Active Hospital Toolkit

Active Hospital Toolkit

Business Planning
All new services will require a business case. Your Trust will have its own business planning template. Ultimately business cases will need sign off from both divisional board level and trust management executive. The business plan will be determined by the scope of your desired new service. Example answers for a potential new service are given here to provide ideas and information. In addition an example business case for a single pathway intervention is included as a case example.

Example Business planning template from Oxford but your Trust will have its own

Here is a populated template – Example Business Case For A Physical Therapist

Summary of proposal

To create a consultant led, Trust wide, exercise medicine service to drive the physical activity agenda through patient centred care ‘making every contact count’ through high quality conversations about moving more between patients and all health care professionals at every appropriate point of contact.

By doing this we will enable person centred care and shared responsibility for health by ensuring that what matters to someone is the highest priority rather than what’s the matter with someone.

We will work as part of an integrated care system breaking down the barriers between secondary care, community care and social care by intervening at every level through an extended and expanding network of trained health care professionals.

This service will be led by a consultant in Sport and Exercise medicine and supported by a multi-disciplinary team working to support and develop physical activity in individual pathways across the Trust.

What is the issue being addressed?

Physical activity has long been recognised as one of the most important determinants of outcome both in the prevention and treatment of disease and as a predictor of wellbeing. It has consistently been highlighted by the National Institute of Clinical Excellence as a core component of treatment pathways. Health care environments provide a unique and powerful opportunity to influence inactive patients to change behaviour in terms of physical activity.

Prevention should be at the heart of everything the NHS does. This has been emphasised in the NHS Long Term Plan [1] and in the Secretary of State’s Prevention Vision, [2] both of which stress the core role of the NHS in preventing disease and improving population health. The Long Term Plan highlights the importance of preventing disease as a route to better health and lower inequalities and to controlling demand management and maintaining sustainable finances.

On a local level, there are variable levels of service in this area.  Recent scoping work across OUHFT and 2 other Trusts show:

  • Some pathways have well established rehabilitation teams working in disease specific silos such as cardiac and respiratory teams.
  • Some pathways are providing a level of intervention often through small pockets of dedicated professionals attempting to respond to NICE guidelines.
  • Most pathways do not offer any consistent level of physical activity intervention. A common feature of interventions, where they exist, is that they are under-resourced. Interventions tend to be disease specific, rather than determined by the symptoms of disease, many of which are common to more than one condition. The nature and characteristics of interventions are disparate across pathways and outcomes are variably collected. It is therefore difficult to measure the impact of services.

Nationally, few health care professionals (HCP) discuss physical activity with their patients as a core component of their disease management. [3] Numerous studies have shown that HCP’s lack the skills and confidence to intervene on this agenda [4]. There is, however, substantial evidence to support the use of behavioural change techniques in health care settings.[5]

As an example, physical inactivity during hospitalisation is an independent predictor of negative outcomes. In older patients, typical of patients admitted to complex medical unit wards, it leads to longer stays, deterioration in quality of life [6] and deterioration in functional ADL’s[7] Hospitalised patients currently spend over 80% of their time in bed and 12% in a chair. This published data resonates closely with data collected from CMU wards locally.

Patients exposed to mobilization during hospitalization show significant improvement in physical function, shorter hospital stays and fewer complications such as pulmonary embolism. They also have no greater risk of falling while in hospital.[8] The Long Term Plan commits to reducing the delayed transfer of care figure to 4000, or fewer, delays over the next 5 years. As part of the package of care to achieve this, it suggests that therapy teams should be placed at the start of inpatient journeys.

In recognition of this problem, and of the priorities of the Long Term Plan, Public Health England have commissioned a programme of work across healthcare. This programme, the ‘Moving Health Professionals Forward programme’ [9] (MHPF) is aimed at changing the consultation behaviour of all healthcare professionals in relation to physical activity – Making Every Contact count (MECC). As a key component of that programme of work they commissioned the ‘Active Hospital Pilot’ to test the feasibility, acceptability, sustainability and transferability of a consultant led, exercise medicine service following a defined model of delivery. This pilot has been independently tested and shown to be feasible, acceptable and transferable to other Trusts. (insert pilot evaluation document as ibox)

This new service will work across the Trust to support physical activity in all pathways. It will support and build on excellent work already happening in some pathways. It will support high risk pathways through standardising care in an evidence based way, through providing resources already developed to support physical activity change. It will work with inpatient pathways to ensure therapy intervention on admission, rather than waiting for discharge planning. It will provide a robust governance structure ensuring consistent data collection, clinical audit and quality improvement. It will provide an ongoing training programme to key staff to ensure they feel empowered to provide impactful support to encourage physical activity. It will work with pathways to ensure that physical activity is an integral part of all patient pathways both on admission, during hospital stay and on discharge to the community. It will create a collaborative network of professionals from across the Trust to learn from experiences and improve service delivery.

This service has the potential to deliver measurable impact on delayed transfer of care, inpatient falls and re-admission rates. Patient benefit though Trust level input on the social prescribing agenda, the integration and rationalisation of rehabilitation services, the identification of high risk and frail patients through physical activity levels and improved impact of re-enablement teams are all outcomes which can and should be realised.

Through this service we will raise the profile of physical activity as an integral and essential component of patient care and ultimately change the culture of OUHFT to a physical activity permissive environment. Through this service, OUHFT can, with confidence, state; ‘We are Active Hospitals’.

 

References:

[1] https://www.longtermplan.nhs.uk/

[2] https://www.gov.uk/government/consultations/advancing-our-health-prevention-in-the-2020s

[3] Carroll JK, Winters PC, Sanders MR, Decker F, Ngo T, Sciamanna CN. Clinician-targeted intervention and patient-reported counseling on physical activity.  Prev Chronic Dis. 2014 May 29; 11():E89

[4] Loprinzi PD, Beets MW. Need for increased promotion of physical activity by healthcare professionals. Prev Med. 2014;69:75–79. doi: 10.1016/j.ypmed.2014.09.002

[5] Gordon L, Graves N, Hawkes A, Eakin E. A review of the cost-effectiveness of face-to-face behavioural interventions for smoking, physical activity, diet and alcohol. Chronic Illn. 2007;3:101–129. doi: 10.1177/1742395307081732

[6] Gerontologist. 2011 Dec;51(6):786-97. doi: 10.1093/geront/gnr044. Epub 2011 Oct 24. How nurses decide to ambulate hospitalized older adults: development of a conceptual model.Doherty-King B1, Bowers B.

[7] Rethinking Hospital-Associated Deconditioning: Proposed Paradigm Shift Jason R. Falvey, Kathleen K. Mangione, Jennifer E. Stevens-LapsleyPhysical Therapy, Volume 95, Issue 9, 1 September 2015, Pages 1307–1315, https://doi.org/10.2522/ptj.20140511

[8]  https://discover.dc.nihr.ac.uk/content/signal-000759/getting-hospital-patients-up-and-moving-shortens-stay-and-improves-fitness).

[9] BMC Med Educ. 2019; 19: 84. Published online 2019 Mar 15. doi: 10.1186/s12909-019-1517-yPMCID: PMC6419815

[10] Michael Brannan, Matteo Bernardotto, Nick Clarke, and Justin Varney. Moving healthcare professionals – a whole system approach to embed physical activity in clinical practice.  PMID: 30876426.

Why is this proposal important to your Trust? How does this proposal support the delivery of the Trusts strategic themes?

This proposal delivers against all three Trust objectives and all 5 strategic themes.

Local Strategy Document

 

How does this proposal deliver transformation?

This proposal supports many of the objectives of the NHS Long Term Plan. Broadly it supports integrated care models of working, supports the crucial preventative care agenda and can impact on each of the high priority patient pathways.

National strategy document

How will we deliver this? In Secondary Care: Active Hospitals

  • Compulsory EPR documentation of physical activity level on admission and at OPA
  • Work with individual pathways to support them to deliver physical activity interventions learning on experience from OUHFT feasibility pilot
  • Identify high-risk pathways to provide tailored and more intense intervention depending on specific local barriers and enablers and identification of high-risk patients. For example:
    • Improve the delayed transfer of care figures through therapy intervention within 14 hours of admission to reduce inpatient deconditioning: learning through experience on CMU
    • Work with Re-enablement team and discharge planning teams
    • Work with cardiac and pulmonary rehabilitation services to improve eligibility and access to a greater number of patients and support the eventual integration of these services
    • Work with cancer services to improve the quality of conversations utilising the Moving Medicine resources and community provision
    • Work with diabetes pathway to improve the quality of conversations utilising Moving Medicine resources and community provision
    • Work with mental health pathways to better understand how to improve opportunities for intervention
    • Work with first contact musculoskeletal practitioners to improve the quality of brief interventions
  • Work with individual discipline groups – drawing on learning from insight work – to identify specific influencers within each group
  • Use of technology and innovation to drive quality improvement in a sustainable and scalable way (eg: Moving Medicine tool, online learning platform, EPR)
  • Use components of Active Hospital toolkit to support the above through governance structure and resources developed
  • Using trained network of self-identified ‘physical activity Ambassadors’ to create a permissive physical activity culture within Trust sites
  • Input into Trust healthy premises strategy by providing environmental prompts to improve the physical activity culture within the organisation

How will we deliver this? In community care: Active Communities

  1. Work with ‘social prescribing’ link workers to (funding from social prescribing budget)
  • Train link workers in motivational interviewing techniques to improve the quality of brief interventions
  • Provide with interactive maps of local resources
  • Support link workers with CPD and QIP/audit
  1. Engage primary care networks through: (funding opportunity)
  • Training for link workers
  • Training for over 75’s nursing teams and use of community interactive maps
  • Training for GPs and over 75’s nurses to better understand the relationship between frailty and physical activity.
  • Support GP practices with audits and QIP’s to ensure that those identified through the electronic frailty index are supported effectively
  • Promotion of Moving Medicine as a consultation tool for all HCP’s
  1. Work with integrated care system as it evolves to bring together the physical activity agenda across voluntary sector, patient groups and county council networks and ensure communication and referral between secondary care and community services is robust.
  • Improve the personalisation of care by improving the quality of conversations between patients and health and social care workers ensuring that we move away from a ‘one size fits all approach.’
  • Offering training to both health and social care workers
  • Work with ICS’s to show how a joined-up approach to physical activity can improve the integration index.
  1. Working with partners to ensure data gathered from predictive prevention is used empathetically and impactfully. For example where individuals are identified as being at risk, brief interventions follow principles of behavioural change science
  2. Work with falls prevention team to improve the impact of physical activity assessment

Example integrated care model

Feasibility and acceptability study

The National Centre for Sport and Exercise Medicine (NCSEM), in partnership with the Centre for Sport and Exercise Science (CSES) at Sheffield Hallam University (SHU), were commissioned by Public Health England and Sport England to conduct an independent evaluation of the Active Hospitals Pilot.

You can read the independent evaluation report here:
Evaluation of the Public Health England and Sport England Funded Sport and Exercise Medicine Pilot in Secondary Care

To create a consultant led, Trust wide, exercise medicine service to drive the physical activity agenda through patient centred care ‘making every contact count’ through high quality conversations about moving more between patients and all health care professionals at every appropriate point of contact.

By doing this we will enable person centred care and shared responsibility for health by ensuring that what matters to someone is the highest priority rather than what’s the matter with someone.

We will work as part of an integrated care system breaking down the barriers between secondary care, community care and social care by intervening at every level through an extended and expanding network of trained health care professionals.

This service will be led by a consultant in Sport and Exercise medicine and supported by a multi-disciplinary team working to support and develop physical activity in individual pathways across the Trust.

Physical activity has long been recognised as one of the most important determinants of outcome both in the prevention and treatment of disease and as a predictor of wellbeing. It has consistently been highlighted by the National Institute of Clinical Excellence as a core component of treatment pathways. Health care environments provide a unique and powerful opportunity to influence inactive patients to change behaviour in terms of physical activity.

Prevention should be at the heart of everything the NHS does. This has been emphasised in the NHS Long Term Plan [1] and in the Secretary of State’s Prevention Vision, [2] both of which stress the core role of the NHS in preventing disease and improving population health. The Long Term Plan highlights the importance of preventing disease as a route to better health and lower inequalities and to controlling demand management and maintaining sustainable finances.

On a local level, there are variable levels of service in this area.  Recent scoping work across OUHFT and 2 other Trusts show:

  • Some pathways have well established rehabilitation teams working in disease specific silos such as cardiac and respiratory teams.
  • Some pathways are providing a level of intervention often through small pockets of dedicated professionals attempting to respond to NICE guidelines.
  • Most pathways do not offer any consistent level of physical activity intervention. A common feature of interventions, where they exist, is that they are under-resourced. Interventions tend to be disease specific, rather than determined by the symptoms of disease, many of which are common to more than one condition. The nature and characteristics of interventions are disparate across pathways and outcomes are variably collected. It is therefore difficult to measure the impact of services.

Nationally, few health care professionals (HCP) discuss physical activity with their patients as a core component of their disease management. [3] Numerous studies have shown that HCP’s lack the skills and confidence to intervene on this agenda [4]. There is, however, substantial evidence to support the use of behavioural change techniques in health care settings.[5]

As an example, physical inactivity during hospitalisation is an independent predictor of negative outcomes. In older patients, typical of patients admitted to complex medical unit wards, it leads to longer stays, deterioration in quality of life [6] and deterioration in functional ADL’s[7] Hospitalised patients currently spend over 80% of their time in bed and 12% in a chair. This published data resonates closely with data collected from CMU wards locally.

Patients exposed to mobilization during hospitalization show significant improvement in physical function, shorter hospital stays and fewer complications such as pulmonary embolism. They also have no greater risk of falling while in hospital.[8] The Long Term Plan commits to reducing the delayed transfer of care figure to 4000, or fewer, delays over the next 5 years. As part of the package of care to achieve this, it suggests that therapy teams should be placed at the start of inpatient journeys.

In recognition of this problem, and of the priorities of the Long Term Plan, Public Health England have commissioned a programme of work across healthcare. This programme, the ‘Moving Health Professionals Forward programme’ [9] (MHPF) is aimed at changing the consultation behaviour of all healthcare professionals in relation to physical activity – Making Every Contact count (MECC). As a key component of that programme of work they commissioned the ‘Active Hospital Pilot’ to test the feasibility, acceptability, sustainability and transferability of a consultant led, exercise medicine service following a defined model of delivery. This pilot has been independently tested and shown to be feasible, acceptable and transferable to other Trusts. (insert pilot evaluation document as ibox)

This new service will work across the Trust to support physical activity in all pathways. It will support and build on excellent work already happening in some pathways. It will support high risk pathways through standardising care in an evidence based way, through providing resources already developed to support physical activity change. It will work with inpatient pathways to ensure therapy intervention on admission, rather than waiting for discharge planning. It will provide a robust governance structure ensuring consistent data collection, clinical audit and quality improvement. It will provide an ongoing training programme to key staff to ensure they feel empowered to provide impactful support to encourage physical activity. It will work with pathways to ensure that physical activity is an integral part of all patient pathways both on admission, during hospital stay and on discharge to the community. It will create a collaborative network of professionals from across the Trust to learn from experiences and improve service delivery.

This service has the potential to deliver measurable impact on delayed transfer of care, inpatient falls and re-admission rates. Patient benefit though Trust level input on the social prescribing agenda, the integration and rationalisation of rehabilitation services, the identification of high risk and frail patients through physical activity levels and improved impact of re-enablement teams are all outcomes which can and should be realised.

Through this service we will raise the profile of physical activity as an integral and essential component of patient care and ultimately change the culture of OUHFT to a physical activity permissive environment. Through this service, OUHFT can, with confidence, state; ‘We are Active Hospitals’.

 

References:

[1] https://www.longtermplan.nhs.uk/

[2] https://www.gov.uk/government/consultations/advancing-our-health-prevention-in-the-2020s

[3] Carroll JK, Winters PC, Sanders MR, Decker F, Ngo T, Sciamanna CN. Clinician-targeted intervention and patient-reported counseling on physical activity.  Prev Chronic Dis. 2014 May 29; 11():E89

[4] Loprinzi PD, Beets MW. Need for increased promotion of physical activity by healthcare professionals. Prev Med. 2014;69:75–79. doi: 10.1016/j.ypmed.2014.09.002

[5] Gordon L, Graves N, Hawkes A, Eakin E. A review of the cost-effectiveness of face-to-face behavioural interventions for smoking, physical activity, diet and alcohol. Chronic Illn. 2007;3:101–129. doi: 10.1177/1742395307081732

[6] Gerontologist. 2011 Dec;51(6):786-97. doi: 10.1093/geront/gnr044. Epub 2011 Oct 24. How nurses decide to ambulate hospitalized older adults: development of a conceptual model.Doherty-King B1, Bowers B.

[7] Rethinking Hospital-Associated Deconditioning: Proposed Paradigm Shift Jason R. Falvey, Kathleen K. Mangione, Jennifer E. Stevens-LapsleyPhysical Therapy, Volume 95, Issue 9, 1 September 2015, Pages 1307–1315, https://doi.org/10.2522/ptj.20140511

[8]  https://discover.dc.nihr.ac.uk/content/signal-000759/getting-hospital-patients-up-and-moving-shortens-stay-and-improves-fitness).

[9] BMC Med Educ. 2019; 19: 84. Published online 2019 Mar 15. doi: 10.1186/s12909-019-1517-yPMCID: PMC6419815

[10] Michael Brannan, Matteo Bernardotto, Nick Clarke, and Justin Varney. Moving healthcare professionals – a whole system approach to embed physical activity in clinical practice.  PMID: 30876426.

This proposal delivers against all three Trust objectives and all 5 strategic themes.

Local Strategy Document

 

This proposal supports many of the objectives of the NHS Long Term Plan. Broadly it supports integrated care models of working, supports the crucial preventative care agenda and can impact on each of the high priority patient pathways.

National strategy document

  • Compulsory EPR documentation of physical activity level on admission and at OPA
  • Work with individual pathways to support them to deliver physical activity interventions learning on experience from OUHFT feasibility pilot
  • Identify high-risk pathways to provide tailored and more intense intervention depending on specific local barriers and enablers and identification of high-risk patients. For example:
    • Improve the delayed transfer of care figures through therapy intervention within 14 hours of admission to reduce inpatient deconditioning: learning through experience on CMU
    • Work with Re-enablement team and discharge planning teams
    • Work with cardiac and pulmonary rehabilitation services to improve eligibility and access to a greater number of patients and support the eventual integration of these services
    • Work with cancer services to improve the quality of conversations utilising the Moving Medicine resources and community provision
    • Work with diabetes pathway to improve the quality of conversations utilising Moving Medicine resources and community provision
    • Work with mental health pathways to better understand how to improve opportunities for intervention
    • Work with first contact musculoskeletal practitioners to improve the quality of brief interventions
  • Work with individual discipline groups – drawing on learning from insight work – to identify specific influencers within each group
  • Use of technology and innovation to drive quality improvement in a sustainable and scalable way (eg: Moving Medicine tool, online learning platform, EPR)
  • Use components of Active Hospital toolkit to support the above through governance structure and resources developed
  • Using trained network of self-identified ‘physical activity Ambassadors’ to create a permissive physical activity culture within Trust sites
  • Input into Trust healthy premises strategy by providing environmental prompts to improve the physical activity culture within the organisation
  1. Work with ‘social prescribing’ link workers to (funding from social prescribing budget)
  • Train link workers in motivational interviewing techniques to improve the quality of brief interventions
  • Provide with interactive maps of local resources
  • Support link workers with CPD and QIP/audit
  1. Engage primary care networks through: (funding opportunity)
  • Training for link workers
  • Training for over 75’s nursing teams and use of community interactive maps
  • Training for GPs and over 75’s nurses to better understand the relationship between frailty and physical activity.
  • Support GP practices with audits and QIP’s to ensure that those identified through the electronic frailty index are supported effectively
  • Promotion of Moving Medicine as a consultation tool for all HCP’s
  1. Work with integrated care system as it evolves to bring together the physical activity agenda across voluntary sector, patient groups and county council networks and ensure communication and referral between secondary care and community services is robust.
  • Improve the personalisation of care by improving the quality of conversations between patients and health and social care workers ensuring that we move away from a ‘one size fits all approach.’
  • Offering training to both health and social care workers
  • Work with ICS’s to show how a joined-up approach to physical activity can improve the integration index.
  1. Working with partners to ensure data gathered from predictive prevention is used empathetically and impactfully. For example where individuals are identified as being at risk, brief interventions follow principles of behavioural change science
  2. Work with falls prevention team to improve the impact of physical activity assessment

Example integrated care model

The National Centre for Sport and Exercise Medicine (NCSEM), in partnership with the Centre for Sport and Exercise Science (CSES) at Sheffield Hallam University (SHU), were commissioned by Public Health England and Sport England to conduct an independent evaluation of the Active Hospitals Pilot.

You can read the independent evaluation report here:
Evaluation of the Public Health England and Sport England Funded Sport and Exercise Medicine Pilot in Secondary Care

Resources

Business planning template

Example Trust Template (subject to local variability)

Evaluation of the Public Health England and Sport England Funded Sport and Exercise Medicine Pilot in Secondary Care

Independent evaluation of the Active Hospitals Pilot

Single Pathway Example Business Case

Physical therapist business case example