Developing a risk stratification tool that will calculate and assess key physical health indicators of patients with severe mental illness

My Topol fellowship problem / project:

Mental health and physical health are inextricably linked. It has been comprehensively documented both in national policy and clinical academic literature that those with mental illness are more likely to have poor physical health outcomes. Many patients are unable to access the physical healthcare they need, experiencing unnecessary health inequalities and increased rates of co-morbidity and mortality. Those with severe mental illness are particularly at risk of dying on average 15-20 years earlier than the general population

My project wants to help reduce this inequality and support a targeted approach to physical health monitoring and early intervention of physical health illness for those with SMI.
This will be achieved through the development of a risk stratification tool that will calculate and assess key physical health indicators for developing cardiovascular disease and diabetes that will link via an electronic interface into our clinical electronic patient record system RiO.

The algorithm will assign scores and weights to data points using a cardiometabolic health tool to identify and predict which patients are at (or likely to be at) high risk of developing these long term conditions and prioritise the management of their care, ensuring early appropriate intervention to mitigate poor outcomes. The aim is to then use the risk stratification tool to extract quality analysis and use the information to inform and improve care for individual patients as well as using the audit data to inform decisions for services and systems across our Trust. We will be able to use informatics to review resource need across the trust and understand which areas require development and support to reduce mortality risks of our patients.

A key factor to support my project and make digital transformation within my NHS Trust a success is the empowerment of our nursing workforce to embrace digital leadership and drive forward meaningful change through information and technology transformation. The nursing workforce is our frontline in the delivery of care and treatment. Any successful change and innovation must involve them. I hope and aim to use the project to promote an environment of quality improvement through the use of clinical information systems and digital solutions, providing positive leadership to support nursing IT initiatives through research in practice.

I have a BSc in Adult Nursing and I am a Nurse with a Specialist Interest in Substance Misuse. I have been qualified for just over 9 years and currently work for Barnet, Enfield and Haringey Mental Health Trust as the Head of Physical Health and the COVID-19 Testing and Vaccination Lead. Working through the pandemic I have had the opportunity to develop our patient and staff COVID-19 testing as well as our staff antibody testing processes. I am currently leading and operationalising 3 different COVID-19 Vaccination programs across our trust and the London Borough of Enfield.

I have a varied background within nursing having started my career working within Trauma Orthopaedics and General Surgery before moving into a nurse lead Primary Care Service within Prisons. This role exposed me to a number of different specialties and I developed an interest in substance misuse and specifically treatment and management of dual diagnosis patients.
Subsequent roles include Substance Misuse Clinical Manager across both a male and female prison and Primary Care and Substance Misuse Clinical Manager for the Specialist Services Division of Barnet, Enfield and Haringey Mental Health Trust.

My work at Barnet, Enfield and Haringey Mental Health trust has seen me lead and develop a number of digital-based projects, including a change of approach to physical health monitoring through the improvement of data collection, and processes working towards providing accurate reporting on physical health interventions and care through the use of digital innovation.