Operational Policy and Procedures For the Crisis Resolution Home Treatment Team (CRHTT)

Transcription

1 Operational Policy and Procedures For the Crisis Resolution Home Treatment Team (CRHTT) Reference OP.CRHT Implementation date: June 2013 Review date: June 2015 Director responsible for monitoring and reviewing policy: Richard McKendrick Director of Specialty Services 1 of 48

2 TABLE OF CONTENTS 1. Document Control Summary and Assurance Summary 3 2. Introduction and Purpose of Policy 4 3. Who is the CRHTT Service for? 4 4. Underpinning Values of the Crisis Service 4 5. Location of Teams Core Functions of CRHT Emergency (Same Day) Assessment Accident and Emergency Screening Gatekeeping Admissions to Hospital Home Treatment Early Discharge from hospital Supporting Police Welfare Checks 21 7 Management of Services Staffing Roles and Responsibilities Handover Meetings and Clinical Reviews Supervision, Training and Continuing Professional Development 27 8 Risk Assessment and Management 27 9 Service User and Carer Involvement Feedback from Service Users and Carers Research And Audit Medication and Medicines Management 29 Appendix 1 CRHTT Emergency Care Pathway 30 Appendix 2 Example of CRHTT Emergency GP Referral Screening Form 31 Appendix 3 Guidelines for Referrers from Secondary Mental Health Services 33 Appendix 4 CAMHS Crisis Pathway 36 Appendix 5 CATSS Mental Health Assessment Matrix 37 Appendix 6 Emergency Department Mental Health Assessment Matrix 40 Appendix 7 CRHT Information Leaflet for Service Users 43 Appendix 8 Risk Management Plan for Service Users Refusing or Avoiding Contact 45 Appendix 9 CRHT Management and Supervision Structure 46 Appendix 10 Service User Feedback Interview schedule 47 2 of 48

3 1.0 Document Control Summary and Assurance Summary Policy Title Policy Aims Status: Policy Committee approves (Date, Comments and areas of consideration Policy Board ratified) Areas / service user groups affected by the policy Operational Policy and Procedures For Crisis Resolution Home Treatment (C.R.H.T.) To ensure consistent practices within clear governance structures for CRHT Review Ratified by Clinical Executive June 2013 All service users who experience a crisis or referred for hospital admission Meets National criteria with regard to: Further comments to be consider at the time of ratification for this policy (I.e. National policy, Legislation and consultation across SHA). If this policy requires Trust Board ratification please provide specific details of requirements PIG Guidance DMT approval / Clinical Executive NB The name Committee refers to all committees within the Trust where policies are developed review and approved. The word policy is used generically for a policy, guideline or protocol, which requires consultation and approval prior to dissemination for use throughout the Trust. List of abbreviations: AMHP CATSS CRHTT FP GP ISA SPoA Approved Mental Health Practitioner Crisis and Telephone Support Service Crisis Resolution and Home Treatment Team Forensic Physician General Practitioner Initial Screening Assessment Single Point of Access 3 of 48

4 2. Introduction and Purpose of Policy The Crisis Resolution Home Treatment Team (CRHTT) is a multi-disciplinary team of mental health professionals providing a 24 hour, 7 day per week service to people experiencing an acute psychiatric crisis. The team provides an alternative to acute hospital admission by providing intensive community based interventions. Where a hospital admission does occur, CRHT can assist in shortening the inpatient stay by facilitating early discharge and support back to the community. This policy provides the operational guidelines under which the Crisis Resolution Home Treatment Team will provide a safe and evidence based service. The nature of the team is such that it is not possible to cover all eventualities within this policy. CRHTT will need to consider the principles of this policy and other Trust policy and guidance when making decisions to best meet the needs of individual service users. 3. Who is the CRHTT Service for? CRHTT provides a service for people in Northamptonshire with severe mental disorders, for example, psychotic illness, affective disorders, personality disorders and dementia. Assessments of suitability for home treatment are considered on an individual basis. The CRHTT is intended to offer a greater level of support than generic community psychiatric teams would normally be able to provide, and is therefore, ideally placed to work with individuals who would otherwise be admitted to hospital with an acute psychiatric crisis. The CRHTT is part of the extended network of community mental health services and adds capacity to the CMHT and Specialist Teams functions. Where a mental health worker is already involved in the care of a service user it is expected that they will continue to provide care alongside staff from CRHTT, on at least a weekly basis. Please see Appendix 1 for pathways into and out of CRHTT. 4. Underpinning Values of the Crisis Service Crisis management is a process of working through a crisis until it is resolved. Successful service user engagement is paramount. The achievement of a therapeutic alliance with the service user is essential before any intervention can be successful. The team take a holistic approach, looking at all the factors involved in the crisis, including biological, psychological and social issues, and use a range of interventions to address these. The service users social network has a powerful effect on their mental health and any treatment provided by the CRHTT must directly address social factors. Crisis staff will approach work with service users from a strengths rather than an illness model, and draw on the innate strengths of service users in 4 of 48

5 order to support them. Communication and engagement processes are of specific importance when dealing with service users with disabilities or whose preferred language is not English. Providing crisis management and educating service users and carers to acquire coping skills will form a significant part of the crisis work. The team will assist the service user and their carer to acquire/learn behaviours to improve and maintain their mental health. The approach should be one of collaboration with the service user and/or their family by doing work with them, so as to promote their ownership of the crisis. As far as is reasonably practicable, the team will work in a way that demonstrates regard for the present, past wishes and feelings of the person receiving services and their cares and/or legal guardian. Standards of care will reflect evidence based practice and fit within the CRHTT referral pathway. CRHT staff will fully exercise their duties in respect of safeguarding adults and children by working with partner agencies to protect vulnerable persons from abuse. This will be achieved through cooperating in discussions, meetings and investigations with relevant agencies whenever abuse is suspected or identified. 5. Location of Teams NHFT has two CRHT teams. The geographical boundaries are determined by the Trust Localities: o The South CRHT Team covers the geographical areas of Northampton East, Northampton West, Daventry and Towcester. The CRHT South team is based at Berrywood Hospital. Contact Telephone No: Out of Hours through Berrywood Reception Fax No: o The North CRHT Team covers the geographical areas of Kettering/Corby and Wellingborough/East Northants. The CRHT North team is based at St Mary s Hospital. Contact Telephone No: Fax No: Core Functions of CRHTT The core functions of CRHT are to provide the following services: 1) Emergency (Same Day Assessments) 2) Accident and Emergency Screening 3) Gatekeeping of inpatient beds 4) Home Treatment 5) Early Discharge from hospital 6) Supporting Police Welfare Checks 5 of 48

6 6.1 Emergency (same day) Assessment An emergency assessment by definition is appropriate for someone who is either: At risk of immediate and significant harm to self, and/or Is an immediate and significant risk to others due to their mental health, and/or Where an admission to a mental health inpatient unit is being considered. Emergency Assessments are accepted by the CRHTT 24hrs a day, from the following sources: GPs (General Practitioners), including Out of Hours services and FPs (Forensic Physician) Community Teams and Specialist Mental Health Teams Community Older Adult Teams CAMHS (Child and Adolescent Mental Health Services) AMHP Service (Approved Mental Health Practitioners) CATSS (Crisis and Telephone Support Service) Open Access Service Users On Call Psychiatrist Telephone referrals are accepted from a professional who has seen the person within the last 24 hours, and has gathered as much clinically relevant information as they reasonably can. This allows for greater discussion, information exchange, decision making and prioritisation within the CRHTT. Service users and carers with open access to the CRHTT (by prior arrangement) can also self refer to the service. Telephone referrals will be taken by a member of the team who will take all the details necessary to complete the appropriate CRHT referral form liaising with the duty co-ordinator when required. (See Appendix 4 and Appendix 5). The process of taking the referral is normally sufficient for the purposes of screening and triaging the referral. Under certain circumstances, if the referral is complex, the team member will discuss the referral with an appropriate medical or senior practitioner within the CRHT team. By collecting information about the person being referred, the team member aims to ensure that the CRHTT is the most appropriate service to meet the client s needs and record the referrers concerns, including the level of urgency and suggested arrangements for contacting and assessing the client. The team member taking the referral will ensure that the referral is discussed within the team and that the arrangements for the assessment are made and communicated to the referrer. CRHT has a duty to ensure they collect detailed histories as part of the assessmentincluding retrieving information from other providers where it is known that a service user has received care and treatment outside of NHFT. After taking the details of the referral it is anticipated that the initial response (first assessment) from the CRHTT will be completed within 1 to 4 hours. Any cases that are not to be seen within this time should have a clearly documented clinical 6 of 48

7 rationale. The urgency and priority of the referral will ultimately be determined during the referral process. As part of the teams assessment, staff will endeavour to obtain historical psychiatric information including details of any care/treatment outside of the NHFT and this will be taken into consideration when formulating an appropriate treatment plan. Emergency assessments will be carried out at the most appropriate location, with the safety of CRHT staff and the service user being considered paramount. Most commonly the CRHTT s initial assessments are undertaken at the following venues: 1. The GP Surgery 2. General Hospital (i.e. A&E Department) 3. CMHT Base 4. Welland Centre / Berrywood Hospital 5. Section 136 Places of Safety (Berrywood/Welland/Police Custody) 6. Home address (subject to consideration of the risks) There will be circumstances where the CRHTT may be requested by the referrer to undertake an emergency assessment within a service user s home. The Duty Coordinator will consider any such requests on a case by case basis taking into account any current and historical risk information. Where a decision is made to offer a service user an emergency assessment at home, the Duty Coordinator will consider the appropriate level of staffing to attend the assessment and assessing staff will ensure that all lone working procedures are adhered to. The referrer may be asked to participate in or request a joint assessment. This is good practice and involves joint working and co-ordination of care. Following all emergency assessments, the CRHTT worker/s involved will complete all of the standard assessment documents as listed below as a minimum: Referral (CRTS using agreed outcomes only and all recorded as emergency) GEN Initial Screening Assessment Tool GEN Working with Risk 1 GEN Care Plan HoNOS Adult Score Sheet (those clustered at 4 and below would not be funded by PBR) GEN Accommodation, employment, SDS & Smoking Epex contact Episode (opened to CRTS if taken on otherwise not required) During an emergency assessment, the assessing staff will establish whether home treatment is appropriate based on an evaluation of; the presenting risk factors including risk to self and others, the suitability of the residential environment, the person s support systems and their ability to engage with the CRHTT. The person(s) completing the assessment can communicate and discuss the assessment findings with the Duty Coordinator before agreeing the outcomes and follow up care with the service user and referrer if required. Where the assessor and/or Duty Coordinator require further clinical support regarding the outcomes of an assessment, these matters should be escalated as follows: 7 of 48

8 Within office hours; - to a member of the CRHT management team and/or CRHT medical personnel. Outside of office hours; - consult the Trust s on call medical staff. Given the priority that the CRHTT must give to emergency assessments, the CRHTT does not accept referrals for next day assessments. Upon completion of an emergency assessment the referrer will be notified and informed of the outcome of the assessment and any actions agreed by the CRHTT. This will be done on the same or next working day, by telephone. In any circumstances where a request is made for an emergency assessment and the service user refuses to either see staff from the CRHTT, engage with the assessment process or becomes un-contactable - CRHT staff will refer to the specific risk management guidance outlined in Appendix 9 in order to ensure that the service users welfare is assessed and the appropriate risk management plans are implemented. General Practitioners and Forensic Physicians (GPs & FPs) - Emergency Referral Pathway for GPs Northamptonshire GPs, within the geographical boundaries determined by the locality areas, can refer to the CRHTT directly. The same also applies in those cases where the GP has a service user in their surgery that requires a same day assessment due to their level of risk. Urgent referrals for secondary mental health services directed to the CMHT are seen within two working days and routine referrals are seen within 10 working days. If the CRHTT receives a GP referral that does not require an emergency (same day) assessment, the Duty Coordinator in CRHT will take the referral details from the GP and ensure that it is received and processed by the relevant team via SPoA. Where a GP refers a service user for an emergency assessment and the client is already open to a team within NHfT, the Duty Coordinator will make contact with the relevant NHfT team to establish whether a joint assessment can be made with either the care coordinator or a duty worker. Where a duty worker or the care coordinator is not available to attend a joint assessment, staff from the CRHTT will undertake the assessment independently. The CRHTT also accept emergency referrals from Forensic Physicians (FPs) working within the Northamptonshire catchment area. It is the responsibility of Duty Coordinator in CRHT to make the referral process as simple for the GP as possible. The referral information is collected using the GP Screening Form (see Appendix 2 CRHTT emergency GP Screening Form) and arrangements are made in liaison with the GP to assess the service user at the most appropriate venue. 8 of 48

9 Localities and Specialist Teams (ISA Team, Care Coordinators, Duty Workers and Medical staff- See Appendix 4 for Guidance on Referrals from Secondary Mental Health Services) The CRHTT accepts emergency referrals from the following specialist teams: 1. Adult and Older Adult Teams 2. Early Intervention Psychosis Service (EIS) 3. Assertive Outreach Team (AOT) 4. Eating Disorders Team 5. ADHD and Aspergers Team 6. Community Forensic Team 7. Community Team for People with Learning Disabilities (CTPLD) 8. Traumatic Brain Injury Service (TBI) 9. Team 63 (Personality Disorder Team) 10. YPD Team (Younger Persons Dementia) There is an expectation that prior to making a referral to the CRHTT the referrer will have implemented a crisis and contingency plan to include increased frequency of contact with the service user along with a medical review. Wherever possible the referrer will have had face-to-face contact with the service user within 24 hours prior to referral to the CRHTT. This is to ensure that the referral is appropriate and the referrer is able to give all the information required for an appropriate referral. Under normal circumstances a member of the team making the referral should participate in a joint assessment with staff from the CRHTT. The assessment will determine if hospital can be avoided by the CRHTT working collaboratively with the referrer and engaging with the service user to deliver home treatment. Where the community and specialist teams are considering assessment under the Mental Health Act, the CRHTT should be contacted and a request made for the team to complete an emergency assessment. This is to ensure that all opportunities for home treatment are appropriately explored before admission. Where a referral is taken from a community/specialist team and the service user is identified to be not at the point of hospital admission, staff within the CRHTT will offer the referrer appropriate signposting and support. This may include a joint assessment. Older Adults (Functional and Organic) The CRHTT aim to provide an inclusive service that does not discriminate on the basis of age or diagnosis. In recognising the inherent expertise of existing older adult services, CRHTT staff will work collaboratively to complement the work of older people s services. The service standards for the CRHTT and older adults are: 1. The CRHTT will provide a service to ALL adults who present with acute mental disorder/crisis and who without the intervention of the team would require hospital admission. 9 of 48

10 2. The CRHTT will assess and screen referrals from A&E (24hrs per day) and provide home treatment as appropriate. (A&E will refer to the appropriate team for the individual which includes other services e.g. CECS) 3. The CRHTT will respond to all emergency referrals from sources identified within this operational policy. During normal working hours any request for the CRHTT to complete an emergency assessment will be notified to and discussed with the respective community team (as determined by GP practice). Wherever possible, during working hours the CRHTT will work jointly with community staff to respond to and assess emergency referrals. 4. The CRHTT will gate-keep all admissions for Older Adults with a functional illness that cannot be treated at home. Gatekeeping will be carried out by the CRHTT following a face to face assessment with the service user. 5. Referrals for service users suffering from Dementia will be seen by the CRHTT for initial assessment for home treatment. Hospital admission will require sourcing a bed from the appropriate units within NHfT. 6. Consultant responsibility for service users taken on by the CRHTT for home treatment will be provided by the CRHT Consultant. 7. During normal working hours (9am-5pm) the older adult team including the Responsible Clinician will be notified by the CRHTT of any circumstances when a bed is required for an older adult and a discussion will take place to identify the most suitable inpatient bed for the service user. 8. The CRHTT will provide an early discharge service to the Older Adults wards in the same manner that this is provided to acute adult inpatient wards (See 6.5). Child & Adolescent Mental Health Service (CAMHS) CAMHS provide assessment and treatment services for young people aged less than 18 years between the hours of 9am and 10pm every day. Outside of these hours (between 10pm and 9am) the adult CRHT team will accept referrals to assess young people aged years from A+E, the Out of Hours GP services, Forensic Physicians (FP s) and the AMHP service. Children and young people aged 18 and under that present at A&E following self harm will be admitted to the acute hospital pending referral to the CAMHS service, the next working day. In cases where a young person between the ages of 16 and 18 years who has self harmed refuses admission to the acute hospital they may be referred to the adult CRHT for assessment. All assessments of young people aged between years will be conducted in accordance with the standard assessment procedure outlined in this policy and the standard assessment records completed. Once the assessment is concluded if there is no further action for the adult CRHTT then the case must be discussed with the CAMHS Consultant on call. In the event that the CRHT worker requires support regarding the assessment of a young person, this can be obtained via the consultant on call for CAMHS. 10 of 48

11 If a role for the CRHTT is identified then the service user will be taken onto the CRHTT caseload over night and the service user/carers will be provided with the relevant contact numbers for the adult CRHTT. The CAMHS Team should be contacted by the CRHT Duty Coordinator first thing the next day to organise a further, joint assessment. It has been agreed that a regular slot for these joint assessments will be provided by CAMHS at 11.00am. This joint assessment will determine the ongoing support that is required and will identify which provider (adult or CAMHs) is the most appropriate to provide ongoing care. If, following an emergency assessment, a mental health inpatient admission is required; a bed will be accessed in the most suitable environment. This decision should be made by the CRHTT assessor in discussion with the CAMHS Consultant on call (See CAMHs Crisis Care Pathway- Appendix 4). Approved Mental Health Professional (AMHP) Service (including Mental Health Act Assessments and Section 136 Assessments) Prior to making an application under the Mental Health Act 1983, the CRHTT must be notified so that they can participate in the assessment process and where possible, provide the service user with an alternative and less restrictive treatment plan. If home treatment cannot be offered and the service user has to be detained, the assessing staff from the CRHTT will notify the respective admission ward that the admission has been gatekept. In these circumstances the staff responsible for the Mental Health Act Assessment will then complete the referral to the admission ward. In accordance with NHFT policy CLP012 Northamptonshire Countywide Procedure for the application of Section 136 of the Mental Health Act, the CRHTT should be notified of all S136 Assessments by the AMHP. The CRHTT should attend the assessment and be involved in the process to determine whether home treatment is appropriate or gatekeep an admission to hospital. Crisis and Telephone Support Service (CATSS) All calls to CATSS are stratified by the call handlers, using the CATSS Matrix (See appendix 5) into one of three categories depending on the nature of the call. These categories are defined below: Red Amber Green The caller presents as an immediate threat to life/personal injury or risk to others. The caller is at some risk but does not need to access services immediately and can be supported initially by CATSS. The caller poses no immediate concerns assurance and advice given, signposting to other services. The CRHTT may receive referrals from the CATTS call handlers in response to red cases and also in response to amber cases where the call handler 11 of 48

12 feels there is still a significant risk after they have supported the person over the telephone. In the first instance the CATSS operators will deal with all red cases as warranting an emergency service and will call 999. Callers who fall under the amber category will be advised to access normal referral routes, but it may be necessary for the CATSS operator to additionally refer the caller to the CRHTT. The CRHTT Duty Coordinator must be notified of all red cases as a emergency referral. RED CASES As soon as it becomes clear that a caller is suicidal or has seriously harmed themselves in any way, the CATSS call handler will verify if the caller wants help and take action to support the caller whilst an emergency response is summoned. The CATSS call handler will notify the respective CRHTT as soon as is reasonably practicable and the Duty Coordinator will treat the notification as an emergency referral. The Duty Coordinator will then liaise with the appropriate emergency services (e.g. police, ambulance, fire) to track the referral and coordinate a response which will involve a face to face assessment by the CRHTT. In instances where individuals refuse to attend A&E for a medical assessment or engage with the police for a welfare check, it is the responsibility of the CRHTT to organise a face to face contact with the individual and if necessary liaise with the AMHP service to organise a Mental Health Act Assessment. This must be done in a timely fashion to ensure the safety and well being of the individual. The CATSS operator will treat the call as an incident and complete an incident record on the Datix system. AMBER CASES In all cases the CATSS worker will seek to obtain the callers name, address, date of birth and (if appropriate EPEX number). During office hours: For people who are not in contact with NHFT services, the CATSS call handler will advise the caller to book an urgent appointment with their GP or to go to the nearest A&E Department. The caller will be provided with the telephone number of both services. However, if the CATSS operator has any specific concerns they can still use their discretion to refer the individual to the CRHTT who will treat the notification as an emergency referral. Callers who are in contact with NHFT services will be advised to ring the duty team for the CMHT or other appropriate team. The caller will be given the appropriate telephone number. 12 of 48

13 Outside office hours: The CATSS call handler will advise all callers to contact their GP out of hours service for their area or to go to the nearest A&E Department. CATTS call handlers will only refer service users to A&E if they have a medical problem (e.g. self harm or overdose). When callers are advised to go to A&E then the CATSS call handler will contact the relevant A&E Department with basic clinical information about the caller. The caller will be informed that the Operator is contacting the A&E Department. In all such cases the CRHTT will be notified by CATSS of the referral, but it will be at the discretion of staff at A&E or the GP whether to make an emergency referral to the CRHTT (See CATSS Mental Health Assessment Matrix- Appendix 5). Open Access Service Users This Self Referral service applies for service users and / or carers where there has been a prior agreement between the Care Coordinator, CRHT and the service user and the plan is documented in the service users CPA care plan. Referrals to establish open access to the CRHTT should be made in the first instance by the Care Coordinator to the CRHTT Consultant. Upon receipt of contact from a service user with open access, the Duty coordinator will make the necessary arrangements for the service user to be assessed for home treatment. On Call Psychiatrist The On-Call Psychiatrist can make emergency referrals to the CRHTT, for instance after assessing a service user at the general hospital. In addition, after a green card referral, a community doctor may refer a service user for an emergency assessment by the CRHTT. Wherever possible it is preferable that the CRHTT are notified and requested to attend a joint assessment where it is anticipated that home treatment may be appropriate. 6.2 Accident & Emergency Screening Each CRHTT provides a dedicated assessment and screening service to designated areas within the Kettering General Hospital (KGH) and Northampton General Hospital (NGH), 24 hours per day. This service is for patients who present following self harm or with acute mental health presentations. The CRHTT North provides cover for the following areas: A&E Department Middleton Assessment Unit Clifford Ward The CRHTT South provides cover for the following areas: A&E Department Emergency Assessment Unit Overspill wards (Beckett, Alibone and Eleanore Wards) Occasionally the acute hospitals will admit someone who has presented after self harming into other parts of the hospital. In such circumstances referrals for 13 of 48

14 assessment may be directed to the CRHTT and should be processed like any other A&E referral. It is a requirement for the CRHTTs to provide a prompt response to referrals from A&E to prevent any breach of waiting time targets. This may involve prioritisation of these referrals by the CRHTT s Duty Coordinator. Fit for Discharge from Acute Hospital Referrals can only be accepted by the CRHTT if the patient is medically fit to leave hospital and is agreeing to be seen. Mental state assessments cannot be undertaken by the CRHTT whilst the service user is significantly impaired by alcohol or other substances or whilst detained under Sec 5(2) or under arrest. All blood results, investigations and treatments need to have been completed by the acute hospital and the service user declared medically fit for discharge, before the service user is officially taken onto the CRHTT s home treatment caseload. The assessing staff from the CRHTT will check the patient s notes for medical fitness. The CRHTT cannot assume responsibility for a patient s care until staff at the general hospital have clearly documented in the service users notes that they are Medically fit to be discharged. To assist and inform their assessment, the CRHTT staff completing the assessment may request a respiratory alcohol level from the service user. All referrals made by the acute hospitals should occur in conjunction with the Emergency Department Mental Health Assessment Matrix (See Appendix 6). Upon completion of this tool by the acute hospital staff, the service user will be graded as either low risk, medium risk or high risk. In all instances where the assessment outcome determines a medium or high risk the service user should be referred to the CRHTT and receive a face to face assessment with a CRHTT worker. Where the outcome identifies low risk, then if the referrer contacts the CRHTT they will be advised as to the most appropriate signposting for the service user. In all cases the matrix tool must be faxed to the CRHTT by A&E staff as part of the referral process. The matrix document will be scanned into EPEX upon receipt by the Duty Coordinator. Where the matrix indicates a screening assessment, the CRHTT worker undertaking the assessment will complete all of the standard assessment documents below as a minimum: 1. Referral (CRTS using agreed outcomes only and all recorded as emergency) 2. GEN Initial Screening Assessment Tool 3. GEN Working with Risk 1 4. GEN Care Plan 5. HoNOS Adult Score Sheet (those clustered at 4 and below would not be funded by PBR) 6. GEN Accommodation, employment, SDS & Smoking 7. Epex contact 14 of 48

15 8. Episode (opened to CRTS if taken on otherwise not required) Irrespective of the outcome of this assessment the CRHTT worker completing the assessment will ensure that a note entry is made in the acute hospital records system. This note must clearly identify the outcome of the CRHTT assessment including any plans for intervention by the CRHTT. Where the assessment identifies that no further input is required from the CRHTT, this must also be clearly recorded. 6.3 Gate Keeping Admissions to Hospital As a Foundation Trust, it is a mandatory requirement that all referrals for hospital admission are gatekept by the CRHTT. The CRHTT are responsible for gatekeeping all adult and older adult functional beds. This is to: Ensure that all patients are treated within the least restrictive environment consistent with their clinical needs. To reduce pressure on inpatient beds. To ensure equity of access to an alternative to hospital admission for patients and families. CRHTT gate-keeping applies to all requests for elective admissions where there is a clearly identified treatment plan. In such cases, the referral must have been discussed with the CRHTT manager and/or Consultant and it must be clearly documented in the service user s clinical records that the admission has been gatekept by the CRHTT. It is a mandatory requirement that all requests for elective admissions are directed in the first instance to the CRHTT. Inpatient admission wards must not accept direct referrals without first discussing them with the CRHTT s Duty Coordinator to ensure that gatekeeping has occurred. Requests for Out of Area (OOA) beds can only be made once the service user s admission has been gatekept by the CRHTT. Where a request for an NHfT inpatient bed is made from another non-nhft hospital or care provider, the CRHTT should be notified but are not required to gatekeep the admission. Mental Health Act Assessments, including S136 assessments, should be attended by a member of the CRHTT. The CRHTT will still undertake gatekeeping responsibility for detained patients or patients who have agreed to an informal admission, who would otherwise be liable for detention. If CRHTT are requesting a MHA assessment there is an expectation that they will liaise with the AMHP and attend the assessment. Service users transferring from a medium-secure or low-secure unit into an acute psychiatric bed do not need to be referred to the CRHTT for gate-keeping. 15 of 48

16 Service users occupying beds within the Trusts Rehabilitation Service may be transferred into an acute psychiatric bed without the need for CRHTT to do a gatekeeping assessment. Service users being admitted into an alcohol detoxification bed via CRI (Crime Reduction Initiative) do not need to be referred or gatekept via the CRHTT. Where a service user is subject to a Community Treatment Order (CTO) and the Responsible Clinician (RC) is considering recalling the service user to hospital, it is good practice for the RC to request an assessment by the CRHTT for their opinion on the appropriateness of home treatment with CRHT support. As the RC is the only person who can recall and discharge a CTO patient, the CRHTT are not required to gatekeep such admissions but may be involved in assisting with the recall process out of hours. The CRHTT do not gate-keep admissions into the Trust s Low Secure beds (Wheatfield Unit, Berrywood Hospital), but do have a role in gatekeeping referrals for admission from the Community Forensic Service into acute psychiatric beds at the Welland Centre and Berrywood Hospital. Where a service user that is under the care of the Forensic Service, requires an urgent admission to hospital the CRHTT will adopt a pragmatic approach to their gatekeeping function. If the Community Forensic Service identify that the service users risk presentation is such that a face to face assessment by the CRHTT is unpractical or increases risk then the CRHTT will gate-keep the admission without seeing the service user. Upon receipt of an appropriately gatekept referral, it is the responsibility of the nurse in charge of the admission ward to source an inpatient bed. Where a bed cannot be sourced from within NHFT or a specialist bed is required (i.e. eating disorders, perinatal care etc) a bed will be sourced by the admission area in accordance with NHFT Policy CLP031- (Policy for identifying an in-patient bed, should a bed not be immediately available). It remains the responsibility of the CRHTT to ensure that any service user referred for a hospital admission, irrespective of its location, is safely conveyed and escorted to hospital. In all circumstances the member of the CRHTT gate-keeping the admission, will assess the presenting risks and determine the most appropriate method of conveyance and escort. Where conveyance issues place an undue resource pressure on the Crisis Service these matters should be escalated to the service manager/manager on call to assist the CRHTT staff to identify a safe solution. It is the responsibility of CRHTT to ensure that all relevant information pertaining to the service user s admission is appropriately handed over to the receiving ward. As part of the gatekeeping process the assessor from the CRHTT will ensure that the following information is completed and recorded on Epex within 4 hours of completing of the assessment: Referral (CRTS using agreed outcomes only and all recorded as emergency) GEN Initial Screening Assessment Tool GEN Working with Risk 1 GEN Care Plan 16 of 48

17 HoNOS Adult Score Sheet (those clustered at 4 and below would not be funded by PBR) GEN Accommodation, employment, SDS & Smoking Epex contact Episode (opened to CRTS if taken on otherwise not required) Where admission to hospital takes place under the Mental Health Act, responsibility for the handover and delivery of MHA paperwork lies with the AMHP. 6.4 Home Treatment Following an initial assessment by the CRHTT, when a service user s suitability for home treatment has been identified, an assessment period will commence. During this time the service user will undergo a medical review and they will work with staff from the CRHTT to develop an individual care plan. Home treatment options will be appropriately planned by the team with the service user and their carer fully involved. Intervention options will be explored and the possible consequences of each option discussed. Service users and carers will be informed that throughout their care under the Crisis Service, support is available 7 days a week, 24 hours a day from the team. The service user will also be informed that their individual care plan will be reviewed constantly in response to their (and their carers) changing needs. All service users taken on for home treatment will be provided with a service leaflet that outlines the level of service they should expect to receive from the CRHTT. (See Appendix 8 - Information Leaflet for Service Users) The CRHTT Consultants are the Responsible Clinicians (RC s) for the all service users on the CRHTT s home treatment caseload. Home treatment will: Be available 24 hours a day and over 7 days a week Provide home assessment, treatment, intervention and/or support as an alternative to hospital admission. Provide support to the care co-ordination function of the community and specialist teams to ensure appropriate service access and management of acute relapse. Provide short-term interventions and management of an individuals care during the period of acute relapse, including signposting to other services or other support services. Continue until the crisis has been resolved. Care Planning 17 of 48

18 Following identification of service user needs, a care plan for home treatment will be formulated with explicit details of the interventions that will be delivered. If it is agreed by the CRHT Multi-disciplinary team that seeing a service user at their home address is unsafe, the care plan should identify a venue where treatment will be delivered. The care plan will be shared with the service user and discussed where appropriate with other staff involved in the service user s care and where appropriate, their carers. CRHTT will ensure that any existing crisis plan or advanced directives are considered when formulating a new crisis care plan. This will ensure that any relapse prevention or relapse reduction initiatives are considered and incorporated into the service users care. The service user s care plan will be evaluated daily during the team handovers and formally reviewed by the full Crisis Service multi-disciplinary team during the weekly clinical reviews. As part of the care planning process there will be particular emphasis on what needs to be achieved to facilitate discharge from the CRHTT. Due to the team approach used by CRHTT, service users (and their carers) will be made aware of the likelihood of contact with several members of the team during the assessment and treatment period. As soon as it becomes apparent that a service user will require ongoing care from secondary services, a referral for a Care Coordinator will be made by the CRHTT. The expectation is that allocation of a Care Coordinator by the respective team will be made within one week of this referral and the CRHTT informed at the earliest opportunity. As part of the care planning process there should be ongoing reviews of the arrangements for facilitating home treatment including the frequency of visits, the most appropriate venue and the number of CRHTT staff that should attend. Consideration should always be given to the service users and carer s wishes and in accordance with the most up to date risk information. Where it has been determined by the MDT that it is appropriate for CRHTT staff to lone visit a service user, the Crisis worker must ensure that they work in accordance with the Trust s lone worker procedures (Trust Policy HSC006 Lone Working Policy) and use any personal protective equipment issued by the Trust. To ensure continuity of care it is expected that any allocated Care Coordinator (or deputy) will actively participate in the delivery of care on a minimum of a weekly basis. The Care Coordinator (or nominated deputy) should also expect to receive regular updates of their client s progress from the CRHTT. Discharge from CRHTT Prior to discharge the CRHTT should ensure that: There is good understanding by the service user, their family, carers and relevant others of why the crisis occurred and how it may be avoided in the future. 18 of 48

19 Coping strategies have been explored with the service user and family/carer. A relapse prevention plan is in place. Service users and their family/carers have had the opportunity to provide feedback and express their views about the CRHTT in order to contribute to the services development The decision to discharge from the CRHTT should be made through consultation between the CRHTT s Multi Disciplinary Team, the Care Coordinator (if assigned), the service user and carer. For service users subject to CPA, discharge should be planned in conjunction with the service user s Care Co-ordinator and whenever possible a joint visit should be undertaken prior to discharge. Upon discharge from home treatment, the member of CRHTT staff completing the discharge will ensure full completion of the CRHT Discharge Summary and will ensure that this is forwarded to all relevant parties. Where a decision is made to discharge a service user directly back to the care of a GP, it is good practice for a worker from within the CRHTT to notify the GP practice before the service user s discharge and if possible discuss the ongoing treatment plan with the relevant GP. There are times when service users and their carers are anxious about being discharged by the CRHTT. It is therefore important that the process of discharge is adequately discussed during the care planning and implementation phase of care. Consideration should be given by the CRHTT to the timing, venue and persons present at the time of discharge from the home treatment caseload. Where the service user does not appear to be responding to home treatment, or risk factors appear to be worsening (as perceived by the service user, their carer or professional staff from within the CRHTT or other involved teams), the CRHTT staff will sensitively discuss the option for hospital admission with both the service user and their carers. In the event that hospital admission cannot be safely avoided, the CRHTT Duty Coordinator will liaise with the appropriate admission ward to facilitate a hospital admission. Where the service user refuses an informal admission to hospital, the Duty Coordinator will make the necessary arrangements to coordinate the service user s assessment under the Mental Health Act. 6.5 Early Discharge From Hospital Early discharge is the process by which the CRHTT identifies and works with service users who are still acutely unwell to; 1) facilitate their discharge from hospital and; 2) commence home treatment. In order for early discharge to take place there must be evidence to show that the presenting risks and symptoms of the service user that indicated their hospital admission have reduced to a point where home treatment is safe for the service user, their family/carers and CRHTT. 19 of 48

20 The CRHTT will manage the patient in their respective community setting in accordance with the process of home treatment detailed above (See 6.4). This home treatment should continue until the service users mental health has improved to a state where they can either be transferred to secondary mental health services or referred back to their own GP. Where a service user s mental state deteriorates following early discharge readmission to hospital may be considered. During the process of accepting a referral for an inpatient admission, the admission ward staff should capture the reasons why the patient needs to be admitted to hospital and identify what needs to change before home treatment by the CRHTT can be reconsidered. During each weekday the CRHTT Duty Coordinator will allocate a member of CRHTT staff to review all referrals for early discharge and liaise with the inpatient wards to identify any potential referrals. This member of the CRHTT will be responsible for attending any joint meetings with the inpatient units, bed meetings and MDT meetings (as required) to discuss, screen and assess actual and potential referrals for early discharge. Referrals for early discharge can be made to the CRHTT by a registered nurse or medical professional. However, all referrals should have been discussed with the relevant inpatient Responsible Clinician (RC). The allocated member of the CRHTT staff will then discuss any new referrals for early discharge with other members of the CRHTT and wherever possible the team Consultant. If, after assessment the patient is not accepted for home treatment, the CRHTT must clearly identify the reasons why early discharge is not appropriate and identify what changes to the patients presentation need to occur before a referral for early discharge by the CRHTT will be reconsidered. The following steps should be completed by the referring ward as part of the early discharge process: The referrer should contact the relevant CRHTT and complete/update the service user s risk assessment (Working with Risk 1). The service user should be aware of a referral to the CRHTT and should have indicated a degree of willingness to engage with the team. It is necessary that the inpatient medical team is aware and agreed to the referral. Discussions with community Care Coordinator (if involved) and any carers is essential. Referrals must be made before a patient is discharged from hospital. The CRHTT should, where possible, be involved with leave plans before they occur. Referral for longer-term service provision should be initiated by ward staff as soon as possible after admission (i.e. CMHT, Psychology, and Forensic Assessment etc). 20 of 48

21 Once early discharge has been agreed between the referrer and the CRHTT, an individualised plan for Early Discharge will be jointly completed by the CRHTT, the service user and staff from the ward. This plan will include the following: Details of any pre-discharge visits to the ward by the CRHTT to continue assessment, build a therapeutic relationship, monitor mental state and risk, and to plan/review care. Regular dialogue with inpatient medical team and ward named nurse to facilitate and identify leave discharge plans. Supported home leave, which may be more than one period prior to discharge depending on the risks and practicalities in the home environment. CRHTT staffs attendance at MDT meetings involving the patient. Record of CRHTT involvement in patient s care plan and contacts on EPEX. Whilst the CRHTT is supporting a service user on leave a medical review can be undertaken by the CRHTT Medical Staff. Following this review the relevant ward team will be notified of the outcome and advised about possible discharge into the care of the CRHTT. IT IS THE RESPONSIBILITY OF THE INPATIENT MEDICAL TEAM TO FORMALLY DISCHARGE THE SERVICE USER FROM HOSPITAL. In all cases where a service user is taken on by CRHTT for early discharge, the inpatient MDT and staff from the CRHTT will jointly compete a Working with Risk 3 (WWR3) document- to outline the risk management plan for facilitating the discharge. It is essential that the service user and carers are also actively involved in this plan. Any referrals for early discharge should be made directly to the CRHTT covering the locality of the service user s intended place of residence post discharge. The CRHTT will accept referrals for early discharge for patients who are detained under the Mental Health Act. Early discharge is not appropriate for inpatients within hospitals outside of the Trust. Early discharge will only be considered once the service user has been transferred back to an inpatient unit within the NHFT. 6.6 Supporting Police Welfare Checks CRHT have a role in supporting the Police when they are asked to determine the welfare of someone that is either currently on the CRHTT caseload, or has been referred for an assessment by the CRHTT and is either not contactable, or refuses to engage with the team. A protocol for managing such situations has been agreed with Northamptonshire Police. Once a decision has been made that a service user requires a police welfare check - (See Appendix 8) the CRHTT Duty Coordinator will contact the police to request a welfare check and agree a time for a member of the CRHTT time to meet the Police at the address where the service user is thought to be. A 21 of 48

22 member of the Crisis staff and police personnel will then jointly assess the person s welfare and take appropriate action to manage any identified risks. Where significant risks are identified, and hospital admission is indicated, the CRHTT will notify the Duty Coordinator who will coordinate all further actions and if required liaise with the AMHP service regarding the arrangement of a Mental Health Act Assessment. 7. Management of Services The Director of Speciality Services has strategic responsibility for the countywide service, with operational responsibility through the Head of Hospitals (North), CRHTT Service Manager and Team Managers. The CRHT brings together a multidisciplinary team into a single operational management structure. Team members contribute their professional specific knowledge and skills and responsibilities. Individual professional groups have additional professional and managerial supervision and appraisal arrangements e.g. AMHP s and medical personnel. The CRHT team managers are responsible to the Service Manager for the operational management and functioning of the teams. This includes the deployment of resources, budget management, meeting clinical governance targets and adhering to Trust policies and procedures. 7.1 Staffing Team staffing requirements reflect the need to maintain a rota which offers availability around the clock. Both CRHT teams operate an early shift, late shift, night shift and long day shift. Staffing establishment / Number of Staff on Shift CRHTT North Mon - Fri Early: 5-6 Staff Sat - Sun Early: 4-5 Staff Late: 5-6 Staff Late: 4-5 Staff Night: 1 Staff (+1 st on call) Night: 1 Staff (+1 st on call) CRHTT South Mon - Fri Early: 5-6 Staff Sat - Sun Early: 4-5 Staff Late: 5-6 Staff Late: 4-5 Staff Night: 1 Staff (+1 st on call) Night: 1 Staff (+1 st on call) CRHTT Guidance for Service Continuity The countywide CRHTT is commissioned to provide a 24 hour service. Out of office hours it is expected that CRHTT can respond to the following: Home treatment telephone calls and support to current CRHTT service users Referrals from the General Hospitals (as per CRHTT Operational Policy) 22 of 48

23 Emergency referrals from Out of Hours GPs Section 136 Mental Health Act (1983) assessments Mental Health Act (1983) assessments CTO recalls Operational staffing levels within CRHT are reduced between the hours of 2100 and 0830 and the service is coordinated by a single Band 6 in each of the respective county bases (North and South). With these staffing arrangements, the CRHTT service is susceptible to disruption in the event of unplanned sickness/absence or exceptional referral rates. In order to maintain service coverage in the event of short notice and/or unplanned sickness/absence, the following steps must be taken to minimise disruption. The Shift Coordinator receiving notification that night cover within their team is affected (i.e. due to sickness, carers leave etc) must immediately notify the team manager or person with delegated responsibility for the service (i.e. the manager on call out of hours). The person receiving this escalation will remain in contact with the shift coordinator to support whilst cover arrangements are sought. The shift coordinator must consider immediate reorganisation of the duty rota (and is given delegated authority to undertake this) to see if alternative night cover arrangements can be identified. (This could include requesting staff on the late shift to work extended hours, utilising staff from the next early shift to cover the night duty, requesting early shift staff to report for duty early or request support from Bank staff with relevant CRHTT assessment experience. The shift coordinator must contact the opposite county team s CRHTT shift coordinator to establish if they can provide night cover or free up capacity to cover the shift by reviewing their duty rota. It is an expectation that staff across the county will work supportively and collaboratively to reduce the likelihood of significant service disruption. Whilst under normal circumstances the night duty is covered by Band 6 CRHTT Workers, a Band 5 worker may act as shift coordinator during a night shift where otherwise the service would be unavailable. There is an expectation that they would be provided with telephone support as appropriate from the Band 6 night worker in the opposite county CRHTT. Such support would include advice when working with complex referrals. Where an immediate solution to night cover within one team cannot be identified, the shift coordinators of the affected team must: 1. Liaise with the shift coordinator of the opposite team and ensure that a handover of all current home treatment cases is provided. This is to ensure that there is continuity of home treatment support. The outgoing shift must hand over potential referrals, risk, current issues and specific patient information to the person coordinating the countywide service e.g. the outgoing shift of CRHTT South will communicate issues to the night duty worker from the North that is expected to cover both sides of the county. This 23 of 48

24 will allow prioritisation of work and preparation for possible situations that may occur during the night. 2. Update the manager on call of the situation and inform them of all actions taken. 3. Inform the site manager of the local general hospital (NGH/KGH) of the service problem. Prior to leaving duty the CRHT coordinator must clear any referrals that have already been received from the acute hospital (to avoid referrals waiting overnight). The service is also to be advised that any persons admitted to the general hospital due to not having received a CRHTT assessment will be seen as a priority as soon as a member of the oncoming shift arrives for duty. 4. Notify the Local out of Hours GP service 5. Inform the relevant Night Manager or Clinical Team Leader based at either the Berrywood Hospital or Welland Centre. 6. Inform the Staff Grade on Call and Consultant on Call (at the earliest opportunity) 7. Inform Switchboard of any contingency arrangements being put in place. In the event that all avenues have been explored and no solution has been found, it may be necessary for the Band 6 night worker who is on shift to liaise with all the support they have available to them to formalise a plan to keep the service available throughout the night. This would include: On call person from North Team Senior Nurse on duty for in-patients (Night Manager or CTL) Medics on call Manager on call As the clinical expertise for crisis work rests with the night worker, their role is essential in planning to provide a seamless service using the resources available to them. Where there is no cover available in one side of the county there is an expectation that the worker from the opposite side of the county will liaise with both general hospital sites to identify what demands for assessment exist. It may be necessary that a CRHTT night worker might commence assessments at one hospital before completing their shift at the opposite site. They may alternatively utilise any additional staffing within the CRHTT. Under such circumstances the night worker would seek support from the Manager on Call, Medic on Call and where available the Senior Night Nurse. This may include direct support in completing assessments or arranging a direct hospital admission to either the Welland Centre or Berrywood Hospitals (subject to being declared medically fit) pending CRHTT assessment at the next available opportunity. The option of admitting a person awaiting CRHTT assessment temporarily into a bed at NGH/KGH should be discussed by the coordinator and/or manager on call. 7.2 Roles and Responsibilities 24 of 48

25 There is a Duty Coordinator assigned to each shift who functions as a focal point of contact for the team to triage calls, prioritise assessments and home treatment activities. The Duty Coordinator will be a senior member of the CRHTT on duty at that time and where possible will be a Band 6. The duties allocated to staff working on each shift correspond to the following roles and enable the CRHTT to deliver its core functions. These are: Duty Co-ordinator Coordinating and leading handover meetings. Deputising for the team manager in their absence Escalating all matters of concern regarding assessments and home treatment to the Medical Personnel. Providing a comprehensive handover of all matters relating to the care and treatment of service users on the CRHTT caseload, to the CRHTT Manager, and medical staff as required. Discussing all referrals with the wider MDT as appropriate. Delegating responsibilities to staff including the update of care plans, risk assessments and other clinical records. Triaging referrals and dealing with clinical information pertinent to the function of the CRHTT. Ensuring staffing levels are appropriately maintained for the shift and that any rota requirements for the following shifts are dealt with. Ensuring that there is an effective handover of pending duties with the oncoming shift co-ordinator including planned assessments. Ensuring that all documentation is completed by team members before the end of each shift. Liaising with staff completing all very urgent and A&E assessments, to ensure that decisions regarding referrals are appropriately discussed with the wider CRHTT MDT. A&E Screening Duties The A&E Screening role will be allocated on a shift by shift basis by the Duty Coordinator will be allocated to a senior member of the clinical team. Where possible this will be a Band 6. They will be responsible for: Being accessible to directly accept telephone calls from referrers. Ensuring a prompt response to the local acute hospital in response to a referral for assessment. Liaising with the Duty Coordinator regarding the outcomes of any assessments undertaken To feedback assessment outcomes to the CRHTT MDT at the handover meeting. To provide education and advice/support to staff at the local acute hospital. Communicating to the shift co-ordinator the number of referrals at A&E and requesting further staff if needed to ensure timely response. 25 of 48

26 Home Treatment Duties Home Treatment duties will be allocated on a shift by shift basis by the Duty Coordinator. Staff allocated Home Treatment duties will be responsible for: Implementing Home Treatment Care Plans Reviewing and updating Home Treatment Care Plans Updating risk documentation Updating the Duty Coordinator on progress and changes. To feedback outcomes / changes to the CRHTT MDT at the handover meeting. Emergency Assessment Duties Emergency Assessment duties will be allocated on a shift by shift basis by the Duty Coordinator. Staff allocated Very Urgent Assessment duties will be responsible for: Responding to requests for very urgent assessment within the agreed response time of less than 4 hours depending on the urgency and priority of the referral. Liaising with the Duty Coordinator regarding the outcomes of any assessments undertaken. Completing all necessary clinical records. Liaising with referrers regarding the outcomes of assessments. Signposting service users and referrers where appropriate. To feedback assessment outcomes to the CRHTT MDT at the handover meeting. Early Discharge Duties Early discharge duties will be allocated on a shift by shift basis by the Duty Coordinator. Staff allocated Early Discharge duties will be responsible for: Reviewing and screening all referrals for early discharge Attending meetings and assessments within the inpatient units relevant to early discharge. Coordinating early discharge arrangements and ensuring these are communicated to the CRHT Duty Coordinator. Updating relevant risk and care plan documents and recording the outcomes of any early discharge assessments on Epex. Liaising with the inpatient wards to identify potential early discharge referrals. 7.3 Handover Meetings and Clinical Reviews CRHTT is a 24 hour service managing high risk service users; therefore, handover meetings play a vital part in providing a safe and effective service. 26 of 48

27 Given the importance of the handover process this time is considered protected. A team handover will take place at least twice a day to discuss and review all current service users and new referrals to the team. Current service user responses to interventions are reviewed by the MDT and adjustments are made to individual treatment plans. Emphasis is on team planning and implementation of care. Any work and referrals (irrespective if taken on) from the previous shift is discussed. Issues of risk are discussed including the planning of visits and safety precautions. Although the handover is considered protected time, referrals will still be accepted during the handover meeting. In addition to the handover meetings, each CRHTT will hold weekly clinical reviews attended by the full multi-disciplinary team. During the review each case on the home treatment caseload is systematically reviewed to determine the appropriateness of the existing care plan, risk management and discharge plans. These meeting should facilitate input from all members of the team across staff disciplines to ensure that concerns and differences of professional opinion are fully discussed and a course of action agreed. Clinical review time is protected and all staff on duty are required to attend. Visits and assessments should not be planned to coincide with the team s clinical reviews, however emergency referrals and A&E demands will be met. 7.4 Supervision, Training and Continuing Professional Development Supervision forms an integral part of the development and support for CRHTT staff. The Team Manager will be responsible for ensuring that staff receive managerial/professional supervision within the team in line with the Trust s Supervision Policy (HR 33). Each member of staff will have an annual IPDR appraisal in which their agreed goals and personal development and job plan will be identified See Appendix 9- CRHT Management and Supervision Structure). In addition to individual supervision; peer group supervision (through staff meetings, clinical reviews) is available to all members of the team on a regular basis. It is essential that staff have regular support to help them deal with the emotional impact of working with risk, life and death. By promoting reflective practice, staff support is integral to maintaining a healthy team that can deliver the organisational task. Staff support also has a preventative role in serious untoward incidences and dealing with incidents as they arise. Multi- professional and multi-agency training will be provided for CRHTT staff to improve collaborative work and to enable more effective service delivery to service users and carers. Training and development provided to the team will reflect the requirements of the Trust, the Crisis Service as a whole and individual staff needs. 8. Risk Assessment and Management The CRHTT s home treatment caseload should consist of service users who would otherwise require care in the hospital setting were it not for support of the 27 of 48

28 team. All staff within the CRHTT will work in accordance with Trust Policy CLP 021- Working with Risk. Upon initial assessment a Working with Risk 1 assessment is completed by CRHTT staff. Risk assessments are updated on a regular basis in response to changes in the service user s presentation and management. At the point of discharge, a further Working with Risk 1 assessment is completed by the CRHTT member completing the discharge. A Working with Risk 3 document should be completed jointly between the inpatient ward and the CRHTT when an agreement is reached to take a service user onto the home treatment caseload as a part of an early discharge. CRHTT staff will adhere to Trust policy on incident reporting (CRM022 Policy for the management of Incidents) which provides guidance on the role of staff in the event of any incident including SI s, drug errors and near misses. Recommendations from SI s reports and Learning Lessons reviews will be discussed in the fortnightly staff meeting and incorporated into the team practice to improve care and service delivery. 9. Service User and Carer Involvement It is vital that the CRHTT encourages service users and carers to play an integral role in the ongoing care and treatment process. Where possible carers will be invited to contribute to the assessment and care planning process. This will be done sensitively without breaching confidentiality. Where appropriate staff within the CRHTT will refer carers to the Carer(s) Development Support Worker within the locality for a carers assessment. 9.1 Feedback from Services Users and Carers Service user and carer feedback of the experience of the CRHTT is integral to developing and maintaining a team that meets service user and carers needs. In developing this aspect of the policy, we have collaborated with Northamptonshire Link to consult with service users and carers, who have experienced the CRHTT, to inform appropriate methods to gather feedback. A tool has been developed for obtaining feedback (See Appendix 10) and this will be administered by an individual who is independent of the team and who has in depth knowledge of what the CRHTT and its associated services provide. The CRHT management team will continue to collaborate with the Link to, to train a small pool of service users to conduct the independent interviews. The process of carer feedback will be developed with the Link along the same principles. Northamptonshire Link will facilitate the collection of feedback which will be feedback to the teams. Service users and their carers who receive the service will be made aware of the Patient Advisor Liaison Service (PALS), the Complaints Procedure and Advocacy Services. 28 of 48

29 10. Research and Audit The CRHTT will endeavour to be involved in research as guided by the research and development department. Audit will be used to inform standards and opportunities to undertake research will be encouraged. 11. Medications and Medicines Management The CRHTTs work in accordance with the Trust s Control of Medicines Policy Trust Policy (MMP001) and the Trust protocol - Crisis Resolution Home Treatment Procedure for Ordering, Storage, Transportation and Administration of Medicines (MMPR002). All Registered Nurses in the team are required to complete a Medication Assessment annually as part of on-going supervision. All medics in the team are required to submit a quarterly medication bag check form to the team manager. 29 of 48

30 Appendix 1: CRHTT Emergency Care Pathway- Red indicates Emergency Pathway Service User GP A&E ROUTINE / URGENT (not for CRHTT) EMERGENCY SPoA CRHTT Improving Access to Psychological Therapies (IAPT) CMHT / CMHT OP EMERGENCY FOR CRHTT A joint assessment to take place wherever possible Assessment MHA SPoA Signpost to Other Services Home Treatment Admission Improving Access to Psychological Therapies (IAPT) Other Services within NHFT CMHT / CMHT OP CRHTT Early Discharge GP 30 of 48

31 Appendix 2: Example of CRHTT EMERGENCY GP REFERRAL SCREENING FORM Surname: First Name: Address: Postcode: NHS Number: CPA Status: Referring G.P.: Address of surgery: What is the reason for referral? D.O.B.: Tel. No.: Ethnicity: Accommodation Status: Smoker: Y N Marital Status: Tel. No: Employed: Y N Occupation: Does the individual have any plans or definite plans to self harm? What are they? Presenting risk factors Is there any history of self harm/suicide in the past? Is there a history of violence and aggression Has the service user been seen in the last 24hours? INDICATORS OF URGENCY Do they need to be seen immediately or within the next 24 hours? Could they be seen within the next 3 days? If person does not need to be seen within the next 24 hour staff to collect all information and pass it on to the local ISA 31 of 48

32 Is the person known to mental health services? (Check Epex) Does the person have any physical illnesses? What is their current medication? What is the person s current family or support network? Please can you fax us more information regarding the referral? Referral taken by..(print) Signed Date:.. Time:. Taken on by CRHTT YES NO If not please advise where SU signposted to: 32 of 48

33 Appendix 3: Guidelines for Referrers from Secondary Mental Health Services to CRHTT The function of the CRHTT is to provide intensive home treatment as an alternative to hospital admission. Referrals will only be accepted by the CRHTT in those cases where the referrer feels hospital admission is required. There is an expectation that prior to a referral to the CRHTT the referrer will have implemented a crisis and contingency Plan to include increased frequency of contact along with a medical review There is an expectation that the referrer will have had face-to-face contact with the Service User within 24 hours prior to referral. This is to ensure that the referral is appropriate and the referrer is able to give all the information required for an appropriate referral. If the Service User has not been seen in the preceding 24 hours a joint assessment, between the referrer and a member of the CRHTT may be agreed at the discretion of the CRHTT Duty Co-ordinator Referrals must be made by direct telephone contact with the CRHTT or else direct face-to-face contact. Referrals made by fax, or letter will not be accepted. The CRHTT Duty coordinator receiving the referral completes the CRHTT Referral form in order to ensure essential information has been gathered. If the referral is considered inappropriate, this will be discussed with the referrer and a clear explanation given. This will be documented on the referral form. The CRHTT Duty coordinator will explore alternative management options with the referrer. If the referral is accepted the Duty Coordinator will gather the required referral information and advise the referrer of a time that a member of CRHTT staff will assess. This will be based on the urgency of the referral The Duty coordinator will advise the referrer that the CRHTT will cannot assume responsibility for the service user until they have been assessed. The Duty Coordinator must ascertain what contingency plans are in place to manage the safety of the service user until they can be assessed by the CRHTT. Under no circumstances will assessments be arranged for the following day after receipt of a referral. All referrals must be assessed the same day The referrer is responsible for ensuring that the HoNOS PBR and the current Risk Assessment are forwarded to the CRHTT, by fax or by advising it is available on Epex. 33 of 48

34 Example of Crisis Resolution Home Treatment Team Referral Form Date: Time: Referrer: Team: Contact Number: CPA Status: Full Name: NHS Number: Current Address: Telephone No: SERVICE USER INFORMATION Postcode: Mobile No: DOB: Marital Status: Ethnicity: Interpreter Required: Y / N Language? Is Service User aware of Referral: (Please Circle) YES NO Has Service User been seen in the last 24 hours (please circle) YES NO Who by? Current Whereabouts: GP & Surgery NAME CONTACT NO. Current Mental Health Workers CPA Coordinator Family Carers Other Agencies Involved REASON FOR REFERRAL, INCLUDING RISK INDICATORS: Behaviour, who else is involved, why today, when last seen by referrer, previous contact with services, early discharge, when was last Risk Assessment completed? What outcome does the referrer expect from this referral? ( This could include if the referrer is concerned enough to do a medical recommendation, is the person willing to work with the crisis team etc) 34 of 48

35 Current Psychiatric Diagnosis: Current Medication: Recreational Drug Use: Y/N Alcohol: Y/N Self Harm: Y/N Suicide: Y/N Risk of Aggression: Y/N Exploitation: Y/N Severe Self Neglect: Y/N Forensic: Y/N Explanation: Relevant Past Mental Health History: Social Issues: Any Other Additional Information: Supported Documentation being Faxed (unless already on EPEX) Current Risk Assessment: ISA Assessment: Information Checked: Previous Assessments: EPEX Other (please specify) Outcome: When complete file in the Referral Record File Referral Accepted: (please circle) YES / NO If No: why and what further action to be taken Discussed with Referrer (please circle) If Yes: Date of Assessment YES / NO Where Assessed: Assessed by: Taken On: Yes / No If No: Why? Refusal discussed with Referrer Yes / No Information taken by Name Signature Date & Time Shift Coordinator aware Name Signature Date & Time 35 of 48

36 Appendix 4: CAMHS Crisis Pathway CAMHS PATHWAY FOR CRHTT years old In Crisis 10 pm to 9 am Mental Health Act Presenting at A & E Presenting at Out of Hours GP NON DSH Deliberate Self-Harm DSH NON DSH Refer to A& E for treatment DSH Presentation Admit to Acute Hospital Assess by Adult CRHTT Admission to Hospital (KGH or NGH) Patient refusing admission to Acute Hospital No Role for CRHTT Case taken on by CRHTT Screened by CAMHS Team the following day 36 of 48 CRHTT to contact CAMHS Consultant to discuss CRHTT to liaise with CAMHS Team the following morning to determine who will provide ongoing care CRHTT to contact CAMHS Consultant re access to CAMHS beds

37 Appendix 5: CATSS Mental Health Assessment Matrix CATSS MENTAL HEALTH ASSESSMENT MATRIX Patient s name Date of birth Number Name of assessor(s) Date Time Assessment categories 1. Background history Does the person pose an immediate risk to self, you or others? (if you answer yes to this question the likelihood is that you will be unable to leave the person alone, or you may have contacted the police) Is the person aggressive and/or threatening? Does he/she have a history of violence? Has the person got a history of self-harm? Does the person, to your knowledge, have a history of mental health problems or psychiatric illness? If yes to any of the above, record details below: Yes No 2. Appearance and behaviour Unsure Yes No Is the person obviously distressed, or anxious? Is the person behaving inappropriately to the situation? Is the person quieter than usual? Is the person distracted? If yes to any of the above, record details below: 3. Issues to be explored through brief questioning Why is the person presenting now? What recent event(s) precipitated or triggered this presentation? Give details below: What is the person s level of social support (i.e.: partner/significant other, family members, friends)? Give details below: 37 of 48

38 Does the person appear to be experiencing any delusions or hallucinations? Is the person in control of their own thoughts and actions? Does the person have children or vulnerable adults living with them If yes to any of the above, record details below: Yes No 4. Suicide risk screen greater number of positive responses suggest greater level of risk yes no d/k yes no d/k Suicide plan/expressed intent Family history of suicide Previous use of violent methods Unemployed/retired Previous self-harm Male gender Current suicidal thoughts/ideation Separated/widowed/divorced Hopelessness/helplessness Lack of social support Depression Family concerned about risk Evidence of psychosis Disengaged from services Poor adherence to psychiatric Chronic physical illness/pain medication Access to lethal means of harm Alcohol and/or drug misuse What category of overall risk have you identified? Give reasons and rationale for your decision. Action plan and outcomes following initial risk screen: Describe all actions and interventions following assessment. Include details of referral to other team(s), telephone calls/advice and follow-up plans. 38 of 48

39 Level of risk Low risk CATSS RISK ASSESSMENT MATRIX Key assessment information Action Timescales Mental health problem may be present, but person has no thoughts or plans regarding harm to self and others. May have already engaged in impulsive self-harming behaviour, but now regrets actions and has no plans or thoughts relating to further self-harming behaviour Patient is confident about maintaining his/her own safety and relative(/significant other(s) are prepared to provide informal support on discharge May benefit from referral to primary care services e.g.: GP, practice nurse, changing minds. Consider whether may benefit from mental health promotion/mental health advice e.g.: safe alcohol consumption information regarding non-statutory agencies. Referral to CRHT service not required. Advice from CRHT staff regarding onward referral and/or follow-up arrangements may be required. Medium Risk Mental health problem(s) present and/or has nonspecific thoughts or ideas regarding harm to self or others e.g.: regrets that selfharm failed to lead to death, but no intention to undertake further self-harm. There is no plan to act on self-harming or suicidal thoughts. However, the person s mental state is at risk of deterioration and they may be physically vulnerable in certain circumstances. Person s agreement to refer to mental health should be sought, but no immediate action required if patient does not wish to engage. Advise to seek further assessment and help via primary care. If person known to mental health services, inform relevant team / worker Advice from liaison staff regarding onward referral and/or follow-up arrangements may be required. In ALL instances if uncertain seek advice from CRHTT staff. Serious mental health problem(s) present, including possible features and symptoms of psychosis and mental state will certainly deteriorate without immediate intervention. Organise any Urgent response from emergency services immediately Notify CRHTT Shift coordinator and complete referral to CRHT Immediate response requested from emergency services and referral to CRHT to be actioned High Risk Has clearly identifiable risk characteristics, such as imminent thoughts or plans relating to self-harm (or harm to others) or suicide. May have already engaged in self-injurious or self-harming behaviour, and on-going suicidal intent remains. May lack capacity and competence to consent to or refuse on-going care and treatment. Adapted from work developed by Harrison et al (2004) Avon & Wiltshire Mental Health Partnership NHS Trust. Not to be reproduced without permission. 39 of 48

40 Appendix 6: Emergency Department Mental Health Assessment Form Patient s name EMERGENCY DEPARTMENT MENTAL HEALTH ASSESSMENT MATRIX Date of birth Number Name of assessor(s) Date Time Factors to be considered when undertaking an initial assessment of a person with a suspected mental health problem: Has a physical cause for the problem(s) been ruled out? Has drug and/or alcohol intoxication been ruled out as a cause? Is the person physically well enough (e.g.: not sedated, overly intoxicated, vomiting or in pain) to undertake an interview with mental health staff? Manage violent and aggressive incidents as per department policy. If on Parvolex only refer once treatment is 4 hours from completion. Any Red = High Risk Refer to CRHTT Amber and Green = Medium Risk Refer or discuss with CRHTT All Green = Low Risk - Does not need referral, however if you have any concerns or wish to discuss further contact CRHTT for discussion. Assessment categories 1. Background history and general observations Does the person pose an immediate risk to self, you or others? (if you answer yes to this question the likelihood is that you will be unable to leave the person alone, or you may have contacted the police) Is the person aggressive and/or threatening? Does he/she have a history of violence? Has the person got a history of self-harm? Does the person, to your knowledge, have a history of mental health problems or psychiatric illness? If yes to any of the above, record details below: Yes No 2. Appearance and behaviour Yes No Is the person obviously distressed, markedly anxious or highly aroused? Is the person behaving inappropriately to the situation? Is the person quiet and withdrawn? Is the person inattentive and un-co-operative? If yes to any of the above, record details below: 40 of 48

41 3. Issues to be explored through brief questioning Why is the person presenting now? What recent event(s) precipitated or triggered this presentation? Give details below: What is the person s level of social support (i.e.: partner/significant other, family members, friends)? Give details below: Does the person appear to be experiencing any delusions or hallucinations? Is the person in control of their own thoughts and actions? If yes to any of the above, record details below: Yes No 5. Suicide risk screen greater number of positive responses suggest greater level of risk Any Red = High Risk Any Amber = Medium Risk Green = Low Risk Suicide plan/expressed intent Previous use of violent methods Current suicidal thoughts/ideation Previous self-harm Hopelessness/helplessness Depression Evidence of psychosis yes no d/k yes no d/k Family history of suicide Unemployed/retired Male gender Separated/widowed/divorced Lack of social support Family concerned about risk Disengaged from services Poor adherence to psychiatric medication Access to lethal means of harm Chronic physical illness/pain Alcohol and/or drug misuse (if alcohol is the primary problem, refer to alcohol liaison nurse accessible through switch) Red = /18 Amber = /18 Green = /18 What category of overall risk have you identified? Give reasons and rationale for your decision. High Medium Low Action plan and outcomes following initial risk screen: Describe all actions and interventions following assessment. Include details of referral to other team(s), telephone calls/advice and discharge/transfer or follow-up plans. 41 of 48

42 Any Red = High Risk Refer to CRHTT Amber and Green = Medium Risk Refer or discuss with CRHTT All Green = Low Risk - Does not need referral, however if you have any concerns or wish to discuss further contact CRHTT for discussion. Level of risk Low risk Medium Risk High Risk MENTAL HEALTH RISK ASSESSMENT MATRIX Key assessment information Action Timescales Mental health problem may be present, but person has no thoughts or plans regarding harm to self and others. May have already engaged in impulsive self-harming behaviour, but now regrets actions and has no plans or thoughts relating to further self-harming behaviour Patient is confident about maintaining his/her own safety and relative(/significant other(s) are prepared to provide informal support on discharge Mental health problem(s) present and/or has nonspecific thoughts or ideas regarding harm to self or others e.g.: regrets that selfharm failed to lead to death, but no intention to undertake further self-harm. There is no plan to act on self-harming or suicidal thoughts. However, the person s mental state is at risk of deterioration and they may be physically vulnerable in certain circumstances. Serious mental health problem(s) present, including possible features and symptoms of psychosis and mental state will certainly deteriorate without immediate intervention. Has clearly identifiable risk characteristics, such as imminent thoughts or plans relating to self-harm (or harm to others) or suicide. May have already engaged in self-injurious or self-harming behaviour, and on-going suicidal intent remains. May lack capacity and competence to consent to or refuse on-going care and treatment. May benefit from referral to primary care services e.g.: GP, practice nurse, changing minds. Consider whether may benefit from mental health promotion/mental health advice e.g.: safe alcohol consumption information regarding non-statutory agencies. Provide Accident and Emergency-Help card Person s agreement to refer to mental health should be sought, but no immediate action required if patient does not wish to engage. Advise to seek further assessment and help via primary care. If person known to mental health services, inform CRHTT who will inform relevant team of their attendance. Mental health assessment required before person can be discharged. Is likely to require close or one to one observation by a member of nursing staff. If person is non-compliant, Common Law powers should be used to temporarily detain the person pending a full mental health assessment. Consider requesting the Police use their powers under sec 136 Mental Health Act (1983). Referral to liaison psychiatry service not required. Advice from liaison staff regarding onward referral and/or follow-up arrangements may be required. Advice from liaison staff regarding onward referral and/or follow-up arrangements may be required. In ALL instances if uncertain seek advice from CRHTT staff. Urgent referral to liaison psychiatry service or on-call mental health staff. Police to be informed if person absconds. All reasonable attempts should be made to stop the person leaving the department before mental health assessment. The presence of hospital security staff may be required. Adapted from work developed by Harrison et al (2004) Avon & Wiltshire Mental Health Partnership NHS Trust. Not to be reproduced without permission. 42 of 48

43 Appendix 7: CRHT Information Leaflet for Service Users Northamptonshire Crisis Resolution Home Treatment Team (CRHTT) This leaflet is for people who have been referred to or are being supported by the Crisis Resolution Home Treatment Team (CRHTT). Crisis Resolution teams were set up to respond to and support adults who are experiencing a severe mental health problem which might lead to admission to a psychiatric hospital. CRHTT offers a flexible, home based care 24 hours a day 7 days a week. Referrals come to the team via the Community Mental Health Teams, the Welland Centre and Berrywood Hospital. The A&E Departments at Kettering and Northampton General Hospitals and the GP out of hour s service. We do not take self referrals or referrals from relatives unless this has been pre agreed as part of your care plan. Who do we help? Our services are available to people from all backgrounds with mental health problems who are in crisis and who, without the help of the team, may require admission to hospital. We provide short term help to people who are experiencing a mental health crisis or who require intensive community support following discharge from hospital. We aim to make the service accessible to everyone who needs it. Who are we? We are a multidisciplinary team. You will be seen by a variety of team members. The team includes: Team Manager Psychiatrists Mental Health Nurses Social Workers Support Workers Clerical Staff What the Crisis Resolution Home Treatment Team (CRHTT) offers After receiving a referral we will contact you to discuss your needs and to plan an assessment meeting. This may take place at your home or at an alternative suitable location (e.g. GP surgery). The initial assessment will be conducted by a member of our team. You will be asked questions about your history and how you currently feel. You will also have an opportunity to ask questions. If the assessment shows that we are the appropriate team to help you, a care plan will be agreed with you. The team will discuss how best to support you and this might include referrals to other services. We regularly discuss the care of people we are working with as a team. What should you expect from the Crisis Resolution Home Treatment Team? Interventions to be intensive and short term (often just up to two or three weeks) 43 of 48

44 The service to determine whether you do or don t need to go into hospital Frequent daily visits as needed Medication to be given if required Social issues like debt and housing to be addressed as part of the overall care plan Support and information to be available for family and carers Involvement to continue until the crisis is resolved For you to be referred onto other services, teams or back to your GP. The CRHTT will also offer you the opportunity to develop a Wellness Recovery Action Plan (WRAP) with them. The WRAP will help you to maintain recovery following discharge from the CRHTT. We recognise the very important role that carers and relatives have in your care. Their needs are important too. If you have a relative or friend who cares for you, they are entitled to a carer's assessment. The CRHTT can provide carers information and make referrals to Carers Development Support Workers. This is their opportunity to discuss any help they might need with supporting you in your recovery. They can also discuss any help that would maintain their own health and balance caring with other aspects of their life, like work and family. For Further Information Please Contact: Richard Amponsah Kelly Gibbons Carey Block Berrywood Hospital Glendon Suite Berrywood Drive St. Mary s Hospital Duston Kettering Northants Telephone No: Telephone No How to make a Complaint or Compliment: We are committed to listening to your experiences, your ideas for improving our service and also when things go wrong. Please tell us when you feel we need to improve our service and you will be listened to carefully, taken seriously and treated without discrimination You can: Speak with any member of staff Contact PALS free on or [email protected] Contact our Complaints Team free on or [email protected] Write to us at Sudborough House, St Mary s Hospital, London Road, Kettering, Northants, NN15 7PW We can also provide you with details of advocacy services. If you would like this information in large print or in a different format or language, please contact the Patient Advice and Liaison Service on or [email protected] Reviewed May of 48

45 Appendix 8: Risk Management Procedures for Service Users Refusing or Avoiding Contact with CRHT Referral to CRHTT for Emergency Assessment Or Concerns about a known CRHT service user Service User contacted but refuses to be seen by CRHT Unable to contact Service User Advise Service User that CRHTT must assess same day Visit / Assessment Contact nearest relative or Other known contacts to establish service user s whereabouts / safety If service User continues to refuse to be seen, they will be informed that a MHA assessment will be requested and CRHT staff are to liaise with AMPH service If CRHTT cannot establish contact, the Police will be notified for joint welfare check. CRHT staff to ensure that AMPH service notified and Urgent MHA Assessment arranged 45 of 48

46 Appendix 9: CRHTT Management and Supervision Structure Head Of Hospitals North Service Manager Band 8a Team Manager (North) Band 7 Team Manager (South) Band 7 Crisis Workers RMN/OT/SW Band 6 Team Administrators Crisis Workers RMN/OT/SW Band 6 Team Administrators Crisis Workers RMN/OT/SW Band 5 Crisis Workers RMN/OT/SW Band 5 Support Workers Band 4 Support Workers Band 4 46 of 48

47 Appendix 10: Service User Feedback Form Optimising team functioning, preventing relapse and enhancing recovery in crisis resolution teams: the CORE programme (CRT Optimisation and Relapse prevention) Phase 1 Service User Interviews Topic Guide Participant ID: CRHT: Date of interview: Gender 1 Male 2 Female Age group Ethnic background 1 White British 9 Bangladeshi 2 White Irish 10 Asian Other 3 White Other Mixed Black/Black British 11 White/Black Caribbean 4 Caribbean 12 White/Black African 5 African 13 White/Asian 6 Black Other 14 Other mixed Asian/Asian British Chinese or other 7 Indian 15 Chinese 8 Pakistani 16 Other ethnic group Number of times interviewee has used CRHT care: Experience of inpatient hospital admission (Y/N): 47 of 48

48 Topic Guide 1a. How did you get help from the CRHT when you needed it? 1b. How should people be able to get help from CRHTT s? Prompts: Pathways into care? Availability of information about how to get help? 2a. What were the main sorts of help you received from the CRHT? 2b. Were there other sorts of help you would have liked? 3. What, if any, were the most positive aspects of the care you received from the CRHT? Prompts: Continuity of care? Choice? Relationships with staff? Types of intervention? 4. What, if any, were the most negative aspects of the care you received from the CRHT? Prompts: Continuity of care? Choice? Relationships with staff? Types of intervention? 5a. What contact did the CRHT have with other services which supported you? 5b. How should the CRHT work with other services? Prompts: Which services should CRHTT s work with? Consultation/permission from service user for information sharing? 6a. What was your experience of CRHT care ending? 6b. When should CRHT care end? Prompts: Time-limited care? Aftercare arrangements? 7. In your experience, what, if any, factors made it difficult for the CRHT to provide good care? 8. Is there anything else which would help us understand what best CRHT care should be and how to achieve this? 48 of 48