Background
Monitoring physical health in individuals with severe mental illness is an essential aspect of comprehensive healthcare. Those with severe mental illness face significantly higher rates of physical illness and mortality compared to the general population. This increased risk arises from a combination of factors, including side effects of medication, lifestyle choices, and difficulties in accessing healthcare (Prescribing Observatory for Mental Health, 2023).
Conditions such as cardiovascular disease, type 2 diabetes, obesity, and metabolic syndrome are prevalent within this group (Vancampfort et al., 2015). Regular physical health monitoring is crucial for the early detection of these risks and effective management of these conditions (Nash, 2014). The World Health Organization (2015), National Institute for Health and Care Excellence (2018) (NICE), and the Mental Health Commission (Finnerty, 2018) emphasised the importance of implementing physical health monitoring standards and tailored interventions. These interventions are designed to educate, support and motivate service users to reduce health risks, adopt healthier lifestyle behaviours, and enhance their overall quality of life.
Development of the Physical Health Monitoring Service [PHMS] at St Patricks Mental Health Services [SPMHS]
The Model for Improvement (HSE., 2019), a widely recognised and effective tool for continuous improvement within healthcare settings was used in the development of the PHMS. It offered a structured framework to plan, test, evaluate and make relevant changes to ensure that interventions were both evidence-based and sustainable. The following three questions provided the framework and roadmap which were essential in the development of the PHMS service:
Project objectives: What are we trying to accomplish?
It was vital that all stakeholder expectations were aligned and that all involved had a clear understanding of what the service entailed. There was strong support from the senior management team with the Director of Services being the project lead. Stakeholders included the Director of Nursing, Assistant Director of Nursing and Programme Managers.
Several stakeholder meetings resulted in a proposal outlining a three-phase project to implement the PHMS which was submitted to the senior management team who approved the project for implementation. Phase one’s objective was to introduce a PHMS for all inpatient service users admitted to the two adult and adolescent inpatient units who were prescribed Lithium and Clozapine.
Outcome measures: How will we know that the change is an improvement?
The following measures were used to demonstrate the change and improvement.
Outcome measures:
1) Introduction of phase one of the PHMS in SPMHS in the first quarter of 2024.
2) Recruitment of a Clinical Nurse Manager 2 (CNM2) to coordinate the PHMS.
3) Clarifying physical health monitoring requirements for inpatients on Lithium, Clozapine, which was expanded to include Sodium Valproate.
4) Commencement of auditing of Lithium, Clozapine, and Sodium Valproate adherence to the PMH standards of all inpatients in the first quarter of 2024 (which expanded to include 28 antipsychotic medication after two months of initial monitoring).
5) Monthly progress reports to the Director of Services and Senior Management Team which include adherence to PHMS standards.
6) A yearly report to the Director of Services and Senior Management Team with a synopsis of adherence rate throughout the year, the progress on the service development and readiness to engage in the next phase.
Process measures:
1) Updated policies and procedures to reflect the new service,
2) Updated protocols of Lithium, Clozapine and Sodium valproate,
3) A high level and detailed process map completed to reflect the PHM actions and communication with multidisciplinary teams.
Stakeholder engagement and process measures: What is the change we can make that will result in improvement?
An iterative ‘Plan-Do-Study-Act’ cycle was utilised to update the PHMS and to make changes throughout. The Plan-Do- Study-Act cycles offer a framework for repeatedly testing changes to enhance system quality (Taylor et al., 2014). This approach is broadly acknowledged and applied in healthcare improvement initiatives. Senior managers, ie. the Director of Services, Programme Manager, Assistant Director of Nursing and the PHMS team reviewed the PHM service monthly. Any challenges were thoroughly discussed with a solution focused approach which fostered a culture of continuous improvement. Each month, the outcomes of the cycle were analysed to inform subsequent actions which promoted sustained progress and improved quality of care. This structured approach facilitated full transparency in the service’s development. It ensured that the service was responsive to the challenges arising and improvements were continuously integrated into the delivery of care for the service. The collaborative input from senior managers was instrumental in driving the service’s growth and effectiveness.
Benefits of the PHMS
Benefits of the PHMS have included early detection of outstanding requirements with regular surveillance enabling early identification of compliance gaps, allowing for prompt corrective actions. Service user safety has been enhanced by ensuring adherence to guidelines and policy. Ongoing monitoring fosters a culture of continuous improvement, as healthcare providers regularly receive feedback and can make iterative enhancements to their practices. This also ensures compliance with regulation 19 of the Mental Health Commission’s Judgement Support Framework which ensures that approved mental health centres in Ireland meet inpatient service users’ physical health needs (Mental Health Commission, 2024). It requires regular medical assessments, trained staff, monitoring through audits, and proper documentation. The goal ultimately is to provide high-quality physical healthcare and maintain compliance with the Mental Health Act 2001 (Finnerty, 2018). Overall, the surveillance reviews were a critical component in the first phase of the service by ensuring standards were consistently met. This development underscores SPMHS commitment to integrating physical health care into mental health services, ensuring holistic and regulatory-compliant care for all service users.
In summary
SPMHS have an ongoing commitment to enhance service user care and safety. The newly initiated PHMS is a proactive step that aims to address the critical need for improved physical health care for individuals with severe mental illness. By implementing this service, SPMHS seeks to not only meet the recommendations outlined by the Mental Health Commission but also to exceed them. This initiative reflects SPMHS’s dedication to elevating standards of care, reducing physical health risks, and promoting overall wellbeing for its service users. The service plans to expand into outpatient care, focusing on monitoring and supporting adherence to psychotropic medications for our community-based service users.
References available on request
