Mental Health Teams

Owned by Mohammad Al-Ubaydli
Last updated: Dec 19, 2024 by Hannah Johnson-Keck
11 min read

Introduction

PKB is 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

  • Tick box exercise

  • Not personalised care

  • There is no way of sharing information with service users

  • All questionnaires are done on paper

  • 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 solution 

  • Integration with Care Notes

  • Access to healthcare data in one secure place

  • Digital care plans

  • Access to appointment letters and appointments

  • Integration with EMIS 

  • Digital recovery 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:

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Usecase

Waiting list management + waiting well

Mental health services face significant challenges with long waiting lists, but PKB empowers service users to take an active role in their care while waiting.

With PKB, mental health organisations can:

  • Support teams in triaging patients effectively using digital tools.

  • Keep service users informed by sending updates on referral acknowledgements and waitlist status changes.

  • Provide a library of waiting well resources and generic care plans, such as goal-setting care plans or generic condition care plans

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Mental Health Organisation rollout of PKB

In 2021, Sussex Partnership NHS Foundation Trust started using PKB to enable their service users to access their mental and physical health records whenever they needed them in one place. Importantly, it also allowed them to choose to share parts of their records with others involved in their care, including their GP, other NHS Trusts, care workers, friends, and family carers.

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

  • Over 53,000 records created

  • Over 3,000 weekly users 

  • Part of a Multi Organisation Network

  • 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 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 toolkit, and there are several mental health-specific care plans that are already in use by our mental health user base such as:  

Journal

  • A place for thoughts and feelings

  • Document recovery

  • Recovery journal

  • Journaling

Appointments

  • Appointment letters and appointments sent to PKB via integration

  • Access upcoming and past appointments

  • Including face-to-face, video and telephone consultations 

  • 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

  • Data feeds from NHS organisations. 

  • The feed includes information on the medication name, dose, unit, frequency, additional instructions on taking this, the start date, and the proposed review/end date. 

  • Medication adherence 

  • Potential side effects library or care plan resources.

Symptoms tracking

  • Tracking and recording symptoms digitally

  • Guide patients on symptom management actions to take if required, RAG instructions

 

 

Add and view data

  • Patients can view hospitals and GP data where an integration with PKB has been set up.

  • Live feeds for demographics, radiology, pathology, documents, appointments and more.

  • Patients can add information themselves.

Waiting well library

  • Resource of information while patients wait for the appointment

  • Videos, links, generic mental health care plans

  • Information for child to adult services

  • Support people while they wait

 

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.

Further information