IMPARTS (Integrating Physical & Mental Healthcare: Research, Training & Services), a King’s Health Partners (KHP) funded initiative, is a programme that facilitates the integration of physical and mental healthcare in general hospital settings to improve patient care.
IMPARTS (Integrating Physical & Mental Healthcare: Research, Training & Services), a King’s Health Partners (KHP) funded initiative, is a programme that facilitates the integration of physical and mental healthcare in general hospital settings to improve patient care. This system is currently embedded as part of routine clinical care in outpatient departments at King’s College Hospital and Guy’s and St Thomas’ hospitals. It is now live in 28 services across the two acute trusts, screening patients in outpatient clinics for conditions such as depression and anxiety. Nearly 10,000 individual patients have been screened through nearly 20,000 screening encounters. Our work to provide holistic care for people with skin disease at the St John’s Institute of Dermatology at Guy’s and St Thomas’ received the BMJ Award for Dermatology Team of the Year 2016. The programme is also being adapted to provide physical health screening for people with severe mental ill health at South London and Maudsley. IMPARTS forms a core part of the KHP’s Mind and Body programme.
IMPARTS is provided through five components: Informatics, Care pathways, Self-help materials, Research, and Training and Education. The informatics component is a web-based screening tool, which allows for the completion of patient reported outcome measures via tablets prior to consultations. Each questionnaire set is bespoke to each clinical team ensuring the questions most relevant to that patient group are asked. The areas covered include depression, anxiety, and smoking as the core measures, health behaviours such as alcohol use, drug use, and adherence to medication, along with quality of life, pain, sleep, and information about the physical condition that might be useful to the clinical team. For example, one team has included a health plan on the screening platform that prompts the patient to think about what they want and need from the consultation, and to set goals and actions. The information is uploaded in real time to the patient’s electronic health record, along with a flag for any issues identified and advice for referrals where appropriate. The information is available to the clinician just prior to seeing the patient, where discussions about any issues raised, around either mental or physical health, and possible onward referrals can then be incorporated into routine consultations.
Screening takes place at regular time points which allows the clinicians and patients to identify and track change in symptoms over time. The back end of the system can be programmed to schedule the delivery of the questionnaires allowing for flexibility in what measures are completed when. This ensures patients are not required to fill in the full battery at every appointment making the process less burdensome and time consuming. The informatics technology was developed by a partner company who continue to support and improve the system.
Referral advice may be displayed alongside the results in the electronic health record following screening. These are typically linked to depression and anxiety but sometimes for trauma, smoking, alcohol or drug use, and the care pathways are based on the existing resources available to the clinical team. For example, if a team has embedded psychological and/or psychiatric support, the referral advice will reflect this may refer to these support services. Different pathways may be triggered depending on the level of need, the scoring thresholds linked to the pathways are agreed between the IMPARTS and clinical teams to ensure patients receive the appropriate level of treatment, whilst remaining pragmatic about resources. Where possible this follows the evidence based stepped-care model for psychological support, whereby the level of intervention and healthcare professional expertise is matched to clinical need. Examples of pathways for probable Major Depression may include referral to the team Clinical Psychologist for specialist therapy if available, or if not a referral to the GP suggesting a referral to Improving Access to Psychological Therapies (IAPT) is made. A protocol for assessing risk around suicidal thoughts has been developed, which includes advice around referring to liaison psychiatry, or taking a patient to the A&E mental health liaison team if applicable. Feedback from clinicians on this point has been very positive. Where there may have been some anxiety initially about looking at suicidal thoughts, clinicians have found that the protocol actually provides a very useful and reassuring formal structure for dealing with these issues.
Self-help materials are developed in collaboration with the relevant clinical team and patients. They are often led by the IMPARTS Consultant Clinical Psychologist, or a member of her team. The materials are tailored to specific physical health problems to help patients cope better in the context of their particular condition. These can be offered to patients who don’t meet criteria for referral but still have a level of need, and they can be offered to patients to supplement a relevant referral. They are also freely available on the IMPARTS website.
These three components, 1) informatics, 2) care pathways/referrals, and 3) self-help materials, are supported by the provision of training to all clinical staff involved with IMPARTS. Informal, bespoke training sessions are delivered by the IMPARTS Consultant Clinical Psychologist, which are designed in collaboration with the clinical team and tailored to their specific needs. This ensures all members of staff understand their roles, and feel confident and competent to incorporate this into daily practice. In addition to the tailored training sessions, IMPARTS has also developed a five day teaching course: Mental health skills for non-mental health professionals, which can be a 15 credit module for a Level 7 MSc course. To date, this course has been delivered to staff members at KHP, however the next course, the 6th course, has been commissioned by external partners.
The final component of IMPARTS is the research infrastructure. The IMPARTS package is primarily a clinical/service development tool but the platform also effectively facilitates research. IMPARTS has general ethical approval for any data collected via the screening platform to be used for research purposes, with additional approval from the patient-led IMPARTS research oversight committee for each specific research proposal. A pseudonymised research database can be created containing data collected via the IMPARTS platform, and from the electronic health record. Patients may also be recruited into research studies and trials via a consent for contact process. A collaboration with Health Psychologists and renal specialists has resulted in the development of an online psychological intervention for people with depression/anxiety with end stage kidney disease. The IMPARTS platform was effectively used to recruit patients into this randomised control trial.
IMPARTS has been implemented in 28 different clinical teams with 16 more in the pipeline, across a wide range of conditions from large generic services s such as rheumatology, diabetes, and dermatology, to highly specialised settings such as endocarditis and neuroendocrine cancer. IMPARTS has significantly increased mental health and psychological wellbeing assessment for these patients. For example, the medical dermatology team screened 39% of patients for mental health problems pre IMPARTS and now screen 98.7% of patients. Where IMPARTS has been embedded there has been overwhelmingly positive responses from both clinical teams and patients. Specific details of this feedback will be presented in the evaluation section.
This platform can also support CQUINS by collecting relevant data in a timely and efficient way, and removing the need for paper questionnaires and resulting issues with storage and data entry.
Further evidence of the benefits of IMPARTS can be seen in the successful application for funding. One clinical team demonstrated the level of psychological need in their patient group and received funding from the Trust to support a full time, permanent post for a dedicated Clinical Psychologist. Another team received funding from commissioners to continue the positions of a liaison psychiatrist and Cognitive Behavioural Therapy (CBT) therapist, and then taken over by the Trust itself.
The IMPARTS team has developed excellent working relationships with clinical teams across the partner trusts where we have worked collaboratively to embed IMPARTS into routine clinical practice. The clinical teams take ownership of the package once implemented but IMPARTS still works closely with teams to support and facilitate development and research. IMPARTS has also recently developed contacts with clinical teams at hospital sites recently acquired by King’s College Hospital NHS Foundation Trust (KCH).
IMPARTS has created and maintained strong links with the IT teams at KCH and GSTT to set up the system initially and also to develop the platform. For example, the KCH IT team assisted us in developing the capability to send patients emails or text messages about smoking cessation services if they indicated their wish for this on the screening platform. IMPARTS works very closely with Teleologic, the company who initially developed the informatics infrastructure, who provide continued support in the maintenance and development of the platform in response to clinician and patient needs.
Several IMPARTS self-help materials have been adopted by national charities, such as the British Association of Dermatology and the Somerville Foundation. Referral pathways are established and strengthened with primary care, IAPT and community mental health teams.
We have also liaised with the Latin American Women’s Rights Service to discuss further developing IMPARTS for patients whose first language is Spanish/Portuguese and are unable to complete questionnaires in English. South East London has a significant number of Latin American patients and this change, when implemented, will widen accessibility and participation. Further widening access to IMPARTS, we are working with colleagues in the mental health learning disabilities team at the South London and Maudsley NHS Foundation Trust (SLaM) to all patients with learning disabilities to complete screening and incorporate reasonable adjustments in referrals and clinical care. Also, at SLaM we are working with colleagues to introduce IMPARTS for mental health patients to assess and manage physical health problems. This pilot is being done in collaboration with the CLAHRC South London team.
We are collaborating with the Health Innovation Network (an Academic Health Science Network) diabetes team to ensure our projects work alongside, and enhance each other rather than duplicating effort. Similarly, with Mindwave, a company working on a patient portal for patients in SLaM. We have started preliminary discussions with pharmaceutical companies about the utility of IMPARTS data for phase IV studies.
The design and development of the package was done with a focus on service users. The IMPARTS steering committee and research oversight committee are chaired by a patient representative and another patient representative is a member of both committees. Other areas of patient and staff involvement include:
1) The self-help materials are developed with input from patients and staff at an early stage of development and then feedback when a draft has been produced. 2) The battery of questionnaires for each service are developed with input from IMPARTS and clinical teams to ensure the most relevant and important information is collected.
3) We also present potential new screening questions and research ideas to a service user advisory group. 4) We seek feedback from psychology/psychiatry services in the Trusts to keep informing the care pathways.
5) Part of screening includes a questionnaire on consent for contact, which asks patients if they would like to be part of a case register whereby researchers can contact them to invite them to participate in research. They are not consenting to a research study at this point but consenting to be contacted about research. This broadens and improves the accessibility to research, which ultimately contributes to better health care.
6) We hold half day, termly seminars on research and clinical practice at the mental/ physical health interface for clinicians, academics, and researchers. The feedback drives development and recently we had a talk from a patient who had experienced IMPARTS screening at outpatient appointments and subsequent referral to a cognitive behavioural therapist specific to that service. The patient discussed how great a positive impact the identification and management of her psychological problems had been on her overall wellbeing. This also had a significant impact on how she well was able to manage her physical health condition.
7) We use informal feedback from staff members to make changes and developments. More recently we asked all staff involved with IMPARTS to complete surveys to provide us with more detailed information on how we can improve.
8) Qualitative research studies with patients from two different services to gain an understanding of their attitudes and opinions of IMPARTS process specifically and the general idea of looking at mental health within the context of physical health conditions. Feedback from these has resulted in a number of changes to the screening process.
9) Feedback is also collected from the 5-day teaching course, which is incorporated in future sessions.
Buy-in from all members for the clinical service (from consultants to healthcare assistants) is necessary for IMPARTS to work optimally. It is crucial that IMPARTS is seen as an opportunity rather than an imposition. Rather than push ahead with implementation based on the enthusiasm of one or two individuals, we’ve learned that the better approach is to go ahead with implementation only when the whole team is on board and engaged. In addition to this we have learned the importance of agreement within the management structure about the strategic direction and implementation of this infrastructure. Again, ensuring all levels of management are in agreement would facilitate implementation. We have also learned to work very closely with the teams to ensure the feasibility of integration in their specific service and learned the different ways of working with different teams.
Our initial funding covered implementation costs only. With this limited resource we have carried out studies evaluating specific components of IMPARTS, but a more systematic programme of evaluation may have helped us refine and improve the IMPARTS model. We are currently applying for additional funding to assess the impact of IMPARTS on process of care, clinical outcomes and costs and develop an optimal implementation strategy for practitioners and service planners.
Early on we found that a lack of confidence discussing and dealing with mental disorders was common in physical healthcare teams and contributed to reticence about implementing IMPARTS. Many clinicians reported avoiding discussing mental health due to a lack of time and fear of ‘opening a can of worms’. To overcome this we instigated mental health training for the clinical teams as a core component of the IMPARTS package, to be undertaken prior to implementing screening. This training is delivered by a consultant clinical psychologist and the IMPARTS project team, and tailored to the needs of the particular team. This allows the training to integrate the clinical and technical aspects of implementing IMPARTS. We also developed a course ‘Mental Health Skills for Non-Mental Health Professionals’ which we’ve delivered for four consecutive years. The course consists of 5 taught days covering distress, agitation, medically unexplained symptoms, substance misuse and managing conflict with the emphasis on learning practical skills using role-plays with professional actors and case-based discussion.
Prioritisation of physical health over mental health has been a major obstacle in implementing and expanding IMPARTS. Embedding IMPARTS in a physical healthcare setting requires time and commitment from staff and sometimes a shift in attitudes to mental health. To promote awareness of the impact of mental health problems in physical illness and the value of detection and management, we initiated a series of half-day seminars addressing research and clinical work currently happening at the mental/physical health interface across KHP. The seminars have been well attended and have attracted many new services keen to implement IMPARTS. We also have a mailing list and twitter account to help disseminate ideas and information about IMPARTS and the mental/ physical health interface more broadly.
For mental health screening to have value it needs to be implemented alongside a strategy of onward management and intervention. One challenge IMPARTS has faced is how to improve detection and management of mental disorder in services that have limited specialist mental health input. To address this we have worked with clinical teams to operationalise care pathways to IAPT and primary care, and supported several business cases for new mental health posts, including clinical psychology, liaison psychiatry and Cognitive Behavioural Therapy (CBT). For patients identified as having lower level distress we have developed a range of self-help materials, which address patients psychological needs in the context of their particular physical health problem.
Getting the IMPARTS informatics system to talk to the electronic patient record systems at KCH and Guy’s & St Thomas’ NHS Foundation Trust (GSTT) in real-time was a huge hurdle. For the IMPARTS system to be scalable and flexible it was vital that data collected via screening linked to the generic hospital Electronic Patient Record (EPR) rather than service-specific databases. We also needed screening data to transfer to EPR in real-time, so the clinicians could view and discuss the results during consultation. Securing buy-in and support from KCH and GSTT Information Technology (IT) at an early stage was crucial. From the start of the project we built strong relationships with IT, which enabled us to meet our initial objectives and expand our informatics capabilities as the project has expanded.
IMPARTS is designed to be self-sustaining and embedded within the clinical service. The IMPARTS project team assist with set up and implementation and the day to day running is managed by the clinical team. The IMPARTS team are available for support, advice and implementing changes however, little input is needed after the initial implementation phase. Permanent integration of the system into the service is not contingent on the IMPARTS team but is reliant on the engagement and hard work of the clinical team.
A number of evaluation projects have been conducted, evaluating 1) feasibility and acceptability, 2) patient and staff experience, and 3) the training component:
1) Feasibility/acceptability:- The IMPARTS project team conducted a small feasibility/acceptability study on the first four services to embed IMPARTS. The proportion of patients declining to screen is very low, at most 5.1%, and certainly much lower than in research studies in comparable settings. The level of assistance required by patients varied across services, ranging from 11.7% to 40.1%. The project team have since investigated reasons for needing help and put some measures in place to improve this. It has also been found that screening has not had an adverse impact on nurse assessment or doctor’s consultations times with there being no statistically significant differences in times for patients who were screened versus those who were not. Similarly, there are no differences in consultation times for patients with identified psychological needs compared with those without.
2) Patient and staff experience:- Two qualitative studies have been conducted by students at King’s College London, supervised by the IMPARTS project team. One conducted telephone interviews with patients attending musculoskeletal physiotherapy appointments, and the second conducted face-face interviews with patients in the limb reconstruction service with identified psychological need and onward referrals. The majority of patients reported that they felt it is important to assess mental health and psychological wellbeing, and they agree that doing so in the acute hospital setting is useful and valuable. Patients in the limb reconstruction service were particularly positive about receiving treatment by mental health specialists who are based within the limb reconstruction team so everything is treated in the same way, this was less stigmatizing; Patients receive treatment for their psychological needs and for some services this is delivered by healthcare professionals who are specialised in treatment within the context of the physical health condition. For example, 17.5% of patients screened in the rheumatology service have been referred to either a liaison psychiatrist or clinical psychologist who is dedicated to that service; The IMPARTS project team recently asked all clinical staff involved with IMPARTS to complete an online survey. Clinicians believed the way in which patients’ mental health needs are met has significantly improved since IMPARTS implementation. They were asked about pre and post implementation, and: Pre – met very well = 5.8%, increased to 23.5% post implementation, Pre – met well = 17.7% increased to 64.7% post implementation.95.3% of clinicians who responded are either extremely or quite satisfied with IMPARTS • Overwhelmingly, clinicians reported that the introduction of IMPARTS has had a positive impact on the daily practice. For example, one consultant said: “it has enabled capture of PROMs related to rheumatology as well as mental health which allows us to have data driving decisions about physical and mental healthcare…better patient outcomes in some circumstances.” Another clinician: “It supports holistic assessment and serves as a spring board for an enhanced consultation process,” and another: “it has alerted me to people with depression that otherwise I might have missed.”
3) Training:- Feedback from students is sought for each taught session and highlights the practical components including observing and participating in roleplays with professional actors were seen as the most valuable part of the teaching. The feedback also shows high increase in confidence managing which is in line with the focus of the course on experiential teaching with roleplays and case based discussion; All former course students were recently asked to complete an online survey. 100% of respondents felt the course increased their knowledge in the assessment and treatment of mental health needs, and 85.7% either strongly agreed or agreed that it increased their confidence in dealing with such problems. Similarly, 85.7% either strongly agreed or agreed that the course has been useful to, and improved, their practice. Finally, 83% of respondents use the skills learned on a daily-weekly basis.
Dissemination is conducted in a number of ways: Research publications using IMPARTS data/platform are feely available on the IMPARTS website; The termly seminars are a great opportunity to update people on the progress and developments of IMPARTS; We regularly engage in social media to inform people of upcoming events, new self- help materials, research, conferences and seminars. Such news is also cascaded across KHP by circulars, bulletins, and mailing lists; There is also a termly IMPARTS newsletter reporting on latest developments and featuring pieces from clinical and IT colleagues; Members of the IMPARTS team regularly attend national and international conferences to discuss the project itself or associated research. The team has put together a symposium for the upcoming Royal College of Psychiatrists International Congress. Allowing an opportunity to discuss the IMPARTS project, work from colleagues within KHP around the mental/physical health interface, and a piece on the collaborative care model and evidence for this from an external speaker. Clinical teams also lead research and audit work, discussing this at national and international conferences/meetings
Additionally, we have had numerous approaches to implement IMPARTS outside of KHP and we are in the process of developing an accreditation model to do so.
The key value of IMPARTS is integrated and holistic package that has been developed. In comparison with some other projects whereby screening alone has been introduced, this programme supplement screening with care pathway development and advice, supporting staff with bespoke training, and the ability to simultaneously contribute to the evidence base on a wide range of topics around the physical/mental health interface
