Using the serious mental illness health improvement profile [HIP] to identify physical problems in a cohort of community patients: A pragmatic case series evaluation

Abstract

Background and objectives

The physical health of people with serious mental illness is a cause of growing concern to clinicians. Life expectancy in this population may be reduced by up to 25 years and patients often live with considerable physical morbidity that can dramatically reduce quality of life and contribute to social exclusion. This study sought to determine whether the serious mental illness health improvement profile [HIP], facilitated by mental health nurses [MHNs], has the clinical potential to identify physical morbidity and inform future evidence-based care.

Design

Retrospective documentation audit and qualitative evaluation of patients’ and clinicians’ views about the use of the HIP in practice.

Setting

A nurse-led outpatient medication management clinic, for community adult patients with serious mental illness in Scotland.

Participants

31 Community patients with serious mental illness seen in the clinic by 2 MHNs trained to use the HIP. All 31 patients, 9 MHNs, 4 consultant psychiatrists and 12 general practitioners [GPs] (primary care physicians) participated in the qualitative evaluation.

Methods

A retrospective documentation audit of case notes for all patients where the HIP had been implemented. Semi-structured interviews with patients and their secondary care clinicians. Postal survey of GPs.

Results

189 Physical health issues were identified (mean 6.1 per patient). Items most frequently flagged ‘red’, suggesting that intervention was required, were body mass index [BMI] (n = 24), breast self-examination (n = 23), waist circumference (n = 21), pulse (n = 14) and diet (n = 13). Some rates of physical health problems observed were broadly similar to those reported in studies of patients receiving antipsychotics in primary care but much lower than those reported in epidemiological studies. Individualised care was planned and delivered with each patient based on the profile. 28 discreet interventions that included providing advice, promoting health behavioural change, performing an electrocardiogram and making a referral to professional colleagues were used. Qualitative feedback was positive. Our observations support the use of the HIP in clinical settings to enhance mental health nursing practice; however, we strongly recommend that training is required to support the use of the HIP.

Introduction

Life expectancy in people with serious mental illness [SMI] is 20% lower than in the general population (Brown et al., 2000). Two thirds of the excess mortality can be explained by natural causes and the biggest killer is cardiovascular disease [CVD] (Goff et al., 2005). There appears to be a natural vulnerability to CVD in people with SMI; there is evidence in treatment naive patients that they have increased amounts of visceral fat, elevated cortisol and excess impaired glucose tolerance (Ryan et al., 2004). Risk factors for CVD that include smoking, a lack of exercise, poor diet, diabetes, hypertension, and lower HDL cholesterol are increased in patients with schizophrenia (Goff et al., 2005, Robson and Gray, 2007). Some antipsychotic medications compound these problems because of their increased risk for weight gain as a side effect (Haddad, 2005). Despite considerable angst among clinicians the trend in the general population of a reduction of ischemic heart disease is not reflected in the population of people with SMI (Lawrence et al., 2003).

Patients with SMI also have higher than expected rates of respiratory disease, some forms of cancer and HIV. These comorbidities have been largely ignored by authors. For example rates of HIV up to 3.8 times higher than those in the general population have been reported by some investigators (Blank et al., 2002). This is because patients are sexually active and are more likely to engage in high risk practices such as sex without a condom (Gray et al., 2002). Rates of breast cancer are consistently high and may be associated with high levels of prolactin caused by antipsychotic medicine and a failure to undertake regular self-examination (Schoos and Cohen, 2003, Robson and Gray, 2007). Other aspects of physical health that include dental and eye health, whilst not resulting in a reduction in life expectancy do make a real and important contribution to the social exclusion experienced by most patients with SMI. For example, the high rates of untreated dental caries observed by authors may not only impact on an individual's ability to engage socially but also to get a job (Robson and Gray, 2007).

In the UK there is considerable debate about whether the physical health of people with SMI is the responsibility of primary or secondary care services. The general consensus is that responsibility for monitoring and managing the physical health of people with SMI should be shared between primary and secondary care (DH, 2006a). However, in practice these needs are not being met and people with SMI often ‘fall through the net’. For example, Brugha and Glover (1998) observed that in 145 people with serious mental illness attending a psychiatric day care unit 41% had unmet physical health problems. Only 2% had their cholesterol checked and recorded in one primary care study, despite a significantly higher physician consultation rate (Burns and Cohen, 1998). In secondary care in a review of 606 in-patients, only 18% had their weight recorded and 3.5% had their cholesterol checked during admission (Paton et al., 2004). In an audit of 1966 in-patients only 11% had documented results for the four tests that should be undertaken each year for those at risk of metabolic syndrome from antipsychotic prescribing (Barnes et al., 2007).

The well-being support programme (WSP; Smith et al., 2007) was developed to improve the physical health of patients with SMI. Patients receive six consultations with a nurse advisor over a 2-year period. The programme has potential in terms of improving modifiable cardiovascular risk factors. There are two major criticisms of the programme; first, because the service is offered by nurse advisors as an ‘add on’ package it will only be accessed by a small minority of patients that are motivated to attend (and who will be more motivated to address physical health problems); second, important aspects of physical health, such as sexual health appear to be excluded.

Physical comorbidity means that patients with SMI will die younger, faster and find it harder to participate in work and social activities. ‘Add on’ services such as the WSP ignore the hard to access and engage patients that have the greatest need. We propose an alternative model for addressing these health inequalities. Mental health nurses are in a unique position to positively affect the physical health of people with SMI at the population level; but need to develop new competencies to enable them to do this. We developed a health improvement profile (HIP) as a pragmatic evidence-based physical health risk assessment for mental health nurses with six specific aims:

• Could be used with all patients with SMI.

• Promotes patient centred working.

• Addresses aspects of physical health where there is increased morbidity/mortality in patients with SMI.

• ‘Red flags’ areas of physical health that require additional care and treatment.

• Requires no more than 3 h to develop competence in using the profile.

• Is free to access.

A series of literature reviews established the parameters at risk in SMI, the normal and abnormal ranges and the recommended action for abnormal ones (Robson and Gray, 2007, White et al., 2009). Pilot work established the face validity and acceptability of the HIP to clinicians and experts by experience (White et al., 2009).

The HIP has 27 items and the male and female versions are slightly different (Table 1). The HIP is undertaken annually and takes approximately 30 min to complete; drawing information from multiple sources. Basic demographic information, age, gender, ethnicity, weight and height are recorded at the top of the form. Each item is marked either ‘green’, if the observation or behaviour is within a healthy range or ‘red’ if it is unhealthy. A list of recommended actions based on best current evidence is provided to guide practice and the nurse should check the box indicating the intervention they have taken. The form is carbonated in triplicate; copies can be placed in the multi-disciplinary notes, sent to primary care and given to the patient.

Nurses are trained to use the tool in a 3 hour workshop delivered by nurse trainers prepared by a 3-day course. We have described the process of developing the HIP and the HIP-training package in detail elsewhere (White et al., 2009). This study explores the clinical utility of the HIP in a real world clinical setting with 31 community adult patients with SMI.