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The Elder Interview: Dr Neil Chadborn, Research Fellow, University of Nottingham

Integrating Care: Finding Commonality Between Organisations to Implement Best Practise

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Neil Chadborn, Zvezdan Bozinovski Photography.

Neil Chadborn’s research focuses on inter-professional and inter-organisational aspects of integrated care for older people. He is currently involved in the PEACH project, to understand how a Quality Improvement Collaborative (QIC) can help organise healthcare services in care homes – and has an Alzheimer’s Society Knowledge Exchange Fellowship, exploring how services within a community can work together and with people living with dementia. We talked to him about the challenges of providing truly integrated care and why networks may provide a more inclusive way to enable people to access support according to their needs.

Why are the inter-professional and inter-organisational aspects a key research focus for you?

My background is in public health research, and that gives me a certain independence – doctors and nurses, for example, come at research from within a tradition of their profession, and this professional perspective shapes their analysis and interpretation. I aim to take the individual person’s perspective (along with that of the family or carers), to understand health issues.

As I am a ‘step away’ from the professions, I can explore how the different agencies interact to provide team-based care – and how this is shaped to the individual needs of a person.

I am constantly on the look-out for how professionals put into practice the notion of ‘person-centred care’. There is often a gap between the ambition of policies and how an individual person experiences this.                                                                                             

While members of the public may be participants in our research, we are also keen to invite people to have an input in the design of the research itself. This includes inviting them to the university to have meetings with us to discuss the research process, involving them in conducting the research itself, or even involve them in helping us to do the interviews rather than being interviewed themselves, or interpreting the data.

Spending time researching technical questions about organisations may lead to losing focus of the end goal of improving the care of people. The importance of this ‘patient and public involvement’ approach is that it avoids this academic bubble – by involving people from the outset, there is a real emphasis on doing research that will have a practical impact and will be relevant to today’s problems.

What does this independence bring to your research?

In PEACH study, the care homes research I am doing, I am looking at the problem of continuity of care – and it’s an excellent example of the benefit of independence as a researcher.

There is currently a national policy drive to improve healthcare in care homes, which has previously been of variable quality. One of the problems is that a person with complex needs may require input from several professionals; geriatrician, social worker, physiotherapist and GP.

We are investigating how best to coordinate the activities of these different professionals. While each professional could conduct research on this problem, they each bring their own perspective – the geriatrician may have a hospital perspective, the physiotherapist may not have expertise in medical conditions.

As a non-clinical researcher, I try to consider the perspective of the person and their experience of being cared for by several professionals. I aim to understand how to take the best from each of those professions, to coordinate around the needs of the individual.

But this has to work at the care home level too – you can put time and resources around one individual, but somehow you also have to make that work for the whole care home to make it practicable, so there’s another level of organisation and facilitation that is needed.

Is there still a silo mentality in health and social care that prevents real integrated care?

Yes and no. Words like ‘silo’ and ‘culture’ are easy to use as blame words, which doesn’t help us to progress or improve things. In a care home, there may be up to four or five different organisations involved in the care of one resident, and we can’t avoid that – we just have to make it work.

Technology is one way that we can help address this, for example – a significant problem is that each organisation has its own database and system.

In Nottinghamshire, there is an NHS organisation that is drawing together the different systems so that this data can be shared across all these different organisations. That is a way of bridging those silo boundaries and enabling team-based work to be efficient.

At what level does change have to happen when we look at developing more integrated, multi-disciplinary care?

We can think about three levels of change; policy, organisational processes and the care of an individual and it’s helpful to look at it in that way. Every practitioner across the board will agree with the aim of improving care for the individual – so that is a commonality.

“We know from implementation research that if you have a strict policy implemented nationwide, it often fails.”

Understanding the great variety within communities – whether that is ethnicity or gender, or geographical factors – implies that services should be developed according to these local factors. So that is a driving factor for these professionals and organisations to think, ‘how do we meet the needs of the individuals?’

So starting from that level of the individual we can then extend out to the care home –  to ask how do we meet the needs of everyone in this care home? Individual- to population-level focus is a way of trying to find commonality between professionals and organisations as a way of prioritising how different agencies work together.

In the PEACH study, we’re using an approach called “Quality Improvement Collaboratives”. Within a geographic area, we’ve got together the different organisations and professionals who work in care homes; the NHS managers, GP, care home manager, social worker, a geriatrician and not forgetting family members of residents.

They discuss how they can work better together – whether new processes or technologies are required. Within the study, we’ve then brought together four of these geographic areas into a “collaborative” so that they can share their best practice and key findings with similar groups in other areas.

While they work on these challenges, the additional benefit is that some of these silo boundaries automatically break down; so the meetings may be strategic, but the team-spirit that develops may filter out to the real-world practice in the care homes – ideally alongside ‘technical’ solutions.

It’s a bottom-up, organic approach and there is a real benefit to this – because we know from research that if you have a strict policy implemented nationwide it often fails because one particular idea either doesn’t fit a locality or different organisations have different priorities and can’t quite address the policy at that time. This is a flexible approach that addresses that local buy-in and allows for local priorities and challenges.

“By involving people from the outset, there is a real emphasis on doing research that will have a practical impact and be relevant to today’s problems.”

Complexity is the big challenge, and appreciating this is the first step to understanding where we can best focus resources. It’s also about recognising what is currently working.

Again a fundamental problem with trying to implement one strict policy is that it doesn’t recognise the strengths or benefits of what is already working well; it’s either trying to duplicate, replace or change those beneficial assets or relationships.

Are there any unique challenges when it comes to providing integrated dementia care?

I work at the Centre for Dementia within the University of Nottingham – and the work I have been doing recently with an Alzheimer’s Society Knowledge Exchange Fellowship is about trying to improve coordination of care to improve support for people living with dementia in the community (see blog article).

In The Netherlands, they are developing a network approach that brings together all the practitioners in the community to support those with dementia.

Together with a colleague in Nijmegen, Marjolein van der Marck, I’m looking at how all the different community services and resources (including charities as well as NHS and social care) can be part of a network of knowledge and support.

In turn, can general services for older people be adapted to be more inclusive of people with dementia? How might this approach be implemented more broadly in the UK?

In this country, this kind of network is more reliant on the third sector at the moment (charities and informal organisations). The Dementia Action Alliance, for example, is bringing together these kinds of support organisations and doing the work of building those networks to make connections more visible. If we ask “how can we make our community dementia-friendly?” I think local networks are the best approach.

The most significant challenge in care homes, as well as communities, is that people don’t have the information to access services or find out whether a service is right for them. A network could help people to find the services that are right for them – to meet their individual needs.

There’s a lot of talk in health and social care about pathways at the moment as maps to enable people to be able to access help and support and that is great. However, a ‘pathway’ will only be focused on one thing – you might be on the dementia pathway but if you also have diabetes, should you be on a diabetes pathway as well, or instead?

Where pathways might not deal well with the diversity of people’s needs or community, working to develop networks may, in the end, be a better and more inclusive way to enable people to access the right support according to their needs.

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By Anna Melville James, feature writer for The Elder Magazine.  You can find the original article here.

For sources of information and support you may find this living with dementia guide helpful.

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Clare Knighton: The Power of Validation

Someone close to me asked me which psychiatric tablet that I take helps me the best. I thought for a few seconds and then replied that actually it wasn’t a pill that helped me the best, but a ‘thing’ – validation. They replied quite honestly that they didn’t know what validation was. So I told them………..

I have blogged before about my journey of mental health distress, about how I found peer support and became an accredited peer support worker. I have blogged about relapse and how that has shaped my journey – I have talked about some of the challenges I have encountered on my recovery road, but now it’s time to talk about things that really matter to me. The things that are forming the concrete foundations that I am building, tools that I can use in my own recovery but also tools I can use to help those I have the privilege of working with.

So, to validation, I could easily give you many a dictionary definition to peruse but in short, validation is making someone’s experience ‘valid’, ‘real’ and ‘true’. If you can do this for someone then you have the power to help them in greater ways than any medication, I believe. Let me give you some examples. I have recently experienced a rapid relapse, that was scary, full of visual and auditory disturbances and scary shadows that were everywhere. For those of you that have experienced such things you will know that telling someone who works in mental health services what you can see and hear is very hard – you worry what they will say, you worry they will call a mental health act assessment – you worry that they will take away your choices – but above all, for me anyway, you worry they won’t believe you! To share something so scary, to ask for help is something I find really hard, and sadly in the past, people have said things like ‘pull yourself together’, or they try to minimise your experience by saying ‘oh it’s all in your mind’ or ‘other people have it worse’.

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How wonderful and powerful it is then, to be with someone who will truly validate what is happening to you – they will say things like ‘that must feel so scary Clare’ or ‘I can’t imagine what that must feel like Clare’. Or even ‘I believe you, and I believe in you’. Thus acknowledging that they can’t take those experiences away but they can sit with you in your distress and help you find fresh avenues to reduce the intensity of your emotions. Validation, when truly experienced can help to safely minimise your distress and for me it creates strong bonds of trust that allow you to walk bravely in the darkness of your experience. How powerful is that?!

I love this quote by Danielle Bernock which says:

 “Trauma is not personal, it does not disappear if it is not validated. When it is ignored or invalidated the silent screams continue internally, heard only by the one held captive. When someone enters the pain and hears the screams, healing can begin.”

Validation is so important, so crucial to healing and recovery, yet many people jump to fix or dismiss the suffering being felt. This can be equally frustrating for both parties.

When I think of my own relapses, I can recall occasions where I felt unheard, yet was desperately screaming inside for help. I can also think of times more recently where someone has said ‘I hear you’ and the difference it makes is truly amazing.

Being a peer support worker, the reciprocity of sharing feelings and experiences is so powerful and I feel honoured to sit with someone in their distress – but as a person who has experienced trauma, I KNOW the wonderful feeling when I have really been heard.

Validation, it’s priceless.

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Clare Knighton is an accredited peer support worker based in Worcestershire.

@knightonstar

 

 

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6th IMH Research Day: Emma Joyes

The 6th IMH Research Day was held on 22nd May 2018. The event highlighted the work of the Institute’s doctoral candidates, Managed Innovation Networks (MINs), and all early-career researchers (including research assistants, research fellows, and research-active clinicians). Topics included Dementia care, Autism, ADHD, ASD, student and workplace mental health, experiences of breast cancer survivors, co-production of well-being tools, Forensic Mental Health, mental health and recovery narratives, just to name a few! All of which contributed to current debates within mental health care.

The Plenary Speaker at this year’s event was Professor Anne Rogers (Professor of Health Systems Implementation, University of Southampton) who’s presentation was titled ‘‘Plus ça change plus c’est la même chose’?: reflections on past and future research in mental health’. Professor Rogers reminded us of our responsibility as researchers to think critically about mental healthcare by looking beyond the medical model and focusing on what is valuable to individuals.

Katherine Dyke presented on the IMH blog and reminded researchers to develop their online profile through the blog. Kat reminded us of the importance of communicating our research through a range of mediums. Contributing to the IMH blog also valuably contributes to ‘Engagement, influence and impact’ section of the Research Excellence Framework. You can write a blog for the IMH – see the ‘contribute’ tab for more details.

Dave Waldram hosted a talk on the Public & Patient Involvement (PPI) support available to PhD students. Dave is willing to support students in the following ways:

  • Review of documentation such as (draft) study proposal, lay (plain English) summary, patient Information. For best results it requires more than one (PP) person
  • Having a conversation with them about the project & applying my prospective & experiences
  • Expanding their networking capabilities, especially in the Patient & Public Involvement (PPI) domain
  • Help with other areas of the research process if required

Please contact Dave Waldram if you would like to discuss PPI support for your project: Dave.Waldram@ntlworld.com

We hosted a spectacular range of 27 oral presentations and 15 poster presentations. The winners of our ‘best oral presentation’ prizes were Melanie Narayanasamy, Anni Bailey, and Katie Turner. The ‘best poster presentation prize’ was awarded to Reem Aldabbagh. Congratulations to our prize winners.

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Artwork by Fred Higton

With special thanks to Professor Mike Slade, Fred Higton, Dr Elena Nixon, Professor David Daley, Dr Melanie Jordan, and Professor Peter Bartlett who sat on the expert judging panel. Professor Peter Bartlett commended the high quality of all the presentations which featured at this year’s event, which made the task of judging ever more challenging. Finally, a warm thank you to Karen Sugars who works extremely hard behind the scenes ensuring the day runs smoothly.

Thank you to all those who presented and attended. It was great to see so many of you there.

The 7th IMH Research Day planning is currently underway and will be held on Tuesday 21st May 2019. Call for abstracts will be circulated later in the year.

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IMH research day 2018 is coming!

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Venue: A floor seminar rooms, Institute of Mental Health, Triumph Road, Nottingham NG7 2TU

Date: Tuesday 22 May 2018, 9.00am – 5.10pm

Plenary Speaker: Professor Anne Rogers

Title of talk: ‘Plus ça change plus c’est la même chose’ ?: reflections on past and future research in mental health

Dear All,

The IMH would like to invite you to attend the 6th Annual Research Day which is taking place on Tuesday 22 May 2018.

The event will highlight the work of the Institute’s doctoral candidates, Managed Innovation Networks (MINs), and all early-career researchers (including research assistants, research fellows, and research-active clinicians).

There will be 27 oral and 15 poster presentations throughout the day. Please visit the IMH website for full programme, further details and the flyer.

We are delighted to announce that the plenary speaker at this year’s research day will be Professor Anne Rogers, Professor of Health Systems Implementation, University of Southampton. Please see IMH website for Professor Anne Rogers’ biography.

If you would like to attend please email IMH.Events@nottshc.nhs.uk giving your name, job title and organisation details by no later than 15 May 2018

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“Roots” Art Exhibition – October 2017 – January 2018 – Reflections and outcomes by Angie Martin

downloadThe purpose of this exhibition was to share my art work and inspire others to try art as a means of helping them through difficult times by finding ways to express their emotions and be in the “here and now”.

People have expressly stated how inspired they have been by the art and staff at IMH have stopped and thanked me stating that the light and life the artwork has brought into the building has been inspiring. Many people have stated that they have felt emotional connections to the artworks.

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Contributions to others and the community

I provided a talk with a group of MA students of Trauma and used the displayed artwork as a talking point for growth and resilience through trauma.

I followed up with an individual student interview to assist with dissertation studies.

I held live discussion with BBC Radio Nottingham (Alan Clifford show).

Developed links with the Nottingham Peace Project and planned provision of and gained council funding to lead “expression through art” workshops for young people in Basford (2018).

Roots Exhibition Book – my story of Trauma, Resilience and Growth with accompanying paintings.

Charitable financial benefits

Sales of paintings have raised £500 to provide a Remembrance Bench for Joel Cooke and £400 for Young Minds Trust. A total of £900 in sales was realised between the 10th October 2017 and 5th of January 2018.

New friendships and new opportunities

I have had a number of people ask me to show them how I paint different styles and I am starting small workshops in January 2018.

I am contributing to Prof Stephen Regel’s Stories and Narratives Project (2018).

I am working with Su Ansell (De Montfort University) on producing a short film about resilience, change and growth (2018).

Personal Growth, empowerment, health and wellbeing

The exhibition has encouraged me to get out and about, meet new people, socialise and converse. Exposure to the environment, particularly travelling on buses was my goal for my trauma treatment. I now have no fear of travelling on buses or passing through Nottingham. My confidence and communication skills are much improved. When I began planning g the exhibition with Elvira I had to take my daughter with me as I struggled with conversation skills. That is no longer the case. I am sure Elvira has noted the differences since we first met. My family and friends often comment on the progress I have made in overcoming my fear of public places and people.

I intend to continue to raise funds for charity, raise awareness of how we can rebuild our resilience and growth through art expression. I will continue to inspire others by sharing my story and art.

Thank you for this wonderful opportunity. I hope the IMH has many successful exhibitions in the future.

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Angie is a qualified teacher with a degree in Psychology and a Masters in Inclusive Education. She worked in New Zealand as an Inclusion Adviser to the Ministry of Education for 7 yrs. She was studying for a second Masters when she developed serious health difficulties resulting from trauma.  Angie was no longer able to follow her academic career. She retired in 2016 and returned to England (her roots). She now has a different and better life as an artist with a love of mother nature.  “There is always hope and It is never too late to try and experience something new in your life”

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Crime in the Mind

On Friday 17th November 2017, Professor Birgit Völlm hosted a forensic psychiatry research seminar “Interventions for Sex Offenders post-SOTP” at the Institute of Mental Health. The seminar was organised by the charity Crime in Mind and chaired by Professor Pamela Taylor. Professor John Gunn introduced the aims and objectives of Crime in Mind outlining the need for investment in research in forensic psychiatry. Crime in Mind aims to fundraise and commission relevant studies and put the scientific study of mentally disordered offenders on to a much firmer financial and political base. For further information see http://www.crimeinmind.org.

Speakers included a range of experts talking about a range of interventions fo sex offenders. Professor Conor Duggan reflected on the evidence base for the treatment for sex offenders referring to a recent report on the prison based Core Sex Offender Treatment Programme (SOTP) which failed to provide evidence of therapeutic effect and showed that in some outcomes treated sex offenders fair worse than untreated controls. Professor Duggan called for further analysis to be done on identifying who is likely or not to benefit from treatment. Fiona Williams and Rosie Travers from evaluation team of the SOTP outlined the design factors of the replacement approaches, notably the Horizon (for medium risk offenders) and Kaizen (for high risk, high need, high priority offenders) programmes.

Professor Belinda Winder and Dr Kerensa Hocken from HMP Whatton outlined the UK Prevention Project. The project, similar to the German Dunkelfeld project, provides a signposting, support and treatment service for individuals who are distressed about unhealthy sexual thoughts and feelings, and are concerned that they will sexually offend but are outside of the Criminal Justice System.

Professor Birgit Völlm described the development of Circles of Support and Accountability. Here the sex offender, known as the core member, is supported by a group of volunteers from the local community and helped to reintegrate into society. Professor Völlm presented findings on the characteristics of core members in England and Wales and a review of the evidence base.

Dr Jackie Craissati described her work in London on the Challenge Project which supports sex offenders with personality disorder. She found that alcohol use was more problematic than drug use in people who failed (i.e. were charged, convicted or recalled) and that housing difficulties are often a trigger point.

Professor Don Grubin outlined the use of pharmacological approaches to sexual offending such as the use of anti-androgens and selective serotonin reuptake inhibitors (SSRIs). SSRIs have fewer side effects than anti-androgens which require close monitoring. Professor Grubin argued that medication is not a substitute for psychological treatment but can produce improvements which help an offender participate in other treatment programmes.

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You can find out more about crime in the mind here: http://www.crimeinmind.org/

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Clare Knighton – Relapse: The monster came back!

It is practically 12 months ago since I last wrote a blog entitled relapse. I spoke about how I was afraid that it would happen; “A lot of the time, the monster is small and I’m hardly aware it’s there. I can get on with my life, with no worries or dark thoughts, the monster stays quiet. At work, I can be extremely productive, full of ideas and positive energy and life is good.”

And then it happened. At first I felt ashamed and embarrassed, I worried what people would think – but then if peer support has taught me anything, it has taught me that by being brave and honest about my experiences, my honesty may give others the courage to do the same.

I don’t just want to blog about the fact I have relapsed, I want to share with you, deep dark parts that I can remember, the part of relapse that nobody sees, and very few bear witness to.

Being a peer support worker can make relapse feel terrible as to me, my role is about so many positive things, and when I don’t feel positive, I feel like I am losing part of my identity, part of who I am.

So let’s look at my relapse together. Despite the fact I run groups about recognising early warning signs, noticing the exact moment it begins is often hard, and it’s only when you look back on the experience, you can pinpoint where it began.

It began by me coming to work, keeping as busy as I could, avoiding taking breaks, not eating, and then going straight to bed when I got home. I was determined to keep the’ monster under the bed,’ and felt this was the only way. Trouble with monsters is, if you ignore them, they just get bigger and more demanding.

They get to a point where everything else comes second as all you can hear and see is the monster. So I took some time off work, with a little ‘encouragement’ from my work colleagues. All the time, I was saying to myself, this isn’t peer support, this isn’t hope, this isn’t recovery. Then I began to hear whispers, first very quiet, and this escalated to a point where I could hear nothing else. The voice I could hear was dark and repetitive and I stopped all my medication,  I had to shut out all sounds, no tv, and just sit in absolute silence. I couldn’t eat, as everything tasted bitter and poisonous, even coffee that I love tasted unbearable. Meanwhile, outside of my house, the world was going as normal, except that I was no longer a participant.

expectations-vs-reality

I’m not sure how long this went on for, but shortly, the home treatment team began to come and see me daily. There’s much I can’t recall about the early weeks they were with me, just that they came, gave me medication, and talked to me and listened to me. I remember feeling so frightened – convinced that something bad would happen if I took any medication, so it really took some convincing and the home treatment team had great patience with me, every day.

As things progressed, I then began to feel that I would lose everything, that the dark monsters that were swirling around would never go – I would lose the job of peer support worker that I loved, that I would lose my house, and end up homeless with nothing; which the voices told me would happen.

So early one morning, I made a bad choice and started to drink alcohol. My old friend addiction had come knocking, and I had answered, willing to go astray to oblivion, to failure, what |I deserved. I drank all day, and remember waking up the next morning, the first thing I did was go to the fridge for another drink. Something stopped me,I could see the disappointment on so many people’s faces, so I closed the fridge and walked away from that fake friend, alcohol.

Time passed by, days rolled into each other, and the home treatment team kept coming, no matter what I said or how hopeless I felt, they came and slowly supported me to a point where I could push the monster back under the bed! They held onto hope when it seemed I had none. I chastised myself for letting go of hope, the cornerstone of peer support.

Peer support colleagues that I had trained with text me regularly, offering support, coffees and validation of just how rotten I was feeling. So with home treatment, peer support colleagues and friends, I began to feel better. The hope that I felt I had lost, came back to me and I could return to the peer support job that I love. Once back at work, my work colleagues welcomed me back to the team and as usual offered their unconditional support, coffee and good humour.

The terrible thing for me, about relapse is that I feel that it will take everything away – leave me with nothing, no purpose, no hope, no life. So now, back at work, I can smile and say – I made it. I’m back and functioning well. All thanks to those around me who had such patience, expertise and belief in me in my darkest hour.

So to finish this blog on a positive, what have I learnt from this relapse? I have learnt that I am strong, and feel sure that knowing my job was sitting there waiting for me was a key factor in pushing my monsters back under the bed. I have learnt to trust people more, allowing them in to understand the nature of my distress, and of course I have added to the breadth of my lived experience which can only help me in my peer support role, and ultimately improve patient experience.

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Clare is an accredited peer support worker based in Worcestershire, a passionate coach, mentor, cat owner and lover of kindness..NHS champion..survivor….expert by experience. You can follow her on Twitter @knightonstar for daily tweets about peer support.

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