Mentoring Frequent Non-Attenders With Hepatitis In A Deprived Area
Dundee Health and Social Care Partnership
Hepatitis C is a potentially fatal disease if left untreated. Treating and curing hepatitis C can not only save a person's life, but also reduces the chance of forward transmission to others, impacting on the health of the population.
Hard to reach groups of people often have complex healthcare needs and lead chaotic lives, suffer health inequalities, socioeconomic deprivation and can have significant substance misuse problems. Treatment requires numerous visits to secondary care clinics or community pharmacies over a period of several months where patients are assessed and receive their curative drug treatment.
With the support of ihub’s Improvement Fund we've been evaluating the impact of providing individual person-centred mentoring to people who have hepatitis C and frequently fail to attend health care appointments. We aimed to see if it was an effective intervention, particularly around:
- the referred person being cured of hepatitis C 6 months after referral
- the impact on attendance rate before and after referral
- the impact on social work outcomes
- time spent by mentor
This project fits aligns with the Scottish Government's aim to reduce health inequalities and the national Health and Wellbeing Outcomes.
It is estimated that for every one person cured of hepatitis C six people are preventing from contracting this disease – targeting a hard to reach population is an effective strategy to improve the health of a population.
The aim of effective mentorship is not just to treat a potentially fatal disease (allowing people to live longer), it is also anticipated that mentoring will provide benefits to participant’s ongoing health and wellbeing
- What was the approach?
The key people working collectively to deliver this project were:
- Mentors from Integrated Substance Misuse Service
- Team Managers from Integrated Substance Misuse Service
- General Practitioners
- General Practice Teams
General Practitioners recruited patients for the project. Secondary care had previously provided a list of registered people with hepatitis who had defaulted from secondary care clinics. The project lead GP contacted them by writing letters (sending these to the person’s home, and attaching to prescriptions) as well as by phoning them regularly (if phone numbers were available).
General Practice Teams would provide a summary of clinical notes for the Integrated Substance Misuse Service and ISMS Team Managers would allocate referrals, based on referral details, to the best suited mentor for the individual.
The team made every effort to engage with people that were referred, including telephone and face top face. They set up appointments to meet either in at home or in a suitable place in the community. From these visits and contacts the mentor would attempt to gain rapport and establish the challenges being faced by the person. The mentor would try to persuade the person that getting treated for hepatitis C should be a priority and provide support where required.
We used Appreciative Inquiry principles, the existing teams working together to develop unique strategies and goals to improve the health and wellbeing of people referred.
Methods used to test the change and monitor progress included regular interdisciplinary team meetings in which referral numbers were monitored and informal discussions occurred to establish how people referred were engaging with the mentoring.
Activities were monitored by utilising routinely collected healthcare data. Primary care notes occurred as usual and these were retrospectively analysed. Routine social care notes were taken and retrospectively analysed to objectively establish time taken and the impact mentoring input has had on the person.
ihub funding was used to enable meetings to discuss the progress and have dedicated quality improvement time devoted to devising outcomes, extracting data and interpreting this.
- What was the impact?
Primary Outcome: Was the referred person cured of hepatitis C 6 months after referral?
Two people verbally stated they were cured due to the mentoring process. It must be acknowledged that there are local, robust services in place. It is also of note that of those referred, 4 people engaged with the mentor and 4 people did not, but both had the same rate of cure. The fact there was initial contact via the GP may have encouraged the person referred to obtain treatment.
Secondary Outcome: Impact on attendance rates
From reviewing records it is clear that people are presenting with different episodes of care, and at times with a complication involving frequent follow up, that may then resolve. Using primary care records and letters sent from secondary care clinics we found there was no meaningful change in attendance rates after the person was referred to the mentor.
Secondary Outcome: Impact on social work outcomes
The GP and ISMS team manager carried out detailed retrospective reviews of social care case note and agreed on how the patient’s situation had changed six months after being referred. There is little evidence of a meaningful improvement in social care outcomes. Despite 75% being cured of hepatitis C retrospective, collectively outcomes were actually reduced. This is likely due to the complexity and multiple health problems faced by the patients.
Secondary Outcome: Time Spent by Mentor
Mentors spent time attempting to engage with this hard to reach group. Proactive efforts included repeated home visits. We estimated 10 minutes per phone call, 90 minutes including travel time for a home visit, and 150 minutes when supporting the individual to attend appointments / services.
- Four individuals that engaged with the mentor took the mentor an average of 28 hours.
- Four individuals that did not engage with the mentor took the mentor an average of 13 hours.
- What was the learning?
Key learning points:
- In primary care a GP (or other healthcare professional based in the practice) lead is required for each individual project to sustain momentum & raise awareness
- Having a mentor with a particular interest in working with this hard to reach population is crucial to the engagement process.
- Regular meetings are required when a new referral process is occurring, to identify and deal with any issues that occur
- Not an intended consequence of the support workers involved became more skilled at assertive outreach, but patients from other practices (outwith this project) were supported to undertake treatment for hepatitis C.
- With such low numbers we were faced with the challenge of presenting results, and risking identifying patients. We were supported in this through discussions with a Caldicott Guardian from NSS.
If being reproduced:
- the capacity of the hepatitis clinics should be assessed first. In this study local colleagues had been involved initially and had agreed that they would support the project.
- a post dedicated to providing mentoring would allow for a larger evaluation to occur.
- the relatively low numbers of patients meant that in-depth statistical analysis was not possible.
Sharing the learning
Locally in the Dundee Health and Social Care Partnership we have discussed the project. These discussion have occurred locally on an informal basis in the context of wider service redesign which is ongoing.
We produced and presented a poster for the Hepatitis Scotland National Conference run by Scottish Drugs Forum on 28th March 2019.
- What are the next steps?
The project didn’t deliver evidence for improved attendance or an objective improvements to participants lifestyles overall. Although this is not a reflection of a failure of a project, an option moving forward would be a similar intervention would be tested at larger scale across multiple practices. Locally we will decide an alternative approach to support this hard to reach group of people.
We believe that this project could be replicated elsewhere in other general practices. Due to the nature of general practice this would be best implemented into their own systems in a way which works for that particular team.