Category: Promoting Clinical Research and Application to Practice
Storyboard Entry Form 2014
Main author: Enzo Mark Di Battista (Clinical Lead Dietitian)
Telephone: 01554 783347
Category: Promoting clinical research and application to practice
Word count: 10631. Storyboard title:a clear concise title which describes the work
Hywel’s Health – A lifestyle intervention programme for those at increased risk of cardiovascular disease.
2. Brief outline of context:where this improvement work was done; what sort of unit/department; what staff/client groups were involved
The Lifestyle Intervention Program (LIP) is an intervention arm of the Hywel’s Health scheme. Hywel’s Health is one of the first schemes of its kind to use the workplace as the setting for identifying and managing increased cardiovascular risk. Launched in 2009 this project was considered a pioneer project with a strong partnership between Hywel Dda Health Board, Public Health Wales, Carmarthenshire County Council, Tata Steel Works (Trostre), Swansea University (School of Medicine) and the Pharmaceutical Industry.
Staff were signposted to the LIP, following cardiovascular risk assessment when high risk of CVD and/or T2D was identified.
The LIP is an 8 session, group-based programme lead by a dietitian and exercise specialist delivered for 1 hour, weekly. The aim of the LIPwas to provide specialist lifestyle support that facilitated significant clinical improvements of cardiovascular risk factors.
3. Brief outline of problem:statement of problem; how you set out to tackle it; how it affected patient/client care
In March 2008 the UK National Screening Committee reported that screening certain subgroups of the population who are at high risk of Type 2 diabetes is feasible, but it should be undertaken as part of an integrated programme to detect and manage cardiovascular risk factors.
The project board scoped local services within Carmarthenshire (initial pilot site) to ensure those identified with increased risk of cardiovascular disease could be appropriately signposted. However, as no local service existed, the scoping exercise identified a service need; to develop an evidence based lifestyle intervention programme.
To supporthigh-risk groups, the project board worked in partnership with Hywel Dda Nutrition and Dietetics Dept., the local authority exercise team and Public Health Wales, Carmarthenshire division to develop and deliver a behavioural and outcome focused lifestyle intervention program.
4.Assessment of problem and analysis of its causes:quantified problem; staff involvement; assessment of the cause of problem; solutions/changes needed to make improvements
The Standardised Mortality Rate for coronary heart disease (CHD) in Carmarthenshire has also fallen in line with the Welsh Average. However the last 2 data points (2006/07 & 2007/08) has seen the standardised CHD mortality rate in Carmarthenshire rise above the Welsh national average. Also, when comparing Carmarthenshire to the other 22 local authorities in Wales for CHD Deaths. Carmarthenshire is ranked 8th out of 22 in the CHD mortality ‘league’. Of adults in Carmarthenshire, 60% areoverweight or obesitywhich is slightly higher than the Welsh average. For those identified as high risk, it is widely recommended that services provide lifestyle improvements to improved cardiovascular risk factor profiles (NICE CG38, 2012). To improve ease of access for staff and facilitate long-term behavioural changes, the intervention was adapted to suit the workplace setting.Prior to the project no LIP existed in the county. Due to a thorough qualitative evaluation framework it has produced learning to provide lifestyle servicesthroughout the county,and into the wider Health Board.
5. Strategy for change: how the proposed change was implemented; clear client or staff group described; explain how you disseminated the results of the analysis and plans for change to the groups involved with/affected by the planned change; include a timetable for change
For the Carmarthenshire pilot, the lifestyle interventions were delivered as cohorts and embedded within the principles of the ‘Plan, Do, Study and Act’ (PDSA) cycle. The LIP has been rolled out to include Pembrokeshire and Ceredigion. There is continuous quarterly monitoring and annual evaluation which not only includes analysis of clinical outcomes and uptake of service but also of staff satisfaction.
This work has informed the development the musculoskeletal programme that is part of the ongoing Health Board agenda; to prevent and treat long term conditions. Specifically, it includes the introduction of behavioural “assessment” and “appraisal” appointments the evaluation of which is ongoing.
6. Measurement of improvement:details of how the effects of the planned changes were measured
Eleven LIP’s were delivered during the Carmarthenshire pilot between 2010 and 2012. Anthropometric data were evaluated and translated into meaningful clinical outcomes associated with risk of cardiovascular disease. Body weight, height, body mass index and waist circumference were measured throughout the intervention sessions. Individuals were invited to additional sessionsup to one year and body weight recorded. Staff satisfaction was captured via questionnaires as each LIP was completed. Attrition data were recorded and reflected upon when modifications to the LIP were implemented. To establish how clinical changes occurred, a series of behavioural and patient reported experiences were recorded and evaluated as part of a Ph.D scholarship. This in-depth qualitative evaluation established the feasibility and efficacy of the LIP for wider dissemination.
The findings emphasis the value of partnership and collaboration on an inter and intra organisational level. The importance of the patient engagement process revealed how individual behavioural sessions can complement group-based programs and significantly improve overall rates of attrition.
7. Effects of changes:statement of the effects of the change; how far these changes resolve the problem that triggered the work; how this improved patient/client care; the problems encountered with the process of changes or with the changes
The Carmarthenshire pilot produced a series of clinical and behavioural patient service outcomes.
- Mean body weight loss for the 8-week program was 2.7%, which is reflective of similar programs at the worksite.
- In total, 72 people were recruited to groups and 45 participants completed (37% attrition).
- We achieved a reduction of attrition rates with the introduction of a behavioural assessment and appraisal clinic (attrition in year 1 = 46%, attrition in year 2 = 25%).
- Participants labeled all aspects of the LIP as Excellent or Good.
- We established a model of best practice for lifestyle intervention programs that can be replicated for level 3 services of The All Wales Obesity Pathway.
8. Lessons learnt:statement of lessons learnt from the work; what would be done differently next time
The delivery of a lifestyle intervention program in the workplace presents a series of challenges. These challenges were met and the recommendations from lessons learnt are as follows:
•The introduction of assessment and appraisal clinics positively influences retention. These should be standard practice.
•Although some individuals had long-term weight loss, the program generally influenced weight outcomes on short term. Longer-term support needs to be integrated into the program. E.g. ongoing weight loss meetings by dietetic assistant and or 1:1 sessions.
•We received a strong program evaluation. We can utilize these positive experiences to further market and promote the program. E.g. when promoting screening element of the intervention, also highlight that many people can have access to support with weight management and/or lifestyle changes.
•Emphasise to clients that follow-up screening will be prioritized to those who continue to engage with the lifestyle services forup to 1 year. This can improve motivation to attend follow-up screening and behavioural changes.
•Referral management needs to be swift to ensure recruitment is managed effectively.
•Continue to evaluate the experiences of the clients and clinical outcomes as part of standard practice.
•Continue to integrate the LIP across the Health Board.
9. Message for others: statement of the main message you would like to convey to others, based on the experience described
Workplace lifestyle intervention programs can produce clinical meaningful outcomes in a hard to reach group. Strong partnerships with employers and management are essential so staff can attend during or around their formal work schedules.
The NHS Wales Awards are organised by the 1000 Lives Improvement Service in Public Health Wales.