Title: Enhanced discharge from inpatient to community mental health care (ENRICH): a programme of applied research to manualise, pilot and trial a Peer Worker intervention
Funder: Department of Health and Social Care

Abstract: Aims and Objectives The aim of the ENRICH programme is to enhance the experience of discharge from psychiatric inpatient care for mental health service users, preventing readmission, reducing costs and improving individual recovery. The primary objective is to establish the effectiveness and cost-effectiveness of a Peer Worker intervention to enhance discharge. Background and rationale Rates of readmission to psychiatric inpatient care are high in the initial weeks post-discharge, as are suicidality and self-harm. Costs of readmission are high. Systematic review evidence suggests that interventions supporting transition from inpatient to community care are feasible and can be cost-effective. There is some evidence suggesting that Peer Worker interventions supporting discharge can impact on readmission rates, associated costs and individual recovery outcomes. A Cochrane review of Peer Worker interventions indicates quality of RCTs is low and an absence of formal cost-effectiveness studies. Mental health service providers are introducing a range of Peer Worker interventions in the UK in the absence of a clear evidence base. Research environment The host SW London Trust-University partnership has a track record in evaluating innovative service development in mental health, including recent NIHR-funded evaluations of self-care and Peer Worker roles. Our East London Trust-University partnerships have piloted a Peer Worker discharge intervention, host the programme CTU and have extensive expertise in conducting RCTs of complex interventions. We have extended NHS and voluntary sector networks focused on developing Peer Worker interventions. Research plan WP1. Manualising the ENRICH intervention Systematic narrative synthesis of evidence for Peer Worker interventions in mental health, to refine the intervention model and finalise intervention components. Work with expert panels will produce the manual for the WP4 trial; WP2. Developing the PROLIFIC Peer Worker Fidelity Index Fidelity index developed to assess the extent to which the intervention is implemented to principles underpinning peer support; WP3. Pilot trial Pilot trial of the intervention conducted in two sites using the protocol for the full RCT (WP4) to test and refine processes of recruitment, randomisation and allocation to intervention. Formal stop-go rules will determine progress to full trial; WP4. Randomised controlled trial Fully-powered pragmatic RCT of the ENRICH Peer Worker intervention conducted in six sites to establish the effectiveness and cost-effectiveness of the intervention. Primary outcome will be readmission to psychiatric inpatient care within one year of discharge. Secondary outcomes include a range of intra-personal, behavioural and service use outcomes; WP5. Impact study Mixed method cohort study of Peer Workers employed in the intervention will explore the impact of the role on wellbeing and employment outcomes for Peer Workers. Projected Outputs & Dissemination plans The programme will produce the ENRICH Peer Worker intervention manual, guidance on training and supporting Peer Workers, the PROLIFIC Fidelity Index for Peer Worker interventions and COMPOSE commissioning Peer Workers for mental health tool for commissioners. Dissemination will be through academic, professional and service user publications and conferences, with outputs promoted through our NHS, professional college, voluntary sector and international networks. A programme website will make findings and outputs readily accessible. We will work to influence mental health commissioning guidance and revisions to NICE guidelines. Relevant expertise & experience of the research team The team has considerable expertise in developing and evaluating Peer Worker interventions in mental health services and so is well placed to deliver programme academic and applied outputs. The PI (Gillard), with mentoring from senior trialist Professor Priebe, has a proven track record in leading inter-disciplinary research teams with high levels of PPI. Our NHS manager (Rinaldi) and NHS/ voluntary sector team members will ensure outputs have applied relevance. Our health economics (McCrone), trial statistics (Bremner) and CTU expertise will ensure trial quality. Justification of costs Co-applicant costs relate to specified responsibilities. Researcher time is costed to undertake specified numbers of interviews. Costs are included to support development and implementation of the intervention in Trusts, and database, data management and quality assurance by the CTU. PPI, including participant payment, is properly costed. Management & Governance, including Programme Management and ethical implications The PI will report to an independently chaired, biannual Programme Steering Committee (PSC) on delivery of agreed outputs, management of risks etc. PSC will appoint a Data Management Committee. PI will chair quarterly Programme Management Team and line-manage Programme Manager. Programme Manager will undertake day-to-day programme management and be trial manager, working with the CTU. Study design and application for ethical approval take full account of issues around randomisation processes, interviewing on sensitive topics and supporting service user researchers. Patient and Public Involvement Service user researchers, Peer Workers and voluntary sector organisations were involved in the research that underpins this proposal, and in designing the programme. We will employ, train and mentor service user researchers to undertake much of this research. Service users and Peer Workers will be supported to sit on the PSC, Lived Experience Advisory Group and Expert Panels.

Lay abstract: The few weeks after discharge from a psychiatric ward can be very difficult. Rates of readmission to hospital, and levels of suicide and self-harm are high. Inpatient care is very expensive and Mental Health Trusts are exploring ways to reduce readmissions. Recent research suggests peer worker roles can be beneficial. Peer Workers are employed in mental health services to support service users by using their own experiences of mental health problems. There is some evidence that Peer Workers help people stay out of hospital after discharge by supporting individual mental health recovery. Nationally lots of different approaches to employing Peer Workers are being tried, but research about what works well, and whether money is saved as a result, is still not clear. The ENRICH team has considerable experience of developing and researching Peer Worker roles. The team includes managers and a Peer Worker from the NHS, voluntary sector partners, experienced service user researchers, and experts in conducting large trials and economic evaluations. We have developed an intervention in which Peer Workers are trained and supported to meet service users on the ward before discharge, and continue to work with them in the community in the crucial post-discharge period. First we will review any new research about Peer Workers and work with Expert Panels &ndash; including Peer Workers and service users &ndash; to refine the intervention. We will conduct a randomised controlled trial of the intervention in six Mental Health Trusts. In each Trust half of service users about to be discharged will be randomly selected to work with a Peer Worker, and half will not. This might be difficult for service users who do not receive a Peer Worker, so we will make sure the process is carefully explained before people agree to take part. We will test this and other research processes in a short pilot trial in two Trusts before the main trial. In the main trial we will keep a record of services participants use in the year after discharge and ask them to complete questionnaires about their experiences on the ward and in the community. We will compare the group who worked with a Peer Worker with those who did not to see if Peer Workers made a difference to readmission rates and cost of services. We will interview Peer Workers to find out how working as a Peer Worker affected them. This programme will produce detailed guidance so that all Mental Health Trusts can employ, train and support Peer Workers to enhance discharge, a questionnaire to check that Peer Worker interventions are based on core values underlying peer support, and workshop materials to help commissioners make decisions about commissioning Peer Workers in mental health services.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;7.1 INDIVIDUAL CARE NEEDS
Health categories: MENTAL HEALTH