Testing an intervention to promote independence following discharge from hospital
South West London & St George’s Mental Health NHS Trust
September 2015
The Health Foundation
Tel 020 7257 8000
Part 1:Abstract
Project title:Testing an intervention to promote independence following discharge from hospital
Lead organisation:South West London & St George’s Mental Health NHS Trust
Partner organisation:None
Lead Clinician:None
Abstract
There is a high prevalence of personality disorders and affective disorders in Kingston and Richmond accounting for 71% of the admission ward population.People with these diagnoses may have difficulty establishing routines that facilitate activities and struggle with problem solving. A lack of routine in self-care and leisure impacts negatively on mental health and quality of life.In this project a post-discharge occupational therapy intervention was implemented to support people to take a more active role in their health. It included strategies to understand an individual’s strengths and to develop skills in looking after themselves and taking part in their community. The intervention is innovative as it has not been tested with people with these diagnoses.
This project had two aims:
- To test an evidence-based intervention called GLOW (Graduating Living skills Outside the Ward) with people with affective and personality disorders in Kingston and Richmond and assess the outcome of the intervention on individual’s self-management measured by social functioning and their quality of life. Use of crisis services wouldalso be measured.
- To assess how the intervention may be implemented within current community mental health services and more widely within the NHS.
GLOWis a manualised occupational therapy intervention that involves assessment by the service user and occupational therapist of motivation for activity, habits and routines, and performance ability. GLOW facilitates growth of self-knowledge of the facilitators and barriers to independent livingboth at home and community. The intervention is delivered over four months commencing with weekly visits focusing on the enablement of self-care activities followed by fortnightly visits in the home and then the community as relevant to individuals’ goals.
In this project three occupational therapists tested GLOW with service users with a mood or personality disorder post-discharge over 8 months.Changes in social functioning and quality of life and crisis services use were measured prior to commencing GLOW, at the end of GLOW and four months post-GLOW. The occupational therapists, managers, consultants and community team members were interviewed regarding GLOW’s deliverability.
Result
Nineteen service users received GLOW. Changes in scores on outcome measures demonstrated that participants increasedthe number ofcommunity and self-care activitiescarried out and used crisis services less. This demonstrates a reduced reliance on mental health services and an increase in self-management of daily life.
Interviews with managers and clinicians indicated thatGLOW was consistent with organisational objectives and was deliverable locally.
Impact
Service users were more active in self-care and community participation at the end of project. GLOW demonstrated cost benefits by reducing crisis use by participants at the end of GLOW and at follow-up.
Challenges
Recruitment was slow initially leading to the target number of service users not being met. In some cases, the intervention took longer than anticipated due to cancellations.
Learning
Detailed planning is needed in to ensure timely receipt of referrals. The manual needs to be adapted to ensure consistency in GLOW delivery. The impact of organisational transformation on planning the spread of GLOW should not be under-estimated.
Part 2: Quality impact: outcomes
This project aimed to support people to take a more active role in their health and care and improve self-management, quality of life and social functioning. GLOW seeks to increaseself-care and recreational activities thereby improving a person’s mental-wellbeing andreduced crisis service use.
Course of intervention
Three occupational therapists implemented GLOW with 19 participants over nine months. At baseline all demonstrated low activity levels with few engaging in activities outside the home.
The primary data collection used self-reported measures:
- Personal and Social Performance Scale
- Time budget diary
- Manchester short assessment of quality of life:
Occupational Circumstances Assessment Interview and Rating Scalehad been identified to measure occupational performance. However the team agreed that to use it within the GLOW assessmentrather than as an outcome measure.
Data was collatedfrom the clinical record on the use of crisis services for three 4 month periods; before, during and after the intervention.
Validity and reliability of the data
Personal and Social Performance Scale
The two researchers using this tool experienced difficulty in scoring answers consistently. They discussed the scores after each collection point to ensure consistency.
Manchester short assessment of quality of life
Several participants identified difficulty rating this. They felt that their quality of life had improved but could not remember what their earlier scores.
Data quality of baseline data
Validity and reliability was maintained by using the measures consistently with all participants in accordance with instructions. The MANSA was not carried out with four participants due to oversight.
Results of the study
Follow-up data has not been collected yet for five participants by this report deadline. Baseline and follow-up data has been analysed for 14 participants. Crisis use data was collected for all 19 participants.
Personal and Social Performance Scale
Figure 1 showsan increase in mean score at the end of the GLOW intervention, indicating an improvement in personal and social performance such as self-care and social activities.The maximum possible score is 100.
Figure 1 baseline and Post-GLOW mean scores on Personal and Social Performance scale (n=19)
A Wilcoxon signed rank test was used and the resulting p value = .041 indicating the difference in scores is statistically significantly different.Participants extended their weekly routine with many new or resumed activities.
The project also considered whether the changes, if any, that the participants made at the end of the intervention periodwere maintained or improved four months later. Figure 2 shows that the mean score improved by three points indicating that improvements were maintained and some slightly further improved at that point.
Figure 2: end of GLOW and four month follow-up mean scores on Personal and Social Performance scale (n=14).
An increase in score indicates an improvement on the scale.
Time Budget measure
Figure 3 presentsbaseline and end of GLOW mean scores on the Time Budget measure for 19 participants. The maximum score on this scale is 112.The mean score for participants increased at the end of the intervention period.
Figure 3. Baseline and end of GLOW mean scores on Time Budget measure (n=19)
An increase in score indicates an improvement on the scale
A Wilcoxon signed rank test was used and the resulting p value = .002 indicating the difference in scores is statistically significantly different. Examples of activity changes includedsleeping less during the day, spending more time doing activities outside the house.
Figure 4 presents the mean scores for 14 participants with follow-up data.The mean score improved by two points indicating that improvements were maintained and some slightly improved at follow-up.
Figure 4. End of GLOW and four month follow-up mean scores on Time Budget measure (n=14)
An increase in score indicates an improvement on the scale
Manchester short assessment of quality of life
Figure5 presents the mean scores for 19 participants for whom MANSA was completed at baseline and post-GLOW.The mean scores for participants decreased by one point post –intervention.
Figure 5.MANSA mean scores at baseline and post-GLOW (n=19)
An increase in score indicates an improvement on the scale
Figure 6 MANSA mean scores for participants Post-GLOW and four months later. (n=14)
Figure 6 shows at four months follow-up the mean score increased by one point. These minor changes could reflect the difficulty participants experienced in using this rating.
Changes in crisis use
Information has been collected on in number of Mental Health Act (MHA) assessments, bed days on an acute ward and home treatment team contacts for each participant.This represents the use of crisis servicesthroughout the project.
Figure 7 Number of Mental Health Act assessments (n=19)
Figure 7 shows that only two participants had a MHA assessment in the four months following GLOW, demonstrating a reduction from 11 at baseline and six during GLOW.
Figure 8 Number of days in an acute mental health ward (n=19)
Figure 8 shows that although two participants spent more than 50 days as an inpatient during the four months following GLOW, 16 participants were not admitted during that time, demonstrating a reduction in days spent in hospital.
Figure 9 Number of Home Treatment Team contacts (n=19)
Figure 9 shows that 16 participants had less contact with Home Treatment Team during the four months following completion of GLOW than during or before GLOW.
Views of stakeholders
These were collected by interview.
Service users:
“I don't think I would have achieved as much as I have done if I hadn't had GLOW in the months after leaving hospital.”
“I’ve learnt to give things a go… basically before I sort of dismiss them”
“I have more of a routine now and I'm more active in a number of ways now than I have been for a while.”
Occupational therapist:
“it was quite practical what I was doing with clients and I think that is why it worked so well.You get a very different picture and a different outcome as well from doing something yourself (as an OT), rather than delegating it.”
HTT Consultant:
“I really have had very good feedback from clients- it's been really helpful, it’s one of the most helpful things that has been offered towards our service users since I've been here.”
Appendix 3 contains results at an individual level for the outcome measures and Appendix 4 contains a case study on GLOW.
Summary of results:
GLOW has shown positive results for the service users increasing their self-management, increasing their participation in community activities and self-care and has shown reduced reliance on health servicesdemonstrated by fewer contacts with crisis services.
Part 3: Cost impact
One of the aims of this project was to assess the impact of the intervention on use of crisis services by the participants and therefore any changes in service costs as a result.
We also calculated the cost of implementing GLOW per participant and assessed if there was a cost benefit to using GLOW, during GLOW and during the four months following GLOW.
The impact of the intervention on use of crisis services by the participants.
To do this we collected crisis services contacts data regarding the following crisis services:
- Number of days in a mental health hospital
- Number of face to face contacts with Crisis and Home Treatment Team
- Number of mental health act assessments
- Number of calls to crisis line
The information was collected for three four month periods,prior to commencing GLOW, during the intervention and during the 4 months follow-up period.
Costs of the crisis services were calculated using PSSRU Unit Costs of Health and Social care 2014 and from advice from a health economist familiar with mental health costings details of which are in Appendix 5. More detailed analysis will be conducted with a health economist in preparation for publication.
The frequency and overall costs of using the above services was calculated at three time points for all participants and changes in costs calculated.
Cost of implementing GLOW per participant
The cost of implementing GLOW per service user was calculated at the end of the intervention phase using information gathered by the occupational therapists and comprised of the following costs to calculate an hourly cost of band 6 community occupational therapist:
Band 6 OT 2015 hourly rate: (source: Trust Finance Dept) £25.00
1,589 hours per year
GLOW training (6 hours) £238.20 over one year , 1 hour .14
Total hourly rate £25.14
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Implementing the GLOW intervention required the following time use, details of which are in Appendix 5:
Duration of face to face contacts with service user, during the three phases of GLOW
Average duration of travel per meeting
Note writing
Report writing
Supervision sessions with SHINE project manager.
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Total time required to implement GLOW: 77 hours
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*Total cost of GLOW per patient= £1935.78
(*doesn’t include cost of travel just cost of travel time)
Cost benefits of GLOW
At the end of GLOW the average reduction in cost of use of crisis services for 19 service users was £4363.00. The total average reduction in cost of use of crisis service for 19 service users from baseline to four months after completion of GLOW was £3104.00, and £3740. 00 when one outlier score is removed.
This study indicates that there is a cost benefit of using GLOW post-discharge from hospital.
Part 4: Learning from our project
This project set out to test an occupational therapy intervention, GLOW with people with mood and personality disorder following discharge from hospital. This was achieved, however the number of people who received GLOW is smaller than planned. This project has been very relevant to service provision in the boroughs involved as indicated by service users and clinicians’ feedback.
Enablers that helped us implement GLOW
There was differing levels of buy-in from teams although all received the same pre-project information. Staff buy-in was gained by attending team meetings to introduce the project and answer any questions and by returning to home treatment teams and the wards weekly to identify potential participants and acknowledge where previous referrals from their teams were taken up successfully
One of the Crisis and Home Treatment Teams was particularly proactive in identifying potential participants and importantly in asking service users if they would be interested in hearing more about GLOW and keeping the researcher informed. As a result 14 people from Richmond received GLOW and eight from Kingston.
The wards OTs were also invaluable in screening the ward caseload with the researcher on a weekly basis and following up on potential participants enabling regular referrals to be received from the wards.
Challenges of completing the project
Whilst the feedback and outcomes from the project are positive the project did not meet its target sample size of 42. The main reason for this was that the set up phase in the month prior to starting the project took place in August, when the many Borough managers, team leaders and consultants were on annual leave. The intention had been to pick up referrals in August, ready for the OTs to commence GLOW with at the start of September. However, only one referral was received in August, meaning the OTs commenced GLOW later than planned which affected their ability to take on new referrals in line with the project plan.
Another challenge the project faced was that GLOW took longer than four months to complete for some service users, due to staff annual leave, bank holidays, service user cancellations and Did Not Attends. This has implications for future users of GLOW. A clear statement on how to systematically respond to this to ensure GLOW is consistently implemented will be added to the manual.
During the project, two teams were going through a change of team managers as well a change in role and function which made picking up referrals from the team more difficult.
There were staff changes during the project that impeded recruitment rate. A research assistant was appointed to start in September 2014 to collect baseline data and develop the database. The person did not start which meant the lead researcher on the project needed to collect baseline data for all participants. The replacement research assistant started in December and left at the end of August.
Learning regarding introducing and sustaining innovation in the NHS
Set up phase
A key lesson has been the importance of making sure that there is more thought given to the set up phase when designing the project plan to take account of impact of holidays, service changes. This would have ensured an increased number of referrals.
We recommend that at the earliest time, for example when applying for R&D and ethics, collate detailed contact list of team leaders, consultants and services leads to contact during set up phase and provisionally book time to meet them once approval is in place. Time set up phase so it doesn’t take place in August when the majority of staff take annual leave.
Implementing a new intervention
The OT who delivered GLOW full-time in this project was not part of a specific community team, and whilst home visits details were given to one team as part of their lone working policy system, she was not formally attached to this team. As the project commenced it became clear that the OT would have benefited from being part of a team, for peer support which is important when working in community mental health.
The following additions to the GLOW manual were suggested following discussions with the OTs:
- Guidance on the actions to take regarding the number of missed sessions and establishing the number of ‘permitted’ missed sessions within GLOW.
- To formalise knowledge regarding personality disorder expected of the OTs to implement GLOW methodically, for example, incorporating tools into the training day such as: ‘Meeting the challenge’, ‘Working effectively with people with personality disorder in the community.’
- Add explicit tools to the GLOW manual to ensure service users are prepared for the end of GLOW- OTs have done this intuitively but needs to be core part of manual to ensure service users know when final sessions are well in advance.
- Provide a template for a Maintenance plan for SUs at end to support them to continue to develop beyond GLOW goals.
Part 5: Plans for sustainability and spread