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Introduction
PKB is
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providing mental health teams and service users a secure platform to view their health and care records, access information about their treatment plans, review medication details, and communicate with their care team, all of which can be made accessible via the NHS App (more information available here). Greater visibility and control over a person's health and care information enable individuals to participate actively in decision-making and self-management through enhanced engagement. To read more about how PKB is the solution for many teams and organisations, scroll down the page.
Current problems
Care plans are written but not accessible
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Tick box exercise
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Not personalised care
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There is no way of sharing information with service users
All questionnaires are done on paper
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Service users repeating themselves, no central place for care plans
Mental health teams don't have all the information and data they need
Large number of people require mental health services
PKB
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solution
Integration with Care Notes
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Access to
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healthcare data
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in one secure place
Digital care plans
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Access to appointment letters and appointments
Integration with
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EMIS
Digital recovery
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Creating a single source for care and a central place for care plans to sit
platform
Online resource library
Secure messaging between service users and the team
Symptom and measurement tracker
Digital questionnaires
PKB benefits
Empowers patients
Access to their health and care records in a single place
People feel more empowered to manage their health and wellbeing
Joining together data from different health providers
Enables patients to track their own health and care
People feel supported by their wider circle of health collaborators
Improves communication
Core features
Some of the core features teams use in PKB to support mental health service delivery include:
Usecase
Waiting list management + waiting well
Mental health services currently face long waiting lists; PKB provides service users with tools to participate in their care.
Mental health organisations can use PKB to enable service users to self-refer, with teams using digital tools to support the triage process. Service users can also receive communication from the organisation to acknowledge their referral and changes to their waitlist times.
Mental Health Organisation rollout of PKB
In 2021, Sussex Partnership NHS Foundation Trust started using PKB
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to enable their service users to access their mental and physical health records whenever they needed them
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in one place. Importantly, it also allowed them to choose to share parts of their
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records with others involved in their care, including their GP, other NHS Trusts, care workers, friends, and family carers.
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Clinical input
Care Notes integration with PKB gives service users access to their 'My care and safety care plan'
The Care plan is created, completed and published in Care Notes and sent to PKB
Care Notes do a demographic update
Sharing data within the network
Appointment letters, appointments, and care plans are all under the mental health privacy label
Giving patients access to their data was the driving force
Recall questionnaire through an API
Features
Care plans are created, completed and published in Care Notes and sent to PKB
Care Notes do a demographic update
Sharing data within the network
Appointment letters, appointments, and care plans are under the mental health privacy label
Giving patients access to their data was the driving force
Recall questionnaire through an API
Outcomes
All active adult users have been added to PKB
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Clinical input
Care plans - any service users with a care plan will see this in their PKB record in PDF format
Care Notes integration with PKB gives services users access to their 'My care and safety care plan'
The Care plan is created, completed and published in Care Notes and sent to PKB
Creating patient PKB records via integration, demographics
Care Notes do a demographic update or the support team is trained to add patient's emails manually
Sharing data within the network they are part of
PKB process in place to document the privacy label changes
Appointment letters, appointments, and care plans are all under the mental health privacy label
Treating the data the same as general health
Giving patients access to their data was the driving force
Recall questionnaire through an API
Key PKB features
Questionnaires
Patient Reported Outcomes (PROMS)
Quality of life questionnaires
Depression scores and programme questionnaires
About Your Mental Health Questionnaire
Messaging
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Over 53,000 records created
Over 3,000 weekly users
Part of a Multi Organisation Network
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23% of patients registered with their record
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Over 7,000 registering a week (since April 2022)
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80% by NHS login and 20% via email invitation
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NHS login is widely promoted (customised login, on the comms, website and on clinic letters)
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Support team - adding email address manually
35% of patients registered
76% by NHS login
Delivery of questionnaires without needing registration
Range of common PROMS already available (eg GAD7, PHQ9, DIALOG and DIALOG+)
High engagement when linking PROMS platform to wider Health Record access
The City and Hackney Collaborative is made up of City and Hackney ICP, North East London CCG, East London FT, The Advocacy Project and Core Art & Sports
Mental health personal health budgets: redesigning the recovery pathway
The aim was to use personal health budgets (PHBs) in a redesigned recovery pathway to help overcome barriers to achieving recovery goals, including for people’s physical health.
Core Arts and Sports and the Advocacy Project utilise the PKB platform as their single aggregated record. Professionals treating patients use PKB to view the patient's medical history to make the best clinical decisions on their behalf. For reference, patients with severe mental illness across City and Hackney in North East London are receiving data from primary, secondary, and voluntary care organisations in a single aggregated record. Read more information on their award-winning work carried out by City & Hackney, which showcases the power of bringing services together across a region.
Each patient is given digital access to their Personal Health Budget (PHB) on PKB
A shared recovery plan called ‘Me and My Goals’ was developed
Brings together Primary Care, Secondary Care (mental health trusts) and voluntary sector organisations to collaborate with people on these shared resources.
People can track symptoms and measurements
No duplication or repeating past medication history
People consider their mental health, physical health and social needs, and identify three goals to stay well and the next steps for each.
Outcomes
The Core Sport programme has successfully engaged its target audience; 46% of members are Black men and ~70% are people from Black, Asian and minority ethnic communities.
In 2022/23, the Core Sport programme:
delivered 94 physical health checks, with 18 people supported to have a further health check with their GP based on the results
engaged 134 new people with the programme
supported 55 people to reduce their blood pressure, with 35 achieving a reduction
supported 59 people with smoking cessation
supported 31 people to achieve a healthy BMI.
National recognition
In September 2021, the team was recognised for its Digital Recovery Platform for Severe Mental Illness, and it picked up three awards for its cross-sector programme of work at the HSJ Value Awards.
The collective walked away with:
Winner of the Digital Clinical Transformation Award
Highly commended for the Primary Care or Community Service Redesign Initiative and the IT & Digital Innovation Award
Finalists for the Mental Health Service Redesign Initiative
Read more about their success here.
To read the full article, click on the link, Mental health personal health budgets: redesigning the recovery pathway
Midlands Partnership NHS Foundation Trust
In 2023, Midlands Partnership NHS Foundation Trust (MPFT) embarked on a transformative journey with PKB across Adult Mental Health Services (AMHS) and the Making Every Contact Count (MECC) initiative.
The aim was to give people access to their health records, enabling self-management of care to improve their experience and reduce service demand.
Support the Trust’s services to share Professional Record Standards Body (PRSB) care plans
Empower service users to make positive changes to their physical and mental health and wellbeing
Improve communication between service users, carers and healthcare professionals
Editable shareable care planning tool.
Fully integrated with the NHS App, allows service users to receive digital letters
Greater patient accessibility, especially around language translation.
Utilises PKB to support the About Me questionnaire as well as PROMs like DIALOG and ReQol for service users
Enabling meaningful discussion between patients/carers and clinicians / clinical teams to establish dialogue and shared decision-making
Monitor people's progress towards their goals
Service users receive an email prompting them to register and complete their PROMs. Once completed, service users' responses are fed back into RiO. Clinicians then utilise these PROMs to develop individualised care plans (including the Care and Support Plan and Overcoming Challenging Times), which are sent to the service users’ PKB records. Read more about the project here.
Outcomes
21% registered with PKB
Used across the region
Auto Trigger FHIR API of QA’s (with that appointment) (repeated with each appointment)
Oxford Health NHS Foundation Trust
The Ketamine Clinic team provides treatment for people with depression who have not responded to other treatments. The team utilised PKB as the digital solution for the pilot. They registered patients on PKB, giving them access to pre-appointment care plans and questionnaires, which improved the efficiency of the appointments.
Click on the link to read the full case study on monitoring the safety of ketamine in treatment-resistant depression.
St.Patricks Mental Health Service
In 2020, St Patrick’s Mental Health Services (SPMHS) became the first health service in Ireland to choose PKB as its Personal Health Record platform.
Central to their objective of placing service users at the heart of their care journey was offering them PKB, giving them access to health information, digital questionnaires, and the ability to involve and interact with professionals involved in their care.
A two-way data flow from PKB to and from SPMHS clinical system RiO was ensured through integrations and single sign-on. Professionals can send questionnaires to service users on PKB directly from Rio, and get the responses back on it.
Features
Central library for support and resources to enhance care and treatment experiences
Questionnaires for every program and every stage, 'assessment,' 'pre,' 'interim,' and 'post,' tailored to the service users' recovery stage
Events and Messages receive PDF doc of the keyworker information and support plan, discharge summary and clinician summary review report
Outcomes
40 questionnaires are available for professionals to send to service users, covering a wide range of conditions such as Eating Disorders, Bipolar Disorder, and Depression, as well as programmes like Mindfulness and Building Healthy Self-Esteem.
Single sign-on to Rio
Two-way data flow
Integration for appointment details, including video links to join them remotely and clinic letters.
Key features
There are key PKB features all mental health services can use with their cohort to capture and view data. A list of them is below.
NHS App
Information from healthcare providers can be accessible via PKB’s web solution and via PKB’s jump off points in the NHS App;
Questionnaires
Patients can initiate a questionnaire by clicking Start Questionnaire on their homepage or directly within the NHS App. Once completed, the questionnaire can be sent to a professional or team.
Teams using the questionnaire tool can ensure the outcome of clinical reviews is recorded, and the patient has a copy. Teams can also identify patients suitable for virtual appointments or PIFU.
PKB's advanced questionnaire functionality
The features include:
Scoring and calculations
Branching, allowing patients to complete the parts of the questionnaire that are relevant to them
Coded fields questionnaires can be mapped to clinical codes
Patients can save drafts
Send questionnaires to patients who aren’t registered or already in your team
PKB’s advanced questionnaire functionality and automated scoring of assessments will be provided, and coded questionnaire responses will be mapped to the patient's graphed measurement section, making it easier for patients and their healthcare collaborators to understand any trends and progress of deterioration as assessments take place over a period of time.
Messaging
Patients have access to message their healthcare team (saving time on the phone)
The Admin team can triage
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Library
A wealth of resources
Online patient leaflets
Support group information
Videos
Care plans
Shareable plans of care
HL7 care plans sent to PKB from Care Notes
My care and safety care plan
Individualised templates with escalation plans
A place to track and record symptoms
Daily journal care plan
messages. Either resolving or passing onto another speciality team
Universal Messaging is the ability for patients to message clinical and non-clinical teams
Team-based messaging allows teams to automatically receive secure messages and questionnaires as a group rather than as individuals
Care plans
PKB’s shared care plans are unique, as they can be co-created and co-edited by anyone with access to the patient's record, including patients and carers. They provide better direction for personalised care by:
Document mental health history
No repetition
Triggers and background to mental health condition
Educational materials
Signposting
Goal writing
Care plan Templates
PKB has a general care plan toolkitand there are several mental health-specific care plans that are already in use by our mental health user base such as:
Bipolar disorder: Is Valproate The Right Treatment For Me? (NHSE decision support tools care plan converted into a PKB care plan
Journal
A place for thoughts and feelings
Document recovery
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Recovery journal
Journaling
Appointments
Appointment letters and appointments sent to PKB via integration
Manually entered appointments
Access upcoming and past appointments
Including face-to-face, video and telephone consultations
Share all details of the appointment
Across PKB sites, patients registering for PKB have led to a 34% reduction in DNA rates (comparing the same patient cohorts pre- and post-registration to the platform). PKB’s DNA page.
Medicines
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Document medications, past and current
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Data feeds from NHS organisations.
Feed includes information on the medication name, dose and unit, frequency, additional instructions on how this should be taken, the start date and the proposed review/end date.
Medication adherence
Descriptiong of why the drug has been prescribed, how this should be taken, dosage information
Potential side effects
Symptoms
Tracking and recording symptoms digitally
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Workflow
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Guide patients on symptom management action to take if required, RAG instructions
Add and View Data
Patients can automatically be added to the correct team through an integrated demographics feed, whereby these resources will be readily available without any manual intervention required by professionals.
Patients can view hospitals and GP data where an integration with PKB has been set up
Data can include blood tests, x-ray reports, clinic and appointment letters, appointments and discharge summaries
Patients can add information themselves
Patients can track key measurements and add any symptoms related to their mental health
Comms Examples
Sussex Partnership NHS Foundation Trust Web page gives patients information and a link to register with their PKB record via the NHS login. https://www.sussexpartnership.nhs.uk/my-health-and-care-record
The below tri-leaflet is also sent to the patient alongside clinical or appointment letters.
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Further information
Further information
How to capture digital outcome measures in PKB: examples outcome measure questionnaire templates and workflow
Severe mental illness: using PKB to provide a digital recovery platform
Mental Health questionnaire templates: examples of questionnaires used by mental health teams
Mental Health care plan template: example of a care plan used by a mental health team
A digital recovery platform for severe mental illness: NHSX Digital Playbook using PKB as the digital solution for the severely mentally ill
Video testimonial of a patient on a waiting list for CBT: given PKB so he could independently act on this advice at home whilst waiting for this therapy to start
Video testimonial of a patient with long term mental health and physical health conditions: didn’t feel in control of their own health and struggled to communicate her background and needs.