Shine 2014 final report
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
www.health.org.uk
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:
1.
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 selfmanagement measured by social functioning and their quality of life. Use of crisis
services would also be measured.
2. To assess how the intervention may be implemented within current community
mental health services and more widely within the NHS.
GLOW is 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 living both 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 increased the number of community and self-care activities
carried out and used crisis services less. This demonstrates a reduced reliance on mental
health services and an increase in self-management of daily life.
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Interviews with managers and clinicians indicated that GLOW 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 increase
self-care and recreational activities thereby improving a person’s mental-wellbeing and
reduced 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 Scale had been identified to
measure occupational performance. However the team agreed that to use it within the
GLOW assessment rather than as an outcome measure.
Data was collated from 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.
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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 shows an 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)
70
60
60
52
50
40
30
20
10
0
Baseline
Post-GLOW
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 period were 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.
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Figure 2: end of GLOW and four month follow-up mean scores on Personal and Social
Performance scale (n=14).
70
61
59
60
50
40
30
20
10
0
Post-GLOW
Four month follow-up
An increase in score indicates an improvement on the scale.
Time Budget measure
Figure 3 presents baseline 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)
57
60
50
40
35
30
20
10
0
Baseline
Post-GLOW
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
included sleeping less during the day, spending more time doing activities outside the house.
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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)
60
54
56
Post-GLOW
Four month follow-up
50
40
30
20
10
0
An increase in score indicates an improvement on the scale
Manchester short assessment of quality of life
Figure 5 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)
50
45
40
35
30
25
20
15
10
5
0
47
46
Baseline
Post-GLOW
An increase in score indicates an improvement on the scale
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Figure 6 MANSA mean scores for participants Post-GLOW and four months later.
(n=14)
50
45
46
Post-Glow
Four month follow-up
45
40
35
30
25
20
15
10
5
0
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 services throughout the project.
Figure 7 Number of Mental Health Act assessments (n=19)
5
4
Mental health act
assessments pre-GLOW
3
Mental health act
assessments during
GLOW
2
Mental health act
assessments four months
post-GLOW
1
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
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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)
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
0
Number of days in acute
MH ward pre-GLOW
Number of days in acute
MH ward during GLOW
Number of days in acute
MH ward four months postGLOW
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 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)
60
50
number of Home
Treatment Team contacts
pre-GLOW
40
number of Home
Treatment Team contacts
during GLOW
30
20
number of Home
Treatment Team contacts
four months post-GLOW
10
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 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.
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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 services demonstrated by fewer contacts with crisis services.
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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)
1,589 hours per year
£25.00
GLOW training (6 hours) £238.20 over one year , 1 hour
.14
Total hourly rate
£25.14
--------------------------------------------------------------------------------------------------------------------------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.
-------------------------------------------------------------------------------------------Total time required to implement GLOW:
77 hours
--------------------------------------------------------------------------------------------------------------------------
*Total cost of GLOW per patient=
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(*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.
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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
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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
During the launch, the project was reported in the trust’s bulletin and a press release led to
report on the local radio station and was picked up by the local authority. The outcomes will
also promoted through the communications team.
At the start, the project manager met with key groups including Lead OTs, Kingston and
Richmond management team, the consultants as well as community and ward teams. This
built local interest although there has been a sustained period of uncertainty and changing
personnel within the community transformation programme and so these relationships will
need to be refreshed.
The Director of Therapies held a workshop with Lead OTs and the project manager to
consider the optimum fit of the GLOW intervention in the emerging clinical pathways. The
intervention could potentially be used to support the transition not only from ward to
community but also the transition from secondary care to primary care. These proposals
have been discussed with each of the service directors. Once the allocation of occupational
therapy resource is known, there will be a decision on how best to take this forward, using a
phased approach Borough by Borough.
Local training events will be planned for OT practitioners in Autumn 2015 once the GLOW
manual has been revised. The outcomes of the project will be presented at the trust’s OT
conference in November 2015.
The project was presented at launch of Trust’s Clinical Research Unit for General Adult
Psychiatry and was reported to the Innovation Group and also in the research bulletin. This
fostered other collaborative research initiatives with service user researchers. Plans are in
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place for a funding application for a randomised control trial of GLOW to evaluate
effectiveness and cost effectiveness.
The Director of Therapies regularly reports progress to the clinical research unit and also the
London mental health leads and research leads. This has sparked interest in GLOW and an
invitation to present the work at the College of OTs Specialist Section in Mental Health. This
was highly successful and has promoted the national interest in the innovation. Preliminary
results were also presented at the College of OT conference in June 2015 Several
conference delegates tweeted about their interest in GLOW following both presentations.
Abstracts have been submitted for the OT Show in November 2015 and the European OT
Conference in June 2016.
Following the presentation at the London Mental Health Leads group, The Director of
Therapies is initiating a London-wide mental health OT conference on intervention research
in January 2016. This will be co-hosted by the professional body, the College of
Occupational Therapists and is a major opportunity to share the learning. This will form the
template for similar UK events as the Mental Health OT specialist section have prioritised
intervention research such as GLOW for the next five years. This will provide more
opportunities for spread.
Alongside this, the project team with a health economist are preparing an Open access
publication of the GLOW feasibility study and will seek support from the Health Foundation.
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Appendix 2: Resources from the project
Media coverage of GLOW:
http://www.swlstg-tr.nhs.uk/news-and-media/news/research-grant-opens-the-door-toindependent-living/
https://www.mentalhealthtoday.co.uk/london-based-project-aims-to-help-people-with-mentalhealth-conditions-live-more-independently.aspx
GLOW features in the London Mental Health Factbook:
http://www.swlstg-tr.nhs.uk/_uploads/documents/news_and_events/london-mental-healthfact-book-cavendish-square-group-final.pdf
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Appendix 3: Outcomes at individual level
Figure 3.1 Personal and Social Performance Scale scores at baseline, end of GLOW and
four months follow-up.
95
90
85
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
0
Baseline (n=19)
End of GLOW (n=19)
Four month follow-up
(n=14)
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19
Figure 3.2 Time Budget scores at baseline, end of GLOW and four month follow-up.
90
85
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
0
Baseline (n=19)
End of GLOW (n=19)
Four month follow-up
(n=14)
1
2
3
4
5
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Figure 3.3 Manchester Short Assessment of Quality of Life
70
60
50
40
Baseline (n=19)
30
End of GLOW (n=19)
20
Four month follow-up
(n=14)
10
0
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19
Figure 3.4 New activities carried out at least once each week by participants at the end of
GLOW and follow-up
wellbeing centre
go to local café
skyping friends
sewing group
getting cab to shops
mindfulness course
Drop-In café
walking group
singing group
Zumba
Recovery college
Art Course
Volunteering
0
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3
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Figure 3.5 Resumed activities carried out at least once a week by participants at the end of
GLOW and follow-up
Weekly food shop
swimming
bike ride
play guitar or piano
going to the cinema
teaching
0
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2
3
4
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Appendix 4: Case Study
A case study is presented to outline the content of the GLOW intervention and how this
leads to outcomes for the service user.
Julie
Julie is a 47 year old woman with a diagnosis of emotionally unstable personality disorder
since 2011. She lives with her 20 year old son. She was admitted to an acute ward for six
weeks prior to being discharged with home treatment team and starting GLOW. She has had
several previous admissions and contact with Home Treatment Team in the previous two
years.
She was referred to GLOW by the Home Treatment Team as the team had identified that
she has been isolating herself at home for over two years and she was interested in getting
back to doing things in the community.
GLOW intervention sessions
High intensity four weekly sessions
Aim: to increase self-care and care of home.
Carry out OCAIRS assessment and home environmental assessment if the occupational
therapist and Julie observed that the home environment did not support daily activities.
Focus of OCAIRS questions:
Habits and routines: structure of week, organisation of time, balance of activities)
Roles: identification of roles, variety of roles, sense of belonging, involvement in roles.
Personal causation: appraisal of abilities, confidence, self-efficacy, autonomy and optimism.
Motor, processing, communication and interaction skills.
Values, interpretation of past experiences, readiness for change.
The results of OCAIRS identified that Julie spends her time at home and does not leave the
house more than once a week. The OCAIRS also identified that she had skills, and had no
difficulty with self-care or caring for her home. She identified interests from the past and the
occupational therapist also used an Interest Checklist to prompt her to identify other
activities she may like to try or had forgotten she enjoyed. The OCAIRS also identified that
Julie had low confidence in her ability to carry out activities she enjoyed in the past like going
to Church and singing in a choir.
After completing the OCAIRS the occupational therapist and Julie set weekly goals of her
going for a short walk daily and by week three going to the chemist or to a coffee shop as
Julie identified that she would like to build up her confidence to leave the house regularly.
Goal setting
Julie set the following goals with the occupational therapist:
To visit three different Churches and identify which she would like to attend church
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To identify if the churches had a choir she could join.
To attend healthy walks groups weekly in the park
To attend Mindfulness group weekly
The occupational therapist met her during weeks 2-4 in a local café and once at a local park
to try out the walking group with the aim of providing a graded approach to returning to
activities in the community.
Medium intensity sessions
During the first of the medium intensity sessions the occupational therapist went clothes
shopping with Julie as she identified that she would like to buy clothes that fit as since her
recent weight gain her current clothes didn’t fit. Support to buy new clothes aimed to
increase Julie’s self-esteem and “old self” that took pride in appearance.
During the remaining medium intensity sessions the occupational therapist provided a
graded approach to accessing other activities such as a singing group and mindfulness
group by meeting her at the venue and exploring environmental barriers to her accessing the
venue independently such as location, bus route or people using the centres and identified
suggestions to overcome some barriers such as finding venue on easier bus route or closer
to home.
Low intensity sessions
During these three session the occupational therapist met Julie in a café to revise goals Julie
set for the week and to offer encouragement and offer suggestions if required regarding
activities.
At the end of GLOW, during the last session the occupational therapist asked the OCAIRS
questions again and put together a maintenance plan to support Julie to continue her
activities and build on the goals she set as part of GLOW.
OCAIRS results identified that Julie had achieved her goals and had enrolled on singing
course, completed a mindfulness course, started attending a new church regularly and
restarted family days out at weekend as well as going to the cinema. Her range of weekly
activities involved her leaving the house everyday and engaging in activities she enjoyed
instead of being at home everyday and feeling that she had no purpose to her day.
Julie showed a reduced use of Home Treatment Team during GLOW and did not use any
crisis services during the four month follow-up.
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Appendix 5: Cost of GLOW
Unit cost of Crisis services
Cost obtained from Unit Costs of Health and Social Care 2014 (Personal Social Services
Research Unit) unless otherwise indicated
*One Mental Health Act Assessment
£771.00
One day on an acute MH ward
£295.00
One contact with HTT clinician: (band 6 community psychiatric nurse)
£37.00
One call to NHS Trust Crisis Line: Graduate mental health worker
£33.00
Cost of GLOW
Activity
Screen and Recruit 1 service
users from caseload and team
Supervision regarding
intervention x 6
Sub total
Intervention Phase
Weekly visits with client in own
home (four visits)
Time per activity
Pre-intervention phase
Band 5
Total time per phase
.5
6 hours
6
6.5
3.5 hours (1.5 hrs with service
user and 2 hour travel time)
Six visits every fortnight in
3 hours (1 hour with service
community or home
user and 2 hour travel)
total
Administration
Clinical report writing (two
1 hour (30 mins per OCAIRS
OCAIRS reports in total)
report)
Clinical note writing x 10
35 minutes
sessions
MDT meetings and
2 hours total
communication
Sub total
Total time required by OT per patient:
14
18
32
1
3.5
2
70.5
77
hours
(*source: Heslin M, Callaghan L. & Byford S. (In submission). Street Triage: A Before and
After Design and Cost-Offset Decision Analytic Model.)
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