Enhancing physical health care for patients with severe mental illness: describing the implementation of a physical health liaison nurse in a mental health outreach team for long-term care

Abstract

Background

Tackling physical health problems in people with severe mental illness is crucial, as they often experience higher rates of chronic diseases and reduced life expectancy compared to the general population. Addressing these physical health disparities could significantly improve overall well-being and quality of life. As the World Health Organization emphasizes the need of additional professionals in bridging the gap between mental health and physical health services, this study evaluates the implementation of a physical health liaison nurse within a Belgian mental health outreach team (MHOT). We aimed to enhance the physical health of patients with severe mental health conditions, ensuring that patients receive comprehensive care.

Methods

A mixed-method approach was employed, combining quantitative and qualitative data collection. The Health Improvement Profile was used as a quantitative screening tool to identify physical health needs. Qualitative data were gathered through interviews with patients and mental health professionals, along with field notes from the physical health liaison nurse. The RE-AIM framework guided the implementation and analysis to ensure relevance and stakeholder engagement. Quantitative data from the screening tool were analyzed alongside qualitative insights to provide a holistic view of the implementation.

Results

The implementation of a physical health liaison nurse facilitated the identification of physical health needs and the development of personalized health plans. Quantitative data showed high rates in being overweight and smoking, and low rates of blood samples among participants. Except for blood samples, referrals or other action showed no significant improvement on health outcomes. Qualitative data revealed the perceived effectiveness of the service, identified real-world facilitators and barriers to implementation, and assessed feasibility.

Conclusions

The integration of a physical health liaison nurse within a MHOT showed promise in addressing physical health needs of patients with severe mental health conditions. In office presence of the nurse facilitated the inclusion of physical health in care plans. Recommendations for future implementations include enhancing stakeholder engagement and addressing identified barriers, such as inadequate funding mechanisms. On a policy level, supporting financial incentives for physical health screening in primary care or promoting capitation based finance models could improve a more holistic approach.

Text box 1. Contributions to the literature
• This study demonstrates the practical benefits and challenges of integrating a physical health liaison nurse (PHLN) into mental health outreach teams.
• The study describes how PHLNs can enhance the regular monitoring of physical health parameters in patients with severe mental illness (SMI), leading to more timely and appropriate interventions, highlighting the importance of liaison roles in bridging gaps between primary care and mental health services.
• The study identifies key barriers to physical health care in mental health settings, while also providing practical solutions like training and digital tools to overcome these challenges.

Background

Integrating mental and physical healthcare remains a challenge requiring innovative solutions. Individuals living with a severe mental illness (SMI) are disproportionately afflicted by physical comorbidities [1, 2]. SMI refers to people with mental health conditions that severely impair global functioning, and mainly comprises patients with schizophrenia, bipolar disorder, or major depressive disorder [3, 4]. Individuals with SMI face a life expectancy gap of 20 years compared to the general population, primarily attributable to untreated or poorly managed physical health conditions [5–9].

People with SMI are insufficiently engaged in primary care. Merely 20% of the persons with a SMI receive cardiovascular screening, contrasting with persons with diabetes in the general population, of which 96% receives cardiovascular screening. Also in residential settings, screening rates are low [1, 10, 11]. Provider- (e.g. stigma) and system-level (e.g. fragmentation of care) barriers contribute to low screening rates [1]. Various studies aimed to improve physical health in people with a SMI exploring a broad spectrum of interventions. Overall effectivity of these interventions is inconsistent and not supported by longitudinal studies. For example, some studies show modest success in weight reduction and improved metabolic outcomes, while others fail to achieve significant long-term results [12, 13]. Using nurses in providing cardiovascular risk management in primary care could reduce cardiovascular risk factors [14, 15].

The World Health Organization (WHO) and The Lancet Psychiatry Commission [16], both advocated for additional liaison services bridging the gap between primary and mental health services. This holds the potential not only to enhance collaboration, but also to improve somatic patient outcomes significantly [14, 16]. To our knowledge, this is the first study exploring the implementation of a physical health liaison nurse (PHLN). This within a Belgian mental health outreach team for long-term psychiatric care (MHOT). This study aims to optimize physical health care for patients with SMI by assessing the feasibility and effectiveness of a PHLN and identifying barriers and facilitators in the Belgian healthcare system.

Methodology

The study aimed to assess the implementation of a PHLN in a MHOT using a multi-faceted approach, combining qualitative and quantitative data collection methods.

Intervention

Based on previous research [13, 17, 18], a mental health nurse within the MHOT was assigned a 0.5 full-time equivalent role as PHLN. During two sessions of four hours, the nurse underwent an in-person manual-based training developed for the study. This included an overview of the most prevalent physical health conditions in individuals with severe mental illness (SMI) to enhance knowledge of health needs. Additionally, the training covered the use of the Health Improvement Profile (HIP), a 27-item tool that helps nurses identify critical aspects of physical health, such as BMI, blood lipids, and lifestyle factors, using a traffic light method to suggest follow-up actions. The HIP has been utilized in various studies [19–21]. The training also included digital communication tools to facilitate collaboration with primary care service providers. Previous research served as a preliminary context analysis, informing recommendations for the development of the manual for the PHLN. Follow-up support was provided by author NM in case of questions or problems [18].

The specific tasks of the PHLN included providing training and raising awareness about physical health comorbidities among colleagues in the MHOT, focusing on common physical health issues in individuals with SMI and their impact on well-being and quality of life [22]. The PHLN also supported primary care services in engaging with people with SMI and reducing stigma, as research has shown that knowledge exchange is perceived as helpful. The PHLN liaised between the MHOT and primary care physicians regarding the physical health of MHOT patients. When primary care professionals were not present or patients were unable to attend consultations due to their mental health condition, the PHLN performed nursing tasks such as taking blood samples and administering medication. The PHLN assessed current physical comorbidities in MHOT patients using the HIP, supported colleagues in the MHOT regarding registered physical health conditions in patients, and followed up on HIP screenings.

Study participants

Patients were eligible to participate if treated by the MHOT in the region of Antwerp, Belgium. Due to ethical considerations, patients were excluded from the study if they were admitted a hospital or experienced an acute psychiatric crisis. Also, this approach avoided the incorrect reporting of physical health status (e.g. substance use, psychotic experiences).

Implementation strategy

The RE-AIM framework was used to evaluate the implementation and impact of a PHLN within a MHOT. No prior research concerning the topic was conducted in a Belgian context, so no previous experiences in the implementation process were identified.

The RE-AIM framework, which stands for Reach, Effectiveness, Adoption, Implementation, and Maintenance, provides a structured approach to assess implementations [23, 24]. The RE-AIM dimensions ‘reach’ and ‘effectiveness’ focuses on the target group intended to benefit while ‘adoption’, ‘implementation’ and ‘maintenance’ are focused on the organization- or team level [24].

Using the RE-AIM framework, the implementation was monitored using a combination of qualitative and quantitative methods to assess feasibility and efficacy. Implementation research has an iterative collaborative and action-oriented nature to promote positive change within healthcare settings. This strategy focusses on both process and health outcomes [25–27].

Reach

The goal was to ensure that the PHLN intervention was accessible to a broad spectrum of patients, especially those who have physical health needs.

MHOT team members were instructed to inform patients about the study during their regular home visits. After verbal consent from the patient, the PHLN accompanied the team member on a home visit to introduce the study, obtain written informed consent, and collect baseline data.

Effectiveness

To assess the effectiveness of the PHLN intervention, the HIP was used. During a total period of 12 months, patients were screened using the HIP at two points in time: baseline and after 6-months follow-up. Changes in HIP scores served as an outcome measure, reflecting improvements or deterioration in patients’ physical health conditions.

Patient records were systematically reviewed before and after the implementation of the PHLN, to assess the presence of relevant physical health information in the patient record, such as basic biometric parameters (e.g., blood pressure, BMI) and information on the patients’ care providers.

Adoption

To examine the integration of the PHLN into their team, the readiness of team members, training of the PHLN, and the overall integration process was evaluated. Barriers and facilitators to adoption were also identified through qualitative interviews with healthcare providers and stakeholders.

Three workgroup meetings were organized: before the implementation, at baseline and after 6-months to bring together MHOT team members and local staff members. These meetings provided insights on the intervention’s impact and possible adjustments.

Implementation

In preparation of the implementation, possible barriers and facilitators for further implementation were explored, and used in the development of the intervention [18].

During the implementation, the PHLN’s activities were monitored based using field notes and qualitative feedback from both team members and PHLN. Results of interviews with relevant stakeholders were used to refine the implementation of the PHLN. Using a leading topic list (see supplementary materials), these interviews aimed to gather insights into the experiences, challenges, and successes of the intervention.

Maintenance

Based on the input of the workgroup meetings and the results of the HIP-screening, the long-term sustainability of the PHLN role within the MHOT was evaluated. This included examining integration into routine practice after the initial study period of 12 months.

Data analysis

Interviews and transcripts of workgroup meetings were analyzed thematically to identify recurring themes and patterns, iteratively guiding refinements to the PHLN intervention and implementation. The theoretical orientation underpinning this analysis was constructivist grounded theory, which emphasizes the co-construction of meaning between researchers and participants. Quantitative data were analyzed using IBM SPSS version 29. After describing both demographic data and information in patient records, comparative methods were used to determine significant changes in HIP-data. The related-samples McNemar change test was used to identify significant differences between items at baseline and 6-month follow-up measures [28].

Reporting of findings

The SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence) checklist, a framework designed to ensure comprehensive and transparent reporting of quality improvement (QI) studies in healthcare [29], was used in reporting results.

Ethical considerations

Ethical approval for the study was obtained from the Antwerp University Ethics Committee with the unique national number BUN B3002021000167. Patients and caregivers were asked to sign an informed consent before participating in the study. Written informed consent to participate was obtained from all of the participants, no participant was unable to give consent.

Results

Reach

Of 200 patients in the total caseload, 120 were found to be eligible to enroll in the study as they met the inclusion criteria. 44 Of eligible patients (36.7%) consented to participate in this study and underwent a first screening by the PHLN. The participants had a mean age of 52.2 years (SD = 13.5), and females comprised 52% of the sample (patient demographics see Table 1).

Table 1.

Demographic characteristics of patients included in this study

n = 44 Mean age: 52.2 years old (SD = 13.5) 52% female
Primary psychiatric diagnosis (%)
Unknown	23,1
Psychotic disorder	42,3
Bipolar disorder	9,6
Alcohol dependence	11,5
Depression	7,7
Personality	5,8

At 6-month follow-up, 20 patients were screened. The flow of the inclusion process is shown in Fig. 1.

Fig. 1.

Flow of inclusion process and patient drop-out during implementation

Effectiveness

Results of the HIP screenings are described in Table 2. The screening yielded the most red flags (> 70%) on the items ‘Smoking’, ‘Body Mass Index’ (BMI) and ‘Waist circumference’, and didn’t show any significant improvements when comparing the first screening with the 6-month follow-up screening. Patients often didn’t know when they had their last blood test performed. In 9 patients, the last blood sample screening for liver function, lipids and glucose dated more than 2 years before this implementation project. Also, if blood samples were taken recently, patients were rarely informed of the results. The 6-month follow-up showed a significant improvement in screening of the liver function, lipids and glucose levels, but around 20% of the respondents did not improve on any of those parameters.

Table 2.

Items of health improvement profile (HIP), showing the percentage of red flagged items in participants for both screenings

Item HIP	Screening 1 (% red flagged items)	Screening 2 (% red flagged items)	Significance (screening 1 versus screening 2)
Body Mass Index (BMI)	77.3**	68.4**	1.00
Waist	75**	70**	1.00
Pulse	17.4	15.8	1.00
Blood pressure	28.3	31.6	1.00
Temperature	6.8	5.3	1.00
Liver function	55.6**	15.8	0.002*
Lipids	71.1**	26.3	0.002*
Glucose	65.9**	15.8	0.001*
Prostate/testicles (man)	68.2**	66.7**	0.5
Cervical smear (woman)	47.4	50	1.00
Menstrual cycle (woman)	50	66.7**	1.00
Teeth	45.7	36.8	1.00
Eyes	51.1**	38.9	0.63
Feet	15.2	11.8	0.25
Breast	37.5	43.8	1.00
Urine	32.6	11.1	0.13
Bowels	43.5	27.8	0.38
Sleep	58.7**	61.1**	1.00
Smoking	76.1**	72.2**	1.00
Exercise	37	36.8	1.00
Alcohol use	15.2	15.8	1.00
Nutrition-know	39.1	21.1	0.25
Nutrition-can	8.7	10.5	1.00
Fluid intake	23.9	15.8	1.00
Caffeine intake	23.9	15.8	0.63
Cannabis use	21.7	31.6	1.00
Safe sex	43.6	52.9**	1.00
Sexual satisfaction	51.4**	52.9**	1.00

> 50% of participants scores red flag = **; Significant differences between screening 1 & 2 =* (p<0.05)

At baseline, an assessment of the electronic patient records was conducted to determine the extent to which physical health data and data related to former medical examinations were included in the records of the MHOT. For all patients, basic data regarding risk factors such as weight, blood pressure, and laboratory results were missing. Approximately half of the clients (n = 19) lacked contact information for their general practitioner(GP), and these details were not available to the psychiatrist.

Adoption

At first, the PHLN encountered resistance both from patients and colleagues, and acceptance of the new role occurred gradually. Initial concerns of team members mostly were that time to address mental health in patients would be reduced. Sufficient presence of the nurse in the office was found to be important because it facilitated availability. Fixed consultation times for colleagues could be beneficial.

“In the first few months, it was mainly taking the initiative but, as time progresses, colleagues are increasingly asking for appointments. I notice a shift in focus…colleagues are more aware of the connection between physical and mental health”.

During the first workgroup meeting, consisting of the PHLN, a manager, 3 psychiatrists, 2 psychologists and the team coordinator, the workgroup was informed. No initial objections were formulated, but psychiatrists expressed skepticism, as physical healthcare is seen as a task for primary care services. But the workgroup concluded that attention to physical health in patients of the MHOT could be improved.

During the second meeting, experiences of the team members and the PHLN were presented. Main point of discussion was the PHLN’s access to the digital shared health record, as psychiatrists questioned the added value of this evolution. However, the workgroup concluded to test this in this implementation.

“… over the past six months, there has been some movement towards giving our patients the much-needed somatic care. This can hopefully develop into a solid foundation upon which colleagues can rely at all times…“(PHLN).

Initial resistance stemmed from fears of reduced focus on mental health care, but this evolved into greater awareness of the importance of addressing somatic needs over time. During the last workgroup meeting the sustainability of the project was evaluated. The PHLN’s access to all shared patient records was regarded feasible, under the condition the PHLN followed a short training regarding ethics and legislation. The workgroup meetings highlighted the importance of physical health in patient care, but as systematic screening and follow-up proved to be a challenge, the workgroup ultimately decided against the structural implementation of a PHLN due to feasibility concerns. The broadened scope including physical health in contacts with patients was perceived as a positive change, and the project led to detecting somatic issues in patients which remained undetected before.

Implementation

Scheduling appointments with patients of the MHOT proved to be challenging. Often, home visits were canceled due to the unavailability of patients or unexpected interventions.

In Belgium, medical data can be shared between both healthcare providers and patients using a collaborative health platform. During the implementation process, following changes in governmental legislation, reading rights for nurses were extended. As a result, health information can be consulted in a more efficient manner.

Maintenance & feasibility

Due to financial barriers, a PHLN exclusively focusing on physical health screening and follow-up was not feasible. The workgroup suggested appointing a physical health reference person, supporting team members regarding physical health in the MHOT’s caseload. A local team procedure was developed to describe this role, agreements on physical health information in the MHOT patient records and access to physical health information during treatment by the MHOT.

As screening and follow-up was perceived as a task of primary care services, we explored possible options for improvement. Screening rates of GP varied, and if present, nurses in the GP’s cabinet can provide screening and follow-up in patients with SMI. As not all GP’s worked together with nurses, we explored to possibility of a nurse-led screening by primary care nurses. This did not seem feasible because these services cannot be charged as they are not described in the nurses’ fee-for-service nomenclature.

Discussion

The present study aimed to describe the implementation process of integrating a PHLN into a MHOT for long-term care, aiming to improve physical health outcomes of patients with SMI.

Health improvement profile (HIP) screening outcomes

The prevalence of smoking (76.1%), high BMI (77.3%), and increased waist circumference (75%) among participants significantly exceeds the general population norms and are major risk factors for cardiovascular disease [30]. In other studies using the HIP as a screening tool, BMI and waist circumference are the most prevalent factors identified. Although slightly higher, our results correspond when compared to people with SMI in Western countries, such as the UK (BMI 70%, waist circumference 43%) and the US (BMI 75, waist circumference 83%). The item with the highest proportion of red flags in our study was smoking, while in the UK and US, this was respectively 58% and 23% [19].

Approximately 20% of participants showed no improvement in blood test parameters, and 45% lacked recent screenings before the project, indicating a significant gap in routine health monitoring. Compared to literature, stating that merely 35% of this population receives annual blood checks, this is rather high [10]. This may be due to non-consent from hard-to-engage patients. Also, prior to the MHOT, patient often were admitted to a residential facility where physical health screening is performed.

Patients with SMI often have difficulties changing unhealthy behavior such as smoking and adopting a healthier lifestyle. However, small steps such as periodic blood tests, eye checks, dental care or encouraging the uptake of more physical activities is feasible by focusing on self-management and shared decision making. Literature suggest different strategies to enhance lifestyle (e.g. staff factors, social support) [31, 32]. Shared decision making was not formally included in the manual and could be a point of improvement. In addition, scheduling issues and home visit cancellations could be linked to systemic barriers or the symptoms of SMI, highlighting the need for flexible and adaptive care models.

Despite a small sample size, the HIP provided an insight into physical health among the patients of the MHOT. The limited statistical and clinical improvement of HIP-items observed between baseline and 6-month follow-up can be attributed to the small sample size and short timeframe of the implementation in a real-world setting with possible confounding factors. This could suggest more time is needed to achieve both clinical and statistically significant improvement in people with a SMI. Other studies on the effects of physical health and lifestyle screening and interventions remain unclear regarding the long-term beneficial effects on physical health in people with SMI [33–35]. It needs to be mentioned that regardless of treatment or follow-up, the SMI mortality gap persists [36]. Also, regardless of a possible positive effect of an improved lifestyle on psychiatric symptoms, it often doesn’t improve the quality of life in patients [37].

The role of the physical health liaison nurse (PHLN)

The PHLN provides valuable insights into the role’s evolution and its gradual acceptance, with a positive shift in the team’s focus towards somatic care. This is important, as physical health promotion in mental healthcare should be a joint venture throughout the organization [38].

The implementation was focused on acceptance by the team and improving patient outcomes within the MHOT. Literature also underscores the role a physical health professionals have in bridging the gap between mental and physical health care for individuals with SMI [39, 40].

The gradual acceptance of this new role among colleagues suggests that, when scaling up, an incremental approach could foster long-term sustainability. A deeper analysis of psychiatric nurses’ perceptions could reveal whether the PHLN role encourages a more holistic approach. However, the duration of the implementation was too short to assess long-term impact and sustainability, but a manual and written team guidance seemed to be of added value [41, 42].

Policy implications

The inadequacy of somatic screening and healthcare coordination for individuals with SMI leads to health inequity. In this study, the absence of GP contact information and physical health data in patient records could indicate systemic issues in the coordination between mental health teams and primary care, reflecting broader challenges in integrated care. As routine physical health assessments are frequently neglected, what could lead to delayed diagnoses and inadequate management of comorbidities. These are systemic barriers that demand attention [43].

With regard to financial barriers, as MHOTs are not funded to provide physical health care services, this implementation project emphasized the role of primary care services. The integration of physical health services within mental health settings, as seen in various models globally, can enhance access to comprehensive care and improve health outcomes [2]. To address health inequities, policy recommendations could include routine physical health assessments in mental health settings, ensuring comprehensive care for individuals with SMI. Belgian primary care services are often financed in a fee-for-service system. In this system, healthcare providers are paid for each service they provide, were physical health screening and follow-up cannot be charged. Health services based on capitation, where a health care provider receives a fixed price for each patient, tend to be more effective in persons with a SMI as it could offer flexible care continuity [44, 45]. Additionally financial incentives could enhance the accessibility and quality of primary care services [18].

Limitations and future directions

Overall, HIP-scores in our study seem to be in line with Western countries, which suggest that it could be a useful tool in persons with SMI in Belgium. Yet, given the sample size and the implementation of the PHLN only in one MHOT, generalization of the findings is difficult. The extension of nurse reading rights in Belgian shared patient records was found to be a critical enabler for facilitating more efficient information sharing and coordination between mental health and primary care services, and could be a point of interest for future research.

Global challenges during implementation included scheduling difficulties, variation in primary care services, and limited access to dental care. These challenges underline the need for a comprehensive approach of physical health for individuals with SMI. Further exploration could involve pilot programs in real-world settings with enhanced training and access, or evaluating alternative funding models to support the sustainability of the PHLN role. This preferable in larger-scale, multi-center to evaluate sustainability. Including a control group in future studies would help clarify the intervention’s effectiveness by providing a comparative baseline.

Conclusion

The present study aimed to improve the physical health outcomes of patients with SMI by integrating a PHLN in a MHOT. Results revealed significant physical health challenges, particularly high rates of smoking, high BMI, and waist circumference, which are major cardiovascular risk factors. Physical health parameters showed little improvement over six months, suggesting a longer timeframe is needed. The study highlighted the PHLN’s valuable role in enhancing somatic care awareness and support within the team. However, financial and real-world barriers limit the sustainability of the PHLN role, encouraging policy makers to include physical health screening in primary care funding and stimulate research integrating PHLNs using a multidisciplinary approach supported by systemic reforms.

Abbreviations

PHLN

physical health liaison nurse

SMI

severe mental illness

MHOT

mental health outreach team

BMI

body mass index

Author contributions

Authors GD, MD and NM were involved in planning the study. The study was led by NM and all authors contributed to interpretation of the results. All authors read, edited, and made critical revisions to the manuscript. All authors approved the final manuscript.

Funding

This study was funded by EBPracticenet Belgium.

Data availability

The data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request.

Ethics and consent to participate declarations

Consent for publication

All participants signed a consent agreeing with the dissemination of the study finding using their pseudonymized personal data.

Competing interests

The authors declare no competing interests.

Contributions

Authors GD, MD and NM were involved in planning the study. The study was led by NM and all authors contributed to interpretation of the results. All authors read, edited, and made critical revisions to the manuscript. All authors approved the final manuscript.

Ethical approval

for the study was obtained from the Antwerp University Ethics Committee with the unique national number BUN B3002021000167, ensuring that the study adhered to ethical standards. Every human participant provided their consent.

Patients and caregivers were asked to sign an informed consent before participating in the study. Informed consent to participate was obtained from all of the participants, no participant was unable to give consent. We protected patient confidentiality by pseudonymizing any names to linked codes before analysis.