THE MAINTAINING MENTAL WELLBEING SESSIONS Paul Lafferty/Marion O Neill EVALUATION OF THE HEALTH CASE MANAGER ROLE Marion O Neill LITERACY AND HEALTH Catriona Carson SOCIAL REFERRAL; LESSONS FROM PRACTICE Julie Truman pm Plenary INTRODUCTION TO AFTERNOON SESSION Alex McKenzie, West Sector Director, NHS Greater Glasgow & Clyde ECONOMIC EVALUATION OF KEEP WELL IN NORTH AND EAST GLASGOW Kenny Lawson, Public Health & Health Policy Research Associate in Health Economics, University of Glasgow PUTTING IT ALL TOGETHER: COMBINING KEEP WELL AND ASSIGN IN SUSTAINABLE ANTICIPATORY CARE Professor Graham C M Watt, Professor of General Practice, University of Glasgow pm Parallel sessions Option 1 Room: Waverly Option 2 Room: Cameronia Option 3 Room: Dalhanna Option 4 Room: Ramillies COMMISSIONING, TARGET POPULATION & IDENTIFYING NEED Facilitator: Heather Jarvie, Keep Well Planning Manager ENGAGEMENT STRATEGIES Facilitator: Anna Baxendale, Head of Health Improvement & Inequalities HEALTH CHECK: CONTENT & COMPETENCIES Facilitator: Dr Paul Ryan, Clinical Director & Gillian Halyburton, Practice Nurse Advisor HI SERVICES: MODELS, CAPACITY & PROCUREMENT Facilitator: Fiona Moss, Head of Planning & Health Improvement 5

7 6

8 PLENARY SESSIONS Key findings from the national external evaluation of Keep well Wave 1 Dr Catherine O Donnell Professor of Primary Care Research & Development, University of Glasgow Kate.O'Donnell@glasgow.ac.uk, Phone: Collaborators: Mhairi Mackenzie, Maggie Reid, Fiona Turner, Yingylng Wang, Julia Clark, University of Glasgow Aim To evaluate the implementation of the Wave 1 sites in particular the extent of their reach and engagement with the Keep Well population and to understand the approaches used. Setting The five Wave 1 Keep Well sites. Methods Mixed methods evaluation, including analyses of routinely collected Keep Well data and longitudinal interviews with local and national stakeholders. Results results will be presented on reach and engagement strategies across this sites and, where available, on baseline clinical indicators. The importance of context will also be discussed. Conclusions and future questions this presentation will reflect on the lessons learned from the evaluation of the Wave 1 sites and suggest issues that need to be addressed in future programmes of anticipatory care. 7

9 PLENARY SESSIONS From input to impact: the impact of Keep well at a population level Dr Jim Lewsey Senior Lecturer in Medical Statistics, University of Glasgow Please see delegate pack for abstract. 8

10 PLENARY SESSIONS What did Keep well deliver - and to whom? Heather Jarvie Keep Well Planning Manager, NHS Greater Glasgow & Clyde heather.jarvie@ggc.scot.nhs.uk, Phone: This presentation provides a strategic overview of the Keep Well programme in Greater Glasgow & Clyde, explaining the rationale and content of the intervention. Keep Well began in North and East Glasgow CHCPs in late 2006, two of five initial Wave 1 pilots in Scotland, followed by: Wave 2 ( ): Inverclyde, West Dunbartonshire, SW Glasgow, Fife, Ayrshire & Arran, Aberdeen Wave 3 ( ): Dumfries & Galloway, Borders & Forth Valley + Well North ( ) Wave 4 ( ): Extension of services in Wave 1 areas to new geographical areas and/or populations The Keep Well programme in GG&C s five pilot sites is underpinned by a common commitment to proactive, targeted CVD prevention achieved through joint working between health improvement services and practices in the least advantaged localities of our Board area. The programme is underpinned by enhanced primary care capacity for health assessments focusing on lifestyle counseling, supported by a variety of patient engagement methods and enhanced health improvement support services. These have been carefully tailored to local circumstances and include enhanced smoking cessation services, stress management and mental wellbeing services, alcohol counseling, healthy eating and exercise classes, literacy support, money and employability advice. Within this broad strategic approach, the Keep Well programme in GG&C has encouraged innovation and diversity of approach across the five pilot sites, to test differing approaches to achieving the programme s overarching aims. These include: programmes targeting Criminal Justice and Community Addiction Team (CAT) service users a Keep Well Health Shop in Parkhead Forge an electronic health improvement service directory a programme of action research to identify & address factors associated with non-engagement a dedicated post to develop inequalities-sensitive engagement, consultation and referral pathways. Since the start of Wave 1, over 25,000 individuals have attended a Keep Well health check, with cumulative uptake rates of 67% in the longest established areas. 9

11 PLENARY SESSIONS Did we do the right things right? Dr Anne Scoular Consultant in Public Health, NHS Greater Glasgow & Clyde Phone: In the context of Keep Well, Doing the right things right has two components: selecting the right models and approaches for reducing health inequalities driven by CVD and other chronic disease which share its aetiology ensuring that we do them right, which means delivering evidence based models in a coordinated, efficient and acceptable way This presentation firstly quantifies the preventable burden of chronic disease in NHS Greater Glasgow and Clyde and then considers the extent to which the programme realised its potential. Over half of all premature deaths in Greater Glasgow & Clyde are potentially preventable. The diseases that cause the greatest burden of ill health also share common preventable risk factors, thus a fully engaged Keep Well programme offers a very real opportunity to reduce several diseases and health problems simultaneously. The key question is therefore whether our prevention activities were as powerful, effective and accessible as we could possibly make them and where can we improve? To address this question, the evaluation of Keep Well in NHS Greater Glasgow & Clyde in 2008 has delivered two types of learning: SUMMATIVE EVALUATION Effectiveness Efficiency Acceptability Equity PROCESS EVALUATION Context Reach Adoption Implementation Maintenance INTEGRATED EVALUATION FRAMEWORK This incorporates a summative judgment on the extent to which the programme s primary aims were actually achieved; and an understanding of the mechanisms by which any positive benefits or unintended consequences were generated. The presentation will draw from a wealth of evaluation evidence to build a picture of the overall effectiveness, efficiency and equity of Keep Well at a population level, variations in delivery of Keep Well across the system and identifies specific actions that should be translated into the wider mainstreaming of anticipatory care to ensure its sustainability as a public health programme. 10

12 PLENARY SESSIONS Economic Evaluation of Keep well in North and East Glasgow Kenny Lawson, Public Health & Health Policy Research Associate in Health Economics, University of Glasgow Phone: Scope To evaluate the cost effectiveness of the Keep Well programme as a CVD primary prevention initiative. The patient group was within Glasgow North and East and the evaluation includes the first 23 months of the programme. Approach An NHS perspective was adopted, where benefits and costs accruing to Keep Well participants and the health service were considered. Benefits were defined as extended (quality adjusted) life expectancy from the reduction of CVD risk factors. Costs incurred were defined as programme expenditure and reimbursement of (dispensed) pharmacy prescriptions; and costs savings were defined as hospitalisations avoided. We developed a prognostic model to credibly extrapolate short term changes in risk factors to lifetime impacts. However, data limitations resulted in several key assumptions. While we had baseline screening, costs and referral information, we do not have follow-up data or comparison groups to report on the actual impact of Keep Well. Consequently, we used secondary studies to estimate short term reductions in CVD risks; and the evaluation became a projection of potential impact. Sensitivity analysis was undertaken to estimate the effect of varying assumptions on the results. Results The Keep Well programme, as operated within Glasgow North and East within the first 23 months, was not expected to be cost effective with a (discounted) cost per QALY estimate of 31,135. This is above the NICE threshold of 20-30,000 which is generally considered to be the upper limit of cost effectiveness. This was the base case scenario, employing the most plausible assumptions. However, this finding is subject to considerable uncertainty. Keep Well could be cost effective under a best case scenario, by employing the most optimistic assumptions. Recommendations It is important to respond to fundamental gaps in the Keep Well evidence base and subsequently re-evaluate the programme. Key recommendations include: (i) Interventions routinely monitor the initial impacts on either reducing CVD (or associated) risk factors; (ii) rescreen patients to assess changes in global CVD risk; (iii) develop comparison groups to assess the impact of Keep Well relative to usual care; (iv) monitor screening and intervention costs as the programme evolves; and (v) longer term follow-up of a representative sample Keep Well patients to monitor pharmaceutical compliance, behavioural change and to establish a formal linkage with ISD to track hospitalisations. 11

13 PLENARY SESSIONS Putting it altogether: combining Keep well and ASSIGN in sustainable anticipatory care Professor Graham Watt University of Glasgow Phone: The model of anticipatory care pioneered by Julian Tudor Hart, based on the intrinsic strengths and possibilities of NHS general practice, responded unconditionally to the problems presented by all patients, whether acute care, or primary, secondary or tertiary prevention, and addressed four aspects of integrated care :- 1. Holistic care, addressing all a patient s problems 2. Continuity, so that promising starts are followed by long term outcomes 3. Co-ordination, so that patients access all possible sources of help (as a singlehanded practitioner, working in the 70s and 80s, this was the weakest part of his approach) 4. Coverage, using epidemiology to measure what had been achieved and what still needed to be done Fragmentation, and inefficiency, arise whenever any of these aspects is neglected. The challenge for Keep Well is to build on promising starts, address issues of coverage, but most of all, develop coordinated, personal care involving the full range of support services. The national adoption of ASSIGN as the preferred CVD risk scoring system, adding deprivation and family history as risk factors, while lowering the intervention threshold from 30 to 20%, has substantial implications for workload, especially in practices with large numbers of patients living in deprived areas, which are characterised by high prevalence, multiple morbidity, unmet need, different expectations, time constraints and practitioner stress. Leadership and co-ordination are the keys to success, but what does this mean? 12

14 PARALLEL SESSIONS: ENGAGEMENT/CONSULTATION Evaluating outreach approaches across Keep well Dr Mhairi Mackenzie University of Glasgow Phone: Collaborators: Prof Kate O'Donnell, Prof Steve Platt, Dr Sanjeev Sridharan What was the intervention delivered? Outreach approaches What was the rationale? In all wave 1 pilots traditional apporaches to reach and engagement left parts of the target population untouched - outreach viewed as a means of reaching this group. What was the context? Range of organisational and professional contexts across the wave 1 pilots Why was it novel? Outreach work in itself is not novel, however, within the context of a health improvement led by primary care it was described as novel What were the desired outcomes? Increased engagement in health checks and/or sustained engagement with health improvement programmes beyond the health check How well was it adopted/implemented? Implemented in a range of different ways across the wave 1 pilot areas What happened? Perceived by practitioners as a successful means of engaging a sub-group of population not previously attending for their Keep Well Health Check but still not reaching the whole of the remainder of the target population. Different data systems, timescales and type of data collected made assessment across wave 1 pilots problematic. What are the transferable lessons? More clearly theorised pathways between 'problems' of nonengagement, outreach mechanisms and outcomes required before impact assessemt is warranted but reasonable qualitative evidence of outreach performing a role of importance to anticipatory care. 13

15 PARALLEL SESSIONS: ENGAGEMENT/CONSULTATION Are we doing the right things to maximise attendance at Keep well health checks? Richard Lowrie Long Term Conditions, NHSGG&C Phone: Team: Janice Richardson, Christie Cryer, Richard Lowrie, Evelyn Borland, Tom Scott, Anne Scoular. With acknowledgements to The Robertson Centre for Biostatistics. What we already know about this topic Perceptions of symptoms and illness behaviour are shaped by social and cultural factors Non-attendance and dropout from primary care preventive initiatives is greater among some groups, including those experiencing multiple deprivation No single, common method ensures attendance across all groups equally, but a personal approach and non-judgemental tone can help overcome inequities of Keep Well (KW) uptake Open, flexible appointments may be more successful in achieving service uptake than letters What was the context? Equity is a primary outcome indicator within NHS GG&C s KW evaluation framework The Glasgow KW pathway established in late 2006, includes patient identification, invitation and delivery of health checks within 18 North and East Glasgow practices Practices achieved variable levels of KW uptake via their own reach and engagement strategies; by January 2010, 12,782 (70%) of the eligible group had attended however 5,446 (30%) had not Individuals eligible for Keep Well who have not attended (NA) have been variously described by healthcare providers, descriptors including hard to reach, unengaged, seldom heard, healthy enough, health wary and many others, despite lack of an empirical understanding of the factors explaining non attendance at Keep Well. Some have concerns that increased pressure on practices to engage and multiple invitations leads to fractured patient-practice relationships or harassment This research was designed to obtain a structured understanding of those who remained unengaged within the Keep Well Wave 1 programme four years after its inception. 14

16 PARALLEL SESSIONS: ENGAGEMENT/CONSULTATION What we planned to find out: 1. Effectiveness evidence on how best to increase health service uptake by marginalised groups 2. How front line staff perceive NA and the challenges of increasing attendance 3. The characteristics of NA (medical, social history, patterns of health and social care utilisation) and how these differ from KW attendees 4. Quantifiable and unquantifiable characteristics associated with KW non attendance 5. The feasibility, effectiveness and cost effectiveness of enhanced efforts by practice nurses using a practice-based model 6. Key lessons to inform future anticipatory care policy on meeting the needs of this subgroup Methods: 1. Literature review of the effectiveness of interventions to increase attendance at health service appointments and/or screening among populations known to engage poorly 2. Semi structured interviews with18 North and East Glasgow staff (GPs, Practice Nurses and Managers, Health Care Assistants, Outreach Workers) from 15 practices. 3. Collection of anonymised demographic, clinical and health services utilisation characteristics from practice records of a sample of NA from 15 practices 4. A case control study to quantify factors independently associated with non attendance by comparing the anonymised characteristics of NA (using univariate logistic regression analysis) with data from 280 attendees prior to date of their KW health check. 5. Tailored invitations for KW checks applying evidence derived from the methodological components 1-4 above, delivered by two nurses working sessionally across 6 practices. The case records of 889 patients labelled as NA were screened with a view to inviting for KW appointments. What we found 1. Literature review. The literature underscored the usefulness of increased flexibility in appointment times, maintenance of accurate, up to date patient information, telephone contacts including reminders, text messaging and . Front line staff should be non-judgemental, informal, empathetic 2. Semi-structured interviews. Staff considered NA to be typically male and younger than those who had engaged. A proportion remained unengaged because they had relocated but their practice records had not been updated. Other suggested practical reasons for not attending included: too busy e.g. working, looking after dependants or fear of crossing territories en route. Perceived emotional reasons for 15

17 PARALLEL SESSIONS: ENGAGEMENT/CONSULTATION non attendance included needle or doctor phobia, worry about withdrawal of benefits or diagnosis of illness, strong-mindedness. Increased attendance was thought more likely through personalised invitations to open, flexible slots, invitation phone calls and reminder calls (made by clinical and non-clinical staff), opportunistic checks particularly if recommended by GPs. But practice staff defended their underuse of phoning, texting, and opportunistic checks, because these methods were usually more time-consuming. Outreach workers (OWs) were valued by the practices that used them, particularly when they supported data cleaning. OWs felt that patients frequently regarded themselves as not entitled to access services, due to low self-worth, not wanting to waste the doctor s time, or wanting to give priority to sicker patients. Although unquantifiable, we observed that some practices minimised the number of NA if they developed bespoke organisational systems, understood the KW ethos and used multifaceted approaches, including: opportunistic appointments and reminders, late and open access clinics, involved all of the practice team and used KW funding to employ full time KW staff. These practices also involved OWs as part of their team. Practice level KWNA proportions varied from 16-42%. 3. Collection of anonymised patient characteristics from practices. The sample comprised 311/4925 (6%) of all NA in KW Wave 1 at the time of data collection. 24/311 (8%) were excluded some having already attended a check (5), not having received any invitations (9), deceased (2), or unsuitable (8). From General practice records, we found that 139/287 (48%), did not respond to any practice invitation; 81/287 (28%) refused, and 64/287 (22%) did not attend appointments. 3/287 (1%) cancelled. In line with practice staff views, we found that NA were predominantly male (55%), and younger than attendees (mean age 51.9 vs 54.6). NA had more commonly received letters as an engagement and appointment method, compared with telephone and opportunistic methods. Fewer than half had any information recorded about key characteristics identified from the literature as predictive on non-uptake of services, including mental health status, behavioural problems, dementia, housebound or long term care status, disability, caring for dependents, employment status or literacy. Similarly, family history of cardiovascular disease and cholesterol values were absent in more than half. When relevant characteristics were sought and found, they were frequently outdated. 202/287 (70%) of NA had used primary and/or secondary care services in the past year; 192/202 (95%) had visited their practice at least once in the previous year (average of 4.5 visits per patient per year). 16

18 PARALLEL SESSIONS: ENGAGEMENT/CONSULTATION History of Primary and Secondary Care Contacts - Unengaged vs Engaged 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 64% 87% 24% 82% 27% 55% GP Practice Nurse Hospital Appt or Referral 14% 13% 8% 4% 6% 34% A&E GEMS & NHS24 Treatment Room Nurse or HCA 11% 26% Other Services (District Nurse, Physio, Mammography, etc.) Unengaged Engaged Types of Appointment 4. Case control study. Younger age and less frequent health services utilisation were independent predictors of NA. Although 202/287 (70%) of NA had utilised health services at least once in the past year, a higher proportion 274/280 (98%) of attendees had used health services in the year preceding the KW check. There was an association between use of unplanned emergency services (A&E,GEMS/NHS 24) and NA but this failed to reach statistical significance. There was no significant association between NA and gender or SIMD ranking within the two North & East Glasgow CHCPs. Fewer attendees had received letters as a form of invitation, with a much greater proportion of attendees receiving opportunistic KW checks. There was no association between phone call invitations and attendance (approximately equal proportions in NA and attendees). 5. Tailored, evidence-based, patient-centred invitations by peripatetic nurse. Working sessionally across practices reduced the chances of opportunistic invitations; thus, handwritten letters and phone calls were our most popular means of invitation. 39% (343 / 889) of those labelled NA were excluded because they were already closely supervised by the practice (e.g. through established clinics), had moved away, already attended a KW check, deceased, seriously or terminally-ill, recently bereaved, housebound, recently refused or a new 45year old and not yet invited by the practice. The remaining 61% (546 / 889) KWNA were invited following careful examination of all practice records. Using combinations of handwritten letter, phone, opportunistic appointment, text or , 192 / 546 (35%) attended KW checks; 354 / 546 (65%) did not. The majority of KW reviews delivered by the peripatetic nurses were with younger males, living in the most deprived areas, who had utilised primary or secondary care services in the past year. 33/192 (17%) had not used any health service in the past year. 31% had ASSIGN scores 20, comparable with those who had attended 17

19 PARALLEL SESSIONS: ENGAGEMENT/CONSULTATION following their invitation by practices. However, of those with ASSIGN 20, the median score among those checked through our programme was 52, compared with 39 for practice-invited attendees. As expected, the checks also identified significant unmet needs: 126 / 192 (66%) were symptomatic in some way and needed treatment. 85 / 192 (44%) received a referral with 66 / 192 (34%) back to the GP. Consultations often revealed harrowing life circumstances and multiple social, physical and economic disadvantage, in the context of which printed invitations had questionable utility. Nevertheless, our experience was that a sizeable proportion (35%) of NA will attend, despite these challenging life circumstances, if better use is made of existing data and tailored nurse-led invitations. Protected time and a non-judgemental, caring attitude were vital. There was also merit in the same healthcare worker inviting and health checking this subgroup of patient. What are the transferable lessons? i. Health wary or Healthy enough can be viewed as transient states which can be overcome by a nurse taking time to establish rapport in a non judgmental way. All of those attending and even those who did not but who discussed the check on the phone expressed no discomfort and often thanks ii. iii. iv. NA have substantial health needs Opportunistic approaches, cleaning and better use of relevant patient level practice data and combinations of evidence-based approaches by sessional nurses can reduce NA by 35%. 60% of NA contactable by phone will attend following discussion with an experienced nurse with an empathic approach; patient telephone numbers should therefore be actively sought Although there is widespread intuitive knowledge of strategies that can increase attendance at KW consultations among primary care professionals, there is substantial variation in systematic application of this knowledge 18

20 PARALLEL SESSIONS: ENGAGEMENT/CONSULTATION What are the competencies required to deliver Keep Well consultations and do we have them? Susan Kennedy University of Glasgow Phone: Collaborators: Kate Randell and on behalf of the steering group What was the rationale? A key evaluation priority for Keep Well was capturing a better understanding of the core competencies required of health care practitioners (HCPs) to deliver Keep Well and investigate how existing practice approximates to this. The aims: Define the core consultation competency framework required of health professionals to deliver Keep Well objectives. Document the extent to which observed practice within Keep Well consultations fits within this framework. Determine, from the perspective of the individuals attending and the health care professionals delivering Keep Well consultations how closely their experience fits with this competency framework. Why was it novel? A literature review was completed to define the Keep Well competency framework. The study drew on two sources of qualitative data: Observing (filming) of Keep Well consultations Interviews with HCPs and patients Other measures used were - the Behaviour Change Counselling Index; the SOLER measure of non-verbal communication skills; and the Consultation And Relational Empathy measure. What were the desired outcomes? Recruitment is ongoing. Current recruitment is detailed over the page: 19

21 PARALLEL SESSIONS: ENGAGEMENT/CONSULTATION North & East CHCPs Key PN= Practice nurse HCA= Health Care Assistant 35 Practices Invited 4 Recruited 8 No Answer 1 Not Eligible 22 Refused 8 Not wanting to be Practice 1: 1 PN - 4 patient consultations completed Practice 2: 1PN (withdrawn) 1 patient consultation completed 1HCA - 1 patient consultation completed Practice 3: 1 PN 3 patient consultations completed Practice 4: 1PN - 1patient consultation completed 1PN - 0 patient consultations completed filmed / recorded 5 Too many other demands / no time 2 Not appropriate too complex / sensitive 2 Taking part in other research 1 Not comfortable taking part 4 No reason given 20

22 PARALLEL SESSIONS: ENGAGEMENT/CONSULTATION How well was it adopted/implemented? Divergent Keep Well Consultation Objectives HCP Objectives - Advising - Complete template - Refer to agencies Health Board Objectives - Reduce health inequalities - Assess risk - Improve health behaviour Learning Outcome Review Role Preparation for Keep Well Underutilised Competencies Competencies from the Literature Utilised Competencies Psychological Concepts/Patient Centred Counselling Skills (Low BECCI scores) (Observation & Interviews) Verbal Communication Techniques Directive Advice Giving (Observation & Interviews) Learning Outcome Explore new methods of training with feedback/supervision Non-Verbal Communication Techniques Dominance of Computer Screen (Low SOLER Scores) Learning Outcome Review structures & processes Communication Style Empathic Caring Non Judgemental (Quotes) Learning Outcome Harness skills for brief negotiation and long term engagement The referral rates varied between practices. In total 174 referrals were made. All referral were appropriate in that the people referred definitely required additional support, however many were very vulnerable and socially excluded and required more intensive work than was originally anticipated which meant that progress with each patient, although significant, was slower than perhaps originally expected. 21

23 PARALLEL SESSIONS: ENGAGEMENT/CONSULTATION A qualitative study of nurses' view and understanding of Keep well Sandra Moore Inverclyde CHP sandra.moore@renver-pct.scot.nhs.uk, Phone: Collaborators: Professor Kate O'Donnell: research supervisor What was the intervention delivered? To obtain a structured understanding of practitioners' perceptions about Keep well, it's underpinning policy and agenda and factors that determine its adoption among practice nurses currently delivering Keep well in Inverclyde CHCP. What was the rationale? In the last decade the government has treated inequalities in health as a priority. Emphasis on reducing the marked differences in the health of people living in areas of deprivation. The NHS, in common with all organisations, operates within an environment of continuous change. Its ability to respond effectively to change cannot simply be achieved through the introduction of new policies, structures or systems, but requires full engagement of the many individuals who constitute the healthcare system, particularly those on the frontline of clinical care. Inverclyde CHP was established in April 2008 as a Wave 2 pilot site, one of five Keep well pilot areas in NHS Greater Glasgow & Clyde. This qualitative research will explore the practice nurses perspective on Keep well, impact of Keep well, social determinants, training and external factors that have influenced their attitudes of the Keep well programme. What was the context? The benefits for the practice nurse, to have an opportunity to voice their views and have them expressed within this research document. Inverclyde CHP will gain data rich information from the analysis on what factors should be considered prior to the roll out of any new initiatives within Inverclyde. From a national perspective this research will feed into the ongoing national evaluation of Keep well and will assist future CHP s new to Keep well to consider lessons learned and what approaches may be beneficial prior to the rolling out of Keep well within their areas. Why was it novel? The success of the Keep well programme depends upon front-line clinicians, dealing routinely with clients, to understand its fundamental aims and objectives. It is imperative that primary care staff 'buy in' to the ethos of the project as they are the first interface for clients. They also support and encourage patients to take up available services promoting health-related behaviour change. This research provided one to one confidential interviews to capture the views and understanding of practice nurses involved with the delivery of Keep well. 22

24 PARALLEL SESSIONS: ENGAGEMENT/CONSULTATION What were the desired outcomes? Explore the emerging themes from the practice nurses interviews. Inverclyde CHP will gain data rich information from the analysis on what factors should be considered prior to the roll out of any new initiatives within Inverclyde. From a national perspective this research will feed into the ongoing national evaluation of Keep well and will assist future CHP s new to Keep well to consider lessons learned and what approaches may be beneficial prior to the rolling out of Keep well within their areas. What happened? I conducted semi structured interviews with practice nurses to identify their buy-in to the Keep well programme What are the transferable lessons? Key findings related to 4 emerging themes from the data analysis. These will be discussed in the presentation. 23

25 PARALLEL SESSIONS: ENGAGEMENT/CONSULTATION The Keep Well Collaborative Long Term Medicines Service (CLTMS): Pharmacy support for medicines adherence among a Wave 1 KW secondary prevention cohort Joan Miller / Richard Lowrie PPSU Richard.lowrie@ggc.scot.nhs.uk or Joanmiller@nhs.net Phone: (RL); (JL) Team: Joan Miller, Sharon Parrott, Richard Lowrie, Jane Doogan, Liz Grant, Janis Walker What was the intervention delivered? 1. Service model. Suitable patients are aged CHD/CVD/diabetes + polypharmacy + under/irregular ordering of repeat medicines or erratic attendance at practice based clinics. Identified from practice lists by pharmacists, then 3 months of repeat prescriptions printed and taken to patient s pharmacy of choice. Community Pharmacists then open a structured discussion on each dispensing, covering reasons for medicines, benefits, ways to improve adherence, onward health/social referrals. 2. A peripatetic support team (0.6wte Pharmacist and 1wte Administrator) work across practices and pharmacies. Key roles include: Initial General practice visits: to explain and discuss the service. Search practice systems to identify potentially eligible patients. Print and screen list with practice to confirm eligibility. Patient contact: explain, invite (2 letters and 2 phone calls if necessary), gain consent for participation and find out each patient s nominated community pharmacy. Follow up General Practice visits: link patients with their pharmacy and pharmacy with patient s practice by printing advance repeat prescriptions and taking these, together with information on diagnoses (on a need to know basis) to Pharmacies with a partially completed intervention proforma and information on expected next pharmacy visit. Training of Community Pharmacists, structured programme of visits (2 3 per year) by team to each participating community pharmacy, peer review of work, clinical /administrative support, evaluation, (clinical governance framework) and financial governance, both covered by Service Level Agreement. Patient tracking. Attendance at KW meetings. 3. Community Pharmacists delivered the repeated adherence support intervention in the pharmacy on each visit by the patient to the pharmacy for their prescription collection. Each consultation included completion of bespoke documentation. A key part of the structured, documented intervention involved a discussion about the need for referral onwards to other KW services. Takes 14 minutes on average. Completed documentation sent back to support team for peer review, collection of information for evaluation then payment to pharmacy. What we already know about this topic/what was the rationale? 24

26 PARALLEL SESSIONS: ENGAGEMENT/CONSULTATION 1. Adherence with CHD medicines is likely to average at 50% and could account for much of the gap between expected and actual health improvement 2. People who do not take most of their medicines as agreed tend to have a shorter lifespan and increased morbidity with poor health literacy. Socioeconomic deprivation, polypharmacy and receiving medicines for asymptomatic conditions e.g. hypertension all exacerbate outcomes. 3. Interventions to improve adherence are complex, labour intensive and of variable success 4. If pharmacists are trained, supported within a governance framework and collaborate with practices at every stage, they can improve adherence and clinical outcomes for people with some conditions 5. The evidence base for pharmacist support reinforces the need for investment to ensure collaboration, (with practices involved at every stage) and address some of the known reasons for poor adherence e.g. consistently maintaining uninterrupted supplies of enough medicines and supporting patients in their quest to remember to take medicines on time every time. What was the context? 1. KW logic model anticipated full adherence with prescribed medicines, which is unlikely In 2007 when the KW CLTMS started, Community Pharmacy had no contractual incentive, protected funding, bespoke training or process to link with practice based KW initiatives targeting patients identified as in greatest need of adherence support in GG&C or anywhere else in Scotland Community pharmacy had no formal links with other KW services e.g. money advice. What were the desired outcomes? 1. To design a feasible, sustainable collaborative service model to enable targeted, eligible patients to receive 1:1 repeated support from community pharmacies 2. To involve practices 3. To train a sufficient number of pharmacists to enable delivery of KW CLTMS 4. To recruit patients and improve regularity and completeness of repeat prescription collection by eligible patients from their General practices. 5. To identify and address any problems with medicine adherence or reasons for practice based KW non attendance 6. To increase appropriate referrals from Pharmacies to other KW services How well was it adopted/implemented? The referral rates varied between practices. In total 174 referrals were made. All referral were appropriate in that the people referred definitely required additional support, however many were very vulnerable and socially excluded and required more intensive work than was originally anticipated which meant that progress with each patient, although significant, was slower than perhaps originally expected. 25

27 PARALLEL SESSIONS: ENGAGEMENT/CONSULTATION Key findings (reflect desired outcomes) 1. Service model: Collaborative service model accepted by CHCPs, KW board, practices, pharmacies, patients. The model continues to function 4 years after inception. 2. Practice involvement: 16 / 17 from North and East Wave 1 agreed to participate; 1 practice declined CLTMS support on basis that their patients did not require assistance with medicines adherence. Additional practices in North, East and South West CHCP now also involved. 3. Training a sufficient number of pharmacists: over 100 pharmacists in 83 pharmacies including all nominated pharmacies in North, East and 16 Pharmacies out with these areas agreed to participate in training and deliver CLTMS. Pharmacists accepted need for and attended training delivered out of hours, involved support staff, relief and locums, practices, KW services. 4. Recruiting patients and improve regularity and completeness of repeat prescription collection by eligible patients from their General practice: Since the service began, in North and East Glasgow (more if South West included), 1061 patients have undergone 7,983 CLTMS consultations with their community pharmacist. Demographics: 54% male, 45% female. 35% aged 60 64yrs, 26% years, 19% years and 17% either < 50 or > 64yrs. 82% form SIMD 1. 92% of patients were identified by the peripatetic pharmacy team; remainder referred to the team by Outreach workers, Practices or Community Pharmacists. We noted slightly better attendance among females, for all patients when the pharmacy was independent (compared with multiples), for all patients identified by the pharmacy team compared to other means of identification. Registration with CLTMS and attendance: 1475 eligible patients were identified (92 per practice) and offered 1:1 CLTMS 414 / 1475 (28%) declined or were uncontactable; 1061 / 1475 (72%) agreed and registered Following advanced prescription printing, transfer to the patient s choice of pharmacy and training of pharmacy staff, 792 / 1061 (75%) registered patients participated in 1 st CLTMS consultation. 100 / 792 (13%) had not yet received a KW health check from their practice. Impact on regularity and completeness of prescription ordering: In the 2 year period leading up to registration, from a convenience sample of 94 eligible patients, 68% of orders for CHD/CVD or diabetes medicines from the practice were for fewer medicines than expected while 69% of prescribed items were ordered beyond the period when they were required. Both variables indicate the difficulty experienced by patients in the first stage of adherence ensuring enough medicines at the right time to enable adherence. In the 1 year period during LTMS service delivery for the same patients, we found that orders for fewer medicines reduced to 27.5% while the proportion of items ordered beyond the interval when they were needed reduced to 38.5%. All 94 patients had received at least 3 CLTMS consultations. From a comparable sample of 50 patients who had not opted into CLTMS, erratic ordering did not change on follow up. 26

28 PARALLEL SESSIONS: ENGAGEMENT/CONSULTATION 5. Identifying and addressing any problems with medicine adherence From a sample of 106 patients who had received a total of 627 CLTMS consultations, Pharmacists acted on information gathered to improve adherence in 269 / 627 consultations (43%). In most cases, this involved an explanation of what the CVD medicines were for and the benefits of regular use or re-alignment of quantities ordered. Telephone prompts for next supply of CVD medicines occurred in 5% of consultations. 6. To increase appropriate referrals from pharmacies to other KW services or practices From the same sample of 106 patients who had received 627 CLTMS consultations, 8% (52 / 627) consultations resulted in referral onwards to KW services e.g. weight and physical activity, money advice, smoking cessation. 25% of consultations resulted in a recommendation back to the patient s GP e.g. dose change. What are the transferable lessons? Poor adherence with medicines for cardiovascular problems is associated with low socioeconomic status, primary prevention, lack of knowledge about disease, multiple drug regimens, co-morbidity e.g. depression. These indicators are concentrated in our KW cohort and based on our results from ordering of repeat prescriptions for CHD, CVD or Diabetes, adherence is likely to be poorer than the 50% cited by published literature. CLTMS begins to address this problem. It is dependent on a support team but is collaborative, feasible, reproducible, and shows some measure of success in addressing poor ordering patterns. In facilitating regular, informed discussion between Community Pharmacists and their patients within a multidisciplinary governance framework, we are implementing available evidence for improving adherence. While acknowledging the limitations of our evaluation, the magnitude and direction of the shift in practice ordering of key medicines indicates CLTMS is of use. Planned evaluation of processes in South West CHCP will look at community pharmacy medicine collection together with community pharmacist and patient views. 7,893 consultations for 1061 patients in need of adherence support without any duplication of effort indicates a high level of acceptance and with first consultations consistently demonstrating 75% attendance, CLTMS model may improve process and outcome measures. In designing new pharmacy services collaboration with practices and involvement of a support team are necessary if we are to achieve meaningful uptake and outcomes. Our work may provide a benchmark for other Community Pharmacy based clinical services 27

29 PARALLEL SESSION: HEALTH IMPROVEMENT OUTCOMES Evaluation of smokefree enhanced services in North, East and South West Glasgow Liz Grant NHSGG&C(Prescribing and Pharmacy Policy) Phone: Collaborators: Katrina Henderson, Jane Doogan, Anne Scoular What was the intervention delivered? Combination NRT and support to patients who had tried and failed for 4 weeks or more through a recognised smoking cessation service and prescribed monotherapy NRT. What was the rationale? Smoking is the single most preventable cause of morbidity and mortality in the UK. In NHS GG &C area, smoking prevalence is 33%, rising to 37% in Glasgow city and 71% in some of the most deprived areas. Given the ease of access and no appointment necessary when people visit pharmacies, together withthe expertise of pharmacists and staff, the community pharmacy is the ideal location for smoking cessation services to be delivered. What was the context? Since 2003, community pharmacists and staff in NHS GG&C have been successfully providing smoking cessation interventions together with NRT. The Enhanced service was developed to equip pharmacists to prescribe combination NRT together with intensive behavioural support to clients living in the North, East and South West CHCPs as part of the Keep Well Service. Why was it novel? This was the first time community pharmacists had provided an intense smoking cessation intervention and prescribed two NRT products to patients. What were the desired outcomes? To support smokers who have relapsed during past NHS quit attempts to successfully give up smoking. How well was it adopted/implemented? The Service was adopted by inviting pharmacy staff to a one day training event. They were given a step by step guide pertaining to service implementation together with training on motivational interviewing and NRT product combination. The Pharmacy Public Health Facilitators visited each pharmacy to ensure staff were confident in service delivery. Smoking Cessation Advisers, GPs and Practice Nurses were informed of the service so that they could refer patients who fitted the agreed criteria to the pharmacies. What happened? The study was evaluated one year after implementation to assess uptake, outcomes and acceptibility by pharmacy staff What are the transferable lessons? Patients fare better if prescribed more than one NRT product and are given more intense support session at the pharmacy. 28