1st April st March 2016 with annual review
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- Gladys Jacobs
- 7 years ago
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1 Service Specification No. Service Complex Mood and Anxiety Conditions (Cluster 4) Commissioner Lead Provider Lead Period Date of Review January Population Needs 1.1 National/local context and evidence base 1st April st March 2016 with annual review The strategy No Health without Mental Health indicates a shift in focus towards prevention, promotion and earlier intervention in mental health. This requires that secondary services work collaboratively with primary care and the developing primary care psychological therapies. Putting people who use services at the heart of everything we do No decision about me without me is the governing principle. Care should be personalised to reflect people s needs, not those of the professional or the system. People should have access to the Information and support they need to exercise choice of provider and treatment; focusing on measurable outcomes and the NICE Quality Standards that deliver them rather than topdown process targets; and empowering local organisations and practitioners to have the freedom to innovate and to drive improvements in services that deliver support of the highest quality for people of all ages, and all backgrounds and cultures More people with mental health problems will recover More people who develop mental health problems will have a good quality of life greater ability to manage their own lives, stronger social relationships, a greater sense of purpose, the skills they need for living and working, improved chances in education, better employment rates and a suitable and stable place to live More people with mental health problems will have good physical health Fewer people with mental health problems will die prematurely, and more people with physical ill health will have better mental health More people will have a positive experience of care and support. Care and support, wherever it takes place, should offer access to timely, evidence-based interventions and approaches that give people the greatest choice and control over their own lives, in the least restrictive environment, and should ensure that people s human rights are protected Fewer people will suffer avoidable harm. People receiving care and support should have confidence that the services they use are of the highest quality and at least as safe as any other public service Fewer people will experience stigma and discrimination NHS Call to Action places patients at the centre to better meet the health needs of the future. There
2 are opportunities to improve the quality of services for patients whilst also improving efficiency, lowering costs, and providing more care outside of hospitals. These include refocusing on prevention, putting people in charge of their own health and healthcare, and matching services more closely to individuals risks and specific characteristics. To do so, the NHS must harness new, transformational technology and exploit the potential of transparent data. The local policy context is described in the Live it Well Strategy and the Kent and Medway Health and Wellbeing strategies. North Kent CCGs and East Kent CCGs and West Kent CCGs have recognised that this specification may not be fully actualised in 2014/15. Therefore the content of the specification should be treated as a transitional process to the new cluster care pathway. Operational practices will be reviewed in accordance with cluster pathways, affordability and activity volumes. As part of the contractual Service Development Improvement Plan a programme of work will be delivered through the year to implementation in 2015 Cluster 4 is a routine planned care pathway to be delivered within secondary care community mental health services. It is characterised by severe depression and/or anxiety and/or other increasing complexity of needs. Individuals may experience disruption to function in everyday life and there is an increasing likelihood of significant risks. The person will have more complex and severe needs than previous clusters, may pose moderate risk to self through self-harm or suicidal thoughts or behaviours. They are unlikely to improve without treatment and may deteriorate with long term impact on functioning. For older people there is increased likelihood of atypical presentations, with physical and cognitive co-morbidities and increased social vulnerability. The care package will contain high intensity psychological interventions and medication. Active support may be given on other aspects of lifestyle and physical health to help with their mental health needs. 2. Outcomes 2.1 NHS Outcomes Framework Domains & Indicators Domain 1 Domain 2 Domain 3 Domain 4 Domain 5 Preventing people from dying prematurely Enhancing quality of life for people with longterm conditions Helping people to recover from episodes of illhealth or following injury Ensuring people have a positive experience of care Treating and caring for people in safe environment and protecting them from avoidable harm X X X X X 2.2 Local defined outcomes
3 Required Outcome Evidence that the Service User: Has had their mental health and social care needs identified and assessed in a timely manner. Has information on the range of psychological, social and medication interventions available to best meet their needs and therefore has been able to make an informed choice. Key processes to support outcome To enable the achievement of the outcome you must: Liaise effectively with primary care providers. Establish and maintain a detailed knowledge and relationship with all local resources relevant to support people with mood and anxiety conditions and to promote interagency working. Have a detailed understanding of the local population and provide a service that is sensitive to its needs including culturally diverse BME groups and other vulnerable/under-represented groups. Screen and triage all secondary care referrals in a primary care setting. Provide prompt and expert assessment of mental health problems Including an assessment and management of risk. Assess people s use of alcohol or drug use and directly offer advice on harm minimisation where relevant. Communicate the outcome of the assessment to the person and referrer promptly (including GP where not referrer). Has received interventions by the specialist service in accordance with NICE guidance, in a stepped care approach. Knows the outcome of the assessment and details of care plan and are involved in reviews Knows who and how to contact the care co-ordinator in between appointments and has a telephone number for out of hours support or in the event of a crisis. Reports Reduction in troubling psychological symptoms An increase in the size and range of their social network Access to training or employment opportunities, or has retained employment. An improved quality of life, confidence, self-esteem and ability to manage own affairs. Provide information on the range of interventions available. Provide psychological interventions in accordance with NICE guidance, in a stepped care approach, avoiding unnecessary or inappropriate intervention. Provide advice on medication, initiate, monitor and review as indicated by clinical need. Provide support in accessing local work opportunities. Provide support in accessing advice on benefits, debts management and housing. Provide support with basic life skills such as nutrition, exercise, hygiene and physical well-being. Involve the person s family or social network as much as possible (with consent). Review effectiveness of interventions delivered through service user feedback and regular review, seeking the opinion of others when required. Experiences the mental health service as seamless, effective and efficient. Considers their independence has been respected, their recovery promoted and is aware of what steps to take to avoid relapse. Maintain contact with service users during acute episode of illness. Provide a follow up contact within 7 days of discharge from the inpatient service or discharge
4 Knows how to access the service in the future. Has had an opportunity to provide feedback on the service. Has recovered within 6 months from start of intervention and that re-referral within 6 months of discharge has not been required. from the crisis resolution home treatment service. Carry out routine Service user and referrer evaluation/satisfaction questionnaires. The cluster will employ a range of outcome measures aimed at reviewing clinical effectiveness and quality of the care provided, as directed by national agencies and agreed by stakeholders locally. It is anticipated that these will include clinical reported outcome measures (CROMs), patient reported outcome measures (PROMs), and patient reported experience measures (PREMs). The focus for cluster 4 is to produce a recovery oriented care plan, positive patient experience and increased well-being and resilience. The cluster will employ a range of outcome measures which will include: o o o A generic clinician rated outcome measure (CROM) i.e. HoNOS A generic patient rated outcome measure (PROM) i.e. Recovery Star, CORE- OM, Warwick Edinburgh Mental Wellbeing Scale A patient reported experience measure (PREM) i.e. Positive Service User Experience Questionnaire. In addition, locally agreed quality indicators will be provided i.e. % in settled accommodation. Nationally required data for quality indicators will be provided via the Mental Health Minimum Data Set (MHMDS) which includes employment status, diagnosis recording. Also to evaluate clinical effectiveness these outcome indicators will be augmented by professionally relevant measures. People significantly at risk as a consequence of their mental illness, as listed below: Depressive episode Phobic anxiety disorders Other anxiety disorders Obsessive compulsive disorder Stress reactions/adjustment disorders Somatoform disorder Mental disorders associated with pregnancy Eating disorders Other neurotic disorders. In addition to the diagnostics category above, the individual must meet the criteria for a cluster 4 care pathway following assessment by a trained HoNOS PbR assessor. 3. Scope 3.1 Aims and objectives of Cluster Pathway The focus of cluster 4 interventions is to provide holistic care that works with people s needs concerns, perceptions and strengths and inspires hope in them. These interventions will draw on current best practice and the recognised clinical evidence base. All care will be formulation based, focused on recovery and will aim to maximise quality of life. Care will aim to achieve service user
5 defined outcomes and provide opportunities to optimise personalisation and social inclusion. Distinct Functions of Cluster 4 Care Pathway: Provide prompt and expert assessment of the mental health condition and the effects on functioning for new referrals Provide prompt and expert assessment of risk, including self-harm and suicidal ideation Assess the Social Care needs of individuals using the FACS criteria Facilitate self-directed support utilising personal budgets where eligible Administer the Mental Health Act where appropriate (to become part of Cluster 5 in 2012/13) Reduce risk to self and others and increase and enable positive risk taking Provide effective, evidence based treatment and care for those with time-limited disorders who could benefit from specialist interventions in order to reduce and shorten distress and suffering. (Most interventions should be completed within 6 months) with some requiring up to 12 months where indicated Support client to return to optimal level of functioning Focus on increasing personal well-being, self-efficacy, hope, meaning and purpose Focus on increasing social recovery and improvement in family and social relationships Provide a range of therapeutic and enabling interventions, role support, family/carer interventions, monitoring and case co-ordination within clearly defined care pathways Assist Service Users and carers in accessing support to reduce distress and maximise personal development and fulfilment Provide advice and support to service users, families and carers Ensure that inappropriate or unnecessary treatments are avoided Referral on to acute care services, Recovery Services for those with more complex and enduring needs. Prompt discharge to primary care following successful treatment. Care co-ordination under CPA. 3.2 Service description/care pathway Adults aged 18 years and over (however, see time-limited inclusion of young people aged 17, below) where the GP has concerns regarding the potential presence of a functional psychiatric/psychological disorder. The majority of referrals should be stepped up from Cluster 3 PCPTS in a stepped care model. Consideration should be given to any additional needs of older people who are new presentations. The pathway will incorporate the following: o o o o o o Criteria for entry, transition and discharge from the pathway Details of the assessments, interventions, monitoring and review processes Multidisciplinary approaches and input as required A comprehensive clinical review of needs and care at cluster specified intervals (cluster 4 to be a minimum of 6 monthly) Outcomes and quality measures Identified opportunities for collaboration with other providers. Interventions can be delivered in a variety of different settings (community, inpatient, residential, supported living) according to the specific needs of individual service users. Interventions for cluster 4 will normally be delivered in community settings but there will be occasions when service users undergo mental health crises of a severity that their needs are best met by acute, inpatient care. EQUALITIES STATEMENT
6 Service users care plans and therapeutic interventions will be adapted to take account of their and their carers specific and changing needs and vulnerabilities. Care will take account of needs arising from the following factors: Language & communication Religion & culture Learning ability Cognitive functioning Physical health & sensory functioning Age related issues Gender Sexual orientation. Appropriately skilled staff and associated clinical resources are required to achieve these equalities INTERVENTIONS In common with all secondary mental health cluster interventions the following therapeutic aims apply: Assessment of presenting difficulties, needs and risks Establish and agree clinical formulation, diagnosis and care plan with the service user Establish risk management, crisis management and relapse prevention plans collaboratively To maximise psychological and physical wellbeing, social role functioning, and optimal independence To ensure the involvement of family and social support networks in care provision. In cluster 4, service users are experiencing severe symptoms/ impairment of functioning impacting on their and their families lives. They will require support to engage and maintain motivation; enhance coping and resilience to promote recovery. All interventions will need adapting for service users where there are added complexities e.g. physical / sensory/ cognitive / cohort needs. Auxiliary support and appropriate facilities may be needed. The needs of older people will be considered. This service works closely with primary care professionals particularly PCPTS and GPs. Clinicians have working knowledge of community resources including statutory, 3 rd organisations and community groups. sector A maximum of four weeks from referral to assessment, however an initial contact to be made within 10 days. When an urgent response is required the service will respond within 4 hours The maximum period between documented HoNOS PbR reviews should be no more than six months See Appendix 4 and 4a ENTRY, EXIT AND CARE TRANSITIONS Entry will initially be facilitated through the single point of access to the secondary care mental health services. Service user needs will be continually reviewed to ensure appropriate cluster assignment and the provision of best and most appropriate care. The most likely outcome following a period of intervention will be discharge from secondary mental health care if local discharge criteria are met (details to be confirmed with commissioners). Possible transitions from cluster 4 could be up to clusters 5, 6, 8, 10, 14 & 15, or down to clusters 3 & 7. In addition, transition to clusters 18 & 19 may occur particularly in later life. DISCHARGE
7 Service users should be discharged back to primary care promptly when they are recovered. This is essential to protect capacity for new referrals. Discharge letters need to be comprehensive indicating current treatment, any substantial changes to treatment and management and procedures for re -referral within 48 hours of discharge with a written copy to the Service User. Transition of service users to another care cluster should involve a formal handover and disengagement should not occur before the new team has established contact Discharge from a cluster 4 care pathway to primary care should take place promptly when the Service User s condition is stable and will take place in discussion with their GP. The pathway is intended to be for a maximum period of six to twelve months, at the end of which, should the service user require further care within secondary care, it is expected that transition to care cluster 6 will commence. Service users are discharged back to primary care and the GP is informed in writing of their progress during treatment. 3.3 Population covered CCG Population Count 15 years and over August 2013 CCGs population 18 years and over Total NHS Ashford CCG 105,300 NHS Canterbury and Coastal CCG 189,700 NHS Dartford, Gravesham and Swanley CCG 209,400 NHS Medway CCG 240,212 NHS South Kent Coast CCG 176,967 NHS Swale CCG 89,380 NHS Thanet CCG 123,300 NHS West Kent CCG 394,496 Grand Total 1,528, Any acceptance and exclusion criteria and thresholds Exclusions: People aged 17 years and under (service provided by CAMHS). However joint working practices should be in place to provide information to 17 year olds before transition to adult services to include a joint multidisciplinary meeting six months before transfer into adult services. People with common mental health conditions whose needs are best met by primary care services in clusters 1, 2 and Interdependence with other services/providers Main dependencies: Liaison Psychiatry, General Practice, primary care talking therapies and providing advice and support to the wider mental health services and relevant community organisations and 3 rd Sector providers working in Kent and Medway.
8 4. Applicable Service Standards 4.1 Applicable national standards (e.g. NICE) Care delivered in clusters will be informed by national, local and professional clinical practice guidelines and policy. It will be the responsibility of each team and each individual clinician to identify guidelines relevant to the service user s care. See appendix 13 and 13a 4.2 Applicable standards set out in Guidance and/or issued by a competent body (e.g. Royal Colleges) 4.3 Applicable local standards Agreed Key performance indicators 5. Applicable quality requirements and CQUIN goals 5.1 Applicable Quality Requirements (See Schedule 4 Parts [A-D]) 5.2 Applicable CQUIN goals (See Schedule 4 Part [E]) 6. Location of Provider Premises Services should be aligned by CCG area Availability of Service Working hours are generally from 9-5 week days with flexible out of hours working for specific tasks which are beneficial to the client and or their family. Service Users and carers will access the local CRHT, Helplines etc. Each service user will have a named care co-ordinator and if unavailable then written details of how to contact the service, where cover arrangements will be in place at all times. 7. Individual Service User Placement n/a
9 Service Specification No. Service Acute Services (CRHTT and Inpatient) and Clusters 5, Non- Psychotic Disorders (Very Severe) 14, Psychotic Crisis and 15, Severe Psychotic Depression. All other pathways may also access acute care pathway. Commissioner Lead Provider Lead Period Date of Review January Population Needs 1st April st March 2016 with annual review 1.2 National/local context and evidence base The strategy No Health without Mental Health indicates a shift in focus towards prevention, promotion and earlier intervention in mental health. This requires that secondary services work collaboratively with primary care and the developing primary care psychological therapies. Putting people who use services at the heart of everything we do No decision about me without me is the governing principle. Care should be personalised to reflect people s needs, not those of the professional or the system. People should have access to the Information and support they need to exercise choice of provider and treatment; focusing on measurable outcomes and the NICE Quality Standards that deliver them rather than top-down process targets; and empowering local organisations and practitioners to have the freedom to innovate and to drive improvements in services that deliver support of the highest quality for people of all ages, and all backgrounds and cultures More people with mental health problems will recover More people who develop mental health problems will have a good quality of life greater ability to manage their own lives, stronger social relationships, a greater sense of purpose, the skills they need for living and working, improved chances in education, better employment rates and a suitable and stable place to live More people with mental health problems will have good physical health Fewer people with mental health problems will die prematurely, and more people with physical ill health will have better mental health More people will have a positive experience of care and support. Care and support, wherever it takes place, should offer access to timely, evidence-based interventions and approaches that give people the greatest choice and control over their own lives, in the least restrictive environment, and should ensure that people s human rights are protected Fewer people will suffer avoidable harm. People receiving care and support should have confidence that the services they use are of the highest quality and at least as safe as any other public service
10 Fewer people will experience stigma and discrimination NHS Call to Action places patients at the centre to better meet the health needs of the future. There are opportunities to improve the quality of services for patients whilst also improving efficiency, lowering costs, and providing more care outside of hospitals. These include refocusing on prevention, putting people in charge of their own health and healthcare, and matching services more closely to individuals risks and specific characteristics. To do so, the NHS must harness new, transformational technology and exploit the potential of transparent data. The local policy context is described in the Live it Well Strategy and the Kent and Medway Health and Wellbeing strategies. North Kent CCGs and East Kent CCGs and West Kent CCGs have recognised that this specification may not be fully actualised in 2014/15. Therefore the content of the specification should be treated as a transitional process to the new cluster care pathway. Operational practices will be reviewed in accordance with cluster pathways, affordability and activity volumes. As part of the contractual Service Development Improvement Plan a programme of work will be delivered through the year to implementation in The service will primarily meet the acute needs of people in care clusters 5, 14 and 15. Care Cluster 5 (Non-Psychotic Disorders (Very Severe)) will be severely depressed, anxious or experiencing other forms of non-psychotic psychological disorder. They will not present with distressing hallucinations or delusions but may have some unreasonable beliefs. They may often be at high risk for suicide and they may present safeguarding issues and have severe disruption to everyday living. The person will have very complex and severe needs, with higher risks, hence their care will require on-going co-ordination and increased risk management. This care package will contain high intensity psychological interventions and probably medication. Aspects of lifestyle and physical health to help with mental health needs will be actively supported. Care Cluster 14, (Psychotic Severe) will be experiencing an acute psychotic episode with severe symptoms which cause severe disruption to role functioning, they may present as vulnerable and a risk to others or themselves. The care package will be specific to immediate needs with concern for longer term engagements, and likely to include psychological therapies and medication. Significant care coordination and risk management will be needed. Aspects of lifestyle and physical health linked with mental health needs will be actively addressed. Service users are likely to be experiencing delusions and hallucinations, and there may be issues of non-accidental self-injury, misuse of substances, depressed mood. A lack of engagement in occupation and activities due to the severity of the symptoms and cognitive problems are common. Disruption to family life, including parenting roles, and safeguarding issues may be present. Vulnerability to abuse/exploitation, together with other concerns, necessitates on-going co-ordination and increased risk management. Care Cluster 15, (Severe Psychotic Depression) will be suffering an acute episode of moderate to severe depressive symptoms. Hallucinations and delusions will be present. It is likely that this group of people will present a risk of suicide and have disruption in many areas of their lives. The person in this cluster is experiencing an acute episode of depressive symptoms with hallucinations and delusions, and with serious risks and disruption to functioning. The care package will be specific to immediate needs, with concern for longer term engagement and likely to include psychological therapies and medication. Significant care coordination and risk management will be needed. Aspects of lifestyle and physical health linked with mental health needs will be actively addressed. Service users are likely to present with non-accidental self-injury and cognitive problems may present. Safeguarding challenges for the person (or for others if they are a parent/ carer) may be present. Activities and role functioning will be severely disrupted.
11 2. Outcomes 2.1 NHS Outcomes Framework Domains & Indicators Domain 1 Preventing people from dying prematurely X Domain 2 Enhancing quality of life for people with long-term X conditions Domain 3 Helping people to recover from episodes of illhealth X or following injury Domain 4 Ensuring people have a positive experience of care X
12 2.2 Local defined outcomes- Required Outcome- Crisis Resolution Home Treatment Evidence that the Service User: Has access to service when in crisis out of hours. Has had their mental health and social care needs identified and assessed in a timely manner. Knows the outcome of the assessment and details of crisis plan and are involved in reviews. Has information on the full range of interventions available and therefore has been able to make an informed choice. Receives interventions and support that are timely and appropriate in their own home. Has, where appropriate received an intervention in accordance with NICE guidance. Knows, along with their family/carers how to contact the crisis team in between home visits. Key processes to support outcome To enable the achievement of the outcome you must: Be available 24 hours 7 days a week. Where possible access via service user s care coordinator. Where appropriate, undertake a mental health and social needs assessment including a physical health assessment and risk assessment. The assessment actively involves the service user, carers/family and relevant others, including the service user s support network. Provide information to the service user and their support network on how the service operates and how to contact between visits. Produce a focused crisis plan which states the number of visits and level of input to be provided and when hospital admission might be warranted. Provide Intensive support with frequent contact (including home visits) throughout the crisis during which on-going risk and needs are monitored. Offer practical assistance with tasks of daily living that enable the service user to recover at home. Provide a range of interventions for both service user and family/carers Develop Relapse prevention plan making every effort to identify and reduce conditions that leave the service user vulnerable to relapse Be able to deliver, administer and monitor medication during a 24 hour period Report that they and their family/carers: Have been informed about the nature of the illness, the crisis Have been involved in decision making and feel supported. Considers their views have been respected and recovery and resilience promoted. have been involved in decision making and monitoring of medication Experiences the mental health service as seamless.
13 The crisis plan is to be shared with the GP and care coordinator within CMHT and others as appropriate. Facilitate admission when required identifying the purpose of admission and what needs to change before home treatment can be restarted. Facilitate early discharge to enable the person to recover from the acute episode in their own home. Transfer care to the CMHT care coordinator once the cr resolved. Required Outcome- Acute inpatients Evidence that the Service User: Has received acute care in the least restrictive environment Key processes to support outcome To enable the achievement of the outcome you must: Ensure access to the acute service in patient wards is available 24hours via the Crisis Resolution Home treatment service. There is timely access to safe, dignified treatment in the least restrictive environment consistent with the need to protect them, their family/carers and the public for service users requiring acute care. PICU provides short-term intensive care for service users admitted to the admission wards and a clear agreement about the service users return to those wards. Transfer to PICU is for a new episode or an acute exacerbation of the service user s condition rather than chronic behavioural disturbance. Advice from PICU staff is available 24hours to the admission wards on management plans. Current symptoms are the prime consideration in determining the appropriateness of transfer to PICU. Once appropriate, service users are transferred back to their admission ward. Has been admitted to a local ward. Knew the purpose of the admission and anticipated length of time in hospital prior to admission. The reasons for admission together with the risk factors and a projected length of stay are identified and communicated prior to admission.
14 On admission was made to feel welcome and introduced to the ward, staff and how the ward is run. Are not discriminated against due to age, gender, ethnicity, sexuality culture, physical or learning disability. Reception and admission arrangements ensure that service users are made welcome, properly informed, orientated to services and facilities available to them in order to maximise their connections to community services and resources. Welcome packs and carers information are available. There are suitable access and facilities for people who have problems with mobility, orientation, visual or hearing impairment or other special needs. Cultural, religious and spiritual care is considered and included with mental health and social care and are addressed in service user s treatment plans. Liaise with the local learning disability services for their contribution towards the assessment, clinical management and treatment of a person with a learning disability. There are protocols in place to ensure joint working, access to services and care co-ordination. Receive care in an environment that provides for their basic necessities, safety, privacy and comfort. Has been treated with respect and their dignity protected and upheld. When detained under the Mental Health Act 2007 was done so legally. Activities such as physical exercise, social interaction, recreation with access to fresh air are available. Provide a dedicated space for service users to spend time with their children away from the wards. Psychiatric intensive care is available in a purpose-built facility provided in a secure environment. It meets the same standards as the admission wards. Provide a dedicated area designed to reduce arousal or agitation and to allow for the dignified de-escalation and management of aggressive behaviour. Has received information and understood their legal status, rights, and their condition and treatment options. There is meaningful dialogue with service users and carers to ensure a mutual understanding of legal status, their rights, risks, treatment options and progress, admission and discharge arrangements and procedures. Has been involved and engaged in the planning and review of their care plan. Share opinions of assessments and provide information necessary for service users to make choices in their treatment and recovery plans.
15 Has had a physical examination within 72 hours of admission and specialist advice sought when required. Has been engaged according to an agreed therapeutic approach by all staff which includes a range of therapeutic inputs Service users social and support network have been involved in the treatment plan as much as possible and where Carers have a significant contribution, they are offered a carers assessment by the care coordinator. Undertake a full physical examination on each admission and seek specialist advice when needed particularly for diabetes, coronary heart disease or epilepsy. All staff are aware of the underpinning therapeutic approach and are to apply these according to their training and competence. This includes clinical and support staff. There is an agreed approach to assessment according to the agreed modality to make a diagnosis and treatment plan. Each ward has a programme of therapeutic activities on both an individual and group basis. Activities are available during the evenings and at weekends. Psychological interventions and support is available. Has been able to have contact with ward staff and talk through their anxieties and problems. Take positive risks to reduce reliance on acute services whilst promoting independence and maximising home and community support. Every effort is made on the admission wards to manage a service user s presentation and behaviour. All members of staff are trained and receive regular training on the legal aspects of the management of both disturbed and violent behaviour. Existing networks and links (family, friends, education, employment and care co-coordinator) are encouraged and maintained to actively reduce the impact of social exclusion during the acute phase of illness. Work collaboratively at the point of admission with service user, family/carers, support network, crisis resolution home treatment team and the wider mental health service on planning for early discharge. The care coordinator identifies the need for a carers assessment. Where carers have a significant contribution the coordinator organises a carers assessment (target 100%). Assist service users and carers to develop personalised relapse prevention and coping strategies that maintain and expand skills, limit the likelihood of relapse and promote recovery.
16 Has had the opportunity to access independent advocacy support. Promote service user access to advocacy services for the resolution of service user and carer concerns at the point of admission. If taken to the Section 136 suite by the police was assessed by approved staff on arrival. Was informed of their rights and the process by both the police and health care staff. There is a local policy in place and arrangements for monitoring the use of Section 136. There is close working between the police, local authority and health care professionals. On arrival people are assessed by an approved section 12 clinician and by an approved mental health practitioner (AMHP). Medical treatments, including ECT will be prescribed and administered safely and in accordance with NICE and the British National Formulary. The Service User, family/carer was involved in discussions about medical treatments, including medication and side effects were explained. They were able to contribute in the review and effectiveness of the medical treatments prescribed. Received Medications and other medical treatments safely. Has been supported to leave hospital safely at the earliest opportunity. Has experienced the mental health service as seamless. Regular feedback to help shape services around the needs of service users. Pharmacy staff routinely advises Service Users about possible side effects and management of side effects. Service user and family/carer aware of discharge arrangements and has a follow up appointment, including the name of their care coordinator and how to contact them. Service user and family/carer has a number for out of hours support. Has been followed up within 7 days of discharge by the care coordinator. On discharge the GP is informed of progress during admission, treatment and prescribing and follow up arrangements. Have an established Acute Care Forum which includes service user and carer representatives and a focus on service improvement. Work in partnership with service users and carers, exchanging information and monitoring standards to improve quality of care. Service Users Council meetings provide a forum for support, exchange of information and news and feedback to assist in the monitoring of standards.
17 3. Scope 3.1 Aims and objectives of service To provide clearly defined 24/7 crisis and Acute care pathways, primarily to meet the needs of those in care clusters 5, 14 and 15 and anyone who needs a diagnosis and response quickly and unexpectedly. It should be available 24/7 and provide consistent and rigorous assessment of the urgency of their care need and an appropriate response to their need within 4 hours of referral. People experiencing severe mental health difficulties should be treated in the least restrictive environment with the minimum of disruption to their lives. Crisis resolution/home treatment (CRHT) can be provided in a range of settings and offers an alternative to inpatient care. The majority of service users and carers prefer community-based treatment, and research in the UK and elsewhere has shown that clinical and social outcomes achieved by community-based treatment are at least as good as those achieved in hospital. Where this is not possible, admission to hospital will be offered where it is considered to be appropriately therapeutic and required to maintain safety for the person or others. This will be for as brief a period as clinically required. The approach will be to: a) to minimise the impact the crisis is having on the person s life b) to maximise wellbeing by mobilising and strengthening the person s internal resources, confidence, self-belief, assets and strengths to work through the crisis c) To promote a return to self-management, to maximise social functioning and an improvement in the quality of their lives. For some service users, interventions and aftercare may be delivered within the legal framework of the Mental Health Act and the Mental Capacity Act CRHT will assess all potential admissions with the view to provide home treatment. However there will be occasions at referral when treatment at home is not an option. In such events CRHT will coordinate the admission and be routinely considered to facilitate early discharge when the factors contributing to admission may have subsided (often a matter of hours). Both inpatient and CRHT staff with the care coordinator will work according to an agreed therapeutic model, jointly in combining assessment skills and in supporting social functioning, symptom management and community reintegration at the earliest opportunity. The focus will be to support the maintenance of existing networks and links to prevent social exclusion during the acute phase with the aim of developing personalised relapse prevention and coping strategies. The Care coordinator is responsible for the service user throughout the acute phase. The nature of acute illness requires expertise in the delivery of care within a legal framework and a conveyance of positive attitudes so as to maximise individual service users recovery and potential for independent living. The Mental Health Act 2007 is the legal framework that mental health staff must follow for all people considered in need of acute care. Particular attention to the needs of Women and some men who are vulnerable to harassment, intimidation, violence and abuse in mixed sex acute settings must be given. People with all levels of learning disability also develop similar mental health problems to the rest of the population however, their presentations may not be typical because of difficulties communication mental illnesses and may manifest as a change in the person s usual pattern of behaviour. As such people with learning disabilities who become acutely mentally unwell will be able to access acute services including inpatient care, on exactly the same basis as the rest of the population.
18 As levels of physical morbidity for people with mental illness are a serious concern, it is essential that attention is given to physical health care. Crisis Resolution Home Treatment Provide rapid assessment of individuals with acute mental health problems 24 hours a day, 7 days a week. Provide as an alternative to hospital admission and for which home treatment is appropriate. To ensure that individuals experiencing acute, severe mental health difficulties are treated in the least restrictive environment as close to home as clinically possible To remain involved until the crisis has resolved and the service user is linked into, or returns to, a routine/planned care pathway. Crisis Home Treatment teams facilitate inpatient admission when home treatment cannot be undertaken safely and to be proactively involved in discharge planning and provide Intensive care at home to enable early discharge from hospital. To reduce service users' vulnerability to crisis and maximise their resilience. Inpatient care The purpose of an adult acute inpatient service is to Provide high standard humane treatment and care in a safe and therapeutic setting for service users in the most acute and vulnerable stage of their illness who cannot be safely treated at home. Offer time limited care and safety to service users Provide a safe environment Assess service users mental health needs which cannot be achieved outside of an inpatient environment. Provide a brief period of treatment which will support their recovery and return home as soon as possible. Outcomes and Measures The cluster will employ a range of outcome measures aimed at reviewing clinical effectiveness and quality of the care provided, as directed by national agencies and agreed by stakeholders locally. It is anticipated that these will include clinical reported outcome measures (CROMs), patient reported outcome measures (PROMs) and patient reported experience measures (PREMs). The focus for Cluster 5, 14 and 15 is to produce a recovery oriented care plan, positive patient experience, and increased well-being and resilience. The cluster will employ a range of outcome measures which will include: A generic clinician rated outcome measure (CROM) e.g. HoNOS A generic patient rated outcome measure (PROM) e.g. Recovery Star A patient reported experience measure (PREM) e.g. Positive Service User Experience Questionnaire In addition, locally agreed quality indicators will be provided e.g. % of service users with annual CPA review, % of service users with settled accommodation. Nationally required data for quality indicators will be provided via the Mental Health Minimum Data Set (MHMDS) e.g. re-admission rates, waiting times, employment status.
19 EQUALITIES STATEMENT Service users care plans and therapeutic interventions will be adapted to take account of their and their carers specific and changing needs and vulnerabilities. Care will take account of needs arising from the following factors: Language & communication Religion & culture Learning ability Cognitive functioning Physical health & sensory functioning Age related issues Gender Sexual orientation. Appropriately skilled staff and associated clinical resources are required to achieve these equalities. 3.2 Service description/care pathway See appendices 5,14 and 15 The service should be available 24 hours a day, 7 days a week in order to provide an urgent response and be able to provide support to service users, their family/carers. To undertake assessments and home visits 24 hours a day. Access to a consultant psychiatrist should also be available. Where possible, known service users should access the service via their care coordinator during normal working hours. The service can be accessed directly by known service users out of hours. Core components CRHT: 1. Access. CRHT is available 24 hours 7 days a week to provide an initial screening for referrals and ensure acute service is appropriate. The preference has been for access to be via the service user s care coordinator. Access arrangements will be discussed and reviewed for PbR. All new service users should have a care coordinator assigned immediately. If inappropriate, make referral to the right service and ensure adequate continuity of care. 2. Assessment. Undertake mental health, social, physical needs and risk assessments involving service users and members of their support network. CRHT will undertake all section 136 assessments. 3. Crisis Resolution. Support the service user and his/her support network with intensive home treatment until crisis is resolved. 4. Interventions. The provision of time limited treatment for people with mental illness who would benefit from the following specialist interventions: a) Psychological. Should be routinely offered as an option. A range of techniques should be available for reducing the severity of symptoms and for increasing resilience to cope with the illness. b) Physical health. Every person should routinely receive a physical examination and any health problems should be identified and treated, seeking specialist advice when appropriate. Services users should be encouraged to register with a GP. The team may take on some limited responsibility where there is clinical competence. c) Medication and medical treatments. The team is responsible for the safe prescribing, administering and monitoring of medication as indicated by clinical need, with blood tests as necessary to monitor therapeutic levels or side effects. d) Social inclusion. The team should have strong links to statutory and 3rd sector organisations and be able to support service user access to mainstream local services. All service users should be supported to consider occupation where possible or supported to retain employment, to find or remain in settled accommodation and make use of local leisure resources. e) Relapse prevention. Every effort should be made to identify and reduce factors which precipitate relapse, build resilience and the action to be taken in the event of a relapse. 5. Family and social network maintenance and support. Every effort should be made to involve service users social and support network in the crisis plan as much as possible and where Carers have a
20 significant contribution, they should be offered a carers assessment. Assessment on a routine basis of the overall wellbeing of dependents whose needs may be compromised by service user illness. Where dependent children act as carers their own needs require regular review. 6. A team approach to regular review a. Daily reviews of assessment findings and effectiveness of interventions are undertaken. In this way the service users benefit from the expertise of the whole team. Liaison with CAMHS for service users under 18 years old. b. These reviews include the service user, members of their support network and members of the wider community team. c. Actions and changes in treatment are made explicit to all involved. Access to Acute care pathway Referrals are received from other secondary mental health services who, following assessment, believe that someone may require admission to hospital. The CRHT Team will undertake a further assessment to determine if admission is required or home treatment can be provided as an alternative. Out of hours Service Users who are open to secondary mental health service and have a crisis plan agreed that includes direct access to CRHT can self refer or be referred by their carer. Urgent care Referral arrangements must be in place for the police, the ambulance service, GPs, primary care mental health workers, helpline and liaison psychiatry service as well as other mental health services Discharge from CRHT service Service user/family/carers to be actively involved in the discharge planning process Discharge planning should begin early in CRHT care. Information about the crisis, interventions provided and recommendations for ongoing care should be exchanged with relevant others (GP, CMHT) Discharge possibilities will be dependent on clinical situation and local service provision and will be dependent on care cluster but could include transfer of care to: Primary care Assertive outreach team Early intervention team Other mental health services. At this point the service user is likely to be stepped down to another cluster. Possible transitions from cluster 5 are cluster 6, 7 8, 10, 14, 15. The most likely transitions are ongoing care within cluster 14 or transition to cluster 15. Possible transitions are down to 4-6, 8, 10, and Possible transitions from cluster 15 are cluster 14, 4-8, 10, and For Older People, there is a greater possibility that they will transition to an organic cluster. Acute Inpatients Referral for admission is following assessment by the Crisis Resolution Home Treatment Team who have assessed that home treatment is not an immediate viable alternative. 1. Therapeutic Model. A defined therapeutic model underpins the provision of service and is adopted and applied by all staff, clinical and support. 2. Access. Access is via the Crisis Resolution Home Treatment Team and available 24 hours 7 days a week who screen the referral for urgency and appropriateness for home treatment. Admission facilities are local and available within each PCT area. 3. Environment. The ward is clean, light and has facilities to meet service users basic necessities,
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