An Evaluation of the Process of Family Health Assessment Using a Trigger Tool to Make A Family Healt

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An Evaluation of the Process of Family Health
Assessment Using a Trigger Tool to Make A
Family Health Plan

• A small scale multiple case study within health
  visiting practice.
• Anne Lewis
• May 2006

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The Family Health Plan (FHP)
A tool to use in partnership with families, to
enable them to identify their own health and
parenting needs and plan action to meet these
needs most effectively at an individual and
public health level using a multi-agency
approach.  (Henderson-Nichol 1999, Billingham
2000)
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FHP Should Involve

• Reciprocal interaction and effective client
  participation
• Joint exploration and mutually agreed plan
  shared responsibility
• Effective partnership working
• Listening, non judgemental approach
• Ownership involvement of users

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Policy context

• Saving lives Our Healthier Nation DOH 1999
• Supporting Families
• DOH 1999
• Making A Difference
• DOH 1999
• Framework for Assessment DOH 1999
• The NHS Plan DOH 2000
• Health Visitor Resource Pack DOH 2001

• Liberating the Talents
• DOH 2002
• Every Child Matters DfES 2003
• Change for Children DfES 2004
• Building on the Best DOH 2003
• NHS Improvement Plan
• DOH 2004
• CNO Review DOH 2004
• Childrens NSF DOH 2004
• Choosing Health DOH 2004

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Literature Review

• Family Health Plan use in health visiting
  practice (Garside 2001, 2002)
• Family health assessment tools in any setting
  (Neabel 2000, Franklin 2001, Skinner 2000, Miller
  2000)
• Family health assessment approaches in health
  visiting practice (Bryans 2003, Mitcheson
  Cowley 2003, Houston 2002, Sanders 2002, 2004)
• The search for health needs processes in health
  visiting practice (Orr 1992, Appleton 1997, Elkan
  2000, Appleton and Cowley 2003,2004)

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A tool that will

• Provide a framework to engage family
• Guide assessment of health needs
• Create opportunity for discussion
• Highlight strengths and identify areas of concern
  
• Allow family to determine own goals and
  interventions

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Trigger Tool (Garside 2001, Sanders 2002,
Houston 2002)
1.   The physical health of my family causes
me No concern 1 2 3 4 5 a lot of concern Think
about weight, diet, exercise, smoking, drugs,
alcohol, disability, illness, contraception, and
accidents  4.  The community that my family and
I live in causes me No concern 1 2 3 4 5 a lot
of concern Think about access to services,
crime, vandalism, public transport, shops, post
offices, library, schools, child care, parks and
play areas, activities for young people, racism  
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Research Aim

• To introduce the family health plan into health
  visiting practice using a set of trigger
  questions to help families identify their own
  health needs and make a plan of action to meet
  their needs.

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Objectives

• To explore the process of implementation and
  determine if
• The tool is usable in every day practice and
  acceptable
• To families
• To practitioners
• The process of using the tool helps families
• To identify their own health needs
• Make an action plan to meet their needs
• With whom and in what circumstances?

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Objectives 2

• To determine
• Any changes or improvements desired to
• The format of the tool
• The process of using the tool
• The number and type of health needs identified
  and by whom
• What action must be taken to meet the needs and
  by whom
• Any resource or training issues

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Research Design

• Methodology Case study
• Methods
• Documentary analysis
• Semi-structured interviews (HVs and families)
• Focus groups with health visitors
• Record keeping and field notes
• Data triangulation
• Analysis Framework (Ritchie and Spencer 2003)

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Ethical Approval

• Local Research and Ethics Committee
• Local Research and Development Committee
• Primary Care Trust
• University Ethics Committee
• Participant information
• Consent and Confidentiality
• Research Governance (DOH 2005)

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Cases

• Two health visitor teams of 3 and their families
• Purposive sampling
• Varied experience, caseload mix
• Training prior to study

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The Intervention

• Intervention offered to all families with
  February 2005 births
• Introduce trigger tool at primary
• Explain purpose / FHP to families
• Leave tool with family
• Discuss at next contact

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The Intervention continued

• Make family health plan
• Family judgement not health visitors
• Family own / keep the FHP
• Review according to need/family wishes
• Identify two families where the intervention
  worked well / less well

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Semi-structured Interviews

• Completed with
• Ten families
• Six health visitors
• Open ended questions
• Tape recorded and transcribed

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Focus Group

• Conducted with six health visitors
• Explored outstanding issues
• Achieved consensus
• Questions and prompts from research
• Independent scribe
• Tape recorded and transcribed

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Documentary Analysis

• Health visitor records
• Personal child health record
• Trigger tool and FHP
• Corroborate findings
• Enhance validity

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Study Results Sample

• Health visitors range 29 48
• (mean 41years)
• Intervention introduced to 31 families
• Carried out with 25 families
• 17 families agreed to interview
• Interviewed 5 families from each team
• All interviews took place with mother

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Study Results Sample (cont.)

• Maternal age range 23 38
• (mean 33 years)
• Eight supported, 2 single parents
• Five had first baby
• All respondents white British
• Housing range council flat to detached, isolated
  rural to urban

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Impact of demographics

• It worked equally well with all families. They
  varied from 19 40 and both ends of the social
  spectrum. I didnt feel there were any
  differences.
• HVO5 FG p.10

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Interpretation of Data

• Findings are grouped into three main themes
• Process of using the tool to make a FHP
• Targeting of vulnerable groups
• Tool Implementation

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1.Process of using the tool to make a FHP

• Encouraged and stimulated discussion
• And this widened it the discussion and
  looked at the whole family we talked about
  siblings and teenagers and it did widen it
  rather than me just looking at the newborn.
  And the tool gave a way in a way of bringing up
  difficult topics.
• HV05 p.2
• There were issues that I raised that I would
  never have raised with her in the normal course
  of the time spent with her..I just liked being
  given the opportunity to consider all these
  different areas.
• F10 p.3

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Impact on Discussion

• I dont think I discussed anything that I
  wouldnt have done anyway ..but Ive always
  found HV very easy to talk with so it was
  fine.
• F02 p.5

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Clarity and Transparency

• The families can actually see that we are not
  just asking questions for asking sake - the
  reason we are asking questions is because we are
  doing an overall assessment of their health.
  
• HV03 p.6

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Role of Health Visitor

• To find out they were concerned were
  interested to find out about whether you had
  issues about where you were living, schooling
  your money your weight things like that did
  shock me a bit because I wouldnt have thought
  they would have done that really.
• F13 p.1

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Structure

• I like the structure of it.. cos Id say
  that, youre tired when youve had a baby and its
  hard to like, think in a clear direction about
  what you want to ask, and your minds wandering
  off anyway, so I think its good to have structure
  and have it wrote down and you know where you are
  up to.
• F05 p.6

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Structure

• It gives uniformity as well doesnt it we are
  all doing it so its not fragmented I think
  if everyone could be offered that its like a
  standard really a guide.
• HV02 FG p.31
• (murmurs of agreement from all)

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Health Needs Identified

• Range
• Concerns in all categories (8 respondents)
• Four or five categories (2 respondents).
• Degree of concern
• Ranged from 5 (a lot) to 1 (a little)
• Mean degree of concern all areas was 2.25
• Areas of most concern
• the physical health of my family
• being a parent and bringing up children

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Making the FHP

• 8 of 10 families completed FHP
• 2 independently of HV, 6 in partnership
• 2 identified concerns and discussed with HV
• FHP related to concerns with higher scores
• Intervention needs identification - FHP

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Client Focus

• We looked at the scores of each question we
  went through each question - from, 1 7
  looking at the scores and where they scored
  highly and a lot of concern then we would have
  a conversation about it - why they had those
  thoughts what was their need
• HV04 p.5

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Empowerment and Participation

• It worked well because it empowered I felt it
  empowered a lot of the families that health was
  their own issue and there were things they could
  do about it and there were resources out there
  for that so it worked well from that point of
  view.
• HV06 p.8

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Empowerment and Participation

• Where it didnt work well - it didnt work at
  all I couldnt engage the families one
  particular mother she was very ill post delivery
  in intensive care when she came out she was
  obviously struggling she was physically very
  tired and recovering as well so she really
  wasnt interested in it at all - though I can see
  why
• HV06 p.1

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Partnership Working

• I would say I was working more in partnership
  I mean you sometimes have to give them direction
  or more understanding around some of the issues
  but generally I felt I was working more in
  partnership with them leading and identifying
  areas of concern to them emphasis rather than
  me leading
• HV05 FG p.21
• Yes I did feel we were working together I
  was involved in deciding what actions were taken
  
• F01 p. 3

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2.Targeting Vulnerable Groups

• Using something like this to develop a profile
  in an area where I know theres need but I
  havent got anything to demonstrate it theres
  nothing there no evidence we could use
  something like this this is a really good tool
  for doing just that.. we could use it to collect
  the data put it on the database then analyse
  the data and then weve got the evidence to move
  the service forward to meet those needs.
• HV04 p.4

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3. Tool Implementation

• Use
• Timing
• Duration of Contact
• Review
• Acceptability
• Action and resources required
• Format

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Action and Resources Required

• Existing resources met needs identified
• Demands within HV expertise/influence
• Potential for greater demand
• Fear unable to meet potential demand
• More multi-agency working
• Increase partnership working

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Format

• Majority liked format and presentation
• Easy straightforward to use and understand
• Liked the prompts (trigger words)
• Minority felt scoring system subjective
• One questioned language use
• More paperwork
• More user friendly suggestions

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Conclusions

• Stimulates discussion
• Explains the process of assessment
• Clarifies HV role (family and community)
• Aids need identification and making FHP
• Aids identification and targeting of vulnerable
  groups

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Conclusions (2)

• Creates structure and standardises practice
• Permission to raise issues/difficult topics
• Normalises concerns for families
• Clients feel empowered and involved
• Enabling effect overall effectiveness and
  client focus
• Promotes partnership working

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Conclusions (3)

• Potential to increase multi-agency working
• Increase demand on resources
• Feasible to introduce into everyday practice
• Format acceptable and easy to use

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Conclusions (4)

• Small scale study findings limited
• Not effective with all families
• Element of choice (use,timing) led by family
• Discretion and professional judgement
• Participation affected by family circumstances
• Literacy and understanding of the process
• Successful implementation linked to marketing,
  training and IT infrastructure

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Thank You For Listening
Anne Lewis Professional Development
Manager Chorley and South Ribble
PCT (anne.lewis_at_chorley-pct.nhs.uk)