Handover | Issue 37 – December 2016 – Equally Well
A recent study on metabolic screening practice in Australian mental health services concluded that it is, in a word, “inadequate”. Of the 955 psychiatrists who responded to the national survey (a 31 per cent response rate), 76 per cent reported that there was no reliable system in place to remind them when to monitor. Unsurprisingly, fewer than half routinely checked weight, fasting glucose or lipids in people who were on antipsychotics, and under 30 per cent checked blood pressure.
In the absence of similar New Zealand research it’s fair to say that we are probably no better at screening people for what’s known as ‘the metabolic syndrome’ (MetS) – a group of risk factors for cardiovascular disease and type 2 diabetes.
Equally Well members have been debating the issue online via Loomio lately, and it seems we have no current national standards or guidance for metabolic screening in mental health and addiction services here. District health boards (DHBs) have been developing their own clinical pathways for this and other areas, but it’s hard to know how many have done this, and whether it’s a priority for mental health services around the country.
Waitematā (WDHB) has been quite proactive over the last decade, especially during the previous couple of years, with a cardio-metabolic screening project led by Equally Well champion Anna Birkenhead getting real traction. Anna shares her experience in shifting organisational culture through system change at WDHB.
It started with an internal policy review, backed at a senior leadership level within the mental health service. The revised policy has been in place for a year now, and has doubled the number of screenings from the previous year. Anna posted the policy recently on Loomio in response to a request and invited others to use or adapt it for their own services.
She is the first to admit that there is still a long way to go, and while many people have elements of screening completed, only about 10 per cent of people are being screened at Waitematā using the cardiovascular disease (CVD) software tool PREDICT, which is being enhanced in functionality for mental health services. WDHB appears to be one of the few mental health services using the tool, which is often used in primary care to assess cardiovascular risk. A regional CVD tool is also being developed, led by Health Alliance.
Cardio-metabolic screening has been part of Anna’s professional life for many years. Since qualifying as a comprehensive (NZCpN) nurse in 1990, she has been working in various mental health clinical roles with much time spent as a crisis team clinician, as well as in leadership roles – coordinator and team manager. Anna’s interest and passion in her current role developed when she was a clinic nurse for metabolic screening two years ago. She saw first-hand the significant difference that could be made to people’s lives, with ordinary approaches such as healthy lifestyle education and support. “Nearly every person I saw was interested and engaged in the process, and as a result, motivated to make positive change,” she said. Healthy lifestyle and CVD risk mitigation is relevant to everyone, but especially to people who use mental health services who have significant additional risk overall.
Supporting people to engage in primary care, is also important. “One other positive benefit I noticed was the interaction in a physical health setting seemed to be more comfortable for people who use our service. Many talked about other (important) aspects of their lives and health as a result,” Anna said.
The 2014 Equally Well summit was timely for Anna. She reflected again on the importance of improving the physical health of people at Waitematā, and was vocal in expressing concerns about how well WDHB mental health services were doing. Director of mental health, Dr Murray Patton, and then regional manager Helen Wood decided they would set up a project to improve their performance in cardio-metabolic screening, and Anna was appointed into the role on a half-time basis.
Her first task was to stocktake what was working and what wasn’t. She discovered screening numbers had been declining in the two to three years prior. This was disappointing, since draft policy had been in place since 2005 and screening started around then, initially with a small project involving Waitematā primary health organisation (PHO) and the University of Auckland. Following the stocktake, the policy was finalised and an implementation plan was put in place. This involved screening of all adults admitted to the service on entry if they had not been screened during the previous 12 months in primary care.
“We want clinicians to be supporting people to overcome barriers and engage with primary care,” Anna explains. For some people it’s difficult or impossible to get to primary health at that time, so they continue to be screened annually by mental health services until they can do so. “The idea is that every year an electronic reminder in our clinical record pops up, indicating the person is due for screening, so either we do it or they do it in primary care. We need to know what their CVD risk is so we can help support them mitigate the risk and understand how best to deliver treatment.”
The policy provides a clear summary of best practice including visuals explaining the screening pathways. It’s complemented by related guidance such as prescribing psychotropic medication, and use of metformin (for pre-diabetes), all in the same place on Waitematā DHB’s intranet. Guidance and professional support has also been made available for mental health staff on how to interpret and respond to electro-cardiograms (ECGs).
Training for 135 nurses has been undertaken, with plans for additional workforce development well under way. A “very streamlined and basic training package” has been developed which includes a section on educating people about lifestyle changes.
There is now an Equally Well champion group – including over 20 nurses across forensic and adult mental health services. At Waitematā this has resulted in the merge of smokefree and cardio-metabolic screening services. Three-monthly auditing will be part of new care standards so cardio-metabolic screening will be built into the system.
As part of the project, Anna managed a small point of care testing (POCT) pilot in the largely rural Rodney district. A portable device was used that enables a full lipid profile and HbA1c to be completed in 11 minutes using a finger prick blood test with no need for fasting or visiting a lab. Ten people considered to be at risk of metabolic syndrome or cardiovascular disease were offered the service, and encouraged to have their weight and blood pressure taken at the same time. The results were impressive and as a result the approach may be extended. Clinicians found that POCT enabled health education to be undertaken, where there would not otherwise have been an opportunity. The majority of people responded positively in terms of engaging in further follow-up or service.
Anna is clear the culture of the organisation and its core business has shifted. “We have to be clever and work smarter to get it done,” she says. “In the face of heavy caseloads and emergencies, people need to see the importance of physical health and understand the evidence about how intervening in lifestyle can reduce risk. It can be quite profound and motivating.”