Me and My Goals with Physical Health Check Care Plan

NHS England reports that people with severe mental illness (SMI) have on average 15 to 20 years shorter life expectancy than the general population.

Many people with severe mental ill-health also suffer from physical ill-health and this is often linked with their mental health and its treatment.

80% of deaths of those with SMI are caused by common diseases such as heart disease, respiratory illnesses, diabetes, cancer and digestive disorders.

Also, health and care workers supporting people with SMI may not be aware of the associated risks of physical ill-health, or may not know how to provide support for such conditions and may focus only on an individual’s mental health.

There are real opportunities to address this, such as this integrated care plan.

Key objectives

All people with SMI should be offered an annual physical health check within Primary Care (their GP). This will measure and record information on smoking, obesity and high blood pressure on EMIS, which will be visible on the person’s Patients Know Best record.

Where such conditions are found, the person with SMI should be offered appropriate support and treatment, which they can set out in their ‘Me and My Goals’ plan, and continue to track their health and wellbeing by recording their measurements independently.

Outcome measures

Every person will be able to see their physical health check data and use their digital care plan ‘Me and My Goals’ to identify their health and wellbeing priorities (‘what matters to me’) . They can also set out their personalised recovery plan with support from healthcare professionals involved in their care.

When invited by the person, professionals from the wider framework of recovery services will be able to see this physical health check data and digital recovery plan, and give guidance and support as appropriate to their role and relationship to the person.

Current Baselines

All activity is face to face, with a lot of patients travelling large distances, where the follow-ups aren’t being efficiently or effectively managed.

Patients do not have a copy of their physical health check, and this information is not always visible to other wellbeing and recovery services supporting the person to get well and stay well.

Patients often feel once they have received a diagnosis for their mental illness, their physical health is neglected. Additionally, they can experience stigma and communication difficulties affecting their ability to seek medical help.

Workflow

Patient: Attends physical health check appointment.

GP practice: adds the physical health check data to patient record (EMIS) and it is then visible on the patient's PKB record.

GP practice with patient: Uses this data to inform person-centred ‘what matters to me’ discussion with the patient where recovery and wellbeing goals, important to the patient, can be recorded in their ‘Me and My Goals’ plan, with the next step to achieve each set out.

PKB: notifies patient a care plan has been added to their record.

Patient: continues to use PKB to track progress, update steps for achieving goals set out in their ‘Me and My Goals’ plan, and communicate with GP/Health Care Assistant etc to record and self-manage their recovery and wellbeing.