Clinical Pathway Team

Transcription

1 Clinical Pathway Team

2 Brief background about Pennine Care s Rehabilitation and High Support Directorate Pennine Care NHS Foundation Trust provides a range of rehabilitation and high support (RHSD) services across Greater Manchester, including step-down rehabilitation units, low secure services and a Psychiatric Intensive Care Unit (PICU). The step-down rehabilitation units are: Beckett Place and Hurst Place in Tameside, Bevan Place and Heathfield House in Stockport, Rhodes Place in Oldham and Stansfield Place in Rochdale. Each unit is gender and age specific, with the exception of Stansfield Place, which is Pennine Care s only mixed sex unit. These units are for service users with complex needs, who have been detained under the Mental Health Act and require long-term treatment. The aim is to promote service users independence, improve their quality of life and prepare them for successful inclusion in the community. The low secure units are: Prospect Place in Rochdale and Tatton Unit in Tameside. These services are both for male services users. They are similar to the step-down units but are for services users who have a higher level of risk, which occur more frequently, and therefore require a more secure unit. The Cobden Unit is Pennine Care s PICU and is based at Stepping Hill Hospital in Stockport. This unit is for men who are acutely unwell, and their level of risk means they cannot be managed therapeutically and safely on an acute ward or in prison. Further details are provided in Pennine Care s suite of brochures, which are available on Pennine Care s website at or by contacting Sue Robson on About the Clinical Pathway Team The following diagram summarises the key roles of the team Complex psychosis Co-morbidity Risk Engagement difficulties Placement problems Clinical Pathway Team Step-down rehabilitation services provided by Pennine Care Assessment for rehabilitation on locked wards Low secure services - provided by Pennine Care Gatekeeping for all male referrals (female referrals to GMW) Risk clinic provision Forensic services Advice and support on how to manage referrals (medium secure referrals to GMW) Advice Care pathways and the placement and management of service users with complex needs PICU - provided by Pennine Care Monitor out of area placements and co-ordinate service users return to local services On average, the team deals with 100 referrals every year. Their ultimate goal for every service user is to establish the most appropriate and least restrictive placement, which is closest to their home. Before the team was established there were in excess of hundred people in low secure out of area placements. The team have successfully reduced this number to two (as at June 2015). Similar reductions have been achieved for out of area step down rehabilitation unit placements, after local commissioners requested support. The Clinical Pathway Team is the first point of contact for all referrals to Pennine Care s RHSD services. The team also has a specific responsibility to assess and decide on the best placement for all men admitted to Pennine Care s low secure services (female low secure referrals go to Greater Manchester West (GMW) NHS Foundation Trust). The team monitors low secure and Psychiatric Intensive Care Unit (PICU) out of area placements and provides advice about appropriate care pathways for service users with complex needs and who are high risk.

3 Meet the team Michael Hirst Michael has worked as a nurse in rehabilitation services for nearly 20 years, including eight years in the Clinical Pathway Team. He has a degree in forensic nursing, a diploma in the care of mentally disordered offenders and is experienced in nursing and management within a secure setting. As a senior member of the team, he provides leadership and has established links with commissioners and allied providers throughout the North West. He leads on the monitoring of the PICU out of area placements and is part of the assessment and pre-admission team. Mobile: michael.hirst@nhs.net Wayne Hanning Wayne has a degree in mental health nursing and has worked in the NHS for eight years and within the Clinical Pathway Team for the past five years. During this time Wayne has developed considerable knowledge and experience of service providers and the management of complex pathways. He is involved in the assessment of low secure referrals, reviewing the PICU out of area placements and supporting service users during their pre-admission and transfer to RHSD services. Dr Iain Mackenzie After gaining two years experience as a consultant on adult inpatient wards, Iain returned to the Clinical Pathway Team in He is the responsible clinician for Prospect Place and Stansfield Place and leads on women s referrals. Mobile: imackenzie@nhs.net Dr Tor Pettit Tor has worked as a rehabilitation consultant for over 12 years in secure and step down placements. He has served on the Royal College Rehabilitation and Social Psychiatry Executive Committee for eight years. He has extensive experience of service development and quality improvement in the NHS and the independent sector. He is the responsible clinician for Bevan Place and the Cobden PICU. Mobile: tor.pettit@nhs.net Mobile: waynehanning@nhs.net

4 Sue Robson Sue has worked for the Pennine Care s Specialist Services Division for seven years. In her current role as divisional capacity and flow manager, Sue oversees all referrals into Pennine Care s RHSD services. She also oversees bed management, including admissions and discharges, working alongside the Clinical Pathway Team. Sue has extensive administration experience in various roles which supports close partnership working between the Clinical Pathway Team, clinical commissioning groups and NHS England. Direct number: Mobile: susan.robson@nhs.net Jill Brooks Jill provides administration support in the management of the referral process and is frequently the first point of contact for referrers. Jill has worked for Pennine Care for seven years in a variety of administration roles. jill.brooks@nhs.net

5 What support can the Clinical Pathway Team provide? Support for referrers The Clinical Pathway Team is the single point of contact for all referrals to low secure and step-down rehabilitation services. The team can provide advice on the management and care pathways for any service users with complex needs - either via the referral or simply over the phone. They have established positive relationships with many NHS and independent secure providers in the North West and can provide advice about how to access forensic and other specialist services. All referrals to male low secure services have to be approved by the team in order to be admitted to Pennine Care s services, or to a private provider. Please note that referrals to female low secure services should be directed to the Bowness Unit, provided by Greater Manchester West NHS Foundation Trust. Support for commissioners, service users and their families and carers The team can provide advice on whether service users are appropriately placed and are receiving high quality care. The team operates a Risk Clinic Service to monitor and advise on a service user s care, to ensure they benefit from the least restrictive environment for their individual needs. How to make a referral Service Contacts Where to send the referral form PICU Step-down rehabilitation units and low secure units Forensic services (not provided by Pennine Care) To request a form: To discuss a case: /2198 N.B. Pennine Care staff can access a form via the intranet under the Trust Approved Documents N.B. Pennine Care staff can access a form via the intranet under the Trust Approved Documents Medium secure services and formal forensic opinions are provided by Greater Manchester West NHS Foundation Trust. Phone and ask for the referrals co-ordinator By fax on: By fax on: As advised by the referrals co-ordinator A pre-admission package is offered by the team to ensure service users experience a smooth transition between services and they are committed to involving the service user in all stages of this process. The team also monitors service users who are in out of area low secure services, to ensure they are appropriately placed. In addition to the above, the team plays a vital role in the development of new services by providing market intelligence, identifying suitable services users and completing the required clinical assessments prior to a new service opening.

6 Contact information If you have any specific queries you can contact the relevant member of staff at the details provided in this booklet. If you have a general query you can phone the team on /4314. Date of publication: September 2015 Reference: 3999/The Clinical Pathway Team Leaflet Pennine Care NHS Foundation Trust