The Newham Mental Health Triple Aim Journey of Discovery 2018 to 2021: Revisiting population needs and the impact of social isolation one year after the start of the pandemic.

 2nd July 2021

By Susan Alfred, Improvement Advisor

In late 2018, Newham Adult Mental Health (NAMH) directorate was one of the first directorates in ELFT to begin using the Triple Aim approach to focus on improving the outcomes, experience, and value for a select population.

The population chosen was: 

“Service users who have had five or more referrals to the assessment and crisis pathway services within a 12-month period”.  

The project work began with the team’s use of the  Three-Part Data Review, a key tool in Triple Aim population health work.  A Three-Part Data review helps a team uncover what really matters by surfacing needs, as well as assets, that are important to that population.  The tool is designed to review the following: 

1. Data available on the population 
2. Survey service users in this population to understand their views on their needs and experience with services.
3. Find out about experience and knowledge of this population from staff  

When all the information is gathered, a team can collate the themes raised and look to work on supporting improvement in these specific areas using a portfolio of activities and projects.  

In 2019, the three-part data review for this project revealed a range of key needs including: 

• Developing better staff co-working 
• More focus on service users concerns around their physical health,  
• More focus on service users’ social circumstances 
• Better links between mental health and substance misuse teams. 

When the team delved deeper into service users’ concerns about their social circumstances, they found struggles with loneliness and isolation  were at the heart of many of the needs raised, and a top priority for activity.  The team went on to test a change idea to start addressing these major needs, supporting the establishment of a Crisis Café to provide a point of social contact for service users.  

When Covid-19 hit in 2020, the project progress was understandably slowed, but the team were able to pick up the pace earlier on this year, regrouping and considering how to move forward afresh.  

As a lot of time had gone by since the start of this work, the team felt that repeating the Three-Part Data Review was needed to ensure they continued to address what mattered to this population.  Frequent attenders to the crisis pathway were interviewed, and again they shared key themes of isolation, loneliness, and feeling disconnected from their families, situations at risk of worsening due to the Covid pandemic.  

Reassured that they continued to have in view a very important area to focus on, the team also saw that this would need multiple stake holder involvement. They invited key stakeholders from housing, social care, and local carer’s networks, to come together to explore and develop ways to approach the issues of isolation and loneliness.  The team used a random word creativity tool to bring together the thinking of all stakeholders and create ideas.  Based on a randomly generated word, in this case the word ‘cartridge’, stakeholders generated a range of ideas centred around (1) methods of connecting/networking with others e.g pen pals, (2) providing access to  ‘safe spaces where people can just be’ and (3) working on a visual tool that would help clarify individual’s needs quickly.   

The team will be meeting again soon and will make use of another QI tool,  Six Thinking Hats, to help consolidate their ideas further and start testing these out. Revisiting the Three-Part Data review not only reinforced the teams understanding of the populations ongoing needs, but acted as an impetus to focus attention on bringing together stakeholders to work on critical areas for change.